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Does physician bias affect the quality of care they deliver? Evidence in the care of sexually transmitted infections
  1. A Khan1,
  2. D Plummer2,
  3. R Hussain3,
  4. V Minichiello3
  1. 1
    Social Research Centre, University of Queensland, Qld 4072, Australia
  2. 2
    School of Education, University of the West Indies, Port of Spain, Trinidad
  3. 3
    School of Health, University of New England, NSW 2351, Australia
  1. Dr A Khan, Social Research Centre, The University of Queensland, St Lucia, Qld 4072, Australia; a.khan2{at}


Background: Primary care providers are well placed to control the spread of sexually transmitted infections (STI); however, care is likely to be influenced by their attitudes and beliefs. The present study investigates the relationship between general practitioner’s (GP) self-reported level of comfort in dealing with patients with STI and the care they deliver.

Methods: A postal survey was conducted using a stratified random sample of 15% of GPs practising in New South Wales, Australia, to assess practitioners’ management of STI. A total of 409 GPs participated in the study yielding a response rate of 45.4%.

Results: Although over two-thirds (69–72%) of GPs were comfortable in managing STI in heterosexual or young patients, fewer than half (40–46%) felt comfortable caring for patients who were sex workers, indigenous, people who inject drugs, gay or lesbian. Practitioners who were comfortable were more likely to offer sexual risk assessment, safe-sex counselling, and were less likely to report limited ability to influence patients’ risk behaviours. Practitioner discomfort was positively associated with reporting constraints in sexual history-taking and the need for training in sexual health.

Conclusions: Practitioners’ care and support for patients with STI are influenced by their inexperience, lack of skills and/or attitudes. The reasons for GP discomfort in managing STI patients need further exploration as does its impact on patient care.

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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.


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.


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.

Table 1 Percentage of general practitioners with some aspects of sexually transmitted infection care by their self-reported comfort in dealing with patients with sexually transmitted infections*

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.


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.

Key messages

  • Many GPs do not feel comfortable treating marginalised populations

  • Care for STI is often compromised by GPs' discomfort in dealing with the patients

  • Further exploration of practitioner discomfort has the potential to improve STI care in primary care settings


The authors are indebted to Dr David Bradford, Past President of the Australasian College of Sexual Health Physicians for his ongoing support and valuable advice during the study. They also wish to thank Drs Suzanne Robertson, Elizabeth Pringle, Miriam Grotowski and Jan Browne for their valuable input in developing the study instruments. The authors are very grateful to all GPs who participated in the study.


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  • Competing interests: None declared.

  • An institutional research grant from the University of New England supported the study.

  • Contributions: AK designed the study, analysed the data, interpreted the data analysis and contributed to manuscript writing. DP, RH and VM contributed to designing the study, interpreting the results, and writing the manuscript.

  • Ethical approval: Ethical approval for the study was granted by the Ethics Committee of the University of New England, Australia.