Objective To compare the experiences of ethnic minority and white British men who have sex with men (MSM) who attend NHS sexual health clinics in Britain.
Methods In 2007–2008, a national sample of MSM living in Britain was recruited through websites, in sexual health clinics, bars, clubs and other venues. Men completed an online survey, which included questions about their experience of attending an NHS sexual health clinic.
Results Analysis is restricted to 363 ethnic minority MSM and 4776 white British MSM who had attended an NHS sexual health clinic in the 12 months before the survey. Compared with white British men, men from an Indian, Pakistani or Bangladeshi background were more likely to be very anxious about attending the clinic (adjusted OR (aOR) 2.58, 95% CI 1.63 to 4.07), express concerns about being overheard at reception (aOR 1.68, 95% CI 1.10 to 2.58), be uncomfortable in the waiting area (aOR 2.08, 95% CI 1.35 to 3.22) or be afraid that people in their community would find out that they have sex with men (aOR 7.70, 95% CI 4.49 to 13.22). The adjusted ORs for being afraid that people in their community would find out that they have sex with men were also elevated for black Caribbean, black African, Chinese and other Asian men.
Conclusion Sexual health clinics should be aware that some ethnic minority MSM, particularly those from an Indian, Pakistani or Bangladeshi background, have heightened concerns about clinic attendance and confidentiality compared with white British MSM.
- Men who have sex with men
- ethnic minority
- sexual health clinics
- sexual behaviour
- gay men
- risk behaviours
- STD surveillance
- Chlamydia trachomatis
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- Men who have sex with men
- ethnic minority
- sexual health clinics
- sexual behaviour
- gay men
- risk behaviours
- STD surveillance
- Chlamydia trachomatis
Men who have sex with men (MSM) remain the group most at risk of acquiring HIV in Britain. In 2010, sex between men accounted for nearly 40% of new HIV diagnoses in this country. MSM in Britain are also more likely to be diagnosed with a sexually transmitted infection (STI) such as gonorrhoea or syphilis than other men.1–3
Approximately 5% of MSM aged 15–44 years in Britain are HIV positive. HIV prevalence is higher among MSM living in London than elsewhere in the country, and prevalence also varies between ethnic groups.1–3 While there has been some research examining the prevalence of HIV and other STIs among ethnic minority MSM in Britain,4–6 little is known about the delivery of sexual health services for this population or indeed for MSM in general.
A number of studies have examined patients' experience of using sexual health services in Britain,7–9 but none of these have described the experiences of MSM, and ethnic minority MSM in particular. Furthermore, the handful of studies, which have focused on ethnic minority engagement with sexual health services in Britain,10 ,11 did not include MSM from an ethnic minority background as a population of interest.
The aims of this paper were, therefore, to examine the experiences of ethnic minority MSM who attend NHS sexual health clinics in Britain and to compare their experiences with those of white British MSM. The findings from this research may inform new ways of working with ethnic minority MSM in an NHS clinic setting.
For this study (the MESH project), we recruited a national sample of ethnic minority MSM both ‘online’ (through the internet) and ‘offline’ (eg, through sexual health clinics or gay venues) between August 2007 and April 2008. The sexual health clinics and gay venues were located in the 15 British towns and cities with the largest ethnic minority populations according to the 2001 census.12 We also recruited, primarily through the internet, a comparison group of UK-born white British MSM. All men were asked to complete an anonymous confidential questionnaire online, which took 20–30 min to complete. The methods have been described in detail elsewhere.12 Ethical approval for the study was granted by the South West MREC (06/MRE06/71).
Men were eligible for the study if they (1) reported ever having sex with men, (2) lived in Britain and (3) were older than 18 years. All men recruited offline (ie, through clinics or gay venues) were asked to complete a questionnaire online.
Men were asked about their socio-demographic characteristics (age, ethnicity, country of birth, place of residence, employment, education) and whether they had attended an NHS sexual health clinic in the 12 months before the survey. Those who indicated that they had attended a clinic were asked to answer questions about their experience of using the clinic they had attended most recently.
Our question on ethnicity was based on the 2001 census for England and Wales.13 Respondents were asked ‘What is your ethnic group?’ They could tick one of the following: white British, white Irish, white other, black Caribbean, black African, black other, black Caribbean-and-white, black African-and-white, Indian, Pakistani or Bangladeshi (IPB), IPB-and-white, Chinese, other Asian, Arab, other ethnic group.
Data were analysed using STATA 11IC (V.11.2; Stata for Windows Corporation). Respondents who described themselves as Chinese or other Asian were combined for the analysis, as were men who described themselves as black Caribbean-and-white or black African-and-white (referred to in the analysis as ‘black-and-white’). We included respondents who described themselves as white British but excluded those who described themselves as white Irish or white Other to maintain comparability with our earlier analysis of ethnic differences in self-reported HIV seropositivity.6 Respondents who described themselves as black other, Arab or other ethnic group were not included because of small numbers.
The seven ethnic groups included in the analysis were: (1) black Caribbean, (2) black African, (3) black-and-white, (4) IPB, (5) IPB-and-white, (6) Chinese and other Asian and (7) white British.
Our earlier analysis of ethnic group differences in self-reported HIV seropositivity6 also included men born in South and Central America or Central and Eastern Europe living in Britain. We did not include men born in South and Central America or Central and Eastern Europe here because most of these men (95%) did not belong to one of the ethnic minority groups above (ie, black Caribbean, black African). In this analysis, we focus on ethnic minority MSM living in Britain.
Differences in the background characteristics of the respondents who belonged to the seven ethnic groups included in the analysis were compared using Mann–Whitney and Pearson χ2 tests (table 1). We then examined differences between ethnic groups in their response to the questions about using an NHS sexual health clinic (eg, uptake of HIV testing, hepatitis B vaccination, STI diagnosis, anxiety about attending the clinic, feeling comfortable in the waiting room) also using χ2 tests (tables 2 and 3). Where we detected differences between ethnic groups in univariable analysis (p<0.05), these were further examined in multivariable analysis. We used binary logistic regression models to test if differences persisted between ethnic groups after adjusting for confounding variables using white British men as the reference group (table 4).
Over 19 000 people clicked through to the homepage of the MESH online questionnaire and gave their consent to take part in the survey. Of these, 17 425 matched the inclusion criteria (ie, they were male, older than 18 years, lived in the UK and reported ever having had sex with a man); 1241 men described themselves as ethnic minority and 13 717 were white British (14 958 in total). Of the remaining 2467 men, 2051 men described themselves as white Irish or white Other. A further 173 men were born in South or Central America, while 243 men were born in Central or Eastern Europe. These 2467 men were excluded from the analysis (see the Methods section, Statistical analysis).
Of the 1241 ethnic minority and 13 717 white British MSM who matched the inclusion criteria, 991 and 11 944 (respectively) completed the whole questionnaire and provided information about their age, ethnicity, HIV testing history, HIV status and whether they had attended a sexual health clinic in the previous 12 months. Of the 991 ethnic minority respondents, 131 were excluded from the analysis because they described themselves as black other (16), Arab (48) or other ethnic group (67). The remaining 860 ethnic minority MSM were included in the analysis along with the 11 944 white British MSM (total =12 804) (table 1).
The majority of the respondents were recruited online through advertisements on a variety of websites (ethnic minority MSM, n=675; white British MSM, n=11 416). A further 44 ethnic minority MSM and 18 white British MSM were recruited through sexual health clinics in the 14 British cities and towns.
Of the 12 804 men, 5139 (40.1%) said that they had attended an NHS sexual health clinic in the previous 12 months (ethnic minority MSM, n=363; white British MSM, n=4776). The percentage of MSM attending an NHS sexual health clinic in the previous 12 months varied between ethnic groups (34%–64%, p<0.01) (table 1). Of the men who had attended an NHS sexual health clinic in the 12 months before the survey, relatively few said that they had attended a dedicated service for MSM (range 14%–22%, p=0.120).
As has been reported elsewhere,6 there were differences between ethnic groups in terms of age, place of birth, residence, education employment, sexual identity (all ps<0.001) and sexual partners (p<0.01) (table 1). With the exception of Chinese and other Asian MSM, the majority of ethnic minority respondents (67%–77%) were born in the UK. Compared with white British MSM, ethnic minority MSM were in general younger, more likely to live in London, more likely to be students and more likely, in some groups, to identify as bisexual. MSM from a black African, black-and-white or IPB-and-white background were more likely to have had sex with a woman than white British MSM. On the other hand, there were no observable differences between black Caribbean, IPB, Chinese, other Asian and white British men on this variable.
HIV testing, hepatitis B vaccination, STI diagnosis
Regardless of ethnic background, the majority of MSM (71%–87%, p=0.200) said that they were offered an HIV test when they last visited an NHS sexual health clinic, and most of these men (85%–95%, p=0.440) had accepted the offer (table 2). The majority of men also said that the clinic had asked them if they were vaccinated against hepatitis B (77%–85%, p=0.900). About half the men said that they had discussed HIV or STI prevention with a nurse, doctor or health advisor during their clinic visit (50%–61%, p=0.750). Approximately a quarter of the men said that they were diagnosed with a STI the last time they went to an NHS sexual health clinic (18%–31%, p=0.680). The numbers were too small to analyse individual STIs by ethnic group. In all ethnic groups, the vast majority of men (92%–100%, p=0.723) said that the person they saw in the clinic (ie, the doctor, nurse or health advisor) explained things in a way that they could understand.
There was little evidence of differences between ethnic groups on any of the above variables (table 2). However, compared with white British men (8%), MSM in all ethnic minority groups were more likely to say that the person they saw in the clinic assumed that they had sex with women (12%–18%) (p<0.001).
Experience of attending an NHS sexual health clinic
Approximately two of five respondents were able to get an appointment in <48 h, a similar number waited 3–7 days for an appointment and one in five had to wait more than 7 days. This did not vary by ethnicity (p=0.801) (table 3).
About half the men said that they were a ‘little anxious’ attending the sexual health clinic. However, the percentage of respondents who said they were ‘very anxious’ attending the clinic varied between ethnic groups. Men from an IPB or an IPB-and-white background were more likely to say they were ‘very anxious’ attending the clinic (33%, 32%) than men in other groups (17%–24%) (p=0.002) (table 3). Men from an IPB background were also the most likely to say they were concerned that other patients could hear them when they were talking to the receptionist (p=0.061). They were also more likely than men in other groups to say that they were uncomfortable sitting in the waiting room with other patients (p=0.050). Men from an IPB background were also the most likely to say they were worried that people in their community would find out that they had sex with men if they disclosed this information in the clinic (28%). This percentage was also elevated for black Caribbean, black African, Chinese and other Asian men (18%–21%) (p<0.001). In marked contrast, very few white British men (7%) or men from a mixed background (ie, black-and-white (4%), IPB-and-white (7%)) were worried about this.
The overall level of satisfaction with the sexual health clinic was high, with 95%–100% of respondents being ‘very satisfied’ or ‘satisfied’, regardless of ethnic group (p=0.639). Regardless of ethnicity, most respondents (88%–100%) said that they would recommend the clinic to other MSM (p=0.106).
Compared with white British MSM, in multivariable analysis, MSM from an IPB background were more likely to be very anxious about attending the clinic, to express concern about being overheard at reception, to be uncomfortable in the waiting area and to be afraid that people in their community would find out that they have sex with men (table 4).
The adjusted ORs for being worried that people in their community would find out that they have sex with men were also elevated for black Caribbean, black African (borderline), Chinese and other Asian men. The ORs for this variable were not elevated for men from a mixed background (black-and-white, IPB-and-white) (table 4). It was notable that for men from a black-and-white background, the ORs were not significantly elevated for any of the four variables above.
In multivariable analysis, compared with white British MSM, men in all ethnic minority groups were more likely to say that the person they saw in the clinic assumed that they had sex with women. The adjusted ORs were >2.0 for all groups except Chinese and other Asian MSM (table 4).
Our study shows that, among MSM in Britain, overall satisfaction with NHS sexual health clinics is very high regardless of ethnicity. Nonetheless some men expressed anxieties and concerns about privacy and confidentiality in the clinic. These concerns were reported by men in all ethnic groups. However, compared with white British MSM, men from an IPB background were more likely to be very anxious attending the clinic, be concerned about being overheard in the reception area and to feel uncomfortable in the waiting room. They were also more likely to be worried that as a consequence of telling someone in the clinic that they have sex with men people in their community would find out. Black Caribbean, black African, Chinese and other Asian MSM also expressed similar fears about people in their community finding out that they have sex with men.
As we have reported elsewhere,14 MSM from IPB and black African or Caribbean backgrounds living in Britain face an array of culture-specific and community-bound challenges not shared by white British MSM. It seems likely that these challenges underpin the problematic experiences reported by some ethnic minority MSM when attending a sexual health clinic. Homosexuality remains stigmatised in many ethnic minority communities in Britain.14 Undoubtedly, this will account for the heightened sensitivities about confidentiality expressed by ethnic minority MSM in our study.
It was striking that MSM from mixed ethnic backgrounds (ie, from IPB-and-white or from black-and-white backgrounds) were rather like white British MSM in many of their responses. In general, they did not display the same level of concern, discomfort and anxiety about attending the clinic as men from a single ethnic background.
Studies among the general population in Britain have also shown that overall satisfaction with sexual health services is high, although people did express some concerns about confidentiality and privacy.9 ,15 A recent systematic review of sexual health services16 also identified the reception area and waiting rooms of sexual health clinics as areas of potential concern for clinic attendees.
While no other British study appears to have examined the experiences of ethnic minority MSM attending sexual health clinics, several studies have investigated the experiences of the wider ethnic minority population. These studies highlighted different patterns in accessing sexual healthcare according to ethnicity. For example, Tariq et al 17 have shown that referral routes to sexual health services are often different for people from South Asian backgrounds than for those from other ethnic backgrounds. Dhar et al 10 also note that sexual healthcare pathways for South Asian women need to be improved in light of their reluctance to access sexual health services compared to other groups. These studies resonate with the elevated concerns reported here by MSM from an IPB background.
In our study, black African, black-and-white and IPB-and-white MSM were more likely to have had sex with women in the previous 12 months than white British MSM. However, there were no observable differences between black Caribbean, IPB, Chinese, other Asian and white British MSM in the percentage who said that they had had sex with a woman. Nonetheless, men in most ethnic minority groups were more likely than white British men to say that the person they saw in the clinic assumed that they had sex with women. We acknowledge that the wording of this question was problematic (‘Did the person you saw in the clinic assume that you have sex with a woman?’) and that responses to the question were likely to be subjective on the part of respondent. Despite these limitations, however, this finding does raise the possibility that some ethnic minority MSM are being stereotyped by clinic staff, regardless of their actual sexual behaviour.
Although ours is the first national study among ethnic minority MSM to examine their experience of using NHS sexual health clinics, it is important to acknowledge some of its limitations. Common to much research on MSM, the study relied on convenience sampling and therefore we cannot claim to have recruited a representative sample of ethnic minority or white British MSM.18–22 Of the 860 ethnic minority MSM who provided information on whether they had attended a sexual health clinic in the previous 12 months, only 363 had done so and could be included in the analysis. The questionnaire for the study was only in English, which would have precluded some ethnic minority MSM with limited knowledge of the language from participating. Another potential limitation is that the participants in all ethnic groups were highly educated. MSM from less educated backgrounds may have had experiences at sexual health clinics not captured by this research. Also, using broad categories such as ‘Black African’ may conceal an array of diverse experiences within each ethnic group. Unfortunately, a validated tool for measuring patient satisfaction with sexual health services was not available when we conducted the survey, although one has been published subsequently.23 ,24
In conclusion, overall satisfaction with NHS sexual health services is high among MSM in Britain. Nonetheless, some men expressed anxieties and concerns about their clinic visit regardless of their ethnic background. These concerns were elevated for some ethnic minority MSM, particularly those from an IPB background, In particular, they were concerned about the confidentiality of the clinic consultation and the possibility that this could lead to people in their community finding out that they have sex with men.
How can the anxieties expressed by some ethnic minority respondents in our study, particularly around confidentiality, be alleviated? Ensuring that all those working in NHS sexual health clinics are aware of, and trained to respond to the significant concerns of ethnic minority MSM using these services is a critical step to increasing engagement with this population. Specifically, making sure that conversations in reception areas cannot be overheard, using the clinical consultation to explain how confidentiality is maintained and avoiding assumptions about sexual behaviour might help to increase confidence among ethnic minority MSM attending NHS sexual health clinics. In addition, including patient-reported measures of anxiety as auditable outcomes could enhance the importance that clinic staff attach to this aspect of clinical care. In this way, the findings from this research could be used for developing and improving services for ethnic minority MSM attending NHS sexual health clinics in Britain.
The vast majority of MSM from all ethnic backgrounds were satisfied with the service they received at NHS sexual health clinics.
Compared with white British MSM, ethnic minority MSM were more likely to be concerned about the confidentiality of the clinic consultation and were afraid that people in their community might find out that they have sex with men.
Compared with white British and other ethnic minority MSM, men from an IPB background had heightened anxieties and concerns about their clinic visit.
The authors thank all the men who completed the online questionnaire; the community representatives and advisory group; the participating sexual health clinics and HIV prevention projects; and Gaydar for technical support and for promoting the survey.
Funding This study was supported by the Medical Research Council (grant number: G0500009).
Competing interests None.
Ethics approval Ethics approval was provided by South West MREC. Approval Number: 06/MRE06/71.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data set for the study is still being analysed and further papers prepared for publication.