Patient and Clinician Sociodemographics and Sexual History Screening at a Multisite Federally Qualified Health Center: A Mixed Methods Study

Kelly W. Gagnon; Robert W. S. Coulter; James E. Egan; Ken Ho; Mary Hawk

doi:10.1370/afm.3012

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Table 1.

Sociodemographics of Patients (N = 53,246)

Sociodemographic	Total^{^a} (N = 53,246)	Documentation of Sexual History Screening^{^b}
Sociodemographic	Total^{^a} (N = 53,246)	Any (n = 22,581)	None (n = 30,665)	P Value
Age, mean (SD), y	43.1 (15.7)	42.3 (15.6)	43.8 (15.7)	<.05
Race/ethnicity, No. (%)				<.001
White non-Hispanic	14,580 (30.3)	5,930 (40.7)	8,650 (59.3)
Hispanic	25,371 (52.8)	10,790 (42.5)	14,581 (57.5)
Black non-Hispanic	5,607 (11.7)	2,465 (44.0)	3,142 (56.0)
Asian non-Hispanic	1,556 (3.2)	622 (40.0)	934 (60.0)
Other non-Hispanic	945 (2.0)	404 (42.8)	541 (57.3)
Sexual orientation, No. (%)				<.001
Heterosexual	47,243 (95.2)	20,722 (43.9)	26,521 (56.1)
Gay and lesbian	1,107 (2.2)	555 (50.1)	552 (49.9)
Bisexual	1,029 (2.1)	506 (49.2)	523 (50.8)
Other	230 (0.5)	110 (47.8)	120 (52.2)
Gender, No. (%)				<.001
Cisgender woman	29,059 (58.1)	13,236 (45.6)	15,823 (54.5)
Cisgender man	20,517 (41.0)	8,641 (42.1)	11,876 (57.9)
Transgender woman	227 (0.5)	100 (42.3)	127 (57.7)
Transgender man	220 (0.4)	93 (44.1)	127 (56.0)
Primary language, No. (%)				<.01
English	37,455 (70.3)	16,053 (42.9)	21,402 (57.1)
Other	15,761 (29.7)	6,528 (41.3)	9,263 (58.7)
Insurance status, No. (%)
Uninsured	6,692 (12.6)	2,809 (42.0)	3,883 (58.0)
Medicare	4,929 (9.3)	2,129 (43.2)	2,800 (56.8)
Medicaid	31,389 (59.1)	13,355 (42.6)	18,034 (57.5)
Private insurance	8,865 (16.7)	3,733 (42.1)	5,132 (57.9)
Other public insurance	1,277 (2.4)	513 (42.6)	764 (57.5)
Medical site, No. (%)				<.001
Site 1	9,241 (17.4)	2,837 (30.7)	6,404 (69.3)
Site 2	8,578 (16.1)	2,571 (30.0)	6,007 (70.0)
Site 3	7,446 (14.0)	4,679 (62.8)	2,767 (37.2)
Site 4	7,288 (13.7)	2,511 (34.5)	4,777 (65.6)
Site 5	3,937 (7.4)	1,681 (42.7)	2,256 (57.3)
Site 6	2,939 (5.5)	1,049 (35.7)	1,890 (64.3)
Site 7	2,596 (4.9)	1,347 (51.9)	1,249 (48.1)
Site 8	2,282 (4.3)	1,207 (52.9)	1,075 (47.1)
Site 9	2,146 (4.0)	1,558 (72.6)	588 (27.4)
Site 10	2,065 (3.9)	1,510 (72.1)	555 (26.9)
Site 11	1,971 (3.7)	609 (30.9)	1,362 (69.1)
Site 12	1,602 (3.0)	421 (26.3)	1,181 (73.7)
Site 13	1,155 (2.2)	601 (51.9)	554 (48.1)

↵a Percentages total down the column to show the distribution of all patients by sociodemographics.
↵b Percentages total across rows to show the distribution of patients having a given sociodemographic between the sexual history documentation groups.

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Table 2.

Sociodemographics of Primary Care Clinicians (N = 56)

Sociodemographic	Total (N = 56)
Age, mean (SD), y	43.5 (12.1)
Race and ethnicity, No. (%)
White non-Hispanic	39 (69.6)
Hispanic	4 (7.1)
Black non-Hispanic	4 (7.1)
Asian non-Hispanic	0 (0.0)
Other non-Hispanic	9 (16.1)
Sexual orientation, No. (%)
Heterosexual	54 (94.7)
Gay and lesbian	1 (1.8)
Bisexual	0 (0.0)
Other	1 (1.8)
Gender identity, No. (%)
Cisgender woman	39 (68.4)
Cisgender man	17 (29.8)
Transgender woman	0 (0.0)
Transgender man	0 (0.0)
Years of employment, mean (SD)	7.1 (8.4)
Clinical credential, No. (%)
Advanced practice registered nurse	35 (61.4)
Medical doctor	17 (29.8)
Physician assistant	3 (5.3)
Doctor of osteopathic medicine	2 (3.5)
Patient panel size, mean (SD)	1,308 (751)
Years since training landmarks, mean (SD)
Credentialing degree	12.3 (11.5)
Postgraduate training	10.4 (12.7)
Any additional training	15.4 (16.9)

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Table 3.

Association of Patient and Clinician Sociodemographics With the Odds of Sexual History Screening

Sociodemographic	OR^{^a} (95% CI)	P Value
Patients
Intercept	0.52 (0.33-0.82)	…
Age, per year	0.99 (0.99-0.99)	<.001
Race/ethnicity
White non-Hispanic	1.00 (referent)	…
Hispanic	1.02 (0.95-1.01)	.52
Black non-Hispanic	1.01 (0.92-1.01)	.87
Asian non-Hispanic	0.88 (0.76-1.01)	.07
Other non-Hispanic	1.05 (0.57-1.33)	.52
Sexual orientation
Heterosexual	1.00 (referent)	…
Gay or lesbian	1.23 (1.04-1.47)	.02
Bisexual	1.12 (0.94-1.34)	.22
Other	0.87 (0.57-1.33)	.52
Gender
Cisgender man	1.00 (referent)	…
Cisgender woman	1.10 (1.04-1.16)	<.001
Transgender man	1.07 (0.72-1.60)	.74
Transgender woman	1.26 (0.86-1.84)	.23
Primary language
English	1.00 (referent)	…
Other	0.91 (0.85-0.97)	.006
Insurance status
Private insurance	1.00 (referent)	…
Uninsured	0.95 (0.86-1.05)	.33
Medicare	1.07 (0.97-1.19)	.17
Medicaid	1.00 (0.93-1.08)	.91
Other public	0.9 (0.75-1.07)	.22
Clinicians
Age, per year	1.01 (0.98-1.04)	.60
Race/ethnicity
White non-Hispanic	1.00 (referent)	…
Black non-Hispanic	0.86 (0.37-1.99)	.72
Hispanic	1.30 (0.51-3.29)	.58
Other non-Hispanic	0.92 (0.41-1.67)	.59
Sexual orientation
Heterosexual	1.00 (referent)	…
Gay or pansexual	1.26 (0.07-23.3)	.88
Gender identity
Cisgender man	1.00 (referent)	…
Cisgender woman	1.80 (1.00-3.21)	.048
Years of employment	0.98 (0.95-1.02)	.37
Clinical credentials
Advanced practice registered nurse	1.00 (referent)	…
Medical doctor	0.99 (0.49-2.01)	.99
Physician assistant	1.07 (0.22-5.22)	.93
Doctor of osteopathic medicine	1.15 (0.31-4.21)	.83
Patient panel size, per patient	0.99 (0.99-0.99)	.02

OR = odds ratio.
Note: Bold indicates a statistically significant association (P <.05).
↵a Estimated using multilevel crossed random effects logistic regression analysis, with adjustment for patients’ age, race and ethnicity, sexual orientation, gender, primary language, insurance status, and patients’ primary care clinicians’ age, race/ethnicity, sexual orientation, gender identity, years of employment, and clinical credentials while clustering by primary care clinician and medical site.

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Table 4.

Sociodemographics of Key Staff Participating in Interviews (N = 21)

Sociodemographic	Staff, No. (%) (N = 21)
Primary care clinician	16 (76.2)
Degree
Advanced practice registered nurse	11 (68.8)
Medical doctor	3 (18.8)
Doctor of osteopathic medicine	2 (12.5)
Physician assistant	1 (6.3)
Medical assistant	3 (14.3)
Clinical leader	2 (9.5)
Gender
Cisgender woman	14 (66.7)
Cisgender man	7 (33.3)
Transgender woman	0 (0.0)
Transgender man	0 (0.0)
Sexual orientation
Heterosexual	19 (90.5)
Gay or lesbian	1 (4.8)
Bisexual	0 (0.0)
Other	1 (4.8)
Race/ethnicity
White non-Hispanic	11 (52.4)
Hispanic	3 (14.3)
Black non-Hispanic	2 (9.5)
Asian non-Hispanic	2 (9.5)
Other non-Hispanic	3 (14.3)

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Table 5.

Summary of Qualitative Results and Key Quotes

Theme	Summary	Quote
Patient gender	Clinicians perceived discomfort from patients when they were not of the same gender.	“I’m a woman and the other person is a guy, and then I have to ask a different sexual history, yeah, some young men, they’re a little embarrassed. And some of my older patient are in [their] 50s, when they want to talk about sexual history, they will ask for a male provider even though I’m their primary care physician. So that would be the hard part. But otherwise, that’s patient preference, so that’s fine.” – DO
Older age	Clinicians stated they ask older patients sexual history questions less frequently compared with other patients, often stemming from the assumption that older patients are not having sex or are not at risk of negative sexual health outcomes.	“If I’m going to be honest, if it’s an older patient–when I say older, let’s see, like over 50, and if it’s someone I know, pretty stable, straightforward, I really know the person, I’m not going to engage in sexual history with that person unless something comes up or that patient brings it up because you do have some of those patients who are celibate for periods of time. We’re talking about having a new partner, then out of the blue, they come in to see me for routine blood pressure follow-up. ‘Oh, by the way, I have a new partner,’ and then I’ll broach that subject about testing and contraception. That type of thing. If it’s a younger patient, I deliberately will broach the sex history.” – MD
Relationship status	Sexual history screening was less of a priority during visits for patients in long-term relationships, with clinicians assuming they are not at risk or do not have any concerns.	“It’s sometimes harder to remember to do it in patients who have long-term partners that I know of. It’s not ideal to assume that they’re monogamous and have no other relationships, but it sometimes kind of falls off the radar if you take care of like a couple who have been together for 10 years.” – APRN
Culture and religion	Clinicians held beliefs about patients’ cultures and religions that they perceived to be very conservative, that made it more difficult or prevented them from asking their patients sexual history questions.	“Certainly, culture comes into it. I would be very reluctant to ask certain women about sex because I know they’re having sex with their husbands and they’re not going out. Most Pakistani women, Indian women in their 40s, 50s, 60s, […] so I think culture. Now, younger ones, I would, but certainly somebody who immigrated as an adult and is living still a fairly traditional life, it’s less likely.” – APRN “I would say a lot of the, I want to say Pakistani, the Muslim faith women that only come in, they will not come into the room without their spouse in there, that can make it difficult.” – APRN
Adolescent age	Clinicians prioritized sexual history screening with adolescent and young adult patients but had to consider parents.	“They may have come in with the parents. I mean, I’m not going to ask them about sexual history in front of the parents, but even with the parents outside, sometimes I think they’re a little bit hesitant because what I find is they’re concerned that it may get back to the parents.” – MD
Sexual and gender minorities	Clinicians noted the importance of sexual history screening for sexual and gender minority patients, with the recognition that this may be difficult for the patient.	“If they come in and it’s fairly obvious they’ve made it known in their chart [that] they identify as transgender [sic] or a man who has sex with men, they might feel uncomfortable because their provider might ask them about sex at every visit. And that’s not fair either. Right? I don’t come in just because I’m a man who has sex with men. I might have diabetes; I might have hypertension. So, I think it’s sort of like that. There’s sort of the two extremes, and then there’s a lot in the middle.” – Clinical leader
Clinician gender	Clinicians who identified as women more often described using soft skills to navigate hesitation or discomfort from patients during sexual history screening, whereas men described accepting patients’ initial reaction.	“I think also for [the patients], it’s a little bit awkward for them to bring it up and I think it’s a little bit easier if I am the one who initiates it. And if they’re okay talking about it, fine, we talk about it, but then there’s some who are a little bit hesitant about it. So I’ll just kind of read into the patient and I go from there.[…] depending on how the conversation is going, then I’ll probe a little bit more.[…] I just try to tell them up front whatever we discuss is between us.” – MD, woman “If they don’t want it, they say, ‘No. Don’t want it,’ and if they do they say, ‘Yeah,’ and then we go ahead and do it. There are some patients that get a little bit kind of like, ‘Why are you asking that? We don’t need to talk about that.’” – APRN, man