Primary healthcare providers are well placed to provide effective sexual healthcare as part of general medical encounters. Studies in north America and the United Kingdom, however, suggest that physicians play suboptimal roles in the clinical management of sexually transmitted infections (STI),1 2 which may partly be caused by their attitudes and perceptions about the infections.3 4 In Australia, available evidence suggests that STI care is compromised by practitioners’ beliefs, anxieties, and attitudes.5 It was found that many general practitioners (GPs) were concerned about their patients’ embarrassment should they take a sexual history.6 One study found that just one in three GPs took a sexual history from a patient whose presenting complaint seemed unrelated to STI.7 Although there is some evidence that practitioners’ attitudes may influence STI care, much less is known about practitioners’ comfort in dealing with STI patients. Furthermore, whether practitioner comfort is associated with optimal STI care is yet to be adequately understood.

METHODS

Data for this study came from a cross-sectional postal survey on the management of STI by GPs practising in New South Wales (NSW), Australia, in 2002. Stratified random sampling was used to draw a 15% sample of GPs working in NSW. The main outcome measure was GPs’ self-reported comfort in dealing with STI patients with different sexual orientations (uncomfortable, somewhat comfortable, and comfortable). Multinomial logistic regression was used to identify factors that were independently associated with self-reported comfort. An attempt was also made to explore whether practitioner comfort was associated with some aspects of STI care.

RESULTS

Of the 900 eligible GPs, 409 returned the completed questionnaire, giving a response rate of 45.4%. Over two-thirds (69–72%) of GPs were comfortable in dealing with heterosexual and young patients with STI, whereas less than half indicated comfort in providing such care for patients who were commercial sex workers, indigenous, intravenous drug users, gay or lesbian. Approximately a quarter (25–29%) of GPs felt uncomfortable in dealing with commercial sex workers, intravenous drug users, gay or lesbian patients. Overall, 26% were comfortable in dealing with all STI patients, whereas 23% felt uncomfortable. Multivariate analysis showed that the overall level of comfort in dealing with STI patients was positively associated with being older (55+ years; adjusted odds ratio (aOR) 4.2, 95% confidence interval (CI) 1.7 to 10.6), practising in rural areas (aOR 2.2, 95% CI 1.2 to 4.2), and having postgraduate training in STI (aOR 4.7, 95% CI 1.9 to 11.8).

GPs who were comfortable were more proactive in sexual history-taking from patients with different sexual orientations (table 1). Practitioners’ comfort was positively associated with offering information on preventive measures against STI, mode of transmission, and the importance of partner treatment. Having STI leaflets for patients was more common among GPs who were comfortable. Conversely, practitioners who were uncomfortable were more likely to report constraints in sexual history-taking, perceive little capacity to influence patients’ risk behaviour, identify patient embarrassment as a barrier to sexual history-taking and recognise the need for training on sexual health.

It is worth mentioning that a comparison of characteristics of the study sample with the GP population in NSW revealed that the study sample was likely to underrepresent male and metropolitan GPs in the state of NSW.

DISCUSSION

This study provides evidence that practitioners are reasonably comfortable in dealing with young and heterosexual patients; however, many practitioners are uncomfortable when dealing with marginalised populations. The level of discomfort reported is higher than that found in an earlier Australian study.7 These data suggest that uncomfortable practitioners experience difficulty in meeting patients’ clinical needs and their expectations for non-judgemental care. This, however, warrants a clear understanding about the nature and origins of practitioner discomfort.

The present study clearly establishes a relationship between practitioners’ self-reported comfort and the types of STI care they deliver. Sexual history-taking was more common among GPs who were comfortable with STI patients, a similar finding to that reported in an earlier US study.8 Practitioner comfort was positively associated with safe-sex counselling and promoting partner treatment, and inversely with their perception of a lack of capacity to influence patients’ risk behaviours. The implications of these findings are significant as practitioner comfort is not simply “bracketed” and concealed from the patient without compromising care. Discomfort is clearly associated with the type of care that is delivered. It is, however, encouraging that 79% of GPs who were uncomfortable did recognise the benefits of sexual health training.

The results of the present study have implications for improvements in both undergraduate and continuing medical education. Given the deficiency in sexual health training in undergraduate curricula,6 9 the present study recommends that greater emphasis be placed on sexual health skills in curricula, especially on training to influence practitioners’ attitudes and behaviours. Simple educational interventions10 through continuing medical education could improve GPs’ effectiveness in sexual healthcare.