Barriers to sexual health care: a survey of Iranian-American physicians in California, USA
Sexual health and quality of life are directly related [1]. Sexual history taking as part of holistic care, however, is not routinely addressed in health care services [2]. According to the Centers for Disease Control and Prevention (CDC) [3, 4], 20 million new sexually transmitted infections occur in the United States each year and in 2013 the total number of STIs among US men and women exceeded 110 million. Among those 15 years and older, these estimates included eight common STIs: chlamydia, gonorrhoea, hepatitis B virus (HBV), herpes simplex virus type 2 (HSV-2), human immunodeficiency virus (HIV), human papillomavirus (HPV), syphilis, and trichomoniasis, with 49 % of incident STIs occurring among young men, vs. 51 % among young women [3, 5]. Research suggests that the lack of a unified approach to sexual health is indicative of a poor sexual health care system within the United States [6]. As a result, the rates of STIs and sexual dysfunctions are higher compared to many other developed countries [7, 8]. Of the nearly 20 million new STIs every year in this country, half occur among young people ages 15–24. In addition to increasing a person’s risk for HIV infection, STDs can lead to severe reproductive health complications, such as infertility [9–11]. Research further suggests that where HIV prevalence is high, rates of unintended pregnancy and unsafe abortion are also high resulting in an increase in maternal deaths as well as long-term health consequences [9, 10]. Physician-patient communication is of fundamental importance in health care [11, 12]. Increased communication correlates with increased use of condoms, whereas lack of communication is a risk factor for HIV and STIs [12, 13].
Failure to correctly diagnose patients with sexual health problems is often due to barriers among medical professionals such as dealing with follow-up, costs and how to do appropriate testing [14]. One study suggests that physicians frequently underestimate the pervasiveness of sexual concerns among their patients [1] and only about 6 % of physicians initiate discussion on this topic on a regular basis [15]. Among US physicians, there is evidence that physicians such as general practitioners do not address sexual health issues proactively with patients [12]. Studies show that patients would like to discuss sexually-related issues with their physicians, but are often reluctant because they fear that the physician will be embarrassed, or will dismiss their concerns [12, 16].
The absence of proactive communication is believed to be due to a lack of training in effective sexual health care [17]. Known factors that serve as barriers to sexual health care include: 1) health care organizational factors such as complexity, time constraints, training and expertise, 2) structural factors such as economics and politics, and 3) the sensitivity of the topic and its impact on the health care practitioners’ personal motivation which could impede or facilitate discussion with patients [2]. The identified barriers also included reluctance in discussing sexual health care with minority groups.
Aside from proactive communication skills and the need for increased education about various aspects of sexual health such as sexual dysfunctions and STIs [18], some of the other identified barriers among US physicians include: underestimation of patient risk; inadequate and/or insufficient knowledge of sexual health; and lack of privacy [19]. Conservative sexual beliefs and cultural biases [20], the gender of both the physicians and the patients, fear of intrusion [5, 21, 22], and age [23] are additional barriers identified among US physicians. More than one-third of new HIV infections occur among those aged 13-29 years as they continue to engage in risky sexual behaviours [24, 25], and 1 in 4 sexually active adolescent females have an STD such as chlamydia or human papillomavirus (HPV) [26]. Compared with older adults, sexually active adolescents aged 15–19 years and young adults aged 20–24 years are at higher risk of acquiring STDs due to a combination of behavioural, biological, and cultural factors. While various forms of barriers to proactive communication are known as lack of cultural competency among the mainstream US physicians [27], literature is limited on US physicians from minority backgrounds with respect to the impact of their cultural backgrounds on the delivery of sexual health care within the USA. A study at the University of California Los Angeles (UCLA) indicated that white primary care providers, were less likely than Hispanic/Asian/African- American/other, to regularly take sexual histories from their patients. Perceived key barriers among physicians included patient’s young age (16 years), language, and the presence of patient’s relative/partner in the consultation room at time of visit [28]. The results of a related study among primary care physicians in four specialties (obstetrics/gynecology, internal medicine, general/family practice, pediatrics), plus urogynecologists [29], showed that these health providers often refrain from doing sexual histories as part of routine and preventive healthcare because they feel uncomfortable. Thus, many physicians miss essential components of a comprehensive sexual history [29, 30].
Having physicians of various foreign-born/subpopulation minority backgrounds is believed to be positive in providing effective sexual health care as research shows that patients who are members of minority groups are more likely than others to consult physicians of the same race or ethnic group [31]. Research indicates that among the US minority physicians, Black and Hispanic physicians have a unique and important role in caring for poor Black and Hispanic patients in California [31, 32]. Foreign-born/minority background physicians may have additional barriers such as personal factors that are reinforced by cultural biases and personal beliefs. These again may be reinforced by a larger societal view, plus personal upbringing and religious beliefs that physicians may hold about sexuality, and therefore about sexual health care [33–35]. Therefore, exploring how foreign-born physicians connect to their patients in the area of sexual health care can uncover helpful strategies that all physicians and those of diverse background can use to establish stronger cross-cultural connections and communication levels. Physicians’ gender also has been considered as a barrier of care when patients are of the opposite gender, very young, or older [36].
The Iranian-American physicians are among the foreign-born/minority medical doctors within the US. Whether they hold similar value system and biases on sexuality, impacting the delivery of sexual health care is relatively unknown. Research suggests that the discussion of sexuality is taboo within the Iranian culture [37–39] and therefore it is important to survey Iranian-American physicians to assess to what degree they experience barriers on this topic in their daily interaction with patients. The communication with patients concerning sexual care in Iran is primarily limited to reproductive care among patients and their physicians [37]. This narrow practice of sexual health care could potentially serve as a barrier to having a proactive communication system for Iranian-American physicians when discussing patients’ sexually-related concerns, in particular with the opposite gender.
Iranian-Americans are Americans of Iranian ancestry and/or people holding Iranian and American dual citizenships. In 1971, Iranian physicians in the U.S. numbered 1,625 [40]. Later the majority of the Iranian-American physicians migrated to the United States subsequent to Iran’s revolution in 1979. Those who immigrated to the US were generally qualified physicians who came with their families with the intent to stay permanently. Of these, at least 5,000 received their primary medical degree in Iran, with advanced training in the United States after immigration [41]. According to the 2010 US Census, it is estimated that there are at least 10,000 Iranian-American physicians across the United States with the vast majority currently practicing in California. The number of Iranian Medical School graduates in the United States had grown to 5,045 post-revolution [42], and they practice primarily in the areas in which most of the Iranian American population is concentrated [40]. Aside from practicing physicians, Iranian immigration to the United States has been continuous since the 1980s. Between 1980 and 1990, the number of Iranian-born people in the United States increased by 74 % [43]. Currently, the United States contains the highest number of Iranians outside of Iran. Iranian-Americans regard their culture and heritage as an important component of their daily life and of their overall identity within the United States [44].
The existing literature on the delivery of sexual health care given by Iranian physicians in Iran is known to be limited due to various barriers such as social stigmatization of sexually related topics [45]. Some studies [46–48] proposed that proactive communication about sexually related issues by Iranian physicians plays a vital part in creating rapport with patients. Limited communication about sexuality has led to a lack of research on the topic and a culturally state-imposed position on sexuality frequently adopted by Iranian physicians in Iran. When coupled with homophobia and sexism, this may subject patients to potential sexual health risks [37, 48, 49]. Many of Iranian-Americans may seek medical help from the Iranian-American physicians due to the English language limitations. The Iranian-American adolescents may have conflicting views with their parents about the nature of sexual health care. In particular, while families and the Iranian-American communities continuously put emphasis on retaining Iranian traditional values regarding sexual issues, through direct exposure to host culture, the Iranian-American adolescents have identified with the sexual values introduced to them in the United States [50].
To date, no data has been reported about possible barriers that may prevent Iranian-American physicians from discussing sexually related concerns with their patients within the US. Our pilot study, to the best of our knowledge, is the very first one to focus on this issue. Research about the nature of sexual health care offered by Iranian-American physicians to Iranian-American patients as well as to the patients of mainstream and diverse ethnic backgrounds, is also unknown. To assess and to identify possible barriers, we conducted a survey of Iranian-American physicians in California, where the majority of these physicians have their practices, to learn more about how they relate to their role as providers of sexual health care within the United States. We acknowledge that this is a difficult and sensitive topic for this population and thus has implications for response rates. However, there is an urgent need to conduct such studies in order to better understand and address possible barriers and thus improve sexual health care delivery among this group of health care providers. Focusing on impediments to appropriate sexual health care will also make it easier to conduct larger studies among both Iranian-Americans and other subgroups of US physicians.