Our study findings demonstrated that young gay men were more likely to have access to free contraceptives and were more likely to seek medical treatment for reproductive health problems as compared to their heterosexual counterparts. Condom use during first sexual intercourse was also higher among young bisexual and gay men. However, among young women, the association between sexual orientation and condom use during first sexual intercourse was reversed. No significant differences were found between women with different sexual orientations regarding their actual accessibility to SRH services.
Whilst we found that gay men had the highest rate of access to free contraceptive and were more likely to seek medical treatment for reproductive health problems compared to heterosexual men, similar studies have reported that SMY were more likely to have less access to SRH services, resulting in low health service utilization. It was also reported that health service utilization is further affected by the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) stigma in China [22–27]. However, our findings were consistent with findings from the 2016 national survey on SMY in China, which reported that only a low proportion of SMY encountered difficulties when receiving health care services [28]. Past efforts to implement HIV prevention interventions targeting men who have sex with men (MSM) in China to increase awareness of safe male-male sex [29–31] may have contributed to higher SRH awareness and higher SRH services utilization in gay men, explaining our findings. Whilst the findings of this study suggests that SMY have relatively better SRH services utilization than heterosexuals, it is important to note that the absolute rate of SRH services utilization was still low, indicating that the majority of SMY do not have access to appropriate SRH services. This may be because homosexually largely remains illegal and stigmatized in China, resulting in lower disclosures of sexuality and same-sex behaviors to SRH providers, and therefore, missed opportunities to obtain required SRH services [32]. Furthermore, given the wide-spread of discrimination against sexual and gender minority (SGM) groups in Chinese society, it has been well documented that SGM patients are more likely to anticipate and experience discrimination in clinical settings, resulting in lower quality of health care [33–34]. Increasing access to SGM/SMY-friendly SRH services via provider training, comprehensive sexuality education, and social campaigns is fundamental for promoting health among SMY.
We also found that bisexual men and gay men had the highest rates of condom use during first sexual intercourse compared to men with other sexual orientations. However, a study conducted by Liu et al. (2015) in China reported that gay and bisexual men were less likely to use a condom during sexual intercourse [35]. A possible explanation for this difference in findings could be because our study assessed the status of condom use at the first sexual intercourse, while the study by Liu et al. assessed the status of condom use for most episodes of sexual intercourse. This may suggest that while sexual minority males may have higher awareness of using contraception at first sexual intercourse, this awareness declines in subsequent sexual intercourses, although there is no evidence in our study to support this hypothesis. However, the study by Liu et al. (2015) and other studies demonstrated consistent results to our findings that lesbians and bisexual women were less likely to use condoms at first sexual intercourse compared with heterosexual women [36–38]. This could be because of the assumption that female-female sexual intercourse is safer than heterosexual or male-male sex.
Overall, this study has several limitations. First, because the internet-based questionnaire utilizes self-reporting and because sexual-related topics remains a taboo subject in China, response bias may be present. However, we attempted to mitigate this bias by utilizing an internet-based questionnaire, as well as by conducting thorough logic checks before data analysis. Second, given that this study was conducted retrospectively, recall bias may be present. Last, because the study utilized a cross-sectional study design, causality cannot be inferred.
However, this study also has several strengths. Over the last decade, with the exception of family planning and HIV or acquired immunodeficiency syndrome prevention and control, SRH has received little attention in policy or public health research in China. Utilizing the largest and most recent national survey on the SRH of college students in China, our study is the most comprehensive study to investigate the accessibility to SRH services for youths with various sexual orientation in China using the three major indicators of SRH; access to free condoms from public health institutions, condom use at first sexual intercourse, and access to medical treatment for reproductive health problems in the past 12 months. Given that our study is the largest study on SRH in college students residing in various areas across China, a large diversity of students is included allowing for greater representativeness and generalizability.