|Year : 2021 | Volume
| Issue : 2 | Page : 142-146
Sexual health problems and health-seeking behavior of men who have sex with men in Agra City, Uttar Pradesh
Khan Iqbal Aqeel1, SS Chaudhary2, SK Misra3, Geetu Singh1, Prashant Lavania4
1 Assistant Professor, Department of Community Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
2 Associate Professor, Department of Community Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
3 Professor and Head, Department of Community Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
4 Professor, Department of Surgery, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
|Date of Submission||19-Aug-2020|
|Date of Decision||11-Mar-2021|
|Date of Acceptance||12-Apr-2021|
|Date of Web Publication||14-Jun-2021|
S S Chaudhary
Department of Community Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Men who have sex with men (MSM) are at high risk of acquiring sexually transmitted illnesses. The gross stigmatization of homosexuality and discrimination has always affected their health-seeking behavior. Objectives: The study aimed to assess the magnitude of sexual health problems, factors associated, and their health-seeking behavior. Methods: Descriptive cross-sectional study was conducted in Agra city, Uttar Pradesh during December 2017 and November 2019 among a sample of 52 MSM. The Snowball technique of sampling was used to recruit the eligible subjects. Data were collected by interview and analyzed using MS excel. Results: Overall prevalence of any sexual health problem in past 1 year was 71.2%. Anal/perianal problems (26.9%) and genital/oral vesicles (26.9%) were the most commonly encountered illnesses MSM who had all their sexual encounters with men (completely homosexual), those MSM who used to play both insertive and receptive roles, had 5 or more sexual partners, used condom irregularly had significantly higher chances of having sexual health problems. Most (70.3%) MSM sought treatment for their sexual health problem from an Allopathic doctor; 29.4% took treatment from a government health facility. The majority (94.1%) of them were reportedly satisfied with the health care facility. Most (79.4%) respondents preferred not to disclose their sexual behavior during interaction with their sexual health care provider. Conclusion: High prevalence of sexual health problems was found among MSM who engage in high-risk sexual behavior. MSM requires access to STIs screening. Behavior change communication is needed to improve their health-seeking behavior.
Keywords: Health care, men who have sex with men, sexual health, snowball sampling
|How to cite this article:|
Aqeel KI, Chaudhary S S, Misra S K, Singh G, Lavania P. Sexual health problems and health-seeking behavior of men who have sex with men in Agra City, Uttar Pradesh. Indian J Public Health 2021;65:142-6
|How to cite this URL:|
Aqeel KI, Chaudhary S S, Misra S K, Singh G, Lavania P. Sexual health problems and health-seeking behavior of men who have sex with men in Agra City, Uttar Pradesh. Indian J Public Health [serial online] 2021 [cited 2023 Mar 26];65:142-6. Available from: https://www.ijph.in/text.asp?2021/65/2/142/318350
| Introduction|| |
Men who have sex with men (MSM) refer to all males (of any age) who involve in sexual and/or romantic relations with other males. There are an estimated 2.35 million sexually active MSM in India. Several reports have documented decreased numbers of sex partners, reduced frequencies of unprotected intercourse, or substantially lower rates of sexually transmitted diseases (STDs) in MSM.,,,, Nevertheless, the incidence of STD in this population remains higher than that in exclusively heterosexual men and women. Targeted intervention program of National AIDS Control Programme focuses upon high-risk MSM frequently involved in unprotected anal intercourse with multiple people which carries a risk of STDs transmission for the receptive partner, resultantly, they are more prone to anal health problems like injuries, fissure/fistula, etc., apart from sexually transmitted infections leading to genital/oral ulcers, vesicles, warts, discharge, etc., Very few Indian studies,,, are available regarding sexual health problems and health-seeking behavior among MSM. In this context, the present study was conducted to assess the sexual health problems and health-seeking behavior among MSM residing in Agra city of Uttar Pradesh.
| Materials and Methods|| |
This descriptive observational study was conducted among the MSM population residing in the Agra district of Uttar Pradesh, India between December 2017 and November 2019. The inclusion criteria for the participants of the study were-Self reported same-sex behavior in the last 1 year; and 18 years or older at the time of interview. Participants were recruited through the snowball sampling technique. The first participant was recruited through a nonprofit peer group. Further participants were subsequently referred by the participants from their peer circles. The exclusion criteria included – (a) Self-reported HIV positive status since the experience of HIV diagnosis increases the guilt associated with their sexual behavior and initial sex encounters with an increasing tendency to report negative experiences. This has a propensity to create bias in the interviews. Furthermore, HIV-positive individuals (especially recently diagnosed) have special psychosexual, physical needs and mental health needs, different from general MSM people; (b) critically ill or suffering from end-stage disease; (c) lack of willingness to participate in the study.
Data collection was done from March 2018 to February 2019. A total of 52 MSM participated in the study. The proforma schedule used for quantitative assessment was pretested, predesigned, and structured. A mixed questionnaire was used in the study where closed-ended questions were asked to assess their socio-demographic characteristics, sexual practices, and health-seeking behavior and open-ended questions were used to explore the reasons for preferring a particular type of health care facility.
Before the start of the interview, the participants were explained the purpose of the study and the sensitive nature of the questionnaire. Informed consent was taken and confidentiality was assured. Information collected on the study schedule was transferred on predesigned classified tables and analyzed according to the aims and objectives and represented by tables analyzed through MS excel. Ethical clearance for the study was taken from the Institutional Ethical Clearance Committee, SN Medical College and Hospital, Agra.
| Results|| |
[Table 1] shows that among the 52 participants, 65.4% of MSM were in the age group of 20–29 years. The mean age of respondents was 27.75 (±6.48) years ranging from 19 to 45 years. The majority of them were Hindus (55.8%). Half of them had graduate/postgraduate degrees; none was illiterate and 7.69% were professionally qualified. Majorities (71.2%) were residing in an urban area, were unmarried (86.5%), and belonged to a nuclear family (73.1%). About a third (32.7%) of them were working as clerk/shop-keeper/farmer and 19.2% were unemployed. The majority of them belonged to lower-middle (61.5%) and upper-lower socio-economic class (30.8%) as per modified Kuppuswamy's classification [Table 1].
|Table 1: Distribution of respondents according to sexual health problems among men who have sex with men (n=52)|
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Sexual health problems
When asked about the occurrence of any sexual health problems during the past 1 year, most of them admitted to having some illness. Commonly reported were anal and peri-anal conditions such as pain in defecation/bleeding per anus/rectal prolapse (26.9%), anal injury (23.1%), and perianal warts (1.9%). Among other sexual health problems, genital/oral vesicles were the commonly reported problems (26.9%) during the past 1 year followed by burning during micturition (19.2%) and genital ulcers (19.2%). Overall, 28.8% of the respondents had no sexual health problem (s) during the past 1 year but the rest (71.2%) had at least one sexual health problem.
Risk factors for sexual health problems
[Table 2] shows the association of various risk factors with sexual health problems among MSM during the past 1 year. A significantly higher proportion of “completely homosexuals” (MSM who had all their sexual encounters with men) (86.4%) and “mostly homosexuals” (MSM who had most of their sexual encounter with men) (72.7%) had a sexual health problem during last 1 year in comparison to “sometimes homosexuals” (MSM who almost had a proportionate sexual encounter with both males and females),, (25%) (χ2 = 10.809, df = 2, P = 0.0044). More than three fourth (77.8%) of MSM who played “passive/receptive role” had a sexual problem during the last 1 year while only 28.6% of MSM who played “active/insertive role” had suffered from a sexual health problem during the same period (χ2 = 7.292, df = 2, P = 0.026). Similarly, MSM with more than 5 sexual partners had significantly higher chances of having a sexual health problem in the past 1 year in comparison to those who had ≤5 sexual partners (84.2% vs. 35.7%) (χ2 = 11.723, df = 1, P = 0.0006). Though MSM who were unmarried, had sex with a man for monetary or other benefits and who were victims or doers of violence with sex partner had higher chances of sexual health problem during the last 1 year in comparison to their counterparts but this was statistically not significant.
|Table 2: Association of various risk factors with presence of sexual health problem during past 1 year (n=52)|
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Health seeking behavior
[Table 3] shows that the majority (70.3%) of respondents sought treatment from an allopathic doctor for their sexual health problem. Almost one in every five MSM (21.6%) took treatment from an Ayurvedic doctor while the rest of the respondents either went for a self-treatment (2.7%) or had not taken any treatment (5.4%). The majority (70.6%) of MSM opted for a private health facility for their sexual health problems. Although the majority (82.4%) got treatment from a qualified doctor; 11.8% had no idea of their doctor's qualification and 5.9% reportedly took treatment from a nonqualified doctor. The better facility was the most commonly cited reason among MSM for preferring a particular doctor or health care facility. Other reasons like “someone known recommended” (17.7%), “doctor was located far from their residence” (14.7%) and “cost-effectiveness” (14.7%) were also mentioned for choosing a particular doctor or health care facility.
|Table 3: Health seeking behaviour in relation to sexual health problems among men who have sex with men|
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On being asked about the overall satisfaction with the health care facility where they had received treatment for their sexual health problem; only 5.9% were reportedly unsatisfied with the health care facility and the reason for their dissatisfaction was overcrowding at the hospital.
Another question which was asked to them was: Have you disclosed your sexual behavior to the health care provider or not? Only 20.6% of the respondents had reportedly disclosed their sexual behavior to the sexual health care provider. Most (79.4%) respondents preferred not to disclose their sexual behavior during interaction with their sexual health care provider. When they were further asked about the reason for not disclosing their sexual behavior to the sexual health care provider, the majority (81.5%) of them mentioned fear and stigma associated with homosexuality as the reason for nondisclosure. Another 14.8% did not disclose thinking that doctors will discriminate with them and will not give proper treatment. Only 1 out of 27 respondents who did not disclose his sexual behavior in front of his health care provider reportedly thought that it was not needed.
| Discussion|| |
The prevalence of STDs/reproductive tract infections (RTIs) among MSM in the present study was found to be 71.2% which was assessed based on their symptoms during the last 1 year. Studies from India carried out in clinics catering only to MSM have shown that nearly 20% of MSM were affected by some STDs like Syphilis, Herpes, Condyloma, etc.,,, Higher prevalence of STD/RTIs among MSM in the present study as compared to other studies is probably due to different diagnostic criteria (i.e., symptomatic vs. laboratory-based prevalence) and different duration of symptoms (i.e., during the last 1 year vs. 3 months) used in our study.
In the present study, more than half of MSM (51.9%) reportedly had one or other anal and or peri-anal health problems like bleeding per anus/rectum, anal/perineal injury, anal discharge or anal warts during the past 1 year. Only one-fourth of the respondents (28.8%) had no sexual health problem in the past 1 year. Moreover probable reasons for such high prevalence could be the high frequency of anal sex, infrequent use of condoms during anal intercourse, multiple partners, and unwillingness to go for health checkups.
When an analysis was done to find selected socio-cultural and sexual behavior determinants of sexual health problems among MSM, it was found that MSM who were completely homosexuals used to play both insertive and receptive roles, had 5 or more sexual partners and those who used condom irregularly had significantly higher chances of having sexual health problem in comparison to their respective counterparts. Analysis of their health-seeking behavior revealed that more than one-fifth of MSM had sought treatment from an AYUSH doctor for their sexual health problem. They believed that traditional healers like AYUSH doctors were better equipped to solve their sexual health problems (probably due to rampant advertisement) and would also keep this a secret.
In the present study, it was also observed that only 29.4% of MSM received treatment for their sexual health problems at a government health care facility. This might be due to fear of discrimination by health care personnel and possible disclosure to those who are attending the same health care facility for some other health problem.
When enquired about reasons for preferring a health care facility/doctor by MSM, better service at the health care facility was the most commonly cited reason. Three reasons which drew our attention were: Someone known recommended (17.7%), the doctor was located far from residence (14.7%) and anonymous health care facility (11.8%). All these three reasons were related to their desire to maintain their secrecy, and predictably no MSM ever preferred his family doctor due to the same reason. It is worth noting that none of the respondents was reportedly dissatisfied with the health care facility where they received treatment for their physical health problem and this indicates that many MSM are not satisfied with treatment facilities for their sexual health problems probably due to further recurrences of the same or other sexual health problems and incomplete cure and so we should make proper arrangement for counseling and complete treatment at the health care facility.
The study also found that the disclosure rate (20.6%) about their sexual behavior/orientation at health care facilities during interaction with their sexual health care provider was quite poor. Disclosure rates to health care provider in a study conducted among 1,424 MSM by Tang et al., at China was 16% while the Disclosure rate was as high as 90% in a study done by Durso and Meyer, 2013 among 198 gay men in New York City. The rates of disclosures to HCPs vary by sociodemographic characteristics of MSM. When they were further asked about the reason for not disclosing their sexual behavior, the majority of them told that they did not disclose it out of fear and stigma associated with homosexuality. Similar studies, conducted by Clover in London and Tadele and Amde in Ethiopia also found that a major barrier in assessing health care among gay and bisexualsis their fear of stigma and discrimination.
| Conclusion|| |
As most of MSM are still involved in high-risk sexual practices, peer-based behavior change communication and HIV prevention program should especially focus on the MSM groups. Integrated comprehensive health care facilities for better management of sexual health problems among MSM should be established which should be anonymous and have HIV/STD testing facilities, cost-effectiveness, discrimination-free environment, and trustworthy and well-qualified doctors. Training of medical and para-medical professionals about psychosexual health issues of MSM is needed to improve the health care of MSM by keeping a nonjudgmental and compassionate attitude toward the MSMs.
The authors deeply acknowledge the study participants who consented to participate in this study. We are highly grateful to Dr. SK Misra, Head of Department of Community Medicine, SNMC, Agra who had given us the opportunity to conduct this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Di Benedetto MA, Romano N, Firenze A. Re-emergence of HIV infection and syphilis among men who have sex with men. Public Health Soc Behav Health 2012;May 16:477.
Doll LS, Judson FN, Ostrow DG, O'Malley PM, Darrow WW, Hadler SC, et al
. Sexual behavior before AIDS: The hepatitis B studies of homosexual and bisexual men. AIDS 1990;4:1067-73.
Steiner S, Lemke AL, Roffman RA. Risk behavior for HIV transmission among gay men surveyed in Seattle bars. Public Health Rep 1994;109:563-6.
Handsfield HH, Schwebke J. Trends in sexually transmitted diseases in homosexually active men in King County, Washington, 1980-1990. Sex Transm Dis 1990;17:211-5.
Bibus D, Wood R, Hartfield K, Hanrahan M, Wood C. A model for distributing HIV-prevention resources. AIDS Public Policy J 1995;9:197-20.
Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. Am J Public Health 1996;86:642-54.
Glick SN, Morris M, Foxman B, Aral SO, Manhart LE, Holmes KK, et al
. A comparison of sexual behavior patterns among men who have sex with men and heterosexual men and women. J Acquir Immune Defic Syndr 2012;60:83-90.
Garg T, Chander R, Jain A, Barara M. Sexually transmitted diseases among men who have sex with men: A retrospective analysis from Suraksha clinic in a tertiary care hospital. Indian J Sex Transm Dis AIDS 2012;33:16-9.
Shinde S, Setia MS, Row-Kavi A, Anand V, Jerajani H. Male sex workers: Are we ignoring a risk group in Mumbai, India? Indian J Dermatol Venereol Leprol 2009;75:41-6.
] [Full text]
Brahmam GN, Kodavalla V, Rajkumar H, Rachakulla HK, Kallam S, Myakala SP, et al
. Sexual practices, HIV and sexually transmitted infections among self-identified men who have sex with men in four high HIV prevalence states of India. AIDS 2008;22 Suppl 5:S45-57.
Setia MS, Lindan C, Jerajani HR, Kumta S, Ekstrand M, Mathur M, et al
. Men who have sex with men and transgenders in Mumbai, India: An emerging risk group for STIs and HIV. Indian J Dermatol Venereol Leprol 2006;72:425-31.
] [Full text]
Berlan ED, Corliss HL, Field AE, Goodman E, Austin SB. Sexual orientation and bullying among adolescents in the growing up today study. J Adolesc Health 2010;46:366-71.
Saewyc EM, Bearinger LH, Heinz PA, Blum RW, Resnick MD. Gender differences in health and risk behaviors among bisexual and homosexual adolescents. J Adolesc Health 1998;23:181-8.
Kinsey AC, Pomeroy WR, Martin CE. Sexual behavior in the human male. 1948. Am J Public Health 2003;93:894-8.
Tang W, Mao J, Tang S, Liu C, Mollan K, Cao B, et al
. Disclosure of sexual orientation to health professionals in China: Results from an online cross-sectional study. J Int AIDS Soc 2017;20:21416.
Durso LE, Meyer IH. Patterns and predictors of disclosure of sexual orientation to healthcare providers among Lesbians, Gay Men, and Bisexuals. Sex Res Social Policy 2013;10:35-42.
Clover D. Overcoming barriers for older gay men in the use of heath services: A qualitative study of growing older, sexuality and health. Health Educ J 2006;65:41-52.
Tadele G, Amde WK. Health needs, health care seeking behaviour, and utilization of health services among lesbians, gays and bisexuals in Addis Ababa, Ethiopia. Int J Equity Health 2019;18:86.
[Table 1], [Table 2], [Table 3]