Psychiatric morbidity, risk-taking behavior, internalized stigma and perceived social support in men having sex with men: A cross-sectional study

Abstract

Background:

Research has shown a high prevalence of mental health disorders in homosexuals with high risk-taking behavior. Sexual minority groups are often prey to many psychosocial stressors such as harassment, victimization, and fear of rejection.

Aim:

To understand the occurrence of psychiatric morbidity, risk-taking behavior, stigma, and social support in the men having sex with men (MSM) population and correlate its relation with each other.

Materials and Methods:

One hundred participants were selected via randomized sample selection from the existing list of registered MSM accessing services from MDACS, and a detailed psychiatric interview was taken with diagnoses as per ICD10 criteria. Measure of Internalized Sexual Stigma Scale and Multidimensional Scale of Perceived Social Support were applied for further evaluation.

Results:

Forty-eight study participants had psychiatric morbidity with substance use and mood disorders being more common. High risk-taking behavior was found to be less in the sample. Internalized stigma was high on identity and social discomfort subscale. The total mean MISS-G score was found to be 35.64 ± 35.57. Social support was more from significant others. MSPSS scale had a total mean score of 58.59 ± 20. There was a negative correlation between stigma and social support. Psychiatric morbidity was associated with high stigma and poor social support.

Conclusion:

This study shows that MSM is at higher risk for psychiatric illnesses like depression and internalized sexual stigma. The social support experienced by them is also poor. Hence, there is a need to spread awareness and address the mental health issues of this minority.

In India, sexual acts among same-sex individuals were considered a crime under section 377, which was decriminalized, in 2018.[1] Even after the judgment, the sexual minority is still discriminated against, ostracized, and abused for what they are.[2,3] Ample research has shown a high prevalence of mental health disorders in men who have sex with men (MSM).[3,4] Prevalence rates of depression were found to be 16% in Nigerian homosexuals as compared to the heterosexual population.[5] The intersectionality of gender, sexuality, and societal expectations can lead to unique psychological distress, including anxiety, depression, substance abuse, and suicidal ideation.[6]

Sexual minority groups are often prey to many psychosocial stressors such as harassment, victimization, and fear of rejection.[1] Such circumstances combined with economic burdens and unwanted marriages due to societal pressure add to the ever-growing list of stressors. Certain external factors, such as social stigma and discrimination, lead to minority stress which results in depression and suicidal ideation.[2] A study in Chennai of about 210 MSM showed that more than 50% of those who had depression were associated with unprotected anal sex and a higher number of male sexual partners.[7] A study conducted in India during the COVID-19 pandemic showed that MSM faced higher stress and loss of employment leading to higher HIV risk.[8]

Social support plays a significant role in helping to cope with the challenges and threats that a person must face. It helps the person to adapt to stressful and critical circumstances and leads to fewer mental health issues.[9,10] Perceived social support has a positive influence on life satisfaction and affects balance and ethnic, gender, and social identity.[11]

Studies have shown an increase in internalized sexual stigma with decreasing social support,[12] with social support being a significant mediator between internalized sexual stigma and psychological well-being irrespective of whether the external social environment recognized the civil rights of LGBTQ individuals.[13] Several studies concluded that depression or mental health issues[14] and alcohol abuse increases HIV risk behaviors and inhibit condom usage.[7,15]

High-risk behavior within complex psychosocial environments such as social stigma, discrimination, and violence against MSMs was studied in an Indian study.[16] The HIV trend in India has been decreasing in the general population but not in the MSM population. According to NACO, 2015, consistent use of condom usage in the MSM population was only seen in half the study group (50-55%) even with the free distribution of condoms in high-risk areas and groups.[17,18]

As the Indian data on MSM in terms of psychiatric morbidity, risk-taking behaviors and the stigma associated with it is limited, we decided to study this sexual minority group for a better understanding of the problems faced by them.

MATERIALS AND METHODS

Study site: The study was initiated after institutional ethics committee approval [Ref No. EC/92/2020 dated 20/2/2021]and after taking written informed consent from the participant. The study was conducted at Mumbai District AIDS Control Society (MDACS) Drop-in centers in Mumbai. The study was conducted over a period of 1 year (2021-2022).

Study sample size

There are about 11,000 homosexual men registered with MDACS. This database is the most comprehensive source available for this population, ensuring that all potential participants are included in the selection pool. The sample size was calculated using the formula for an infinite population. The participants were selected randomly using a random number table from the existing list of registered MSM accessing services from MDACS, which ensured that everyone had an equal probability of being chosen. This method helps to minimize selection bias and enhances the representativeness of the sample.

Almost all our study references focusing on depression had wide prevalence rates ranging from 15% to 55%. Hence, the mean prevalence was taken to be 35%, q = (100-p) = 65%, Z = 1.96 ~ 2, d = Absolute error = 10%.

Sample size = z²pq ÷ d² = (2)² × 35 × 65÷ (10)² = 91.

Considering nonresponder correction of 10%, the sample size was 100.

Inclusion criteria

• Age between 18 and 50.

• Identified as men who have sex with men.

Exclusion criteria

• Male-to-female transgender

• Heterosexuals

• Those already diagnosed as having a psychiatric disorder and under treatment.

Tools

• Proforma

  A semistructured proforma was devised to include sociodemographic variables, psychiatric history, psychosexual history and mental status examination. Diagnosis of mental health conditions was made by using ICD-10 diagnostic criteria.[19] This diagnosis was made by a post graduate psychiatry resident doctor, when interviewing the participants. Detailed Psychosexual history and high-risk taking behavior was assessed with closed ended questions on condom usage, use of alcohol/cannabis or other recreational drugs before or after sexual activity and history of sharing needles/razors/toothbrush with partners.

• Measure of internalized Sexual Stigma in Gay (MISS-G)

  The MISS-LG[20] is a 17-item scale assessing the negative attitudes that lesbians and gay men have toward homosexuality in general and toward themselves as homosexuals. It[18,21,22] has 3 subscales viz. identity (5 items), social discomfort (7 items), and sexuality dimension (5 items). A total score derived from the 5-point Likert-type scale ranged from 1 (I disagree) to 5 (I agree), whereby a higher score indicated greater ISS. For understanding whether the internalized stigma was low a score of <51 was considered and for high stigma, a score of >51 was considered.

• Multidimensional scale for Perceived Social Support (MSPSS)

  MSPSS is a 12-item 7-point Likert-rated scale designed to measure perceptions of support from 3 sources: Family, Friends, and a Significant Other.[23] It gives a total and 3 subscale scores. To understand whether the social support was poor or good in our participants, a total score below 48 was considered poor, and above 48 was considered good.

Both the scales were translated and validated into Hindi and Marathi language after obtaining permission from the authors to use the scales in the study.

Study procedure

The study was initiated after ethics committee approval. Participants were screened and only those satisfying the inclusion and exclusion criteria were included in the study after written informed consent. One-time confidential interview was taken at MDACS drop-in centers in Mumbai. No identifying data of the participant was linked to the study. The psychiatric interview lasted for about 45-60 min, and all the scales were applied as per the aims of the study.

Statistical analysis

Descriptive statistics using a frequency distribution table were used to study sociodemographic variables, the prevalence of psychiatric morbidity, and risk-taking behavior. The correlation of psychiatric morbidity, sexual stigma, and social support was done using Pearson’s coefficient.

RESULTS

The mean age of our sample was 30.24 years ± 7.84 years. Our participants mostly ranged from 22 to 38 years. 88% of participants were unmarried, 9% were married, and 3% were divorced. All our participants were literate: 6% were professionals, 36% were graduates, 27% had higher secondary and 31% had completed secondary education. Forty participants were skilled workers, 15 participants had shops or businesses, 23 were semiskilled workers, and 6 were professionals with only 10 participants being unemployed. Two participants were commercial sex workers. The majority of our sample hailed from the lower middle socioeconomic class (55%), 36% were from the upper lower and about 9% were from the upper middle class.

Around 48 of our participants had psychiatric morbidity. The types of psychiatric morbidities among these 48 participants revealed a high presence of mental and behavioral disorders due to psychoactive substance use viz. nicotine dependence syndrome for cigarettes and chewing tobacco continuous use (37, 77%) and alcohol dependence syndrome continuous use (18, 37.5%). Mood disorders prevalent were mostly depressive disorders, viz., mild depressive disorder without somatic syndrome (10, 20.8%), moderate depressive disorder without somatic syndrome in 14 (29%) participants and severe depressive disorder without psychotic symptoms in 12 (25%) participants. Adjustment disorders were found in 22 (46%) participants with the specifier being grief reaction (death of a family member/friend) or chronic persistent stressor followed by mixed anxiety depression in 6 (12.5%) of the study participants. Around 41 participants fulfilled the criteria of more than ICD 10 psychiatric diagnosis. None of the participants had suicidal ideas or thoughts at the time of the interview.

On assessing risk-taking behavior 12% reported no or inconsistent usage of condoms, 24% of participants used alcohol, around 6% used cannabis or other recreational drugs before or after sexual activity and more than 30% did it for money or favors [Table 1]. The assessment of participants for internalized stigma across the 3 subscales, revealed slightly higher means for sexuality dimension and social discomfort than the sexual identity with the total mean MISS-G score being 35.64 ± 35.57. When we assessed the social support perceived by our participants, a slightly higher mean was seen by support from a significant other when compared to family and friends with the total mean MSPSS score being 58.59 ± 20. A significant negative correlation of stigma with perceived social support was seen [Table 2]. A significant association was seen between a higher stigma of MISS-G and the presence of psychiatric morbidity (P < .0104). Similarly, poor social support as per MSPSS was associated with higher psychiatric morbidity (P < .0013) [Table 3].

Table 1.

High risk-taking behavior

High risk-taking behavior	Number of participants n=100 (%)
	Present (%)	Absent (%)
Use of condoms	88	12
History of taking alcohol before or after sexual activity	24	76
History of taking cannabis/recreational drugs before or after sexual activity	6	94
History of sharing needles/Toothbrush/razors with partner	3	97
History of sexual activity for:
• Money • Favour	34 30	66 70

Table 2.

Internalized Sexual Stigma, Perceived Social Support, and Correlation

MISS-G Subscale scores	Mean±SD	MSPSS Subscale scores	Mean±SD	Pearsons Correlation of MISS-G subscales with MSPSS total score
				r	P
Sexuality	10.16±3.50	Friends	17.82±8.07	0.0364	0.71919
Identity	8.95±4.31	Family	17.71±7.98	−0.614	0.00001*
Social	15.71±15.69	Significant other	21.26±6.79	−0.285	0.004053*
Total	35.64±35.57	Total	58.59±20.04	−0.3853	0.000076*

^* Signiifcant

Table 3.

Association between Psychiatric morbidity with Internalized Stigma and Perceived Social Support

Internalized Stigma and Perceived Social Support Total scores	Total number of participants n=100		Fischer’s Exact Test P
	Psychiatric Morbidity Present n=48 (%)	Psychiatric Morbidity Absent n=52 (%)
MISS-G >51	12 (25)	3 (5.76)	0.0104*
MISS-G <51	36 (75)	49 (94.2)
MSPSS <48	15 (31.2)	3 (5.76)	0.0013*
MSPSS >48	33 (68.7)	49 (94.2)

^*Significant

DISCUSSION

Several researchers had a similar prevalence of psychiatric morbidity as our study. As per the type of morbidity alcohol and depression were higher than our findings. Studies have reported alcohol use in several MSM in the range of 26% to 60%,[18,21,22] but dependence was reported in 15%[21] which is in keeping with our findings. Tobacco use though common was not reported by other researchers. Many MSM are also found to be consuming other recreational drugs,[18] due to which nicotine use could be less, though we did not get this in our sample.

Depressive symptoms have been widely found in MSM population though the severity of depression has not been studied.[5,21,24] An Indian study reported current major depression in 29%, anxiety disorder in 24%, current or prior manic episodes in 3.4%, current or prior hypomanic episodes in 9.5%, and with history of psychotic disorder in 7.4%.[24] We had severe depressive symptoms in 12 participants and adjustment disorders in 22%. However, none of the participants were aware that it was a mental illness. Many accepted it as a part of their coping as MSM, but none gave suicidal acts or behaviors. Our findings of anxiety disorders were less as compared to others as per ICD-10 diagnostic criteria as we used diagnostic criteria and not rating scales for screening of participants for depression or anxiety symptoms. Methodological variation and the use of different scales could be responsible for the difference in the prevalence rates of psychopathology.

Our sample had an overall less amount of various risk-taking behaviors. It could be assumed that these counseling services offered by NGOs in collaboration with MDACS where the MSM were regularly reporting, were helping in curbing the rise of sexually transmitted infections as they were given awareness about the same and were investigated regularly. Researchers have also reported inconsistent condom usage in 54.9% of the subjects.[18] A study reported 63% of the participants showed depressive symptoms to being paid for the sexual activity, whereas 27% reported unprotected anal intercourse within the previous 3 months of the study.[7]

As per MISS-G our sample was at high risk of internalized sexual stigma on the ‘Sexuality’ subscale which had statements like “When I like a man, I do anything to prevent people from finding out”, “When I have sex with a man, I feel awkward” and on the ‘Social discomfort’ scale which asked for statements like “I would not tell my friends that I am gay because I would be afraid of losing them” as compared to the ‘Identity’ subscale which asked, “I’m worried to understand whether I like women”, “If it were possible, I would do anything to change my sexual orientation,” etc. Similar findings were reported in Italian and Belgian MSM.[13] The presence of higher internalized sexual stigma in our study sample can be attributed to the fewer social acceptance, stigma and discrimination faced by Indian MSM as compared to Italian or Belgian MSM population.

We found that in our sample significant others extended more social support than family or friends. The social support by ‘Friends’ was assessed using statements like “I have friends with whom I can share my joys and sorrows”, “My friends try to help me,” etc. The social support from ‘Family’ was analyzed by asking “I get the emotional help and support I need from my family”, “I can talk about my problems with my family,” etc. The score of ‘Significant Other’ subscale was analyzed using statements like “There is a special person with whom I can share my joys and sorrows”, “I have a special person who is a real source of comfort to me,” etc. The role of the community in the social support of MSM is highlighted in our study. MSM people feel closer to and supported by their friends or significant other as compared to family. This is possible because of the role of nongovernmental organizations, which can be credited for creating close communities for the welfare and upliftment of the MSM in India. This has brought the MSM in contact with other MSMs to share their stress and problems.

Most of our sample had not shared their sexual orientation to their family which is in keeping with findings of Safren et al.[7] where only 26% of the participants’ families were aware of their sexual orientation. Several researchers reported that their participants were victims of violent crime (29%),[16] 60% felt that informing their sexual orientation to others was one of their life’s most stressful experiences,[24] 23% had encountered verbal abuse while 3.8% had experienced both verbal and physical assault and 56% said that their families had rejected them because of their sexual orientation.[25] This therefore still speaks of the awareness to be done in society where acceptance is not there and the sexual minority continue to face criticism and stigma.

There was a negative correlation of stigma with perceived social support which can be interpreted as MSM having low perceived social support had higher internalized sexual stigma. Similar findings on the subscales of social discomfort with stigma were reported by other researchers.[13] This implies that the MSM who have lower social support due to stigma and discrimination faced by them would fear the consequences of ‘losing a friend’ or negative criticism after expressing their homosexuality and ‘coming-out.’ This internalized sexual stigma can be tackled by providing good social support.

There is a significant association between higher stigma, poor social support, and psychiatric morbidity. Lorenzi et al.[13] also reported that internalized sexual stigma was significantly correlated with anxiety and depression with patients demonstrating higher internalized sexual stigma having higher scores on anxiety and depression scales. Similarly, they reported that anxiety and depression were negatively associated with social support which is in keeping with our findings.[13] Good social support can diminish the symptomatology of anxiety and depression as was reported in an earlier study in which the population of Chennai had lower levels of depression due to higher social support as compared to the population of Kumbakonam.[26] Social support from friends and family helps the individual deal with the stressors more compatibly. It reduces the likelihood of mental health problems and helps the individual adjust to difficult and stressful situations.[27]

Limitations

The study’s generalizability may be constrained because the sample was obtained through outreach efforts with local MSM nongovernmental organizations affiliated with MDACS. The sample size was modest. We did not use any control group. The diagnosis of the psychiatric morbidity was done by a postgraduate resident and not by a psychiatrist. The involvement of lesbian sexual minorities and a larger sample size would have helped to understand the mental health issues faced by the community. Differentiation between Kothi, and Panthi, as categories of MSM was not done.

CONCLUSION

This study demonstrates the need for mental health awareness among Indian MSM who are involved in high-risk-taking behaviors. There is a need for mental health initiatives to be undertaken for the community and the role of social support in tackling mental health issues.

Authors’ contributions

Study conception and design: All authors. Material preparation, data collection, and initial analysis: NP. Interpretation and detailed analysis of the data: NP, NS The first draft of the manuscript: NP Critical revision for important intellectual content: All authors.

Data availability statement

Data will be made available on reasonable request

Ethical statement

We also declare that the study was assessed and approved by the institutional ethics committee/institutional review board and that the letter of approval is available with us for examination. Ref No EC/92/2020 dated 20/2/2021.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results/clinical information/image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.

Funding Statement

Nil.