Physical Violence and Psychological Distress Among Asian and Pacific Islander Sexual Minority Men in the United States Before and During the COVID-19 Pandemic

Abstract

Purpose:

This study examined differences in self-reported physical violence and psychological distress among Asian American and Pacific Islander (AAPI) sexual minority men (SMM) before and during the 2019 novel coronavirus (COVID-19) pandemic (2019 vs. 2020).

Methods:

We used data from 1127 AAPI SMM who completed the 2019 (August 2019–December 2019) and 2020 (August 2020–January 2021) cycles of the American Men's Internet Survey (AMIS). We assessed differences in experiencing physical violence and serious psychological distress by year of survey completion. We used Poisson regression with robust variance estimation to examine whether physical violence was associated with serious psychological distress before and during COVID-19. Multivariate analyses adjusted for sociodemographic characteristics and the interaction between year and violence.

Results:

A greater percentage of AAPI SMM had serious psychological distress in 2020 during the pandemic relative to 2019 before the pandemic (56.6% vs. 35.64%, p < 0.001). AAPI SMM who experienced physical violence in the last 6 months were more likely to experience serious psychological distress than those who never experienced physical violence. The association between violence and psychological distress among AAPI SMM was not significantly different before and during the COVID-19 pandemic.

Conclusions:

Violence against AAPI SMM in the United States is widespread. Although we did not find significant differences in exposure to physical violence among AAPI SMM before and during the COVID-19 pandemic, the increase in serious psychological distress during the pandemic among AAPI SMM may indicate heightened need of mental health services.

Introduction

Recent data reveal that violence and hate incidents toward Asian American and Pacific Islander (AAPI) people in the United States have dramatically spiked during the 2019 novel coronavirus (COVID-19) pandemic.¹ Hate incidents are defined as acts of violence or hostility motivated by bias or prejudice against characteristics such as race, ethnicity, gender, or sexual orientation.² Although several factors may be attributed to the surge in violence toward AAPI communities, the political and social stigmatization of AAPI individuals in relation to the coronavirus is considered a driving factor.³ Specifically, the use of language such as “Chinese virus” and “Kung flu” amid the pandemic has perpetuated anti-Asian sentiment and furthered its expression through acts of physical violence and discrimination.⁴

Analysis of preliminary police data demonstrates that hate crimes against Asian American people increased by 149% from 2019 to 2020 across 16 of the largest cities in the United States.^1,5 Furthermore, ∼6603 reports of attacks against AAPI people were documented between March 2020 and March 2021 by STOP AAPI Hate, an advocacy organization that tracks and responds to reports of violence toward AAPI people.⁶

Although these numbers present a significant uptick in violence toward AAPI communities, incidents of anti-Asian hate are likely greater than what police data and hate crime reports portray.⁷ Specifically, Asian Americans are the racial/ethnic group that are least likely to report hate crimes in the United States.^7–9 Reluctance to report hate incidents to authorities can result from fear of retaliation, uncertainty regarding the motivations behind hate incidents, and concerns about unwanted attention.⁷ Additional barriers to reporting hate incidents may include lack of confidence in the justice system, language barriers, and low levels of knowledge.^8,10 Furthermore, structural factors related to demographic characteristics such as gender, ethnicity, age, immigrant status, and socioeconomic status may create greater challenges to reporting.¹¹ Given these barriers, extant data may not capture the full extent of anti-Asian hate incidents in the country.

According to a recent survey conducted by AAPI Data and SurveyMonkey in March 2021 that surveyed a large segment of the U.S. Asian population, 12% of Asian American adults and 10% of Pacific Islander adults experienced hate incidents in 2020 compared with 8% of Americans overall in the same year.¹⁰ Survey results also revealed that despite the common perception that women are more likely to experience hate incidents than men, a greater percentage of men indicated ever experiencing an anti-Asian hate incident than women (31% vs. 25%, respectively).⁷ Other sociodemographic factors such as age and nativity were also found linked to increased likelihood of experiencing an anti-Asian hate incident among participants.⁷ These results underscore how intersecting vulnerabilities that result from having multiple marginalized identities can not only increase risk of experiencing prejudice and victimization but also present barriers to reporting hate incidents and seeking support.

AAPI gay, bisexual, and other sexual minority men (SMM) can experience marginalization based on their race/ethnicity as well as their sexual orientation. Earlier studies have found that AAPI SMM in the United States experience elevated levels of racism and discrimination with negative implications for their overall physical and mental health.^12,13 Specifically, AAPI SMM's experiences of social rejection and devaluation across multiple contexts and communities can lead to high levels of psychological distress and poor mental health.^14–16 With the rise in reports of anti-Asian violence during the COVID-19 pandemic, AAPI SMM may be uniquely affected given their multiple marginalized statuses. Intersectionality theory posits that these marginalized social categories may interconnect to shape systems of oppression and increase vulnerability to poor outcomes.^17,18 As targeted violence toward a specific community has harmful consequences beyond the physical and emotional impacts at the individual level, increased efforts to understand the scope and magnitude of this issue are urgently needed.

We used data from the 2019 and 2020 cycles of the American Men's Internet Survey (AMIS) to compare the prevalence of self-reported experiences of physical violence and psychological distress among AAPI SMM in 2019 versus 2020. Study results have timely implications for the targeted prevention and intervention of violence and mental health in AAPI communities.

Materials and Methods

AMIS is an annual, cross-sectional, web-based behavioral survey of U.S. cisgender men who are aged 15 and older and who report having ever had oral or anal sex with a man.¹⁹ The online survey collects data on sociodemographic characteristics, sexual behavior, health-related behaviors, and HIV prevention services. Participants are recruited through convenience sampling through web-based and social media advertisements.²⁰ The 2019 cycle of AMIS was conducted from August to December 2019 and the 2020 cycle was conducted from August 2020 to January 2021. No incentives were offered for participation. All study procedures were approved by the Institutional Review Board at Emory University, and each participant provided informed consent before completing the survey. Additional details about AMIS methodology are available elsewhere.²¹

Measures

Outcome variable

Psychological distress was measured by the K-6 Mental Health Scale,²² a six-item instrument that asks about the frequency of experiencing particular emotional states in the past 30 days. Responses range from “none of the time” (coded as zero) to “all the time” (coded as four). The items were summed to yield a score between 0 and 24, with higher scores indicating greater psychological distress.²³ Serious psychological distress was defined by a score of 13 or greater.^22,24

Focal independent variable

Experiences of physical violence were assessed with a question that asked, “Has someone ever physically hurt you (pushed, shoved, slapped, hit, kick, choked or otherwise physically hurt you)?” Response options included “No,” “Yes, in the last 6 months,” “Yes, but not in the last 6 months,” “I prefer not to answer,” and “Don't know.” Given decreased likelihood of AAPI persons to report hate crimes, we combined “I prefer not to answer” and “Don't know” to include these responses in analyses.

Control variables

We assessed participants' sociodemographic information including age, sexual identity, primary language (English vs. another language), education level, income, and country of birth (born in the United States vs. foreign born). These sociodemographic characteristics are important determinants that shape the contexts in which AAPI persons experience health and wellbeing,²⁵ and were included as control variables given their potential influence on our outcomes of interest.

Statistical analyses

We restricted the analytical sample to complete and unduplicated surveys from SMM who had oral or anal sex with a male partner in the past 12 months and who identified as Asian, Native Hawaiian, or other Pacific Islander, including participants who indicated multiple races or Hispanic ethnicity. We calculated average psychological distress scores among participants in 2019 (prepandemic) and 2020 (during the pandemic). We used chi-square or t-tests to determine whether experiencing physical violence, serious psychological distress, and sociodemographic characteristics differed by year. Poisson regression with robust variance estimation was used to assess the relationships between year (2019 vs. 2020), physical violence, and the outcome of psychological distress. Year of survey completion and sociodemographic factors that were significant (p < 0.05) in univariate analyses were included in the multivariable model. Interaction terms between year and experiencing physical violence were included to examine for the presence of conditional effects.

We report the estimated unadjusted prevalence ratios (PRs) and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) from the model. All analyses were conducted using STATA v. 13.1.²⁶

Results

In 2019 and 2020, 1127 AAPI SMM participated in AMIS. Among participants, 876 identified as Asian, 176 identified as Native Hawaiian or other Pacific Islander, and 75 identified as both Asian and Native Hawaiian or other Pacific Islander. The average age of participants was 26.7 years. The majority identified as homosexual or gay, used English as their primary language, and were born in the United States. About half had a bachelor's degree or higher and had annual household incomes of $40,000 or greater. Whereas 6% (55/911) of participants indicated having experienced physical violence in the last 6 months, about one-third (33.6%; 306/911) had ever experienced physical violence and nearly half (47.5%; 535/1127) had serious psychological distress.

We compared the sociodemographic characteristics, experiences of physical violence, and psychological distress of AAPI SMM in 2019 (n = 491) before the pandemic with those in 2020 (n = 636) during the pandemic (Table 1). There were no statistically significant differences in experiencing physical violence in the last 6 months (7.1% vs. 4.8%) or in mean psychological distress scores (9.9 vs. 9.4) among AAPI SMM in 2019 before the pandemic compared with 2020 during the pandemic. However, a significantly greater percentage of AAPI SMM reported serious psychological distress in 2020 relative to 2019 (56.6% vs. 35.6%, p < 0.001).

Table 1.

Characteristics of 1127 Asian or Pacific Islander Sexual Minority Males by Year; American Men's Internet Survey, 2019 Versus 2020

	2019 (N = 491a)	2020 (N = 636a)	pb
	n (%)	n (%)
Age (years), M (SE)	26.38 (0.10)	27.00 (0.37)	0.27c
Sexual identity			0.20
Heterosexual or straight	2 (0.41)	5 (0.79)
Homosexual or gay	375 (76.37)	469 (73.74)
Bisexual	103 (20.98)	134 (21.07)
Otherd	11 (2.24)	28 (4.40)
Primary language			0.85
English	453 (92.45)	589 (92.76)
Another language	37 (7.55)	46 (7.24)
Education			<0.001
Less than high school	38 (7.87)	17 (2.69)
High school diploma/GED	82 (16.98)	98 (15.51)
Some college or technical degree	129 (26.71)	208 (32.91)
Bachelor's degree or higher	234 (48.45)	309 (48.89)
Annual household income			<0.001
<$20,000	84 (17.14)	78 (12.28)
$20,000–$39,999	74 (15.10)	126 (19.84)
$40,000–$74,999	109 (22.24)	127 (20.00)
$75,000+	141 (28.78)	239 (37.64)
Prefer not to answer/don't know	82 (16.73)	65 (10.24)
Nativity			0.47
Born in United States	352 (71.98)	465 (73.93)
Foreign born	137 (28.02)	164 (26.07)
Experienced physical violence			0.12
No	327 (66.60)	263 (62.62)
Yes, in last 6 months	35 (7.13)	20 (4.76)
Yes, but not in last 6 months	122 (24.85)	129 (30.71)
Prefer not to answer/don't know	7 (1.43)	8 (1.90)
Psychological distress, M (SE)	9.90 (0.27)	9.38 (0.31)	0.21c
Serious psychological distresse			<0.001
Yes	175 (35.64)	360 (56.60)
No	316 (64.36)	276 (43.40)

^a Denominators may be smaller for some variables due to missing data.

^b Chi-square p-value unless otherwise stated.

^c t-test p-value.

^d “Other” included “Another sexual identity,” “prefer not to answer,” and “don't know.”

^e Score of 13 or greater.

GED, general education development; M, mean; SE, standard error.

Results from the univariate and multivariable Poisson regression with robust variance estimation models for the outcome of experiencing serious psychological distress are given in Table 2. In univariate analyses, we observed that AAPI SMM who experienced physical violence in the last 6 months were more likely to experience serious psychological distress compared with AAPI SMM who had not ever experienced physical violence (PR = 2.26, 95% CI = 1.79–2.89, p < 0.001). Those who experienced physical violence but not in the last 6 months were also more likely to experience serious psychological distress compared with AAPI SMM who had not ever experienced physical violence (PR = 1.57, 95% CI = 1.29–1.90, p < 0.001).

Table 2.

Robust Poisson Regression Models Predicting Serious Psychological Distress Among 1127 Asian or Pacific Islander Sexual Minority Men; American Men's Internet Survey, 2019 and 2020

	Total Na	Serious psychological distress
		n (%)	RR (95% CI)	aRR (95% CI)
Experienced physical violence
No	590	165 (27.97)	Ref	Ref
Yes, in the last 6 months	55	35 (63.64)	2.26 (1.79–2.89)	1.83 (1.18–2.84)
Yes, but not in the last 6 months	251	110 (43.82)	1.57 (1.29–1.90)	1.46 (1.10–1.93)
Prefer not to answer/don't know	15	9 (60.00)	2.15 (1.39–3.31)	2.29 (1.23–4.27)
Year of data collection
2019	491	175 (35.64)	Ref	Ref
2020	636	360 (56.60)	1.59 (1.38–1.82)	1.02 (0.78–1.32)
Age	—	—	0.97 (0.96–0.98)	0.97 (0.95–0.98)
Sexual identity
Heterosexual or straight	7	3 (0.56)	Ref	—
Homosexual or gay	844	385 (72.23)	1.06 (0.45–2.51)	—
Bisexual	237	125 (23.45)	1.23 (0.52–2.92)	—
Another identity	34	20 (3.75)	1.32 (0.54–3.23)	—
Primary language
English	1042	490 (47.02)	Ref	—
Other	83	43 (51.81)	1.10 (0.89–1.37)	—
Education
Less than high school	55	38 (69.09)	Ref	Ref
High school diploma/GED or less	180	88 (48.89)	0.71 (0.56–0.89)	0.80 (0.68–1.14)
Some college or technical degree	337	194 (57.57)	0.83 (0.68–1.02)	1.04 (0.78–1.40)
Bachelor's degree or higher	543	210 (38.67)	0.56 (0.46–0.69)	0.80 (0.57–1.11)
Annual household income
<$20,000	162		Ref	Ref
$20,000–$39,999	200		0.90 (0.74–1.09)	0.88 (0.68–1.13)
$40,000–$74,999	236		0.63 (0.51–0.79)	0.62 (0.46–0.82)
$75,000+	380		0.77 (0.65–0.92)	0.74 (0.57–0.94)
Prefer not to answer/don't know	147		1.05 (0.87–1.27)	0.97 (0.74–1.26)
Nativity
Born in the United States	817	399 (48.84)	Ref	—
Foreign born	301	130 (43.19)	0.88 (0.76–1.02)	—
Year × violence
Year × no violence			Ref	Ref
Year × yes, in the last 6 months			1.00 (0.59–1.09)	1.00 (0.59–1.09)
Year × yes, but not in the last 6 months			1.08 (0.75–1.57)	1.08 (0.75–1.57)
Year × prefer not to answer/don't know			0.87 (0.39–1.94)	0.87 (0.39–1.94)

^a Totals may be smaller for some variables due to missing data.

aRR, adjusted risk ratio; CI, confidence interval; Ref, reference; RR, risk ratio.

In addition, younger age, lower levels of education, and lower household incomes were associated with greater likelihood of having serious psychological distress (p < 0.001). In the multivariable analysis, AAPI SMM who experienced physical violence in the last 6 months and those who experienced physical violence but not in the last 6 months remained more likely to experience serious psychological distress than those who did not experience physical violence (aPR = 1.83, 95% CI = 1.18–2.84, aPR = 1.46, 95% CI = 1.10–1.93, respectively; p < 0.001) (Table 2). Participants who indicated that they preferred not to answer or did not know whether they experienced physical violence were also more likely to have serious psychological distress than those who did not experience physical violence (aPR = 2.29, 95% CI = 1.23–4.27; p < 0.001).

The year of data collection (pre vs. during pandemic) and the interactions between year and experiencing physical violence were not significantly associated with serious psychological distress in the multivariable model.

Discussion

We found that more than a third of Asian SMM surveyed during the COVID-19 pandemic (2020) reported experiencing physical violence with ∼5% reporting violence in the last 6 months. Experiencing physical violence was associated with reporting serious psychological distress among Asian SMM. Whereas participants surveyed during the COVID-19 pandemic were more likely to experience serious psychological distress than those surveyed before the pandemic in 2019, our results suggest that the association between violence and psychological distress did not differ substantially before and during the COVID-19 pandemic.

Despite recent data indicating an increase in anti-Asian hate crimes during the COVID-19 pandemic,^1,5 we found that there were no significant differences in reports of having experienced physical violence in the last 6 months or before the last 6 months in this sample of AAPI SMM in 2019 before the pandemic compared with 2020 during the pandemic. Our results align with those of an earlier study that surveyed Asian adults in April 2021 and found that the proportion that experienced discrimination was similar to that of Asian adults surveyed before the pandemic.²⁷ These findings highlight that violence against AAPI SMM in the United States was widespread even before the pandemic. As our data do not specify the motivation or source behind the physical violence experienced by study participants, we are limited in concluding that these experiences were the result of anti-AAPI sentiment or other biases. Nonetheless, these experiences require contextualization within the multiple and converging systems of oppression associated with AAPI identity and sexual identity.

As AAPI SMM face systemic discrimination due to their intersectional marginalized identities as racial/ethnic and sexual minorities, the internalization of racism and homophobia among AAPI SMM may lead to normalizing experiences of victimization.²⁸ As a result, exposure to violence among AAPI SMM may have been accepted as part of the status quo both before and during the pandemic. In addition, discrimination and violence can take many forms, and our focus on physical violence may have limited the actual scope of violence experienced among AAPI SMM. Specifically, verbal harassment, online harassment, shunning, and civil rights violations are also forms of violence that can take place against AAPI communities in the United States.⁶

Of note, we found that a greater percentage of AAPI SMM experienced serious psychological distress in 2020 during the pandemic compared with 2019 before the pandemic. The widespread reports of violence against AAPI communities during the COVID-19 pandemic²⁷ may have contributed to increased fear about experiencing physical attacks in AAPI SMM. In the same survey of Asian adults in April 2021, approximately one-third (32%) indicated that they feared that someone might threaten or physically attack them.²⁷ As anticipating discrimination can lead to increased psychological distress,^29,30 heightened concern about experiencing potential violence has implications for the health of AAPI SMM.

Furthermore, the COVID-19 pandemic drastically affected all sectors of society, and individuals have faced stressful circumstances that have shaped the emotional wellbeing of communities across the country.^31,32 The ramifications of COVID-19 may account for the greater prevalence of serious psychological distress among AAPI SMM in 2020 than in 2019. Of note, serious psychological distress was already high among AAPI SMM before the pandemic (35.6%). These data suggest that the impact of violence on mental health continues to be an important yet potentially overlooked issue in this community.

In our multivariable model, experiencing physical violence in the last 6 months or ever in the past were both significantly associated with increased likelihood of serious psychological distress. Participants who reported more recent experiences of violence (last 6 months) had a stronger association with serious psychological distress than those with older experiences. As SMM are often targets of violence due to their sexual identity,³³ the current surge in reports of violence against AAPI people in the United States may make AAPI SMM multiply vulnerable to the negative psychological consequences of experiencing or anticipating discrimination. These findings demonstrate the urgent need to address the underlying causes of violence against minority communities such as Asian SMM.

Furthermore, our results suggest that AAPI SMM may be in increased need of mental health services as they attempt to cope with the stressors and stigma related to their marginalized identities during the pandemic. Our multivariable model also demonstrated that AAPI SMM who did not report whether they had experienced physical violence because of not knowing or preferring not to answer were more likely to have serious psychological distress than those who had not experienced physical violence. This may be the result of the confusion or lack of certainty about whether an individual was the target of a hate crime, which can exacerbate stress and escalate anxiety about potential violence.³⁴

As previously noted, internalized oppression can silence AAPI communities and lead to self-doubt or self-denigration,²⁸ potentially minimizing the severity and impact of exposure to violence. Individuals who avoid disclosing instances of violence may struggle to cope with the experience, which may increase distress resulting from the incident.³⁵ As Asian American people are less likely to report hate crimes than other racial/ethnic groups,⁸ AAPI SMM may need support in appropriately identifying and processing physical attacks and instances of hate crimes in ways that promote their mental health.

Of note, the interaction between year and violence was not significantly associated with psychological distress among AAPI SMM. Hence, there was no evidence that the relationship between violence and psychological distress differed pre- versus during the pandemic. These data highlight that regardless of when violence occurs, AAPI SMM who experience physical violence are likely to experience serious psychological distress.

As sociodemographic factors including age, education, and income were also associated with serious psychological distress among AAPI SMM, our findings underscore the role of social and economic contexts in shaping the mental wellbeing of racial/ethnic and sexual minority populations.³⁶ Specific subgroups of AAPI SMM (e.g., low-income AAPI SMM) may require focused efforts to ensure that their mental health needs are addressed. As factors such as income and age have also been shown to be linked to risk of violence in AAPI communities,^3,5,7,10 they are important considerations to understanding why certain AAPI SMM may be more vulnerable to hate crimes in the United States.

Limitations

Results should be interpreted with attention to study limitations. AMIS data are from repeated cross-sectional convenience samples, which do not allow for true prospective analyses of changes during COVID-19. The sampling also likely introduces potential for selection bias and are not generalizable to all AAPI SMM online. Of note, individuals who chose not to take the survey in English were excluded, and people who primarily speak languages other than English may be more likely to be targets of violence.⁵ Surveys only assessed self-reports of physical violence, which may be underreported among AAPI SMM.

Furthermore, we are unable to capture the potential effects of other forms of violence (e.g., nonphysical) on AAPI SMM. We are also unable to specify the cause or source for the acts of physical violence experienced by AAPI SMM, which obscures our understanding of factors that may contribute to anti-AAPI violence. Although surveys did not capture the specific ethnicities of AAPI SMM, the different ethnic backgrounds of this population are important for understanding their diverse experiences of violence and mental health. As data for the 2020 AMIS cycle were collected during August 2020 to January 2021, data likely underestimate the full extent of violence and psychological distress that AAPI SMM experienced throughout the COVID-19 pandemic. Furthermore, given the 6-month reference period for experiencing physical violence used in the survey, some participants in 2020 who reported experiencing violence but not in the last 6 months may have experienced physical violence during the pandemic (e.g., participants who completed the survey in December 2020 who experienced physical violence in April 2020).

Conclusions

As the United States continues to cope with the complex effects of the COVID-19 crisis, mental health experts are anticipating a long-term impact on mental health across the country, particularly among sexual and gender minorities and people of color.^31,32 Understanding how the intersection of these identities may potentially disproportionately impact psychological distress levels among the AAPI SMM community is critical to providing locally responsive and tailored strategies that account for mental health disparities. Our study found that although experiences of violence among AAPI SMM did not significantly differ before and during the pandemic, AAPI SMM in 2020 during the pandemic were more likely to have serious psychological distress than in 2019 before the pandemic. As AAPI SMM overall, who experienced physical violence were more likely to experience serious psychological distress, our results highlight the importance of developing strategies to address the concerns of violence and mental health alongside efforts to address the root causes of systemic racism and oppression.

Due to the violence and harassment that AAPI persons are continuing to experience in the United States,⁴ AAPI SMM may develop new concerns about potential physical attacks as U.S. society reopens. The hesitancy to rejoin an “in-person” society could conceivably lead to feelings of isolation that may possibly fuel additional psychological distress. Hence, improved education, resources, and violence prevention programs that are tailored for AAPI communities are needed to protect against the different forms of violence that underlie these stressors. As a subgroup of this already extremely vulnerable and marginalized group of AAPI persons, Asian SMM will need even more nuanced strategies and support.

Authors' Contributions

J.J.L. conceptualized the study and led the analysis and writing. D.A.K., R.P.K., J.E.L., S.D.B., and T.H.S. provided substantial contributions and supported the analysis, review, and editing of the 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

The study was funded by grants from the National Institutes of Health (P30AI050409 and R01MH110358). J.J.L. was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award No. KL2TR002317.