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Published in final edited form as: Community Ment Health J. 2021 Jul 3;58(4):624–632. doi: 10.1007/s10597-021-00864-z

Recent incarceration and other correlates of psychological distress among African American and Latino men who have sex with men

Jordan J White 1, Nickolas D Zaller 2, M Isabel Fernandez 3, Pilgrim Spikes 4, Stephen Flores 4, Carl A Latkin 1, Cui Yang 1
PMCID: PMC8720901  NIHMSID: NIHMS1756671  PMID: 34216334

Abstract

There is a dearth of research on the intersection of incarceration and psychological distress among African American men who have sex with men (AAMSM) and Latino MSM (LMSM), populations which bear a large burden of HIV in the U.S. Recent incarceration is an important context to examine psychological distress given the critical implications it has on health outcomes. Using baseline data from the Latino and African American Men’s Project (LAAMP), a multi-site randomized HIV behavioral intervention trial, this paper examined the association between recent incarceration and psychological distress, assessed by the Kessler Psychological Distress Scale (K10). Among 1,482 AAMSM and LMSM (AAMSM: 911, LMSM: 571), we found 768 (52%) had ever been incarcerated, 138 (9.3%) had been incarcerated in the past 3 months (i.e., recent incarceration). After adjusting for race, education, access to resources, current living arrangement, participant-reported HIV status, and substance use, participants who had been recently incarcerated were more likely to have mild psychological distress i.e., K10 score 20–24 (aRRR:1.43, 95% CI: 1.20, 1.71) or severe psychological distress, i.e., K10 score>30 (aRRR: 1.89, 95% CI: 1.22, 2.93) than those without history of incarceration. Future interventions should address the needs of individuals with a recent history incarceration by providing case management and supportive services to AAMSM and LMSM in order to adequately address the confluence of HIV risk and mental health disorders among these populations.

Keywords: incarceration, HIV prevention, men who have sex with men, mental health

Introduction

While the U.S. correctional system has seen population declines since 2008, African American and Latino populations continue to represent more than half of adults incarcerated 1. There continues to be an expanding population of minority men who have previously experienced incarceration 2. Among African American males, an estimated 33% has ever experienced felony conviction, and 15 % has ever been to prison; data among Latinos is lacking due to failures to collect and report ethnicity data 3. Sexual minority men are also negatively impacted by incarceration. Gay and bisexual men are three times as likely to be incarcerated compared to general U.S. adult population 4. Typically, the time leading up to incarceration is predicated by a series of stressful events including interactions with police, arrest, and conviction that may impact mental health 5,6. Thus, incarceration often manifests as a significant life event that may lead to negative physical and mental health outcomes 7–9. Incarcerated populations often face an intersection of multiple health conditions including psychological distress, substance use, HIV, and mental health disorders 10,11. Psychological distress measures assess for anxiety and depressive symptoms which often reflect the presence of a mental disorder 12. The prevalence of psychological distress among the general U.S. population is about 5% 13,14. According to the Bureau of Justice Statistics, 26% of people incarcerated in jail and 14% in prison reported mental health problems (i.e. psychological distress, serious psychological distress) in the past 30 days 13.

Several factors can negatively impact the psychological wellbeing of people who have experienced incarceration 7,15. Although there is evidence that incarceration may improve the physical health of some individuals (e.g., HIV care provided during incarceration) 16–18, data suggests that incarceration can exacerbate mental disorders after incarceration when re-entering communities 10,19. According to the Bureau of Justice Statistics, 26% of people incarcerated in jail and 14% in prison reported mental health problems in the past 30 days 13. Incarceration may account or contribute to disparities in mental disorders 20–22 and HIV among racial and sexual minority men, particularly American men who have sex with men (AAMSM) and Latino MSM (LMSM) 18,23–25. Recent estimates suggest a 50% lifetime risk of HIV-infection among AAMSM and 25% among LMSM; in contrast, the lifetime risk for HIV acquisition among white MSM is 9% 26. While African American and Latino men have similar and often lower rates of mental disorders than white men; the clinical onset and impact is often more persistent among minorities 27,28. Prior studies indicate an elevated risk of mortality after incarceration 29,30, particularly in the immediate weeks after release (i.e. recently incarcerated individuals). Two of the leading causes of death post-release from correctional settings are mental health-related, i.e., suicide and drug overdose 31,32.

There is a need to expand research on psychological distress and mental health disorders among AAMSM and LMSM to inform future programs that can improve access of mental health services among AAMSM and LMSM populations, particularly those with experiences of adversity such as incarceration 33.Much of the literature on formerly incarcerated individuals has focused on all-cause mortality 34, substance use 30,35,36 and experiences of violence 37,38. Little is known about the impact of incarceration on psychological distress among sexual minority men including AAMSM and LMSM 39,40. To address this gap, the goal of the current paper is to examine the association between recent incarceration and psychological distress (in the past four weeks) among AAMSM and LMSM. We hypothesized that recent incarceration, as measured by incarceration in the past 3 months, was significantly associated with elevated severity of psychological distress experienced by AAMSM and LMSM after incarceration.

Methods

Baseline data from the Latino and African American Men’s Project (LAAMP), a Centers for Disease Control and Prevention (CDC) - funded multi-site randomized HIV behavioral intervention study of 1,482 (AAMSM: 911, LMSM: 571) were analyzed. AAMSM were enrolled from Baltimore, Chicago, greater Milwaukee, greater Detroit region, and New York City. LMSM were enrolled from Miami and New York City. Data reported here are from baseline interviews conducted from 2007 through 2009. This study was approved by Institutional review boards at each of the study sites. Participants were paid for participation and the compensation varied by study site, ranging from $25.00 to $40.00.

Recruitment

Participants were recruited from gay bars, dance clubs, college campuses, health departments, community-based organizations that serve MSM populations as well as referrals from participants and local health providers. A brief screening was conducted to identify eligible men for the studies. Eligibility criteria included: 1) being at least 18 years of age; 2) identifying as African American or Hispanic/Latino; 3) having at least 2 sexual partners in the past 3 months (at least 1 of whom must have been male); 4) engaging in condomless anal sex with a man in the past three months. Participants were ineligible to participate if they identified as transgender, or did not reside in the cities of the study sites.

At the baseline visit, participants confirmed eligibility and provided written informed consent. Participants completed a behavioral assessment using audio computer-assisted self-interview (ACASI) technology. Following completion of the assessment, all participants received HIV risk-reduction counseling. A rapid HIV antibody test was offered if participants reported being HIV-negative or did not know their current HIV status. For the five African American sites, participants were required to take an HIV-test if they indicated their HIV-status as negative or unknown. If they provided documentation that they had been diagnosed with HIV infection, testing was not conducted. HIV-testing was available to all participants at the Latino sites, but it was not conditional for participation in the study. One of the goals at the Latino sites was to examine if participants took an HIV test after completing the intervention. Latino participants had to be 18 to 49 years of age and report being HIV-negative or unknown status during the eligibility screener. Preliminary positive rapid test results at the baseline visit were confirmed by Western blot testing. Newly diagnosed persons were referred to medical and social services. The full methods have been previously reported elsewhere 25.

Measures

Psychological distress was assessed by the Kessler Psychological Distress Scale (K10) 41, a 10-item scale of distress based on questions about anxiety and depressive symptoms experienced in the most recent 4 week period. The K10 is a screening instrument and practitioners should make a clinical judgment if an individual needs treatment 41. The K10 has been used to assess psychological distress among AAMSM 42, Latinos 43 as well as gay and bisexual men in the U.S. 44. In the current sample, the K10 had a Cronbach’s alpha of 0.91, indicating excellent reliability. We added up the participant responses to the 10 questions in the K10, and constructed a 4-level nominal variable using cut-off scores consistent with published literature 41 to assess severity of psychological distress as follows: <20: likely to have no psychological distress; 20–24: likely to have mild psychological distress; 25–29: likely to have moderate psychological distress, 30 and above: likely to have severe psychological distress.

History of incarceration was assessed by asking “have you ever spent at least one night in jail or prison?” If the answer was affirmative, participants were asked the follow-up question, “was this in the past 3 months” for the recent history of incarceration. A categorical variable of history of incarceration (no history, incarcerated more than 3 months ago, incarcerated within the past 3 months) was created. Sociodemographic factors included age, race (Latino vs. African American), and education (Grade 12, GED or less vs. College, associate or technical degree). Access to resources in the household was assessed by asking the frequency (Never or once a while vs. fairly often or very often) of not having enough money for rent, food or utilities, such as gas, electric and phone. Current living arrangement was assessed with response options “Your own house or apartment,” “Your parent(s) or another family member’s house or apartment,” “At someone else’s house or apartment”, “In a rooming, boarding, halfway house, or a shelter/welfare hotel,” “On the street(s) (vacant lot, abandoned building, park, etc.)” or “other.” Given the high rates of housing instability among CJ involved populations and racial/ethnic and sexual minority males, a binary variable for current living arrangement was constructed for living in own, family member’s or someone else’s house or apartment vs. others 45. Current HIV status was assessed by one question “What was the result of your most recent HIV test before today?” For participants who never had an HIV test, their HIV status was coded as “unknown.”

Participants were asked about the frequency of substance use, including alcohol, marijuana, ecstasy, powered cocaine, rock/crack cocaine, methamphetamines/other amphetamines, poppers, club drugs, heroin, Viagra, recreational/prescription drugs. The most commonly used substances in this sample were alcohol and crack/cocaine. The current analyses focused on frequent binge drinking and crack/cocaine use over the last 3 months. Frequent binge drinking was assessed using one of items from the Alcohol Use Disorders Identification Test (AUDIT)-C 46 “Over the last 3 months, how often did you have six or more drinks on one occasion?” Frequency of crack/cocaine use was assessed by one question “Over the last 3 months, how often did you use powdered cocaine/rock or crack cocaine?” Response options for both questions being “never,” “less than once a month,” “once a month,” “2 or 3 days a month,” “once a week,” or “2 or 3 days a week.” If participant responded “once a week” or “2 or 3 days a week” to any of these questions, they were classified as frequent binge drinker or frequent crack/cocaine users. A 4-level nominal variable was constructed as “0-not frequent binge drinker or frequent crack/cocaine user,” “1-frequent binge drinker, but not frequent crack/cocaine user,” “2- frequent crack/cocaine user, but not frequent binge drinker,” and “3-frequent binger drinker and frequent crack/cocaine user”47.

Data Analysis

Bivariate associations between psychological distress and history of incarceration, sociodemographics, HIV status, and substance use were examined using chi-square statistics. Multinomial logistic regression models were used to assess the relative risk ratio (RRR) for participants with recent history of incarceration for mild, moderate, or severe psychological distress as compared to those without recent history of incarceration at baseline. Relative risk allows for the comparisons of probability of an outcome occurring within a group or subpopulation, while odds ratios compare the likelihood an on outcome between two groups 45. Other covariates that were statistically significant (p<.05) associated with psychological distress in the bivariate models were entered into a multivariate model. Generalized estimating equations (GEE) were used to account for clustering from the same study site. Statistical analyses were performed using Stata Version 15.0 (College Station, TX).

Results

Data from a total of 1,482 participants were included in the current analysis. Overall, 768 participants (52%) had ever been incarcerated, 630 (43%) had been incarcerated more than 3 months ago and 138 (9.3%) had been incarcerated in the previous 3 months (i.e., recent incarceration). Thirty-two AAMSM participants (23%) who had been incarcerated and 106 LMSM (77%) experienced recent incarceration, respectively. Psychological distress was reported by 610 participants (41%). Among those with recent incarceration (n=138), 78 participants (57%) reported mild to severe psychological distress and 60 participants (43%) reported no psychological distress. Participants without recent incarceration (n=1,344), 812 (60%) reported no psychological distress and 532 (40%) reported mild to severe psychological distress. Participants’ socio-demographic and behavioral background information is provided in Table 1.

Table 1.

Socio-demographic characteristics and history of incarceration of 1482 Latino and African-American men who have sex with men (LAAMP)

Total sample No psychological distress Mild psychological distress Moderate psychological distress Severe psychological distress p-Value*
(n = 1482) (n-872) (n=279) (n=167) (n=164)
Had ever been incarcerated
No 714(48%) 464(53%) 126(45%) 69(41%) 55(34%)
Yes 768(52%) 408(47%) 153(55%) 98(59%) 109(67%) <0.001
Have been incarcerated in the past 3 months
No 1344(91%) 812(93%) 246(88%) 149(89%) 137(84%)
Yes 138(9%) 60(7%) 33(12%) 18(11%) 27(16%) <0.001
History of incarceration
No history 714(48%) 464(53%) 126(45%) 69(41%) 55(34%)
more than 3 months ago 630(43%) 348(40%) 120(43%) 80(48%) 82(50%)
in the past 3 months 138(9%) 60(7%) 33(12%) 18(11%) 27(16%) <0.001
Race
Latino 571(39%) 376(43%) 94(34%) 61(37%) 40(24%)
AA/Black 911(61%) 496(57%) 185(66%) 106(63%) 124(76%) <0.001
Age
< 24 288(19%) 161(18%) 57(20%) 38(23%) 32(19%)
25–34 292(20%) 172(20%) 55(20%) 32(19%) 33(20%)
35–44 504(34%) 297(34%) 99(36%) 56(34%) 52(32%)
> 45 398(27%) 242(28%) 68(24%) 41(24%) 47(29%) 0.945
Education
Grade 12, GED or less 793(54%) 433(50%) 156(56%) 97(58%) 107(65%)
College, associate or technical degree 689(46%) 439(50%) 123(44%) 70(42%) 57(35%) 0.001
How often was there not enough money in the household for rent, food or utilities
Never or once a while 1162(78%) 738(85%) 216(77%) 116(70%) 92(56%)
Fairly often or very often 320(22%) 134(15%) 63(23%) 51(30%) 72(44%) <0.001
Current living arrangement
House/apartment (own, family member's or some else's) 1273(86%) 772(89%) 235(84%) 138(83%) 128(78%)
Rooming, boarding, halfway house/shelter/welfare hotel, street or others 209(14%) 100910%) 44(16%) 29(17%) 36(22%) 0.001
Sexual identity
Homosexual/gay /same gender loving 950(64%) 570(65%) 173(62%) 105(62%) 102(65%)
Heterosexual/straight 47(3%) 25(3%) 8(3%) 8(4%) 8(3%)
Bisexual 426(29%) 240(28%) 91(33%) 47(28%) 48(29%)
Queer/not sure/ questioning/other 59(4%) 37(4%) 7(2%) 8(4%) 7(3%) 0.743
Self-reported HIV status
Positive 426(29%) 219(25%) 91(33%) 59(36%) 57(35%)
Unknown 394(26%) 227(26%) 77(27%) 39(23%) 51(31%)
Negative 662(45%) 426(49%) 111(40%) 69(41%) 56(34%) 0.001
Substance Use
Not frequent binge drinker or frequent stimulant use (cocaine/crack) 1063(72%) 700(80%) 181(65%) 95(57%) 87(53%)
Frequent binge drinker 181(12%) 84(10%) 39(14%) 31(19%) 27(16%)
Frequent stimulant use (cocaine/crack) 166(11%) 66(8%) 39(14%) 31(19%) 30(18%)
Frequent binge drinker and stimulant use 72(5%) 22(2%) 20(7%) 10(5%) 20(13%) <0.001
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*

chi-square statistics

Results of the adjusted multinomial logistic regression model are presented in Table 2. After adjusting for race, education, access to resources, current living arrangement, self-reported HIV status, and substance use, participants who had recent incarceration were more likely to have mild psychological distress, i.e., K10 score 20–24 (aRRR: 1.43, 95% CI: 1.20, 1.71) or severe psychological distress, i.e., K10 score>30 (aRRR: 1.89, 95% CI: 1.22, 2.93) than those with no history of incarceration. As compared to those who never or once in a while had insufficient resources, participants with high frequency of insufficient money for rent, food or utilities were more likely to have mild psychological distress (aRRR: 1.43, 95% CI: 1.04, 1.98), moderate psychological distress (aRRR: 2.14, 95% CI: 1.30, 3.54), or severe psychological distress (aRRR: 3.57, 95% CI: 2.40, 5.32). Participants with an unstable living environment were more likely to have severe psychological distress (aRRR: 1.79, 95% CI: 1.14, 2.81) than those with stable living environment. Finally, frequent binge drinking use was significantly associated with mild psychological distress (aRRR: 1.78, 95% CI: 1.17, 2.73), moderate psychological distress (aRRR: 2.69, 95% CI: 1.76, 4.11) and severe psychological distress (aRRR: 2.29, 95% CI :1.37, 3.82).

Table 2.

Adjusted multinomial logistic regression models for psychological distress among Latino and African-American men who have sex with men (n=1,482) (LAAMP)

Mild psychological distress Moderate psychological distress Severe psychological distress
aRRR (95% CI) aRRR (95% CI) aRRR (95% CI)
History of incarceration
No history Reference Reference Reference
more than 3 months ago 0.97(0.84,1.13) 1.12(0.73,1.74) 1.22(0.85,1.75)
in the past 3 months 1.43(1.20,1.71)*** 1.36(0.69,2.69) 1.89(1.22,2.93)**
Race
Latino Reference Reference Reference
African American/Black 1.13(0.78,1.64) 0.72(0.25,2.11) 2.08(1.05, 4.39)*
Education
Grade 12, GED or less Reference Reference Reference
College, associate or technical degree or higher 0.86(0.64,1.16) 0.81(0.69,0.96)* 0.67(0.57,0.80)***
How often was there not enough money in the household for rent, food or utilities
Never or once a while Reference Reference Reference
Fairly often or very often 1.43(1.04,1.98)* 2.14(1.30, 3.54)* 3.57(2.40, 5.32)***
Current living arrangement
House/apartment (own, family member's or some else's) Reference Reference Reference
Rooming, boarding, halfway house/ shelter/welfare hotel 1.33(0.71,2.50) 1.48(0.84,2.62) 1.79(1.14,2.81)*
Self-reported HIV status
Positive Reference Reference Reference
Unknown 0.83(0.51,1.35) 0.67(0.41, 1.10) 0.95 (0.37, 2.48)
Negative 0.75(0.37,1.52) 0.53 (0.23,1.24) 1.12 (0.34, 3.72)
Substance Use
Not frequent binge drinker or
frequent stimulant use (cocaine/crack) Reference Reference Reference
Frequent binge drinker 1.78(1.17,2.73)** 2.69 (1.76, 4.11)*** 2.29 (1.37, 3.82)***
Frequent stimulant use (cocaine/crack) 2.00 (1.43,2.82)*** 3.05 (2.09, 4.45)*** 2.77 (2.27, 3.37)***
Frequent binge drinker and stimulant use 2.99 (1.32, 6.75)** 2.59 (0.78, 8.63) 4.36 (1.32,14.46)*
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*

p<.05

**

<.10

***

p<.001

Discussion

Our results indicate the burden of psychological distress among AAMSM and LMSM who have recently experienced incarceration. Mental health has critical implications for physical health. 12,48Mental health disorders can affect one’s ability to engage in health promoting behaviors such as consistent condom use 49,50, HIV testing 51, PrEP uptake 52,53 and utilization of substance abuse treatment 54. Psychological distress has also been associated with antiretroviral adherence 55,56. These factors inform HIV outcomes and the physical health of these populations. Moreover, data suggests that most adults with mental health disorders in the U.S. do not receive the care they need with African Americans and Latinos utilizing mental health services at about one-half the rate of white Americans 57.

Previous studies have assessed psychological distress among AAMSM and among LMSM, but none within the contexts of recent incarceration (e.g., probation, parole, community re-entry). Incarceration has been found to negatively impact housing stability 58; and economic stability 59,60. However, correctional settings offer a possible intervention point for addressing the trajectories of mental disorders (e.g. motivational interviewing, cognitive behavioral therapy etc.) as well as HIV risk 61,62. Recent studies suggest opportunities exist for PrEP screening and linkage 63 as well as mental health screening 64 in correctional settings. In community re-entry, social supports such as community health workers 65 or peer navigators 66 and culturally competent clinic environments 67 may assist AAMSM and LMSM in addressing their mental health while building trust between these populations and their health care providers. Another finding from the current study is that participants who reported financial insecurity, housing instability, or substance use had a greater likelihood of having elevated severity of psychological distress. This is consistent with previous studies that have examined the intersection of mental health status, housing, and financial stability among those with histories of recent incarceration 68. Furthermore, studies have found those with co-occurring substance use and mental disorders are more likely to be re-incarcerated 69,70. Individual stressors such as housing stability and financial stability may influence initiation of HIV risk behaviors or negative coping responses (i.e., substance use) 71,72. Thus, there is a need to integrate social services and interventions to address housing, financial stability and substance use among AAMSM and LMSM with recent histories of incarceration.

Limitations of the current study should be noted. Participants were recruited using convenience sampling and thus may not be representative of AAMSM and LMSM communities beyond the study sites. The data presented are from a multi-site study of urban cities and therefore may not be representative of rural areas or other cities. Despite these limitations, the current study presents urban cities in the Northeast, Mideast, and South; thus, there is geographic diversity among the sample population. This study relied on participants’ reports of their behaviors, which are subject to recall and social desirability bias. Cross-sectional data limit our ability to draw a causal inference between incarceration and mental health. Focusing on recent psychological distress may not capture changes in mental health over time that predate the onset of incarceration. In addition, reasons for incarceration were not explored in the current study. Future studies should explore how reasons for incarceration, such as immigration detention, may operate as additive stressors that impact the mental health of AAMSM and LMSM. For public health interventions with limited resources, we need to identify sub-populations at elevated risk. Individuals with histories of incarceration often face reduced social support 73, family breakdown19, social rejection and stigma 74,75. Integrating culturally competent screening for mental health 76 and social services 77,78 in correctional settings may support AAMSM and LMSM in managing their mental health and HIV risk. Interventions must address the different ways that recent incarceration intersects with HIV risk and mental health status among AAMSM and LMSM.

Acknowledgments

This research was supported by the cooperative agreements between the Centers for Disease Control and Prevention (5UR6PS000355-035UR6PS000437-03, 5UR6PS000434-03, 5UR6PS000429-03, 5UR6PS000433-03, 5UR6PS000425-02).

Footnotes

Author Disclosure Statement(s)

No competing financial interests exist for the authors.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Center for Disease Control and Prevention.

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