|Year : 2018 | Volume
| Issue : 3 | Page : 239-244
Depression and its correlates in men who have sex with men (MSM) in India
Geeta Shyamsunder Soohinda1, Prabhleen Singh Jaggi2, Harshavardhan Sampath1, Sanjiba Dutta1
1 Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
2 Institute of Human Behavior and Allied Sciences, New Delhi, India
|Date of Web Publication||27-Sep-2018|
Dr. Harshavardhan Sampath
Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim
Source of Support: None, Conflict of Interest: None
Background: The sexual minority status of the gay and bisexual community puts them into a unique vulnerability state for mental health problems. One of the factors associated with this stress is remaining in “closet” leading to a higher prevalence of depression. Aims: This study aimed to estimate the prevalence of depression in Indian men who have sex with men (MSM) and to assess the association of depression with disclosure, if any, in this community. Materials and Methods: This was a cross-sectional observational study of Indian men recruited through an advertisement on a dating website exclusive for gay men. Depression was assessed on self-reported scale of the Centre for Epidemiologic Studies Depression Scale-Revised (CESD-R). Results: Most of the men who took part in the study belonged to the age group of 25–35 years with mean age of the study sample being 30.31 years (standard deviation [SD] ±8.58). A majority of them were salaried, had higher education, and belonged to the Hindu religion. Most of the participants were either exclusively or predominantly homosexual (72%) followed by men with bisexual orientation (18%). On measures of disclosure/“outness,” out of 277 respondents, 171 (61.73%) were not open about their sexuality, 92 (33.21%) were sometimes open, while only 14 (5.05%) were always open about their sexual orientation in front of others. The average age of coming out of closet (n = 232) was 19.71 years (SD ± 6.67). The mean score on CESD-R scale was 25.65 (SD ± 16.38). Depression was present in 163 participants (58.84%) of the entire sample. The depression scores negatively correlated with age, with scores being higher in younger age group. Depression was not associated with the type of sexual orientation. Although the depression scores were higher in those who were in the closet, it was not statistically significant. Those who had negative experience of coming out of closet had significantly higher scores on CESD-R compared to those who had positive reaction on coming out. Conclusion: Depression is highly prevalent in Indian MSM.
Keywords: Depression, disclosure, gay men, Indian men who have sex with men
|How to cite this article:|
Soohinda GS, Jaggi PS, Sampath H, Dutta S. Depression and its correlates in men who have sex with men (MSM) in India. Indian J Soc Psychiatry 2018;34:239-44
|How to cite this URL:|
Soohinda GS, Jaggi PS, Sampath H, Dutta S. Depression and its correlates in men who have sex with men (MSM) in India. Indian J Soc Psychiatry [serial online] 2018 [cited 2022 Jan 18];34:239-44. Available from: https://www.indjsp.org/text.asp?2018/34/3/239/242354
| Introduction|| |
Depression is a major public health problem worldwide, contributing to significant disability, mortality, and socioeconomic loss. According to a WHO report, more than 80% of the burden of this disease occurs in low- and middle-income countries including India. The National Mental Health Survey of India (2015–2016) observed that the lifetime prevalence of depression was 5.25% among individuals above 18 years of age.
One of the known risk factors for depression is a “homosexual orientation,” i.e., having a physical and psychological attraction toward the same biological gender. Research suggests that men who have sex with men (MSM) are at greater risk of psychiatric disorders, especially depression, substance use, and suicide, compared to their heterosexual counterparts.,, The overall lifetime prevalence of depression in this community is 1.5–2 times more compared to heterosexuals. Meyer attempted to explain the processes through which minority stress influences the mental health of this community, a concept known as “minority stress model.” According to this model, due to their sexual minority status, MSM grapple with unique factors such as stress due to rejection by community, discrimination, and stigma against homosexuality leading to concealment of one's sexual orientation, i.e., “being in the closet.” Many MSM are thus forced to keep their sexual orientation hidden for fear of society's negative reaction toward them. These stressors operate from adolescence through adulthood, making MSM vulnerable to mental health problems. When MSM come to terms with their sexual orientation, they are faced with a dilemma whether to hide their orientation (being in the closet) or disclose it to significant others (disclosure/being out of closet). Both these options are fraught with risks. Hiding their orientation leads to low self-esteem due to non-acceptance of their nature, while disclosure to significant others puts MSM at a risk of facing hostile reaction and stigma, both of which predispose them to develop emotional problems.
Indian data on mental health of MSM are limited.,, A World Bank study on the economic cost of stigma and exclusion of the lesbian, gay, bisexual, and transgender (LGBT) community reported that depression is 6–12 times higher among MSM than the general population in India. However, the report was based on studies conducted on non-representative samples (HIV-infected clients attending health-care facilities) leading to response bias. Furthermore, the inherent difficulties of studying this hidden and discriminated community have contributed to researchers neglecting this vulnerable population. To address this research gap, the present study sought to shed light on depression in Indian MSM and to find if it is influenced by disclosure of homosexual orientation status to others.
We aimed to assess the rates of depression and its correlates in a sample of Indian MSM. We also wanted to specifically find how disclosure of sexual orientation and the reactions of others impacted on depression.
| Materials and Methods|| |
This was a cross-sectional, observational study of Indian men who visited a dating website exclusive for gay people. Recruitment of participants was done through an advertisement inviting participants for the study displayed on the website. This advertisement was visible to 100,000 “impressions” (user logins) from India. Users clicking on the advertisement were led to the study's survey website. Information regarding the scope of the study, confidentiality, and absence of any personal identifiers in the survey was displayed before users could begin the survey. This study also employed the respondent-driven method for recruitment by encouraging participants to forward the link to the study's survey website, to their gay or bisexual friends and acquaintances from India. The following were used in English language for data collection:
- A sociodemographic questionnaire to gather data including age of coming out (disclosure) and previous history of any mental illness
- Questions on disclosure of sexual orientation (coming out) were assessed using the following questions: (a) Are you open about your sexuality? Responses were recorded in the form of always, sometimes, or never and (b) How would you describe others' reactions to your disclosure of sexual orientation? Responses were recorded as positive, negative, or mixed
- The Kinsey scale was used to categorize the sexual orientation of respondents. This scale was developed by Drs. Alfred Kinsey, Wardell Pomeroy, and Clyde Martin subsequent to the research findings that showed people did not fit into exclusive heterosexual or homosexual categories. Ratings are from 0 to 6, with people at “0” having exclusively heterosexual/opposite sex behavior or attraction, while those at “6” report exclusively homosexual/same-sex behavior or attraction. Ratings 1–5 are for those who report varying levels of attraction or sexual activity with either sex.
- The Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) was created in 1977 by Laurie Radloff and revised in 2004 by Eaton et al., This scale is one of the most widely used instruments in the epidemiological studies to screen for depression. It has a good sensitivity and specificity and high internal consistency. For our study, we used a recommended cutoff score of ≥21.
Statistical analysis was done using MINITAB 17 statistical software (Minitab, Ltd, PA: Minitab, Inc). Mean, standard deviation, and percentage were used for descriptive statistics. We used Spearman's rho for correlation between variables. Kruskal–Wallis test was used to find out the significance of association between variables.
| Results|| |
Over a period of 2 months, 298 individuals participated in the study. Data from 21 individuals had to be excluded due to incomplete or repeat data. Most of the men who took part in the study belonged to the age group of 25–35 years with mean age of the study sample being 30.31 years (SD ± 8.58). A majority of them (64%) were salaried, 94% were either graduate or postgraduate, and almost 70% belonged to the Hindu religion. Almost 64% of the respondents reported their relationship status as being single (64%), while 20% of them were married [Table 1]. On the spectrum of sexual orientation [Table 2] as measured on the Kinsey sexual orientation scale, most of the respondents expressed their orientation as either exclusively or predominantly homosexual (72%) followed by men with bisexual orientation (18%). Nearly 8.6% reported being predominantly heterosexual with incidental homosexual behavior. About 57 (20.58%) respondents reported to have been suffering from a psychiatric illness. Among these, 37 (13.36%) respondents reported depression and 13 (4.99%) reported anxiety followed by bipolar disorder in 4 (1.44%), with 3 respondents reporting unspecified psychiatric illness.
|Table 2: Distribution of sexual orientation across the Kinsey scale (n=277)|
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About 171 (61.73%) respondents were not open about their sexuality, 92 (33.21%) were sometimes open, while only 14 (5.05%) were always open about their sexual orientation in front of others. The average age of disclosure of sexual orientation, i.e., coming out was 19.71 years (SD ± 6.67). Nearly 37.75% of the respondents reported a positive reaction, 15.26% a negative reaction, while 46.99% experienced mixed reactions from others on openly disclosing their sexual orientation.
The mean score on CESD-R scale was 25.65 (SD ± 16.38). Using the recommended cutoff of ≥21 on CESD-R scale, depression was present in 58.84% (n = 163) of MSM respondents. Depression scores negatively correlated with age, i.e., higher in younger age group (Spearman's rho = −0.114, P = 0.05). Depression was not associated with any spectrum of sexual orientation on Kinsey scale [Table 3]. There was a negative correlation between depression scores and age of coming out, but it was not statistically significant (Spearman's rho = −0.043, P = 0.51). Although depression scores were higher in those who did not disclose their orientation, it was not statistically significant. Those who experienced negative reactions during disclosure (coming out) had significantly higher scores on CESD-R compared to those who had positive or mixed reactions (Kruskal–Wallis H = 10.23, P = 0.006).
|Table 3: Association of depression with sexual orientation and disclosure in men who have sex with men|
Click here to view
| Discussion|| |
A majority of the 277 respondents in our study sample had higher education, were employed, and belonged to higher income-earning group with a mean age of 30.31 years. Since the survey was based on MSM accessing an internet dating website, our sample characteristics reflect the patterns expected, namely, educated and sexually active section of this community. Most of the respondents belonged to the Hindu religion with some representation from the Christian and Muslim communities. This may reflect the religious distribution of the population of India. In addition, lower representation from other religions may be a reflection of religious taboos and restrictions that discourage expression of sexual orientation and subsequent behavior. On the spectrum of sexual orientation as measured on the Kinsey scale, most of the respondents reported their orientation as either exclusively or predominantly homosexual (72%) followed by men with bisexual orientation (18%).
In our study, depression was present in almost 60% of the respondents, which is higher than the prevalence of depression in the general population. Western studies have consistently shown higher lifetime rates of depression among MSM as compared to heterosexual men., Studies on 12-month prevalence of major depression showed rates between 9.8% and 31% for MSM compared to 3.9% and 10.2% for heterosexual men. Higher rates of depression among Indian MSM could be due to greater stigma. This can be explained in the context of the restriction imposed by the society and law on expression of a nonheterosexual orientation.
There are only limited studies on the prevalence of depression among Indian MSM. Research on HIV-positive transgender MSM sex workers in Chennai reported depressive symptoms and suicidal feelings among many of the respondents. However, the qualitative nature of the study and the narrow sample of MSM (transgender, sex workers, and HIV–positive individuals) preclude any inferences to be drawn on the extent of depression in this community. Another study in Chennai among MSM with HIV/AIDS (n = 210) accessing medical care reported that 55% of the respondents experienced clinical depression as rated by the CES-D scale. Again, this study focused on HIV-infected individuals leading to a response bias not reflecting the true prevalence of depression among MSM. A Mumbai-based study on MSM (n = 150) seeking support from a non-governmental organization (NGO) trust for sexual minorities reported a depression rate of 29% using the Mini International Neuropsychiatric Interview (MINI). This rate is almost half as our finding (58.84%). Probable reasons could be the differences in assessment tools (CESD-R vs. MINI), assessment methods (interviewer based vs. anonymous online surveys), and social support. While interviewer-based assessment is a better method to assess psychiatric conditions, in a highly stigmatized community, they make work counter productively due to social desirability bias, a limitation acknowledged by the authors themselves. Due to anonymity granted by our online survey, the respondents could have volunteered their depressive symptoms more openly. Furthermore, the social support provided by the NGO could be a protective factor, mitigating the effects of stigma and discrimination, which are known risk factors for depression. More research is definitely needed in this area to validate our findings. Despite these differences, the common finding of high rates of depression in Indian MSM cannot be ignored. Psychosocial stressors including stigma, discrimination, prejudice, and societal/family pressure to conform play a greater role in our society compared to the West, placing Indian MSM more susceptible to mental health problems. However, recently, the rights of this silent and hidden community have come to the forefront, especially centered on Section 377 of the Indian Penal Code, criminalizing homosexual activity. Although public perception toward the gay community is gradually changing, these individuals are still forced to remain “in the closet” for the fear of rejection and discrimination from family, friends, and peers.
In our study, age negatively correlated with depression, with younger MSM having significantly more depression scores. This finding is concurrent with the current literature. A review by Corboz et al. reported that younger MSM appear to be at higher risk of depression than their older counterparts. In the Indian context, this finding bears special significance. In the traditional Indian community, marriage forms the central fulcrum for a healthy and well-adjusted social life. Gay men on reaching marriageable age come face to face with the reality of societal and family pressures for marriage versus the stress of disclosure and coming out of closet and facing abuse, discrimination, and rejection. Furthermore, young MSM are at a higher risk of depressive and suicidal ideas due to the developmental tasks of questioning and developing sexual identity and the subsequent coming-out process, with disclosure comes a chance of upsetting the parents, guilt, and the fear of losing out emotional and monetary support from the family. The common strategy for them is to avoid marriage altogether while some are pressurized into heterosexual marriages, worsening the stress and leading to mental health problems. This is compounded by the fact that there is no social or legal recognition for same-sex relationships in India. These pressures significantly reduce once the MSM has crossed the “marriageable age.” This could explain the lower prevalence of depression in the older age group.
Although we found higher depression scores in MSM who had exclusively/predominantly homosexual orientation than bisexual orientation, this trend was not significant. Literature on this is mixed, with some studies reporting bisexuals having a higher rate of depression than their homosexual or heterosexual counterparts, while in others showing no differences. A review by Ross et al. found that only four studies reported bisexual-specific data for lifetime major depression, major depressive episode, or mood disorder. Pooled estimates yielded a prevalence of 0.43 (95% CI: 0.31, 0.55; I2 = 88.4) among bisexual people, 0.42 (95% CI: 0.29, 0.55; I2 = 96.1%) for gay men, and 0.25 (95% CI: 0.16, 0.36; I2 = 99.8%) for the heterosexual group. Other researchers often combine bisexual men in the homosexual category resulting in poor comparability. There is no research in the Indian context comparing depression between homosexual and bisexual men. This area thus needs further research.
In our study, disclosure of sexual orientation and the age of disclosure were not associated with depression. The stress of living in the closet and managing ones double identity have been reported to be risk factors for depression in some Western studies., Similarly, “coming out of the closet” has been shown to increase social support and reduce isolation among gay and lesbian people in liberal Western societies. However, not all studies report such associations. Experience of stress associated with disclosure is due to anticipation or actual negative and sometimes abusive reactions from friends, family, and peers., In societies where high levels of stigmatization and no legal framework exist to support the homosexual community, nondisclosure may be a coping mechanism to avoid stigma and victimization. Since there are no other Indian studies that have assessed disclosure and its relationship with depression, our findings need validation in the Indian context.
We found that the depression scores were significantly associated with negative experiences of MSM after disclosing their sexual orientation. As discussed previously, after disclosure (coming out), minority stress operates in the form of stigma and discrimination by family, peers, colleagues, and the community at large leading to emotional problems., Hence, it is not surprising that negative coming-out experiences are significantly associated with depression among MSM. However, 37.75% of MSM reported positive coming-out experiences, an encouraging shift in the attitude toward homosexuality, corroborated by a survey showing 62% of Indians reporting no concern if their neighbor belonged to the LGBT community.
The following are some important strengths and limitations of our research. There are very few Indian studies on MSM. Most of these have narrowly focused on MSM with HIV/AIDS patients or sex workers. This is understandable due to the difficulties inherent in the identification of gay men in the community. We thus used an anonymous online survey to circumvent this problem. This is the first Indian study to assess the impact of disclosure of orientation on depression in Indian MSM. Our research is not without its limitations. As with all previous studies on MSM, true representative community sampling is improbable. It can be argued that the online survey method we used also suffers from sampling bias. In addition, a single user could theoretically have filled multiple online survey forms intentionally. Another limitation is that disclosure of orientation is a fluid and complex concept; hence, measures of disclosure in this study, based on single question, may not have fully evaluated the construct. However, there are no validated scales that assess disclosure in MSM. Since we used a self-report questionnaire for the assessment of depression compared to interview method, it might have not given us the true figures of prevalence of depression. The cross-sectional nature of our study is weighed down by not being able to prove causality but only association.
| Conclusion|| |
Our results showed a much higher rate of depression in Indian MSM compared to Western data, especially in the younger age group. Although disclosure of sexual orientation of MSM was not found to be associated with depression, negative reactions of others postdisclosure were significantly associated with depression. The conflict of choosing to disclose one's orientation and face minority stress and discrimination versus concealing it and living a double life is a constant challenge faced by MSM. This community needs our attention and support due to their vulnerable status. A change in the perception and acceptance of family, friends, and colleagues of MSM will go a long way in helping them “come out of the closet” without the fear of being rejected and ostracized and living their lives with self-acceptance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]