Abstract
Purpose: We assessed differences between gay and bisexual men in enacted stigma, and how the association between stigma and depressive symptoms may vary according to sexual orientation identity.
Methods: Participants (671 gay and 331 bisexual men who have sex with men) in Baltimore's 2011 and 2014 National HIV Behavioral Surveillance completed an anonymous survey, including 3 enacted stigma dimensions and the Center for Epidemiologic Studies Depression Scale. Adjusted prevalence ratios were calculated through Generalized Estimating Equation models adjusting for theorized confounders (demographic, socioeconomic, and relational factors).
Results: Bisexual men reported stigma experiences less frequently than did gay men (verbal harassment 22.7% vs. 32.3%, and discrimination 15.7% vs. 23.0%). Relevant depressive symptoms were reported by 43.1% of bisexual men and 34.2% of gay men (p < 0.001). Statistically significant differences in depressive symptoms between bisexual and gay men disappeared after adjusting for socioeconomic factors. The three enacted stigma dimensions were significantly associated with depressive symptoms, but their interaction with sexual orientation identity was not.
Conclusion: This study confirms the association between enacted stigma and depressive symptoms among gay and bisexual men. However, sexual orientation identity did not modify this association as hypothesized. The bisexual men presented other psychosocial stressors that may explain their higher prevalence of depressive symptoms. The high levels of verbal harassment, discrimination, and physical assault reported by gay and bisexual men and their negative effect on mental health indicate the need to develop new effective public health strategies to avoid these consequences of homophobic and biphobic culture.
Keywords: bisexual men, discrimination, gay men, mental health, stigma
Introduction
Despite major changes over the past two decades, gay and bisexual men remain stigmatized in many countries worldwide due to their sexual orientation.1,2 Stigma has been defined as the social discrediting of a marginalized individual or group by others due to perceived negative attributes.3 Stigma is a complex and broad concept, which may include perceived, internalized, and enacted stigma.4–6
Compared to bisexual individuals, gay men report higher rates of enacted stigma (verbal harassment, discrimination, and physical violence),7,8 which has been attributed to their greater visibility.9 On the other hand, bisexual individuals may experience pressure to conform to a binary sexual orientation,10 and prejudice due to specific stereotypes associated with bisexuality such as confusion, promiscuity,11,12 or being a “bridge” population for HIV.13 Bisexual men may also confront prejudicial behaviors and attitudes within the LGBT community.14–17
Both gay and bisexual men are at increased risk for adverse mental health outcomes in comparison to their heterosexual counterparts, but bisexual men have been found to present higher rates of adverse outcomes than gay men.10 These mental health disparities have been attributed to numerous factors, such as stigma10,18 and socioeconomic position19–21 as well as their interrelation.7,10 Several studies have evaluated the association between mental health and sexual orientation-related stigma,16,22–29 but without evaluating if this association differs between gay and bisexual men.
Are mental health disparities between gay and bisexual men explained mostly by differences in demographic, socioeconomic, and relational factors? Or is enacted stigma related to depression differently for gay versus bisexual men? For example, experiencing frequent enacted stigma could facilitate the development of tools, strategies, or mechanisms to cope with their negative effects on mental health among gay men. In contrast, among bisexual men, the differential stress of not disclosing their sexual orientation and internalizing negative attitudes toward effeminacy could modify the effect of enacted stigma on their mental health.30
The aim of our study was to assess differences between gay and bisexual men in enacted stigma, and how the association between stigma and depressive symptoms may vary according to sexual orientation identity, using data collected in Baltimore in 2011 and 2014. Our general hypothesis was that sexual orientation identity can affect stigma experiences and modify their effect on depressive symptoms, producing different patterns for gay and bisexual men.7,22–24 Following the structural framework proposed by Mulé et al.31 and the minority stress model,18 our specific hypotheses were as follows: (1) we expect higher prevalence of depressive symptoms in men reporting more enacted stigma experiences; (2) race/ethnicity7 may modify the association of stigma with mental health; (3) stigma and other minority stressors18,27,32 are situated within general environmental circumstances; as bisexual men may have a lower socioeconomic status compared with gay men,19–21 this can confound the association between stigma and depressive symptoms33; and (4) being open about one's sexual orientation and being in a relationship can have negative consequences for bisexual people34,35 in ways that differ from gay or heterosexual men, thus modifying the impact of stigma on depressive symptoms.
Methods
Sampling and recruitment
The National HIV Behavioral Surveillance (NHBS) is conducted in rotating annual cycles to monitor HIV prevalence and sociobehavioral characteristics among men who have sex with men (MSM), injection drug users, and those with a heightened risk through heterosexual sex, in ∼20 cities in the United States.36,37 NHBS procedures have been published previously.38,39
For this study, we focused on the MSM sample recruited in the Baltimore metropolitan area in 2011 and 2014. The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB) and the Maryland Department of Health IRB (H.34.03.07.02.A1). MSM were recruited using venue-based, time-space sampling methods described elsewhere.36 Eligible participants were males 18 years of age or older who were residents of the Baltimore metropolitan region, reported oral or anal sex with another man in the past 12 months, and were able to complete the survey in English or Spanish.38 After completing the informed consent procedures, eligible participants responded to a structured computerized interview administered anonymously by trained interviewers.
Measures
Health determinants
Sociodemographic characteristics included age, race/ethnicity, education level, employment status, household annual income, homelessness (past 12 months), and marital status. Race/ethnicity was classified according to the racial group or groups with which the men identified, and a further question for those with Hispanic or Latin-American origin. Household annual income before taxes was dichotomized applying the cutoff point of $20,000 (average poverty threshold for a family of three in 2014, as defined by the United States Census Bureau)40 to be consistent with previous research.7,41
Sexual orientation-related variables
Respondents were asked to identify which category best described them (heterosexual or “straight,” homosexual or gay, and bisexual) and a question on sexual orientation disclosure regarding same-sex attraction: “have you told anyone that you are attracted to or have sex with men?” (Yes/No).
Enacted stigma
The enacted stigma scale included in NHBS was adapted from previously published surveys,42–45 and assessed discrimination based on perceived same-sex attraction. Specifically, men were asked if they had experienced any situation (out of a list of five) as a result of someone knowing or assuming they were attracted to men. These five items covered three enacted stigma dimensions45: verbal harassment (being called names or insulted), discrimination (receiving poorer services in restaurants, stores, or other businesses; been treated unfairly at work or school; and been denied or given lower quality health care), and physical assault (physically attacked or injured).
Depressive symptoms
Depressive symptoms were measured with the 10-question version of the Center for Epidemiologic Studies Depression (CES-D-10) Scale,46 which was included only in the Baltimore local survey. The revised CES-D-10 measured with a four-point scale the frequency with which each mood or symptom had occurred “during the past week”46: scores range from 0 to 30, and a cutoff point of 10 or higher indicates the presence of clinically relevant depressive symptoms.
Statistical analysis
The statistical power, calculated retrospectively for the bisexual group due to its smaller sample size (n = 331), allowed the detection of prevalence ratios of 1.5 on relevant depressive symptoms between men who had experienced enacted stigma and those who had not, with alpha risk of 0.05 and beta of 0.1. The χ2 was used to test differences between gay, bisexual, and heterosexual groups, between waves, between participants who did or did not complete the CES-D-10 Scale, and between individuals who did or did not report depressive symptoms.
To evaluate differential item functioning (DIF)47 of the enacted stigma scale by sexual orientation identity, three nested models were constructed with logistic regression for each item (dependent variable): Model 1 only included the total stigma score (number of experiences endorsed); Model 2 added sexual orientation identity; and Model 3 also included the interaction between the total stigma score and sexual orientation identity. McFadden's pseudo R2 > 0.02 between Model 1 and Model 2 and between Model 2 and Model 3 indicate, respectively, uniform and nonuniform DIF.
We built Generalized Estimating Equation (GEE) models using a Poisson distribution to assess differences by sexual orientation identity, first in stigma and second in depressive symptoms. In both cases, to examine the hypothesis, four nested models were constructed: adjusting for study wave and age (Model 1); then adding race/ethnicity (Model 2); introducing education level, household annual income, employment status, and homelessness as socioeconomic factors (Model 3); and finally adding sexual orientation disclosure and marital status as relational factors (Model 4). These nested models were compared using the quasi-likelihood under the Independence model Criterion.48 GEE models were constructed to account for clustering49 by venue and date. Poisson regression distribution was selected to estimate the prevalence ratio,50 which is easier to interpret and communicate in cross-sectional studies than an odds ratio.
To assess differences in enacted stigma between gay and bisexual men, models were constructed for any experience of enacted stigma, and also for each specific dimension of enacted stigma (dependent variable). To study the relationship between stigma and relevant depressive symptoms (dependent variable), the models tested interactions between sexual orientation identity and stigma, among stigma dimensions, and of stigma with race/ethnicity, sexual orientation disclosure, and marital status. Analyses were conducted using STATA 12.0 (StataCorp. 2011; StataCorp LP, College Station, TX) and SAS 9.4 (SAS Institute Inc., Cary, NC).
Results
Sample characteristics
Most of the participants identified as gay (n = 671), followed by bisexual (n = 331) and heterosexual men (n = 57). Table 1 shows that gay men were significantly younger, more frequently living with a partner, employed, with a higher level of education and household annual income, less frequently homeless, and had a lower prevalence of relevant depressive symptoms (34.2% vs. 43.1% and 59.3%; p < 0.001) than bisexual and heterosexual men. As the sexual orientation-related stigma scale was not administered to the heterosexual participants, this group was excluded from the analysis. Compared with bisexual men, gay men reported more frequently being non-Hispanic White, having disclosed their sexual orientation, and having experienced verbal harassment (32.3% vs. 22.7%; p = 0.002) and discrimination (23.0% vs. 15.7%; p = 0.008).
Table 1.
Health Determinants, Depressive Symptoms, and Sexual Minority-Related Enacted Stigma in Men Who Have Sex with Men by Study Wave and Sexual Orientation Identity in the Baltimore-Towson-Columbia Metropolitan Statistical Area, 2011 and 2014
| Gay (n = 671), n (%) | Bisexual (n = 331), n (%) | Heterosexual (n = 57), n (%) | p* | Gay and bisexual MSM (n = 1002), n (%) | 2011 (n = 468), n (%) | 2014 (n = 534), n (%) | p | |
|---|---|---|---|---|---|---|---|---|
| Health determinants | ||||||||
| Sexual orientation identity | ||||||||
| Gay | 671 (67.0) | 306 (65.4) | 365 (68.4) | 0.319 | ||||
| Bisexual | 331 (33.0) | 162 (34.6) | 169 (31.6) | |||||
| Age groups | ||||||||
| 18–24 | 202 (30.1) | 70 (21.1) | 8 (14.0) | <0.001a,b | 272 (27.1) | 155 (33.1) | 117 (21.9) | <0.001 |
| 25–39 | 283 (42.2) | 113 (34.1) | 21 (36.8) | 396 (39.5) | 153 (32.7) | 243 (45.5) | ||
| ≥40 | 186 (27.7) | 148 (44.7) | 28 (49.1) | 334 (33.3) | 160 (34.2) | 174 (32.6) | ||
| Race/ethnicity | ||||||||
| Non-Hispanic White | 151 (22.6) | 35 (10.6) | 12 (21.1) | <0.001a | 186 (18.6) | 65 (13.9) | 121 (22.7) | <0.001 |
| Non-Hispanic Black | 442 (66.3) | 264 (79.8) | 40 (70.2) | 706 (70.7) | 360 (77.1) | 346 (65.2) | ||
| Hispanic | 25 (3.7) | 7 (2.1) | 2 (3.5) | 32 (3.2) | 11 (2.4) | 21 (3.9) | ||
| Multiracial | 37 (5.5) | 20 (6.0) | 2 (3.5) | 57 (5.7) | 26 (5.6) | 31 (5.8) | ||
| Other | 12 (1.8) | 5 (1.5) | 1 (1.8) | 17 (1.7) | 5 (1.1) | 12 (2.3) | ||
| Missing | 4 (0.1) | 0 (0.0) | 0 (0.0) | 4 (0.4) | 1 (0.2) | 3 (0.6) | ||
| Education level | ||||||||
| Grades 1–8 | 5 (0.7) | 6 (1.8) | 2 (3.5) | <0.001a,b | 11 (1.1) | 5 (1.1) | 6 (1.1) | <0.001 |
| Grades 9–11 | 28 (4.2) | 62 (18.7) | 14 (24.6) | 90 (9.0) | 58 (12.4) | 32 (6.0) | ||
| Grade 12 or GED | 228 (34.0) | 138 (41.7) | 22 (38.6) | 366 (36.5) | 195 (41.7) | 171 (32.0) | ||
| College, Associate's or Technical degree | 213 (31.7) | 86 (26.0) | 13 (22.8) | 299 (29.8) | 144 (30.8) | 155 (29.0) | ||
| Bachelor's degree | 127 (18.9) | 30 (9.1) | 4 (7.0) | 157 (15.7) | 45 (9.6) | 112 (21.0) | ||
| Any postgraduate studies | 70 (10.4) | 9 (2.7) | 2 (3.5) | 79 (7.9) | 21 (4.5) | 58 (10.9) | ||
| Household annual income | ||||||||
| $0 to $19,999 | 264 (41.6) | 202 (63.3) | 39 (73.6) | <0.001a,b | 466 (48.9) | 243 (54.4) | 223 (44.1) | 0.002 |
| ≥ $20,000 | 370 (58.4) | 117 (36.7) | 14 (26.4) | 487 (51.1) | 204 (45.6) | 283 (55.9) | ||
| Missing | 37 (5.5) | 12 (3.6) | 4 (7.0) | 49 (4.9) | 21 (4.5) | 28 (5.2) | ||
| Employment status | ||||||||
| Employed | 423 (63.0) | 154 (46.5) | 27 (47.4) | <0.001a,b | 577 (57.6) | 243 (51.9) | 334 (62.5) | 0.001 |
| Full-time student | 51 (7.6) | 15 (4.5) | 0 (0.0) | 66 (6.6) | 28 (6.0) | 38 (7.1) | ||
| Unemployed or retired | 139 (20.7) | 121 (36.6) | 22 (38.6) | 260 (25.9) | 149 (31.8) | 111 (20.8) | ||
| Unable to work for health reasons | 33 (4.9) | 25 (7.6) | 6 (10.5) | 58 (5.8) | 23 (4.9) | 35 (6.6) | ||
| Other | 25 (3.7) | 16 (4.8) | 2 (3.5) | 41 (4.1) | 25 (5.3) | 16 (3.0) | ||
| Homelessness in the past 12 months | ||||||||
| No | 620 (92.4) | 243 (73.9) | 39 (68.4) | <0.001a,b | 863 (86.3) | 392 (84.1) | 471 (88.2) | 0.061 |
| Yes | 51 (7.6) | 86 (26.1) | 18 (31.6) | 137 (13.7) | 74 (15.9) | 63 (11.8) | ||
| Missing | 0 (0.0) | 2 (0.6) | 0 (0.0) | 2 (0.2) | 2 (0.4) | 0 (0.0) | ||
| Marital status | ||||||||
| Married or cohabiting with a man | 206 (32.3) | 38 (11.8) | 0 (0.0) | <0.001a,b,c | 244 (25.4) | 109 (23.9) | 135 (26.8) | 0.412 |
| Married or cohabiting with a woman | 0 (0.0) | 40 (12.4) | 15 (27.8) | 40 (4.2) | 22 (4.8) | 18 (3.6) | ||
| Not married or cohabiting | 432 (67.7) | 244 (75.8) | 39 (72.2) | 676 (70.4) | 325 (71.3) | 351 (69.6) | ||
| Missing | 33 (4.9) | 9 (2.7) | 3 (5.3) | 42 (4.2) | 12 (2.6) | 30 (5.6) | ||
| Sexual orientation disclosure | ||||||||
| No | 28 (4.2) | 109 (32.9) | — | <0.001 | 137 (13.7) | 71 (15.2) | 66 (12.4) | 0.196 |
| Yes | 643 (95.8) | 222 (67.1) | — | 865 (86.3) | 397 (84.8) | 468 (87.6) | ||
| Missing | 0 (0.0) | 0 (0.0) | 57 (100.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| Depressive symptoms (score ≥10) | ||||||||
| No | 416 (65.8) | 181 (56.9) | 22 (40.7) | <0.001a,b,c | 597 (62.8) | 276 (61.7) | 321 (63.8) | 0.509 |
| Yes | 216 (34.2) | 137 (43.1) | 32 (59.3) | 353 (37.2) | 171 (38.3) | 182 (36.2) | ||
| Missing | 39 (5.8) | 13 (3.9) | 3 (5.3) | 52 (5.2) | 21 (4.5) | 31 (5.8) | ||
| Verbal harassment | ||||||||
| No | 453 (67.7) | 256 (77.3) | — | 0.002 | 709 (70.9) | 332 (71.1) | 377 (70.7) | 0.900 |
| Yes | 216 (32.3) | 75 (22.7) | — | 291 (29.1) | 135 (28.9) | 156 (29.3) | ||
| Missing | 2 (0.3) | 0 (0.0) | 57 (100.0) | 2 (0.2) | 1 (0.2) | 1 (0.2) | ||
| Service discrimination | ||||||||
| No | 580 (86.4) | 296 (89.4) | — | 0.180 | 876 (87.4) | 404 (86.3) | 472 (88.4) | 0.325 |
| Yes | 91 (13.6) | 35 (10.6) | — | 126 (12.6) | 64 (13.7) | 62 (11.6) | ||
| Missing | 0 (0.0) | 0 (0.0) | 57 (100.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| Work/school discrimination | ||||||||
| No | 579 (86.4) | 303 (92.1) | — | 0.009 | 882 (88.3) | 406 (86.9) | 476 (89.5) | 0.214 |
| Yes | 91 (13.6) | 26 (7.9) | — | 117 (11.7) | 61 (13.1) | 56 (10.5) | ||
| Missing | 1 (0.1) | 2 (0.6) | 57 (100.0) | 3 (0.3) | 1 (0.2) | 2 (0.4) | ||
| Health care discrimination | ||||||||
| No | 657 (97.9) | 320 (97.0) | — | 0.359 | 977 (97.6) | 456 (97.4) | 521 (97.7) | 0.747 |
| Yes | 14 (2.1) | 10 (3.0) | — | 24 (2.4) | 12 (2.6) | 12 (2.3) | ||
| Missing | 0 (0.0) | 1 (0.3) | 57 (100.0) | 1 (0.1) | 0 (0.0) | 1 (0.2) | ||
| Any discrimination | ||||||||
| No | 517 (77.0) | 279 (84.3) | — | 0.008 | 796 (79.4) | 364 (77.8) | 432 (80.9) | 0.223 |
| Yes | 154 (23.0) | 52 (15.7) | — | 206 (20.6) | 104 (22.2) | 102 (19.1) | ||
| Missing | 0 (0.0) | 0 (0.0) | 57 (100.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| Physical assault | ||||||||
| No | 610 (90.9) | 312 (94.3) | — | 0.066 | 922 (92.0) | 424 (90.6) | 498 (93.3) | 0.121 |
| Yes | 61 (9.1) | 19 (5.7) | — | 80 (8.0) | 44 (9.4) | 36 (6.7) | ||
| Missing | 0 (0.0) | 0 (0.0) | 57 (100.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
Bold denotes significance at a level of p < 0.05.
Statistically significant differences (p < 0.05) between sexual orientation identity groups are specified in superscript letters: aGay versus bisexual; bgay versus heterosexual; cbisexual versus heterosexual.
GED, General Educational Development; MSM, men who have sex with men.
There were significant differences in age, race/ethnicity, education level, household annual income, and employment status between men in the 2011 and 2014 waves. The comparison between participants who did and those who did not complete the CES-D-10 scale (Supplementary Table S1) only showed differences in age (p = 0.017) and household annual income (p = 0.009). No DIF between gay and bisexual men was observed for any of the enacted stigma questions (Table 2).
Table 2.
Differential Item Functioning of the Enacted Stigma Scale by Sexual Orientation Identity
| Item | Pseudo R2 change |
Relative β change | ||
|---|---|---|---|---|
| Uniform DIF | Nonuniform DIF | Overall DIF | ||
| “You were called names or insulted” | <0.01 | 0.004 | 0.004 | 0.003 |
| “You received poorer services than other people in restaurants, stores, other businesses or agencies” | 0.001 | 0.003 | 0.004 | 0.003 |
| “You were treated unfairly at work or school” | 0.003 | <0.01 | 0.003 | <0.001 |
| “You were denied or given lower quality health care” | 0.017 | <0.01 | 0.017 | 0.029 |
| “You were physically attacked or injured” | 0.002 | <0.01 | 0.002 | <0.001 |
Pseudo R2 and relative change of coefficient statistics for DIF analyses by sexual orientation identity (gay vs. bisexual men).
DIF, differential item functioning.
Depressive symptoms by enacted stigma
Figure 1 shows that the prevalence of depressive symptoms was statistically higher among gay men who reported experiencing enacted stigma than among gay men who did not: verbal harassment (43.78% vs. 29.77%, p = 0.001), discrimination (46.21% vs. 30.60%, p = 0.001), and physical assault (51.67% vs. 32.34%, p = 0.003). However, among bisexual men, statistically significant differences were only detected in discrimination (p = 0.031).
FIG. 1.
Percentages of participants presenting relevant depressive symptoms among those who reported (darkest gray) or not (lighter gray) sexual minority-related enacted stigma, separately for gay and bisexual men in Baltimore, 2011 and 2014. Bold denotes significance at the level of p < 0.05.
Enacted stigma by sexual orientation identity and socioeconomic factors
Table 3 shows nested models examining which characteristics were independently associated with reporting any enacted stigma experience. Prevalence of enacted stigma experience was statistically lower among bisexual men, the oldest group (≥40 years), and non-Hispanic Black men. Participants who were unable to work for health reasons and those who reported past 12-month homelessness presented statistically higher prevalence of enacted stigma experiences. Supplementary Table S2 shows models constructed separately for each dimension.
Table 3.
Generalized Estimating Equation Models Using a Poisson Distribution to Assess the Association of Sexual Orientation Identity and Other Characteristics with any Enacted Stigma Experience (Dependent Variable) Among Gay and Bisexual Men in the Baltimore-Towson-Columbia Metropolitan Statistical Area, 2011 and 2014
| Model 1 |
Model 2 |
Model 3 |
Model 4 |
|||||
|---|---|---|---|---|---|---|---|---|
| Estimate, aPR (95% CI) | p | Estimate, aPR (95% CI) | p | Estimate, aPR (95% CI) | p | Estimate, aPR (95% CI) | p | |
| Intercept | 0.49 (0.43–0.57) | <0.001 | 0.57 (0.46–0.71) | <0.001 | 0.61 (0.42–0.89) | 0.010 | 0.60 (0.40–0.88) | 0.010 |
| Sexual orientation identity | ||||||||
| Gay | Ref. | Ref. | Ref. | Ref. | ||||
| Bisexual | 0.75 (0.61–0.92) | 0.005 | 0.77 (0.63–0.95) | 0.012 | 0.69 (0.56–0.85) | 0.001 | 0.74 (0.58–0.93) | 0.011 |
| Wave | ||||||||
| 2011 | Ref. | Ref. | Ref. | Ref. | ||||
| 2014 | 0.94 (0.80–1.10) | 0.447 | 0.92 (0.78–1.08) | 0.283 | 0.93 (0.78–1.09) | 0.365 | 0.94 (0.79–1.11) | 0.449 |
| Age groups, years | ||||||||
| 18–24 | Ref. | Ref. | Ref. | Ref. | ||||
| 25–39 | 0.92 (0.77–1.11) | 0.378 | 0.89 (0.74–1.06) | 0.191 | 0.86 (0.71–1.03) | 0.096 | 0.87 (0.71–1.06) | 0.155 |
| ≥40 | 0.73 (0.59–0.91) | 0.004 | 0.71 (0.58–0.88) | 0.002 | 0.63 (0.50–0.80) | <0.001 | 0.66 (0.52–0.85) | 0.001 |
| Race/ethnicity | ||||||||
| Non-Hispanic White | Ref. | Ref. | Ref. | |||||
| Non-Hispanic Black | 0.83 (0.68–1.01) | 0.062 | 0.79 (0.64–0.98) | 0.029 | 0.75 (0.60–0.93) | 0.009 | ||
| Hispanic | 1.18 (0.83–1.69) | 0.360 | 1.11 (0.75–1.64) | 0.607 | 1.08 (0.70–1.67) | 0.735 | ||
| Multiracial | 1.01 (0.70–1.44) | 0.975 | 0.92 (0.64–1.32) | 0.650 | 0.99 (0.70–1.39) | 0.935 | ||
| Other | 0.92 (0.51–1.68) | 0.792 | 0.82 (0.40–1.66) | 0.575 | 0.72 (0.31–1.67) | 0.440 | ||
| Education level | ||||||||
| Grades 1–11 | Ref. | Ref. | ||||||
| Grade 12 or GED | 0.95 (0.70–1.28) | 0.730 | 0.91 (0.68–1.23) | 0.538 | ||||
| College, Associate's or Technical degree | 1.07 (0.78–1.48) | 0.672 | 0.97 (0.70–1.35) | 0.876 | ||||
| Bachelor's degree | 0.85 (0.57–1.27) | 0.430 | 0.79 (0.53–1.17) | 0.242 | ||||
| Any postgraduate studies | 0.98 (0.62–1.57) | 0.945 | 0.81 (0.49–1.34) | 0.412 | ||||
| Household annual income | ||||||||
| ≥ $20,000 | Ref. | Ref. | ||||||
| $0 to $19,999 | 0.99 (0.83–1.19) | 0.942 | 1.02 (0.85–1.23) | 0.800 | ||||
| Employment status | ||||||||
| Employed | Ref. | Ref. | ||||||
| Full-time student | 0.79 (0.56–1.12) | 0.192 | 0.74 (0.51–1.07) | 0.113 | ||||
| Unemployed or retired | 1.01 (0.84–1.22) | 0.931 | 1.00 (0.83–1.21) | 0.991 | ||||
| Unable to work for health reasons | 1.45 (1.07–1.97) | 0.017 | 1.49 (1.10–2.01) | 0.009 | ||||
| Other | 1.12 (0.75–1.69) | 0.576 | 1.17 (0.77–1.77) | 0.468 | ||||
| Homelessness in the past 12 months | ||||||||
| No | Ref. | Ref. | ||||||
| Yes | 1.54 (1.23–1.92) | <0.001 | 1.50 (1.20–1.88) | <0.001 | ||||
| Sexual orientation disclosure | ||||||||
| Yes | Ref. | |||||||
| No | 0.74 (0.53–1.04) | 0.080 | ||||||
| Marital status | ||||||||
| Married or cohabiting with a man | Ref. | |||||||
| Married or cohabiting with a woman | 0.66 (0.33–1.29) | 0.222 | ||||||
| Not married or cohabiting | 1.18 (0.97–1.42) | 0.095 | ||||||
| QICu | 2403.5 | 2382.8 | 2254.2 | 2126.3 | ||||
Bold denotes significance at a level of p < 0.05.
Nested models: first, adjusting by study wave and age (Model 1); then adding race/ethnicity (Model 2); next adding socioeconomic factors, including education level, household annual income, employment status, and homelessness (Model 3); and finally adding sexual orientation disclosure and marital status as relational factors (Model 4).
aPR, adjusted prevalence ratio; CI, confidence interval; QICu: quasi-likelihood under the Independence model Criterion.
Association of depressive symptoms with enacted stigma
Table 4 shows adjusted prevalence ratios (aPR) for depressive symptoms. As the interactions between sexual orientation identity and enacted stigma were not statistically significant, they were not included in the final model: aPR of the interaction with verbal harassment was 0.80 (95% confidence interval [CI] 0.54–1.16), with discrimination it was 1.06 (95% CI 0.71–1.58), and with physical assault it was 0.86 (95% CI 0.44–1.68). Statistically significant higher prevalence of depressive symptoms in bisexual men compared with gay men (reference category) in Models 1 and 2 disappeared after adding socioeconomic factors in Model 3 (aPR 1.10, 95% CI 0.91–1.32) and relational factors in Model 4 (aPR 1.06, 95% CI 0.87–1.30). The three enacted stigma dimensions, as well as the interactions between the dimensions, were significantly associated with depressive symptoms. Significantly higher aPR were seen for nonemployed men (1.30 for those who were unemployed or retired and 1.78 for those unable to work for health reasons) as well as for full-time students (1.51) and those who indicated “other” for employment status (1.60), also for men who were neither married nor cohabiting (1.35). No statistically significant interactions were found between the three dimensions of enacted stigma and race/ethnicity (p = 0.42, 0.46, and 0.08), sexual orientation disclosure (p = 0.19, 0.83, and 0.68), or marital status (p = 0.77, 0.27, and 0.61).
Table 4.
Generalized Estimating Equation Using a Poisson Distribution to Assess the Association of Sexual Orientation Identity, Enacted Stigma, and Other Characteristics with Clinically Relevant Depressive Symptoms (Dependent Variable) Among Gay and Bisexual Men in the Baltimore-Towson-Columbia Metropolitan Statistical Area, 2011 and 2014
| Model 1 |
Model 2 |
Model 3 |
Model 4 |
|||||
|---|---|---|---|---|---|---|---|---|
| Estimate, aPR (95% CI) | p | Estimate, aPR (95% CI) | p | Estimate, aPR (95% CI) | p | Estimate, aPR (95% CI) | p | |
| Intercept | 0.27 (0.21–0.34) | <0.001 | 0.26 (0.19–0.35) | <0.001 | 0.26 (0.18–0.38) | <0.001 | 0.22 (0.14–0.33) | <0.001 |
| Sexual orientation identity | ||||||||
| Gay | Ref. | Ref. | Ref. | Ref. | ||||
| Bisexual | 1.28 (1.08–1.52) | 0.005 | 1.27 (1.06–1.51) | 0.008 | 1.10 (0.91–1.32) | 0.335 | 1.06 (0.87–1.30) | 0.551 |
| Enacted stigma dimensions and their interactions | ||||||||
| Verbal harassment | ||||||||
| No | Ref. | Ref. | Ref. | Ref. | ||||
| Yes | 1.52 (1.19–1.93) | 0.001 | 1.51 (1.19–1.93) | 0.001 | 1.42 (1.12–1.80) | 0.004 | 1.39 (1.09–1.77) | 0.008 |
| Discrimination | ||||||||
| No | Ref. | Ref. | Ref. | Ref. | ||||
| Yes | 1.79 (1.38–2.32) | <0.001 | 1.78 (1.37–2.31) | <0.001 | 1.83 (1.40–2.37) | <0.001 | 1.76 (1.35–2.29) | <0.001 |
| Physical assault | ||||||||
| No | Ref. | Ref. | Ref. | Ref. | ||||
| Yes | 2.14 (1.39–3.30) | 0.001 | 2.13 (1.39–3.28) | 0.001 | 2.00 (1.28–3.13) | 0.003 | 2.04 (1.29–3.22) | 0.002 |
| Verbal × Discrimination | ||||||||
| No | Ref. | Ref. | Ref. | Ref. | ||||
| Yes | 0.49 (0.33–0.75) | 0.001 | 0.50 (0.33–0.76) | 0.001 | 0.45 (0.30–0.69) | <0.001 | 0.48 (0.31–0.75) | 0.001 |
| Verbal × Physical | ||||||||
| No | Ref. | Ref. | Ref. | Ref. | ||||
| Yes | 0.35 (0.17–0.72) | 0.005 | 0.36 (0.17–0.73) | 0.005 | 0.39 (0.19–0.81) | 0.011 | 0.41 (0.20–0.82) | 0.012 |
| Discrimination × Physical | ||||||||
| No | Ref. | Ref. | Ref. | Ref. | ||||
| Yes | 0.39 (0.18–0.84) | 0.016 | 0.39 (0.18–0.84) | 0.016 | 0.29 (0.12–0.70) | 0.006 | 0.29 (0.11–0.73) | 0.009 |
| Verbal × Discrimination × Physical | ||||||||
| No | Ref. | Ref. | Ref. | Ref. | ||||
| Yes | 6.26 (2.19–17.91) | 0.001 | 6.26 (2.19–17.92) | 0.001 | 7.80 (2.52–24.16) | <0.001 | 7.23 (2.30–22.77) | 0.001 |
| Wave | ||||||||
| 2011 | Ref. | Ref. | Ref. | Ref. | ||||
| 2014 | 0.97 (0.82–1.14) | 0.693 | 0.97 (0.82–1.15) | 0.728 | 1.02 (0.87–1.21) | 0.782 | 1.02 (0.87–1.21) | 0.777 |
| Age groups, years | ||||||||
| 18–24 | Ref. | Ref. | Ref. | Ref. | ||||
| 25–39 | 0.96 (0.79–1.17) | 0.695 | 0.96 (0.79–1.18) | 0.718 | 0.96 (0.78–1.19) | 0.738 | 0.97 (0.79–1.20) | 0.806 |
| ≥40 | 1.19 (0.96–1.47) | 0.112 | 1.19 (0.96–1.48) | 0.107 | 1.11 (0.88–1.40) | 0.358 | 1.11 (0.89–1.40) | 0.354 |
| Race/ethnicity | ||||||||
| Non-Hispanic White | Ref. | Ref. | Ref. | |||||
| Non-Hispanic Black | 1.04 (0.82–1.30) | 0.758 | 0.86 (0.69–1.08) | 0.193 | 0.84 (0.67–1.06) | 0.140 | ||
| Hispanic | 0.99 (0.58–1.67) | 0.960 | 1.01 (0.61–1.67) | 0.978 | 1.02 (0.61–1.71) | 0.931 | ||
| Multiracial | 1.06 (0.72–1.54) | 0.779 | 0.96 (0.66–1.40) | 0.827 | 0.95 (0.65–1.40) | 0.812 | ||
| Other | 1.08 (0.63–1.84) | 0.790 | 0.97 (0.53–1.79) | 0.923 | 0.98 (0.51–1.86) | 0.944 | ||
| Education level | ||||||||
| Grades 1–11 | Ref. | Ref. | ||||||
| Grade 12 or GED | 0.94 (0.74–1.20) | 0.634 | 0.95 (0.74–1.20) | 0.647 | ||||
| College, Associate's or Technical degree | 0.96 (0.74–1.24) | 0.757 | 0.95 (0.74–1.24) | 0.717 | ||||
| Bachelor's degree | 0.72 (0.51–1.02) | 0.068 | 0.73 (0.52–1.03) | 0.071 | ||||
| Any postgraduate studies | 0.81 (0.51–1.27) | 0.356 | 0.82 (0.52–1.28) | 0.385 | ||||
| Household annual income | ||||||||
| ≥ $20,000 | Ref. | Ref. | ||||||
| $0 to $19,999 | 1.26 (1.03–1.55) | 0.026 | 1.21 (0.98–1.49) | 0.079 | ||||
| Employment status | ||||||||
| Employed | Ref. | Ref. | ||||||
| Full-time student | 1.51 (1.02–2.24) | 0.042 | 1.51 (1.03–2.23) | 0.037 | ||||
| Unemployed or retired | 1.32 (1.07–1.63) | 0.010 | 1.30 (1.05–1.61) | 0.015 | ||||
| Unable to work for health reasons | 1.78 (1.36–2.33) | <0.001 | 1.78 (1.36–2.34) | <0.001 | ||||
| Other | 1.65 (1.20–2.27) | 0.002 | 1.60 (1.15–2.22) | 0.005 | ||||
| Homelessness in the past 12 months | ||||||||
| No | Ref. | Ref. | ||||||
| Yes | 1.10 (0.87–1.38) | 0.417 | 1.08 (0.86–1.36) | 0.488 | ||||
| Sexual orientation disclosure | ||||||||
| Yes | Ref. | |||||||
| No | 1.10 (0.88–1.38) | 0.411 | ||||||
| Marital status | ||||||||
| Married or cohabiting with a man | Ref. | |||||||
| Married or cohabiting with a woman | 0.99 (0.56–1.78) | 0.984 | ||||||
| Not married or cohabiting | 1.35 (1.08–1.68) | 0.008 | ||||||
| QICu | 2187.3 | 2180.2 | 2076.6 | 2095.9 | ||||
Bold denotes significance at a level of p < 0.05.
Nested models: first, adjusting by study wave and age (Model 1); then adding race/ethnicity (Model 2); next adding socioeconomic factors, including education level, household annual income, employment status, and homelessness (Model 3); and finally adding sexual orientation disclosure and marital status as relational factors (Model 4).
Discussion
Bisexual men reported enacted stigma experiences less frequently than did gay men even after adjustment. In contrast, our results indicated that socioeconomic and relational factors explain differences between gay and bisexual men in prevalence of depressive symptoms. As expected, men who reported enacted stigma experiences presented higher prevalence of clinically relevant depressive symptoms than those who did not, but the effect of these experiences was not cumulative. Against our a priori hypothesis, sexual orientation identity did not modify the association of enacted stigma with depressive symptoms, neither did race/ethnicity, sexual orientation disclosure, or being in a relationship.
Prevalence of enacted stigma experiences and depressive symptoms
The large proportion of men reporting enacted stigma related to their sexual minority status in the Baltimore NHBS sample analyzed in this article was very similar to U.S. national estimates obtained in 20 cities in 201141: one-third reported verbal harassment, one quarter reported discrimination, and 8% reported physical assault as a result of perceived same-sex attraction.41 The NHBS national report did not provide information on enacted stigma separately for gay and bisexual men, but other studies have found a higher enacted stigma prevalence among gay men compared with bisexual men,7,9,29 as in our study. We found that these differences were not attenuated after adjusting for demographic variables, and socioeconomic and relational factors.
It is worth highlighting that more than one-third of the men in our sample had clinically relevant depressive symptoms, 59.3% among heterosexual MSM, 43.1% among bisexual respondents, and 34.2% among gay men. This result is consistent with a Californian study showing that 25.1% of homosexually experienced heterosexual men, 14.6% of bisexual men, and 11.9% of gay men reported high levels of psychological distress in the last 30 days.51 Furthermore, it adds weight to hypotheses of added social strain among heterosexual and bisexual MSM.51
Effect of stigma on depressive symptoms by sexual orientation identity
Within the context of the minority stress model,18,32 one might expect that those reporting enacted stigma experiences would more frequently show depressive symptoms. Our findings confirm the association between stigma and prevalence of depressive symptoms, but not the cumulative effect of stigma experiences or our general hypothesis about different patterns of association for gay and bisexual men. Physical assault was the enacted stigma dimension most strongly associated with depressive symptoms, followed by discrimination and verbal harassment.
Interactions among enacted stigma dimensions were all statistically significant. The aPR of the interactions between two stigma dimensions were <1, indicating that experiencing two enacted stigma dimensions did not increase the risk of presenting depressive symptoms. This pattern was similar for individuals who reported experiences in all of the three enacted stigma dimensions (aPR 2.03; not tabulated), very close to the aPR of individuals reporting only physical assault experiences. This suggests a saturation phenomenon instead of a cumulative effect of stigma experiences on depressive symptoms. In the case of men who experienced physical assault, for example, additionally experiencing discrimination and/or verbal harassment did not increase the strength of the association between stigma experiences and depressive symptoms.
Stigma measurement
No DIF on the enacted stigma scale indicated that gay and bisexual men answered similarly. However, as this scale focuses on experiences that only happen if someone knows or assumes same-sex attraction, it does not capture the unique challenges related to the disclosure of a bisexual orientation or identity. To address this limitation, specific instruments to assess bisexual stigma have been developed, such as the Anti-Bisexual Experiences Scale52 and the Bisexual Identity Inventory,53 covering dimensions related to internalized stigma. A systematic review54 has found that internalized stigma could be more important than enacted stigma experiences when considering mental health outcomes. Internalized stigma in the current context refers to the internalization of anti-LGB social attitudes by sexual minority individuals.55 Further research measuring both enacted and internalized stigma is needed to understand the effect of stigma on poor mental health.
Demographic and social characteristics of gay, bisexual, and heterosexual participants
Similar to Baltimore's general population, the majority of the participants in this study identified as non-Hispanic Black, but this proportion was significantly higher among bisexual than among gay men (79.8% vs. 66.3%, p < 0.001). Previous research proposed a dynamic ecological model in which race/ethnicity was an important factor in terms of how men organize, interpret, and share their sexual identities.56 The intersection of race/ethnicity and sexual and masculine identities influences sexual behavior, as it limits (and expands) men's options for what may be considered acceptable sexual behavior.56,57 Gay men were younger than bisexual men, and heterosexual men were the oldest group (27.7%, 44.7%, and 49.1% ≥ 40 years old). Some evidence has suggested that a stronger internal dilemma of violating male gender role expectations58 and nonconformity of same-sex attraction59 among older generations may underlie some of these differences.
In this study, men who identified as gay had the highest socioeconomic position, measured by higher education level, employment rates, and household income, and less homelessness, followed by bisexual and heterosexual MSM, the latter presenting the most disadvantaged position. Other studies have also reported socioeconomic differences in this direction between gay and bisexual men.7 The mechanisms underlying these associations would benefit from further study. Our findings suggest that this worse socioeconomic position exacerbates depressive symptoms among bisexual men showing that social instability (e.g., in housing, employment, income, criminal justice, and social relationships) can exacerbate stress and contribute to poor mental health outcomes among these men. Socioeconomic disadvantages may also partly explain the high prevalence of depressive symptoms among heterosexual MSM in our sample. Together, these findings suggest a need to better understand the intersectional relationship between sexual orientation and socioeconomic position.
Limitations and strengths
First, it is important to note the high prevalence of relevant depressive symptoms reported by heterosexual men (59.3%), to whom the enacted stigma scale was not administered. Second, since the sample only included venue-based MSM, participants may not be representative of gay and bisexual men who do not socialize in MSM-identified spaces and suburban or rural men, where stigma is likely to be higher.60–62 It is also important to note that our sample of MSM did not include bisexual men who were not sexually active with men. Third, although GEE models were constructed to account for correlations among individuals recruited in each venue and date, it is possible that some clustering remains unaccounted for, thus either underestimating or overestimating variability. Fourth, as data were collected at two time points, differences found between the 2011 and 2014 waves could be due to either recruitment processes or societal changes. To take this into account, the source wave was included in the models for adjustment. Fifth, enacted stigma and CES-D-10 scales being administered by interviewers, and the difference in time frames (no specific time vs. the past week), may have biased answers and modified results. Finally, the survey design was cross-sectional, which constrains the assessment of causality.
One of the strengths of this study is the large sample size of bisexual (n = 331) and gay men (n = 671). In addition, it is the first study from the NHBS which included use of the CES-D-10 to measure depressive symptoms. This allowed us to understand in further detail the relationship between mental health and enacted stigma among gay and bisexual men.
Conclusion
This study confirms the association between enacted stigma and depressive symptoms among gay and bisexual men, but, contrary to our a priori hypothesis, sexual orientation did not modify this association. The bisexual group presented other psychosocial stressors, which may explain their higher prevalence of depressive symptoms.
The high levels of verbal harassment, discrimination, and physical assault reported by gay and bisexual men, and their negative effect on mental health, indicate the need to develop new effective public health strategies to avoid these mental health consequences of homophobic and biphobic culture. Strategies may include advocating for education on sexual diversity, developing community-building or empowerment interventions to prevent stigma, and designing educational interventions for confronting and coping with mistreatment that consider the specific characteristics of gay and bisexual men.
Supplementary Material
Acknowledgments
The authors acknowledge Aurea Martin for her help with English proofreading, the editing process, and finalizing this article.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This work was supported by the Centers for Disease Control and Prevention by a cooperative agreement with the Maryland Department of Health, a contract of training in research, ISCIII FIS Rio Hortega CM15/00167, DIUE of Generalitat de Catalunya (2014 SGR 748), and National Institute on Drug Abuse K01 DA041259 awarded to Dr. German.
Supplementary Material
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