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https://doi.org/10.1177/1557988318784149
American Journal of Men’s Health
2018, Vol. 12(5) 1197 –1214
© The Author(s) 2018
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DOI: 10.1177/1557988318784149
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Special section-HIV/AIDS/STIs
Since HIV and AIDS was first described in men who have
sex with men (MSM) in Los Angeles in 1981 (Centers for
Disease Control and Prevention [CDC], 1981), high HIV
prevalence and incidence rates have continuously been
reported among MSM in most countries (Beyrer et al.,
2012). In low-and middle-income countries including
many in Africa, Asia, and Latin America, MSM have the
highest rates of HIV infection among all at-risk groups
(Beyrer et al., 2012). In several high-income countries, for
example, France, the Netherlands, the United Kingdom,
and the United States, HIV infections have been on the
increase among MSM since early 2000s although the
overall trends of HIV infections in these countries are in
decline (Beyrer et al., 2013). In the United States, MSM
account for 56% of the 1.1 million people living with HIV
784149JMHXXX10.1177/1557988318784149American Journal of Men’s HealthQiao et al.
research-article2018
1Department of Health Promotion, Education, and Behavior & South
Carolina SmartState Center for Healthcare Quality (CHQ), University
of South Carolina Arnold School of Public Health, Columbia, SC, USA
2School of Psychological and Cognitive Sciences and Beijing Key
Laboratory of Behavior and Mental Health, Peking University, Beijing,
China
Corresponding Author:
Guangyu Zhou, School of Psychological and Cognitive Sciences
and Beijing Key Laboratory of Behavior and Mental Health, Peking
University, 05 Yiheyuan Street, Beijing, 100871, China.
Email: gyzhou@pku.edu.cn
Disclosure of Same-Sex Behaviors to
Health-care Providers and Uptake of
HIV Testing for Men Who Have Sex
With Men: A Systematic Review
Shan Qiao1, Guangyu Zhou1,2 , and Xiaoming Li1
Abstract
To promote HIV-testing and offer optimal care for men who have sex with men (MSM), health-care providers (HCPs)
must first be aware of their patients’ sexual behaviors. Otherwise, HCPs may overlook MSM’s risks for HIV infection
and their special health-care needs. For MSM, reporting their same-sex behaviors to HCPs (disclosure to HCPs) may
promote their linkage to HIV prevention and treatment cascade and improve their health outcomes. No literature review
has been conducted to examine the relationship between disclosure to HCPs and uptake of HIV-testing among MSM. The
current study reviewed and synthesized findings from 29 empirical studies published in English by 2016. We summarized
the rates of MSM’s disclosure to HCPs, investigated the association between disclosure and HIV-testing among MSM,
identified potential facilitators and barriers for disclosure, and discussed the implications of our findings in research and
clinical practices. The disclosure rates varied across subgroups and study settings, ranging from 16% to 90% with a median
of 61%. Disclosure to HCPs was positively associated with uptake of HIV-testing. African American MSM were less likely
to disclose to HCPs. MSM who lived in urban settings with higher education attainment and higher income were more
likely to disclose. MSM tended to perceive younger or gay-friendly doctors as safer targets of disclosure. Clinics with
LGBT-friendly signs were viewed as safer contexts for disclosure. Having previous communications about substance use,
sex, and HIV with HCPs could also facilitate disclosure. The main reasons for nondisclosure included lack of probing
from HCPs, concerns on confidentiality breach and stigma, and perceived irrelevance with services. Providing appropriate
trainings for HCPs and creating gay-friendly clinical settings can be effective strategies to facilitate disclosures of same-sex
behaviors among MSM and meet their specific medical needs. Interventions to promote disclosure should give priorities
to MSM from the most marginalized subgroups (e.g., MSM in rural areas, MSM of ethnic minorities).
Keywords
MSM, disclosure of same-sex behavior, disclosure to HCPs, HIV-testing, literature review
Received January 28, 2018; revised May 22, 2018; accepted May 28, 2018
1198 American Journal of Men’s Health 12(5)
and more than two-thirds of all new infections in 2014
(CDC, 2017). The disproportionate burden of HIV infec-
tions in MSM, demands more vigorous responses to con-
trol and reduce viral transmission in MSM communities.
Awareness of HIV infection could result in reducing
risk behaviors and thus decrease the likelihood of HIV
transmission to others (Hall, Holtgrave, & Maulsby,
2012; Marks, Crepaz, & Janssen, 2006). HIV testing, at
least annually recommended by the CDC for sexually
active MSM, is also the first step to link HIV-infected
MSM into HIV treatment cascade and other medical ser-
vices (Cooley et al., 2014). Although home-based rapid
HIV testing kits have been approved for self-testing since
2012, health-care providers (HCPs) still play a critical
role for MSM’s uptake of HIV-testing and counseling ser-
vice (Lorenc et al., 2011). A recent national HIV-testing
behavioral surveillance among MSM in 20 U.S. cities
suggested that 53% of MSM who had been screened for
HIV within past 12 months reported their most recent test
was performed in a clinical setting (CDC, 2016).
To ensure optimal care and provide necessary sexually
transmitted infections (STI) screening and HIV diagnosis
for MSM, HCPs must first be aware of their patients’
same-sex behaviors. Otherwise, HCPs may overlook
MSM’s special health-care needs and fail to recommend
appropriate preventive strategy. For example, pre-expo-
sure prophylaxis (PrEP) as an effective way to prevent
HIV infection is still in low uptake among MSM
(McCormack et al., 2016). HCPs’ awareness of their
patients’ sexual orientation or same-sex behavior is criti-
cal for evaluating PrEP as a biomedical approach for HIV
prevention. Studies have reported that HCPs, who are
aware of a patient’s same-sex behavior, are more likely to
make recommendations for routine HIV and STI testing
and hepatitis A or B vaccination (Ng et al., 2014). For
MSM, disclosure to HCPs about their same-sex behav-
iors or homosexual orientation could be an entry point for
their linkage to HIV prevention and treatment cascade.
Disclosure to HCPs is a challenge for MSM given the
stigmatized and even illegal nature of same-sex behaviors
in many settings. Previous studies reported various rates
of disclosing to HCPs among MSM with a range from
49% to 70% in the United States (Petroll & Mosack,
2011), 16% in China (Tang et al., 2017), and probably
lower in Africa. The rates of disclosures to HCPs vary by
sociodemographic characteristics of MSM. Empirical
studies suggest that race/ethnicity, age, income and edu-
cation level may be associated with disclosing to HCPs
among MSM (Magnus et al., 2010; Ng et al., 2014;
Petroll & Mitchell, 2015; Wall, Khosropour, & Sullivan,
2010). Disclosure to HCPs may be affected by MSM’s
sexual identity. One study, conducted in New York City
with 396 self-identified LGB, reported bisexually identi-
fied individuals less likely than gay-identified individuals
to disclose their sexual orientation to a HCP (Durso &
Meyer, 2013). MSM’s disclosures to HCPs may also be
affected by perceived societal norms and attitudes of
HCPs toward gay men. The concerns of confidentiality
breach, the worries about denial of medical services, and
the fears of stigma from HCPs or from broader sociocul-
tural context impede the openness between MSM and
their physicians (Adams, McCreanor, & Braun, 2008;
Fay et al., 2011; Malebranche, Peterson, Fullilove, &
Stackhouse, 2004).
Existing literature on disclosure issues in MSM have
explored disclosure of HIV serostatus to sexual partners
and its impacts on reduction of risk behaviors. Some
studies focused on disclosure of same-sex behaviors to
parents and other family members, and whether these dis-
closures affect their psychological well-being (Lin et al.,
2016; Qiao, Li, & Stanton, 2014). Some research exam-
ined the association between nondisclosure of sexual ori-
entation and high risk sexual behaviors (CDC, 2003;
Zhao et al., 2016). Although increasing studies investi-
gate MSM’s disclosure to HCPs, no literature review has
been conducted to synthesize the findings regarding the
relationship between disclosure of same-sex behaviors in
clinical settings and uptake of HIV-testing among MSM.
The current systematic review of global literature aims
to: (a) describe the rates of disclosure to HCPs; (b) report
published associations between disclosure and utilization
of HIV-testing service and other medical services; and (c)
identify the factors affecting the decision-making and
practices regarding disclosure to HCPs.
Method
Data Source and Searching Algorithm
An extensive search of four databases including PubMed,
Web of Science, CINAHL, and PsycINFO was conducted
for peer-reviewed journal articles published by November
2016. Searching terms included MSM, same-sex behaviors,
and same-sex disclosure to a health-care professional or in
health-care settings. The search algorithm was the combi-
nation of the following terms (a) MSM OR homosex* OR
sexual minority OR gay (b) disclos* OR out* OR aware*
(c) same-sex OR male–male sex OR sexual orientation (d)
health-care provider OR primary care provider OR general
practitioner OR physicians OR clinician OR doctors.
Moreover, related papers from references of included stud-
ies were also hand-searched and experts in the field of HIV
disclosure were consulted with for additional references.
Definitions and Inclusion Criteria
The commonly accepted term ‘men who have sex with
men’ (MSM) was used in this review, which included
Qiao et al. 1199
men self-identified as gay or bisexual and men who had
experience of same-sex behavior. Although same-sex
behavior and homosexuality were often used interchange-
ably in the literature, empirical studies have revealed dis-
cordance between self-reported sexual identity and sexual
behaviors (Savin-Williams, 2006). For example, some
men engage in same-sex behaviors, but they do not nec-
essarily identify themselves as gay (Dharma & Bauer,
2017). The same-sex behavior of the MSM population
was the main interest in this review to cover both homo-
sexual and nonhomosexual orientations mainly because
of its broader behavioral implication in the context of
HIV infection and transmission.
Accordingly, “disclosure to HCPs” was defined as the
MSM patients’ disclosing to their HCPs either same-sex
behavior or homosexual orientation in clinical settings.
The review mainly focused on disclosure of same-sex
behaviors that can help HCPs capture actual sexual behav-
ior to better estimate the scope of HIV risk of the patients.
Studies using terms of disclosing homosexual orientation
were also included because disclosing homosexual orien-
tation is more inclusive term including the domain of dis-
closing same-sex behavior. In addition, “health-care
provider” was referred to trained health-care professionals
including primary care providers, clinicians, and other
medical personnel who assumed the responsibilities to
take care of patients for their physical health.
Inclusion criteria for reviewed papers included: (a)
being published in peer-reviewed journals in English
between 1981 and 2016; (b) being empirical studies
(qualitative, quantitative or mixed studies) among HIV
negative MSM participants aged 15 years or above; and
(c) including measures on disclosure of same-sex behav-
iors to health-care providers. Studies on LGBT popula-
tions without segregating MSM as subgroup were not
included in the final review. The studies among HIV
negative MSM were only chosen because our main inter-
est was to examine the same-sex behavior disclosure and
HIV testing which might not be a meaningful issue among
HIV positive MSM.
Screening and Data Extraction
Initially, 355 articles were retrieved through searching
the four electronic databases. After removing 213 dupli-
cated records, 142 articles were screened based on their
titles and abstracts. Then 82 articles were further excluded
by title screening and 44 articles by abstract screening
which resulted in 16 articles for full-text screening. An
additional 17 articles were retrieved through manual
search and 7 articles were obtained through consultation
with experts in the field, which results in a total of 40
articles for full-text screening (Figure 1). Eleven full-text
articles were excluded due to not segregating MSM as
subgroup (n = 5), focusing on disclosure to psychiatrist (n
= 3), recruiting participants less than 15 years of age (n =
2), and targeting MSM living with HIV (n = 1). Finally,
29 studies were included in the final reviews.
Figure 1. PRISMA search flowchart for the reviewed studies.
1200 American Journal of Men’s Health 12(5)
Data were extracted and coded using structured tables
to incorporate the study characteristics, sample character-
istics, and disclosure characteristics. The study character-
istics included authorship, study site, years of data
collection, and study design. The sample characteristics
included sample size, age, ethnicity, residence, and inclu-
sion criteria. The disclosure characteristics summarized
information on type of health-care providers, measures of
disclosure, the rate of disclosure, association between
disclosure and HIV-testing and other health outcomes,
and the factors influencing disclosure. The structured
tables and coding instructions were pilot tested with a few
articles before the formal data extraction.
Two researchers conducted data extraction using pro-
tocol suggested by Higgins and Green (2011). They
worked independently to extract data from each article.
Kappa scores were calculated to assess inter-rater vari-
ability. Values of Kappa above 0.75 reflect excellent
agreement (Orwin, Cooper, & Hedges, 1994). The Kappa
score was 0.92 for quantitative studies and .85 for qualita-
tive studies. The disagreements in the data extraction
were resolved by discussions between the two
researchers.
Assessment of Study Quality
The quality criteria proposed by Kmet et al. (2004) were
used to assess methodological quality of the reviewed
studies in terms of research design, measurement, data
collection and analysis, and finding reports. Ten criteria
were used for qualitative studies and 14 criteria were
used for quantitative studies. There are three responses
for each assessment criteria: yes (2 points), partial (1
point), and no (0 points). The final score for study qual-
ity was a percentage of the sum score of all the applied
criteria divided by possible maximum sum score with a
range from 0% (no criteria met) to 100% (all criteria
met) for each study. Quality assessment was conducted
independently by two researchers and all the disagree-
ment were discussed and resolved. The score of quality
ranged from 60% to 100 % for qualitative studies with a
mean of 79% and from 60% to 100% with mean of 90%
for quantitative studies (see Appendix 1).
Results
Study Characteristics
The basic characteristics and the main findings of the
reviewed studies were summarized in Table 1. Majority
of the studies were conducted in high-income countries,
including the United States (n = 18), Canada (n = 1),
Germany (n = 2), New Zealand (n = 3), and UK (n = 3).
Two studies were conducted in China (upper-middle
income country). No studies explored disclosure to HCPs
among MSM in African or Latin American countries.
In terms of study design, quantitative design accounted
for 79% (n = 23) of the total studies (n = 29). There were
five qualitative studies and one quantitative study with
open-ended questions in the survey. Internet technologies
were widely applied in participants’ recruitment and data
collection. Audio computer-assisted interviewing, online
sampling (via Facebook profiles), and online survey (via
websites or email list of MSM/LGBT organizations) have
been employed in some quantitative (n = 14) and qualita-
tive (n = 1) studies.
Sample Characteristics
Given the various inclusion and exclusion criteria for par-
ticipant recruitment in the reviewed studies, the MSM
participants in these studies were diverse in terms of age,
race/ethnicity, and residence. In most of the studies, they
were young and lived in or migrated into big cities.
Several of studies conducted in the United States focused
on ethnic minorities including African American
(Arrington-Sanders et al., 2016) and Hispanic/Latino
populations (Joseph et al., 2014; Oster et al., 2013).
Disclosure Characteristics
Target and measurement. In most of the studies, the target
of disclosure was generally referred as health-care pro-
viders. Some studies used the term “doctors” and “physi-
cians” (Koch et al., 2016; Petroll & Mosack, 2011), some
used the term “(regular) doctor, nurse, or healthcare pro-
viders” (Ramirez-Valles et al., 2014; Wall et al., 2010),
or “health-care professional” (Ng et al., 2014; Tang et al.,
2017; Wilkerson et al., 2010) or “medical provider”
(Arrington-Sanders et al., 2016). Some studies explicitly
focused on general practitioners (GPs) (Fitzpatrick et al.,
1994; Ludlam et al., 2015; Metcalfe et al., 2015) and pri-
mary health-care provider (Marcus et al., 2015; Petroll &
Mitchell, 2015). In a study on MSM’s disclosure of sex-
ual behaviors, Guo and colleagues asked the participants
to identify all the individuals who knew their same-sex
behaviors, including doctors (Guo et al., 2014).
It is notable that the measurements of disclosure to
HCPs were not consistent across the studies. Generally,
there were four types of questions used to investigate dis-
closure in clinical setting: (a) the questions asking MSM
whether or not they had discussed or told sexual orienta-
tion/sexuality with their HCPs (Arrington-Sanders et al.,
2016); (b) the questions asking MSM if they had told any
HCPs that they were attracted to or have sex with men or
have male sexual partners (Bernstein et al., 2008; Chapin-
Bardales et al., 2016; Joseph et al., 2014; Lo et al., 2012;
Magnus et al., 2010; Ng et al., 2014; Oster et al., 2013;
1201
Table 1. Characteristics of Reviewed Studies.
Author Country Year Research design & data collection Sample characteristics HCPs type Disclosure measure Proportion Association with HIV testing
Arrington-Sanders
et al. (2016)
United
States
2014–2015 Quantitative design;
Cross-sectional internet-based
survey, recruitment in adolescent
clinics, internet ads, venue-based
outreach
147 YBMSM (age: M = 21.3 years old,
SD = 2.1)
Criteria: Aged 15–24 years old, self-
identified Black male, prior anal sex
with a male, U.S. resident
Regular medical
provider
Have you disclosed your sexual
orientation to your medical
provider?
61.9% N/R
Bernstein et al.
(2008)
United
States
2004–2005 Quantitative design;
Cross-sectional survey by CDC staff
with handheld computers (NHBS
project)
452 MSM
Criteria: at least 1 male sex partner in
the past year
Health-care
provider
Have you told any health-
care providers that you are
attracted to or have sex with
other men?
61.3% HIV test in the past year: OR
= 0.98, 95% CI [0.65, 1.48]
Chapin-Bardales
et al. (2016)
United
States
2011 Quantitative design;
Cross-sectional survey with
handheld computer via CDC staff
(NHBS project)
353 MSM
Criteria: >18 years old, male, ever sex
with male past 12 months
Health-care
provider
Have you told your HCP that
you are attracted to or have
sex with men?
49% HIV test in past 12 months
was associated with
disclosure: aOR = 1.4, 95%
CI [1.1, 1.7]
Durso and Meyer
(2013)
United
States
2004–2005 Quantitative design;
Cross-sectional survey by CDC staff
with handheld computer (NHBS
project)
198 GBM (age: M = 32.44 years old, SD
= 8.88)
Health-care
provider
Participants were asked
to report the degree of
disclosure of their sexual
orientation to health-care
providers using a scale from
1 (“out to none”) to 4 (“out
to all”).
Out to health-
care providers
for gay men
(90%) and for
bisexual men
(61%)
N/R
Fitzapatrick et al.
(1994)
UK 1991–1992 Survey with some open-ended
questions
677 gay men including 623 registered
with GPs and 102 men (age: M = 32.6
years old, SD = 10.1)
Criterion: men who have had sexual
contact with men in the last 5 years
General
practitioner
Did your general practitioner
know that you are
homosexual?
Of these
registered GPs,
56% said that
their GPs knew
their sexuality
N/R
Guo, Li, Liu, Jiang,
and Tu (2014)
China 2009 Quantitative design;
Paper-based cross-sectional survey,
sampling via peer outreach,
informal social network, the
Internet, and venue-based
307 young migrant MSM (age: M = 23.73
years old, SD = 2.86)
Criteria: 18–30 years old; ever had sex
with men; migrant without a permanent
Beijing local residency
Doctor Participants were asked to
identify all the individuals who
knew about their same-sex
behavior, including to doctors.
24% Never had HIV test among
open to doctors (18%) vs.
no open to doctors (31%),
p < .05
Joseph et al.
(2014)
United
States
2007–2008 Quantitative design;
Cross-section survey, recruited
in multiple venues and though
referrals & advertisements
608 Hispanic/Latino MSM (age: M = 34.6
years old, SD = 9.45, range: 18–52)
Criteria: 18–49 years old, sex with
male partner in the past 3 months in
addition to multiple sex partner
Health-care
provider
Did you disclose your sex with
male to HCP?
61.1% Repeat/recent test: aOR =
1.97, 95% CI [1.30, 2.96];
Test avoiding (never
testing or last test more
than 5 years ago): aOR =
0.70 95% CI [0.46, 1.05]
Koch et al. (2016) Germany 2013–2014 Quantitative design;
Cross-sectional online survey
1429 MSM (median age: 40 years old,
range: 16–78)
Criteria: had no MenC vaccination
Physician openness regarding sexual
orientation toward their
physician
55.3% N/R
Lo, Turabelidze,
Lin, and
Friedberg
(2012)
United
States
2008 Quantitative design;
Cross-sectional survey by CDC
staff with handheld computer,
venue-based, time-space sampling
(NHBS project)
339 MSM (age: M = 35, range: 18–80)
Criteria: >18 years old; engaged in
male–male sex during the previous year
Health-care
provider
Have you ever disclosed same-
sex attractions or male–male
set to health-care providers?
73% HIV testing during previous
12 months: APR = 1.6, 95%
CI [1.2, 2.0]
Ludlam, Saxton,
Dickson, and
Hughes (2015)
New
Zealand
2014 Quantitative design;
Cross-sectional self-reported
survey from both community and
internet
3168 GBM
Criteria: >16 years old, male, have sex
with a men in past 5 years
Usual general
practitioner
(GP, doctor)
Does your usual general
practitioner (GP, doctor)
know you are gay or bisexual
or have sex with men?
50.5% Ever had an HIV test: aOR
= 6.6, 95% CI [5.2, 8.3];
Recent HIV testing: aOR =
3.3, 95% CI [2.7, 3.9]
(continued)
1202
Author Country Year Research design & data collection Sample characteristics HCPs type Disclosure measure Proportion Association with HIV testing
Magnus et al.
(2010)
United
States
2008 Quantitative design;
Cross-sectional survey by CDC staff
with handheld computers (NHBS
project)
500 MSM
Criteria: self-identify as male, having had
sex with another man in the last year,
>18 years old, living in Washington
DC, speaking English or Spanish
Health-care
provider
Have you told any health-
care providers that you are
attracted to or have sex with
other men?
80% N/R
Marcus,
Gassowski,
Kruspe, and
Drewes (2015)
Germany 2013–2014 Quantitative design;
Online-survey cross-sectional by
personalized invitation messages
from MSM social networking and
dating websites
15297 MSM
Criteria: >16 years old
Primary health-
care provider
Outness toward primary health-
care provider about sexual
orientation?
(Responses: less than half know,
half or more know, not
applicable)
40.0% Recently test vs. distantly test
aOR = 1.79, 95% CI [1.60,
2.00]; Recently tested vs.
never test aOR = 4.54,
95% CI [4.02, 5.11]
Metcalfe, Laird,
and Nandwani
(2015)
UK 2011–2012 Quantitative design;
Cross-sectional survey in electronic
and paper formats
204 MSM
Criteria: >16 years old
General
practitioner
Whether your GP was aware of
your sexual orientation?
40% N/R
Metheny and
Stephenson
(2016)
United
States
N/R Quantitative design;
Cross-sectional internet-based
survey via Facebook
319 rural MSM (age: M = 30 years old,
SD = 11.74)
Clinician 7-point Liker-type, “My primary
care provider definitely does
not know that I am a gay” to
“definitely know that I am gay
and we talk about it openly”
Mean 5.7, 95% CI
[4.7, 5.7], range
from 1 to 7.
Recoded into
81.4%
“HIV test in past 12 months
and received a single
HAV and HBV vaccines”
coded as 1. Disclosure was
associated with HIV test
and HAV/HBV vaccination:
aOR = 1.26, 95% CI [1.08,
1.47]
Ng et al. (2014) Canada 2008–2009 Quantitative design;
Cross-sectional self-reported
survey, venue-based time-space
sampling recruitment method
925 MSM (median age: 30 years old for
no disclosure group and 32 years old
for disclosure group)
Criteria: Identifying as men aged >19
years old, reported ever having sex
with other men
Health-care
professional
Have you told a health-care
professional you have male sex
partners?
23% Ever been tested for HIV:
disclosed group 91%
(646/714) vs. not disclosed
group 58% (122/209), p
< .001;
Have been tested for HIV
in previous year: 76%
(526/694) vs. 42%, p < .001
(83/198)
Oster et al.
(2013)
United
States
2008 Quantitative design;
Cross-sectional survey via Interview
by CDC staff with handheld
computer (NHBS project)
1734 Latino MSM (median age: 31 years
old) Criteria: being male, >18 years
old, U.S. resident, speaking English or
Spanish, at least one sex partner during
last year, had a negative or confirmed
positive HIV test result, identified as
Hispanic or Latino
Health-care
provider
Have you ever told a health-
care provider that you are
attracted to or have sex with
men?
66% HIV test in past 12 months:
aPR = 1.3, 95% CI [1.2, 1.3]
Petroll and
Mitchell (2015)
United
States
2011 Quantitative design;
Cross-sectional survey via online
sampling by Facebook profile
722 GBM representing both men of 361
male couples (age: M = 33.01 years old,
SD=10.79, range: 18–68)
Criteria: male, >18 years old, living in
United States, had a relationship status
being “in a relationship, engaged, or
married,” had oral and/or anal sex
previous 3 months
Primary care
provider
Does your primary care doctor
know that you have sex with
men?
65.2% N/R
Table 1. (continued)
(continued)
1203
Author Country Year Research design & data collection Sample characteristics HCPs type Disclosure measure Proportion Association with HIV testing
Petroll and
Mosack (2011)
United
States
2007 Quantitative design;
Self-administered, written cross-
sectional survey
271 MSM invited at a Gay Pride festival
(age: M = 35 years old, range: 18–74)
Criteria: Reported having seen as PCP
within the prior 5 years
primary
physician,
nurse
practitioner,
or physician
assistant
Do you believe your doctor
knows your sexual
orientation?
71.4% 59% for HIV testing among
disclosure group vs. 13%
among not disclosure
group
Ramirez-Valles,
Dirkes, and
Barrett (2014)
United
States
2006 Quantitative design;
Internet-based cross-sectional
survey, sample recruited through
various means, including social
and health services agencies,
snowballing, electronic lists
182 self-identified as gay or bisexual (age:
M = 66 years old, SD = 5.39, range:
56–82)
Regular doctor,
nurse or
health-care
provider
Do you think your regular
doctor, nurse or health-care
provider knows your sexual
orientation/gender identity?
71% N/R
Tang et al. (2017) China 2014 Quantitative design;
Cross-sectional online survey
via banner in three gay dating
websites
1424 MSM Criteria: >16 years old, born
male, ever having sex with a man
Health
professional
Have ever disclosed sexual
orientation to health-care
professionals?
16% The odds of disclosure were
greater among MSM who
had ever tested HIV aOR =
3.36, 95% CI [2.50, 4.51]
Wall et al. (2010) United
States
2009 Quantitative design;
Online cross-sectional survey
4620 MSM
Eligibility: >18 years old, U.S. resident, at
least one male sex partner in the last
year visited a doctor, nurse, or other
HCPs in the prior 12 months
Doctor, nurse,
or health-care
provider
When you visited a doctor,
nurse, or health-care provider
in the past 12 months, did you
tell the HCP that you have sex
with men?
44.5 % Being offered with HIV
testing: OR = 19.22, 95%
CI [15.79, 23.41] for Age
20 group; OR = 14.45, 95%
CI [11.46, 18.21] for Age
30; OR = 10.86, 95% CI
[7.06, 16.70] for Age 40;
OR = 8.16, 95% CI [4.22,
15.77] for Age 50
Whitehead,
Shaver, and
Stephenson
(2016)
United
States
2014 Quantitative design;
Cross-sectional online survey via
banner ads on Facebook
477 cisgender men (age: M = 32.62 years
old, SD = 13.42)
Criteria: >18 years old, rural home zip
code, self-identified LGBT,
Primary health-
care provider
Outness to PCP (range 1–7) 4.52 (SD = 2.33).
Recoded into
64.6%
Association between outness
to PCP and health-care
utilization: Regression
coefficient = 0.119 (SD =
0.026, p < .001)
Wilkerson,
Smolenski,
Horvath,
Danilenko, and
Rosser (2010)
United
States
2005 Quantitative design;
Online cross-sectional survey
2577 MSM
Criteria: male, >18 years old, U.S.
resident, have sex with men at least
once during their lifetime
Doctor or health
professional
Talked with a doctor or health
professional about having sex
with men.
62.1% N/R
Author Country
Conducted
time Design & data collection Sample characteristics Main findings
Adams et al.
(2008)
New
Zealand
N/R Qualitative design via focus groups 50 self-identified gay men Disclosure was more likely to happen if gay men thought it was relevant to the issue they are seeing
the doctor about.
Because of potentially physically and emotionally risky, some gay men may hide or not reveal their
sexuality to doctors.
Adams,
McCreanor, and
Braun (2013)
New
Zealand
N/R Qualitative design with focus groups 45 gay men, age ranged from 24 to 64
years old
Perceptions of importance or necessary may influence gay men’s disclosure decision. Some
nondisclosure participants did not think disclosure as an important or significant issue. A minority
of participants viewed disclosure of gay identity to doctor as needed.
Table 1. (continued)
(continued)
1204
Table 1. (continued)
Author Country
Conducted
time Design & data collection Sample characteristics Main findings
Clover (2006) UK 2002–2003 Qualitative design, based on
semistructured interview with
purposive sampling
10 gay men aged between 60 and 70
years old
Criteria: >60 years old, living in London
Fears of a lack of understanding, discrimination, or poorer treatment led some men to choose not to
disclose their sexuality to health-care providers. This choice was not related to being open about
sexuality more generally; some men who were usually very open being reluctant to talk openly to
health workers.
Fitzapatrick et al.
(1994)
UK 1991–1992 Mixed methods;
Survey with some opened questions
677 gay men including 623 registered
with GPs and 102 men (age: M = 32.6
years old, SD = 10.1, range: 16–71)
Criterion: men who have had sexual
contact with men in the last 5 years
Men who viewed their GPs’ practice as unsympathetic toward homosexual men were less likely to
have informed their general practitioner of their sexual orientation.
Malebranche et al.
(2004)
United
States
2000–2001 Qualitative design with focus group 86 BMSM
Criterion: being African American, >18
years old, English speaking, MSM
Racial and sexual stigma toward BMSM impacts how open BMSM are with health providers about
their sexuality.
Martinez and
Hosek (2005)
United
States
2002–2003 Qualitative design semistructured
interview with purposive sampling
6 young BMSM (age: M = 21.5 years old)
Criterion: African American who engage
in sex with other men but not identify
as gay
Trusting relationship with health provider could facilitate communication on same-sexual behavior.
Underhill et al.
(2015)
United
States
2013–2014 Qualitative design with one-on-one
interview
56 MSM (31 MSWs: median age = 27
years old, 25 MSM: median age = 39
years old)
Criteria: English-speaking cisgender
adult men of self-reported negative
or unknown HIV status, reported
condomless anal sex with a man in the
past 6 months
MSM who did not report sex work described sex with men to clinicians more often. Medical barriers
and perceived discrimination impede sexual behavior disclosure to clinicians.
Note. HCP = health-care provider; N/R = not reported; M = mean, SD = standard deviation; YBMSM = young black men who have sex with men; HIV+ = HIV seropositive; HIV- = HIV seronegative; NHBS = National HIV
Behavioral Surveillance System; GBM = gay and bisexual men; GP = general practitioner; PCP = primary care provider; HAV = hepatitis A virus; HBV = hepatitis B virus; MSW = men who engage in sex work; OR = odds ratios;
aOR = adjusted odds ratios; aPR = adjusted proportion ratios.
Qiao et al. 1205
Petroll & Mitchell, 2015; Wall et al., 2010); (c) the ques-
tions asking MSM to estimate whether their doctor knew
their sexual orientation (Ludlam et al., 2015; Metcalfe
et al., 2015; Petroll & Mosack, 2011; Ramirez-Valles
et al., 2014)); and (d) the questions asking MSM to assess
the openness toward HCPs about sexual orientation
(Koch et al., 2016; Marcus et al., 2015; Whitehead et al.,
2016). The first three types of measurements typically
yielded dichotomous or categorical variables while the
fourth type of measurement produced continuous
variables.
Disclosure/awareness rate. Depending on the types of dis-
closure measurement, some studies reported the propor-
tion of MSM who had disclosed their same-sex behaviors
to their HCPs, while some examined the proportion of
HCPs who had known their patients’ same-sex behaviors.
Of the 15 studies that described MSM’s disclosure to
HCPs, the disclosure rates ranged from 16% in 1,424
MSM in China (Tang et al., 2017) to 90% in 198 gay men
in New York City (Durso & Meyer, 2013), with a median
of 61% (Joseph et al., 2014). Eight studies investigated
HCPs’ awareness of their patients’ same-sex behaviors.
The awareness rates ranged from 24% in 307 MSM in
Beijing China (Guo et al., 2014) to 81% in 319 rural
MSM in the United States (Metheny & Stephenson,
2016), with a median of 51% (Ludlam et al., 2015).
Disclosure rates among MSM and awareness rates
among HCPs were relatively high in the United States,
followed by other high-income countries including
Germany (Koch et al., 2016; Marcus et al., 2015), New
Zealand (Ludlam et al., 2015), the UK (Metcalfe et al.,
2015), and Canada (Ng et al., 2014). The studies con-
ducted in China reported two lowest disclosure rates
(Guo et al., 2014; Tang et al., 2017). Of the studies con-
ducted in the United States, two studies in Hispanic/
Latino MSM reported a disclosure rate of 66% (Oster
et al., 2013) and 61% (Joseph et al., 2014), respectively;
and one study in young black MSM reported a disclosure
rate of 62% (Arrington-Sanders et al., 2016).
Associations Between Disclosure and HIV
Testing and Other Health Outcomes
Uptake of HIV testing is one of positive consequences of
disclosure to HCPs. The majority of the quantitative stud-
ies examined the relationship between disclosure and
various aspects of HIV testing among MSM. Disclosure
to HCPs was linked to HCPs’ recommendations of HIV
testing (Bernstein et al., 2008; Petroll & Mosack, 2011;
Wall et al., 2010). Disclosing same-sex behaviors to
HCPs was also associated with MSM’s ever having HIV
testing (Bernstein et al., 2008; Guo et al., 2014; Ludlam
et al., 2015; Ng et al., 2014) and with recent (e.g., in the
past 1 or 2 years) and repeated testing (Chapin-Bardales
et al., 2016; Joseph et al., 2014; Lo et al., 2012; Marcus
et al., 2015; Ng et al., 2014; Oster et al., 2013). However,
one study reported no significant association between
disclosure of same-sex behaviors to HCPs and uptake of
HIV testing among MSM in New York City (Bernstein
et al., 2008).
In addition to HIV testing, disclosure to HCPs might
also be associated with further discussions of HIV risks
between MSM and their doctors as well as uptake of STI
testing and Hepatitis vaccinations. HCPs who were aware
of their patients’ same-sex behaviors were more likely to
ask about the types of sexual behaviors that their patients
had with male and female partners, about their risks for
STI or HIV, and about sexual functioning (Petroll &
Mosack, 2011). MSM who had disclosed their same-sex
behavior to HCPs were more likely to have taken specific
sexual health checks and appropriate STI tests (Ludlam
et al., 2015; Ng et al., 2014). Disclosure to HCPs was also
related to receiving hepatitis A and/or B vaccinations
(Metheny & Stephenson, 2016; Petroll & Mosack, 2011).
Disclosure to HCPs was also related to health service
utilization and general well-being among MSM.
Whitehead and colleagues examined the association
between disclosure and primary care utilization among
the rural LGBT population in the United States
(Whitehead et al., 2016). A “health score” was used to
represent the percentage of health tasks (age-and anat-
omy-appropriate vaccinations and health screenings)
each participant had obtained within a recommended
time-period. The study indicated that openness to HCPs
about sexual behaviors was significantly associated with
higher health scores (Whitehead et al., 2016). Disclosure
to HCPs might also contribute to better psychosocial
well-being for MSM. For example, Ramirez-Valles and
Dirkes reported that MSM who had disclosed to HCPs
reported higher perceived health status and lower depres-
sion than their counterparts who had not disclosed
(Ramirez-Valles et al., 2014).
Factors Influencing Disclosure
In Table 2, we presented main factors that might influ-
ence disclosure to HCPs. These factors identified by the
reviewed studies were categorized into seven domains:
demographic characteristics, socioeconomic characteris-
tics, sexual identity, partner pattern and relationship, indi-
vidual perceptions, HIV-related risk, and health-care
facility characteristics.
Demographic characteristics. Most of studies have exam-
ined how the demographic factors may contribute to
complicated practices of disclosure to HCPs. Race and
ethnicities are key demographic factors investigated in
1206
Table 2. Factors Influencing Disclosure of Same-Sex Behaviors to HCPs.
Demographic
characteristics
Socioeconomic
characteristics
Sexual
identity
Partner
pattern &
relations MSM’s perceptions Health facility characteristics
Race
/ethnics
Birth
place Age Urban Income Edu – –
General
openness
Perceived
relevancy
Perceived
risks
Gay/gay
friendly
doctors
Trusting
relations
with HCPs
Interactions
with doctors
Adams etal. (2008) Y
Adams etal. (2013) Y
Bernstein etal. (2008) Y Y N Y N Y N
Clover (2006) Y Y
Durso and Meyer (2013) N N Y N Y N Y
Fitzapatrick etal. (1994) Y Y
Guo etal. (2014) N Y N Y N Y
Joseph etal. (2014)
Lo etal. (2012) Y
Ludlam etal. (2015) Y N Y Y
Magnus etal. (2010) Y
Malebranche etal. (2004) Y
Martinez and Hoesek (2005) Y
Metcalfe etal. (2015) Y Y Y Y
Ng etal. (2014) Y Y Y Y Y N
Oster etal. (2013) Y
Petroll and Mitchell (2015) N Y Y Y Y N
Petroll and Mosack (2011) Y Y N N Y
Tang etal. (2017) Y Y
Wall etal. (2010) Y Y Y
Note. Y = investigated by researchers and found to be relevant to disclosure. N = investigated by researchers and found to be nonsignificant. HCPs = health-care providers; MSM = men who have sex
with men.
Qiao et al. 1207
studies among MSM in the United States. MSM of color
were less likely to disclose their same-sex behaviors to
HCPs (Bernstein et al., 2008). Some studies indicated
that Black men were less likely to inform HCPs that they
engaged in same-sex behaviors (Magnus et al., 2010),
compared with White, Latino or Asian men (Petroll &
Mosack, 2011). Wall and colleagues reported that His-
panics were more likely than white non-Hispanics to dis-
close same-sex behaviors to their HCPs; and black race
was not associated with disclosure of same-sex behaviors
to HCPs (Wall et al., 2010). Two recent studies suggested
that race was not related to disclosure (Durso & Meyer,
2013; Petroll & Mitchell, 2015). Several studies investi-
gated the link between place of birth and disclosure. One
of the studies indicated that MSM born in the United
States were 1.9 times more likely to disclose to HCPs
(Bernstein et al., 2008). Oster and colleagues discovered
that MSM born in Central America were less likely to
report ever disclosing same-sex behavior to their HCPs
(Oster et al., 2013). However, Durso and Meyer (2013)
reported that being born outside of the United States was
not a significant predictor for disclosure to HCPs about
same-sex behaviors.
Age is another critical demographic factor that may be
related to disclosure to HCPs. However, the findings are
mixed in our review. Some studies indicated that younger
MSM (i.e., <20 years of age) were more likely to disclose
their same-sex behaviors to HCPs (Wall et al., 2010).
Some studies suggested that older age (i.e., >34 years)
was associated with disclosing to HCPs or reporting their
HCPs awareness of their same-sex behavior (Durso &
Meyer, 2013; Ludlam et al., 2015; Ng et al., 2014; Petroll
& Mitchell, 2015). One study conducted in New York
City reported no association between age and disclosure
(Bernstein et al., 2008). Another study conducted among
migrant MSM in China, reported a lower mean age of the
participants who had disclosed to HCPs, but the associa-
tion did not reach significance in multivariate logistic
regression analysis (Guo et al., 2014).
Socioeconomic characteristics. Higher socioeconomic sta-
tus was associated with a higher disclosure rate. MSM
living in the urban settings, or being originally from
urban areas were more likely to tell their HCPs about
their sexual orientation or same-sex behaviors (Guo et al.,
2014; Petroll & Mosack, 2011; Petroll & Mitchell, 2015).
Higher income was a strong predictor for disclosure of
same-sex behavior to HCPs (Bernstein et al., 2008; Ng
et al., 2014; Petroll & Mosack, 2011; Petroll & Mitchell,
2015). The findings on the role of education level in dis-
closure were mixed. Several studies suggested that higher
education attainment was a facilitator for disclosure to
HCPs (Ng et al., 2014; Petroll & Mitchell, 2015), while
some studies reported no significant association between
education and disclosure (Bernstein et al., 2008; Durso &
Meyer, 2013; Guo et al., 2014; Ludlam et al., 2015;
Petroll & Mosack, 2011).
Sexual identity. Existing literature has explored how sex-
ual identity might influence disclosure of same-sex
behaviors to HCPs among MSM. A study among MSM in
Canada suggested that participants with self-reported
sexual identity as bisexual, queer, two-spirit, or straight
were less likely to tell their same-sex behaviors to HCPs
compared to the ones self-identified as gay (Ng et al.,
2014). One study among MSM in New Zealand indicated
that bisexually identified MSM were less likely than their
gay counterparts to make HCPs aware of their same-sex
behavior (Ludlam et al., 2015). However, a study con-
ducted in New York City suggested that sexual identity
was not a significant predictor for disclosure. Petroll and
Mitchell (2015) also reported that there was no signifi-
cant difference between gay or bisexual men in terms of
disclosure to HCPs.
Partner pattern and relationship. Researchers have
investigated if partner pattern and relationship status
might be associated with disclosure. MSM who had
female partners in the past year were less likely to dis-
close their same-sex behavior to HCPs (Bernstein et al.,
2008). A study conducted among MSM in China sug-
gested that living with a male partner was associated
with disclosure to HCPs (Guo et al., 2014). It was
reported that having male sexual partners currently, or
in the past 6 months, was associated with disclosure to
HCPs (Ng et al., 2014; Tang et al., 2017). However,
several studies suggested there was no significant asso-
ciation between disclosure and being in a stable rela-
tionship with a male partner (Durso & Meyer, 2013;
Petroll & Mosack, 2011).
Individual perceptions. The decision to disclose to HCPs
might be affected by MSM’s individual perceptions and
judgment of the benefits of the disclosure to HCPs (Durso
& Meyer, 2013; Stein & Bonuck, 2001). The factors may
include their openness about their sexual behaviors, per-
ceived stigma and discrimination, and perceived rele-
vancy between disclosure and service-seeking. Durso and
Meyers (2013) explored the relationship between disclo-
sure to friends and disclosure to HCPs, discovering that
time since coming out to an LGB friend was positively
associated with disclosure to HCPs. However, a qualita-
tive study conducted in the UK suggested that openness
about same-sex behaviors might be selective (Clover,
2006). Some men who were usually very open could be
reluctant to talk openly to their HCPs and chose not to
disclose to HCPs due to fears of discrimination or poorer
treatment (Clover, 2006). Disclosing to family or friends
1208 American Journal of Men’s Health 12(5)
about same-sex behavior was not correlated with disclo-
sure to HCPs (Guo et al., 2014).
Stigma and discrimination could be one of the main
reasons for nondisclosure to HCPs. Internalized
homophobia was a prominent reason of nondisclosure
(Durso & Meyer, 2013). Intersecting stigma, multiple
layered stigma that MSM simultaneously experience
because of same-sex behavior and other aspects of their
identities or behaviors, such as their race/ethnicity, drug
use, and experience of commercial sex, impedes their dis-
closure of same-sex behavior to HCPs (Underhill et al.,
2015). Racial and sexual discrimination toward Black
MSM hindered them from disclosing to HCPs
(Malebranche et al., 2004). In-depth interviews among
MSM including male sex workers in a U.S.-based quali-
tative study suggested that male sex workers were less
likely to discuss their same-sex behavior to clinicians
(Underhill et al., 2015).
Another key reason for nondisclosure to HCPs among
MSM is their perceived low relevancy between disclo-
sure to HCPs and the health service they seek. Several
qualitative studies reported that MSM did not tell their
same-sex behaviors to doctors because they believed it
was not important or relevant to their health care (Adams
et al., 2008; Metcalfe et al., 2015). The final decision to
disclose depended on the type of health issue the person
was seeking treatment for (Adams et al., 2008; Lo et al.,
2012). A quantitative study conducted in the UK sug-
gested that the participants who felt that it was important
for the doctor to know about their same-sex behaviors in
clinical visits were more likely to make their HCPs aware
than those who did not feel it was important (Fitzpatrick
et al., 1994).
HIV-related risk. The perceived risks of HIV infections
and other STIs may also affect the decision-making
regarding disclosure to HCPs. For example, the MSM
who suspected their partners having STIs and had a his-
tory of STIs themselves were more likely to tell their
same-sex behaviors to HCPs (Guo et al., 2014). However,
one study reported that self-assessed likelihood of acquir-
ing HIV over one’s lifetime was not significantly associ-
ated with disclosure to HCPs (Ng et al., 2014).
A number of studies investigated high-risk sexual
behaviors among MSM as proxy measures of perceived
risks of HIV infection. There is a lack of consistent find-
ings regarding the relationship between disclosure and
high-risk sexual behaviors. MSM who had disclosed to
HCPs were more likely to report condomless anal inter-
course in past 6 months (Ng et al., 2014). MSM were
more likely to report their same-sex behavior to their
practitioner if they had more than one recent male sexual
partner (Ludlam et al., 2015). Participating in group sex
in the past 12 months and using recreational drugs in the
past month were significantly related to disclosure to
HCPs (Tang et al., 2017). MSM who had been engaged in
sex trade or had experiences in seeking partners on the
Internet were more likely to tell their same-sex behaviors
to HCPs (Guo et al., 2014). However, some studies
reported that disclosure was not significantly associated
with unprotected anal intercourse (Bernstein et al., 2008;
Tang et al., 2017).
The number of male sex partners might be related to
disclosure; but the results were mixed. Some studies indi-
cated that large numbers of male sex partners was associ-
ated with higher rate of disclosure to HCPs or HCPs’
awareness of same-sex behaviors (Ludlam et al., 2015;
Wall et al., 2010). Some studies reported no significant
association between disclosure and having a large num-
ber of male partners in the past year or the past week
(Bernstein et al., 2008; Guo et al., 2014).
Health-care facility characteristics. Disclosure to HCPs is
complicated and challenging for MSM. The majority of
such communications occurs in clinic settings and may
be affected by features of the health-care facilities, includ-
ing the characteristics of HCPs, relationships of MSM
and their HCPs, and the MSM’s past experiences with
health-care facilities.
Gay or gay-friendly doctors were perceived as safer
targets of disclosure. Petroll and Mosack (2011) reported
that MSM were more likely to disclose to gay and younger
HCPs. A qualitative study among HIV-positive MSM
suggested that male doctors were more likely than female
doctors to be informed about a patient’s same-sex behav-
iors. In addition, MSM who viewed their doctors as
unsympathetic toward MSM tended not to talk with their
doctors about same-sex behaviors (Underhill et al., 2015).
Clinics with LGBT signs and gender-neutral language
were viewed as a safer context for disclosure (Metcalfe
et al., 2015).
Trusting relationships with health-care providers
could facilitate communication on accurate information
about sexual behaviors (Martinez & Hosek, 2005). MSM
who believed that they did not need support from HCPs
might not discuss their same-sex behaviors with HCPs
(Metcalfe et al., 2015). One of basic reasons for nondis-
closure to HCPs was the concerns for confidentiality
breach. Many MSM were reluctant in disclosing to HCPs
because they did not want their same-sex behaviors being
documented in their medical records.
Past communication patterns with doctors and previous
experiences in health-care facilities might also affect dis-
closure practice. For example, some MSM attributed their
nondisclosure to the ways in which HCPs communicated
with them. MSM did not disclose because the HCPs never
asked about sexual orientation or same-sex behaviors
(Metcalfe et al., 2015). Likewise, some studies indicated
Qiao et al. 1209
that having previous communications about substance use,
sex, and HIV facilitated disclosure (Klitzman & Greenberg,
2002; Meckler, Elliott, Kanouse, Beals, & Schuster, 2006).
Previous negative experiences affected MSM expectations
for health-care services and further influenced their deci-
sion-making regarding disclosure. Experiences with soci-
etal and institutional racism influenced the openness of
Black MSM to speak with HCPs about their sexuality.
Black MSM did not openly talk about same-sex behaviors
to their doctors due to fear of additional discrimination
(Malebranche et al., 2004). Fear of discrimination or poor
treatment has led some MSM to choose not to disclose to
HCPs (Clover, 2006).
Discussion
Summary of Main Findings
This literature review synthesizes current findings regard-
ing MSM’s disclosure of same-sex behaviors or sex orien-
tation to health-care providers, examines the relationship
between disclosure to HCPs and HIV-testing, and elabo-
rates the potential factors affecting disclosure to HCPs in
clinic settings. In summary, the disclosure rates varied
across subgroups and study settings, ranging from 16% to
90%, with a median as 61%. Studies on disclosure of
same-sex behaviors to HCPs were limited in developing
countries. Generally, disclosure to HCPs was positively
associated with uptake of HIV-testing. Disclosed MSM
also reported more health-care utilization, better perceived
health status, and lower depression. MSMs in urban set-
tings, with higher education levels and higher income,
were more likely to disclose. Ethnic minority status was
related to nondisclosure. Younger or gay-friendly doctors
were perceived as safer targets of disclosure. Having previ-
ous communications about substance use, sex, and HIV
facilitated disclosure. Clinics with LGBT signs and gen-
der-neutral language were viewed as a safer context for
disclosure. The main reasons for nondisclosure included
HCPs never asking about same-sex behaviors and MSM
worrying about confidentiality or perceiving irrelevance
between disclosure and health-care seeking.
Our review suggests that MSM’s disclosure to HCPs is
a significant area in HIV prevention and treatment among
MSM. Empirical studies confirm a positive link between
sexual behavior/identity disclosure and engagement in
HIV prevention. Awareness of patients’ sexual behaviors
can help HCPs realize individuals’ needs for HIV preven-
tion and care and thus provide tailored sexual health care,
including routine screenings of HIV and STIs, hepatitis
vaccinations, and other biomedical prevention methods
(e.g., PrEP). Promoting disclosure to HCPs could be a
promising strategy to increase MSM’s linkage to HIV
prevention and care.
The current review also identifies multiple layers of
barriers for MSM’s disclosure to HCPs, ranging from
individual-level features (such as age, race, sexual iden-
tity, and perceptions of disclosure), characteristics of
health-care facilities, and structural-level factors (stigma
and discrimination, poverty, and low socioeconomic sta-
tus). Social ecological model could facilitate understand-
ing how these factors interplay together in impeding
MSM’s disclosure. Given the importance of health-care
facilities in the decision-making and process of MSM’s
disclosure, creating a gay-friendly context and providing
appropriate training for HCPs could be a promising strat-
egy to promote disclosure and increase MSM’s linkage to
HIV-related service.
Knowledge Gaps
Caution is needed in understanding and interpreting the
exploratory and mixed findings given the following limi-
tations of the existing empirical studies. First, there is a
lack of theoretical frameworks to guide existing studies.
Without a solid theoretical ground, the majority of empir-
ical studies on MSM’s disclosure in clinical settings yield
descriptive analysis or simple examinations of potential
associations rather than systematical hypothesis-testing
guided by a conceptual framework. The minority stress
proposed by Meyer (2003) might be a potential frame-
work that could be adapted for organizing and synthesiz-
ing empirical findings in the future.
Second, there is a prominent research gap between
high-income countries and low- and middle-income
countries, especially some sub-Saharan countries where
cultural context, social norms, as well as policies and leg-
islation have interwoven a net of stigma and discrimina-
tion against same-sex behaviors and/or MSM (Itaborahy,
2012; Risher et al., 2013; Wirtz et al., 2014; Wolf, Cheng,
Kapesa, & Castor, 2013). As MSM have been strongly
marginalized or criminalized in these societies, it is not
surprising that research and intervention efforts for this
group are also limited.
Third, existing literature might have methodological
issues in terms of study design, sampling and recruitment
strategies, and measurement. A dearth of longitudinal
studies limits the ability to investigate the causal relation-
ship between disclosure to HCPs and HIV-testing behav-
ior. Without longitudinal studies, it is also hard to explore
the dynamics of process in which potential factors affect
the decision-making and practices regarding disclosure to
HCPs.
It is notable that almost all the empirical studies in the
current review, including qualitative studies, examined
the disclosure issues only from the perspectives of MSM.
The dearth of data collected from health-care providers
prevents us from learning the perceptions and practices of
1210 American Journal of Men’s Health 12(5)
HCPs, thus we have fewer opportunities to obtain a more
comprehensive picture of disclosure issues in health-care
services. However, one study has identified that HCPs
asking about sexual identity and behavior could help
MSM disclosure their same-sex behavior (Fitzapatrick
et al., 1994). This study suggested the importance to com-
prehensively investigate the role of communication
between HCPs and their patients in clinical settings.
Another trend in sample recruitment is that increasing
number of studies have applied social media (e.g.,
Facebook, websites) as tools of recruiting MSM and col-
lecting quantitative data. The different approaches in
sampling and data collection may contribute to inconsis-
tency of results. However, the representativeness and the
validity of the data collected through this approach has
been assessed and compared with the ones collected
through other approach and venues, such as behavioral
surveillance survey or gay bars, which suggested consis-
tent findings by the two survey methods (Raymond et al.,
2010).
The mixed results could be attributed to the diversity
of measurement instruments for key variables used in the
existing studies. For example, so far there was no stan-
dardized measure to assess the disclosure of same-sex
behaviors to HCPs. Some examined disclosure of same-
sex behaviors, some focused on sexual orientation, some
asked about MSM’s disclosure behaviors, while others
asked MSM to report HCPs’ awareness of same-sex
behaviors. As for the measurement of HIV-testing, there
were also different measures with various recall periods.
The various measures largely impede us from comparing
and synthesizing results across studies.
Limitations of the Current Review
The review is subject to the following limitations. First,
the number of reviewed studies was limited by our
research protocol. Although we used a search algorithm
combing various key terms, we might not include all rel-
evant keywords. The narrow scope of the search algo-
rithm limits our reaching out full literature on the research
topic. Second, only the peer-reviewed journal papers
published in English were retrieved. Empirical studies
published in other languages, in project reports, and other
grey literature were not included in the current review.
This limitation might contribute to the lack of studies on
MSM in Africa and Latin America in our review. Third, a
few studies on disclosure of sexual behaviors among
LGBT were not included in the review. In these studies,
MSM were usually part of the study sample. The findings
for MSM subgroups were not explicitly reported in the
original papers, and thus were not extracted and summa-
rized in the current review. Fourth, we were not able to
conduct a meta-analysis on the association between
disclosure of same-sex behavior in clinical setting and
uptake of HIV-testing due to the diversity of measures for
both variables. Finally, without the guidance of a theo-
retical framework, we did not investigate dynamics or
mechanisms of how the various factors facilitate or
impede the disclosure in clinical settings.
Implications to Research and
Practice
In despite of these limitations, existing literature has
demonstrated the importance of MSM’s disclosure to
their HCPs in terms of accessing HIV prevention and
treatment as well as receiving higher quality of care ser-
vice that meet their needs. The findings based on empiri-
cal evidence have the following implications for public
health professionals and health-care practitioners. First,
promoting disclosure of same-sex behavior to health-care
providers should be incorporated into HIV prevention
and routine health-care interventions for MSM. Awareness
of same-sex behaviors and knowledge of sex history will
assist HCPs to develop more individualized and effective
care service and examinations including optimizing the
benefits of biomedical prevention technologies such as
PrEP (Underhill et al., 2015).
Second, future research and intervention efforts should
be concentrated in the most vulnerable and marginalized
MSM groups who are suffering from intersectional stigma
and multiple layered health inequalities. Disclosure to
HCPs is far from universal practice among MSM, even in
the high-income countries. MSM (sexual minorities) who
are African Americans (racial minorities) or rural resi-
dents (geographical minorities) face triple difficulties in
disclosure practice and should be given priorities in future
intervention efforts and resources distribution. In the
regions where medical mistrust and concerns regarding
disclosure are often compounded by health inequality and
intersectional stigma, promotion of disclosure could be
integrated into human rights advocacy for MSM as well as
in stigma and health disparity reduction campaigns in
medical institutions (Muzyamba, Broaddus, & Campbell,
2015).
Third, health-care providers play a critical role in ini-
tiating discussion about sexual behaviors. Many MSM
have worried that disclosure might lead to discrimination
and poor health-care service. Their concerns may come
from fears of racial and sexual discrimination and are
often exaggerated by their negative encounters and expe-
riences within health-care facilities. Positive and gay-
friendly attitudes of HCPs, trust relationship between
HCPs and their patients, and effective confidentiality pro-
tection will facilitate disclosure. In addition, HCPs need
advanced communication skills and experiences, espe-
cially in terms of probing and guiding discussions on
Qiao et al. 1211
sensitive topic such as sexual orientation and behaviors.
Literature on disclosure issues in clinical settings among
LGBT suggested that this population expect their HCPs
to initiate such discussion (McNair, Hegarty, & Taft,
2012; Pierre, 2012). Therefore, potential strategies for
capacity building of health-care facilities in terms of dis-
closure promotion may include providing special sensi-
tivity training and health communication workshops that
focus on disclosure issues among HCPs, and remodeling
the clinical environment to provide a gay-friendly context
to facilitate disclosure.
Future Directions
Based on the synthesis of empirical evidence and analysis
of limitations of existing literature, we propose several
suggestions for future study in this topic. First, more the-
oretical studies are needed to develop solidly conceptual
frameworks as blueprints for empirical studies and inter-
vention. Recent literature review and theoretical studies
on lesbians’ disclosure of same-sex behaviors to HCPs
could shed insights on disclosure issues among MSM.
For example, an identified disclosure model developed
by McNair and colleagues posited that disclosure patterns
were mainly influenced by sexual identity experience, the
risk of disclosure perceived, and the quality of the
patient–provider relationship. They further explained
how the three influences interact with each other (McNair
et al., 2012).
Second, future studies also need to pay more attention
to methodology issues. With the guidance of theoretical
models, there can be more accurate and consistent mea-
surement instruments developed and applied in empirical
studies. Research is needed in psychometric evaluation of
scales and measures and comparison of validity and reli-
ability by different approach in sample recruitment and
data collection.
Third, health education intervention for MSM and
health communication training projects for HCPs are
needed to promote disclosure of sexual behaviors in clini-
cal settings. To the best of our knowledge, there have no
health intervention projects with a focus on MSM’s dis-
closure of sexual behaviors or orientation to HCPs. Some
sensitization trainings among HCPs in Africa have shown
the efforts in this direction with some preliminary effi-
cacy (Elst et al., 2013).
In summary, disclosure to HCPs about same-sex behav-
ior could promote uptake of HIV testing and other routine
screenings among MSM, increase their health-care utiliza-
tion, and improve their access to biomedical HIV preven-
tion technologies. Disclosure issues among MSM in
clinical settings are related to decision-making, health
communication, patient–provider relationship, clinical
training and guidelines, and stigma and discrimination in
health facilities and society. Research and intervention
efforts need multidisciplinary perspectives and collabora-
tion. Effective communication and early disclosure of
same-sex behaviors will assist HCPs to provide more indi-
vidualized and appropriate care services and will optimize
the health-care benefits for MSM.
Acknowledgments
The authors wish to thank Christine Beyer for her contribution
to language editions. We also appreciate the support from
Wendi Da, Yanping Jiang, and Rifat Haider in the manuscript
revision
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
study was supported by National Institutes of Health (NIH) [grant
numbers R01HD074221, R21AI122919 and MH0112376]. The
content is solely the responsibility of the authors and does not
necessarily represent the official views of the NIH.
Ethical Approval
All procedures performed in studies involving human partici-
pants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable
ethical standards.
Informed Consent
Informed consent was obtained from all individual participants
included in the study.
ORCID iD
Guangyu Zhou https://orcid.org/0000-0003-2053-6737
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