Poor mental health more commonly experienced by gay and bisexual men who are younger, poorer, less educated or black

While it is well established that men who have sex with men are more likely to experience poor mental and emotional health than other men, there are significant inequalities within this group, researchers report in the Journal of Public Health. Rates of depression, anxiety, self-harm and suicidal thoughts are higher in younger men, less educated men, poorer men and black men.

"Minorities are routinely thought as more homogenous than they actually are... In addition to an overall mental health inequality between the sexual majority and sexual minorities, other common inequalities persist within sexual minorities,” the authors say.

Data come from the 2011 Stonewall Gay & Bisexual Men’s Health Survey, which recruited a convenience sample of 5799 men living in the UK. Whereas other large surveys of men who have sex with men (MSM) have primarily recruited through gay dating apps and websites, the recruitment sources for this survey were varied, including employers promoting the survey to their employees; the social media accounts of Stonewall; promotion by gay community leaders, celebrities, businesses and professional networks; and Gaydar.

Glossary

depression

A mental health problem causing long-lasting low mood that interferes with everyday life.

anxiety

A feeling of unease, such as worry or fear, which can be mild or severe. Anxiety disorders are conditions in which anxiety dominates a person’s life or is experienced in particular situations.

sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

confounding

Confounding exists if the true association between one factor (Factor A) and an outcome is obscured because there is a second factor (Factor B) which is associated with both Factor A and the outcome. Confounding is often a problem in observational studies when the characteristics of people in one group differ from the characteristics of people in another group. When confounding factors are known they can be measured and controlled for (see ‘multivariable analysis’), but some confounding factors are likely to be unknown or unmeasured. This can lead to biased results. Confounding is not usually a problem in randomised controlled trials. 

The survey included questions required for validated screening tools for the symptoms of depression and anxiety. Respondents were directly asked whether they had deliberately harmed themselves or attempted to take their own lives in the previous year.

The median age was 32 years; 94% were of white ethnicity; only 14% were born overseas; 58% were university educated. There was a broad distribution of incomes. Approximately equal numbers reported living alone, living with a male partner, or living with others (but not a male partner).

Throughout the sample, many men reported poor mental health. Overall 21% were depressed and 17% anxious. Six per cent had self-harmed and 3% attempted suicide in the last year.

All four negative outcomes were more common in younger age bands. The odds of men aged under 26 years suffering poor mental health were between two times (depression and anxiety) and seven times (suicide attempt and self-harm) higher than for men aged 45 years and over. The authors say this finding is consistent with other data showing that young men are more likely to experience homophobic abuse or assault. Specific services for younger gay and bisexual men continue to be required, they say.

The lower a man’s income, the more likely he was to be depressed, anxious, to self-harm or to attempt suicide. After adjusting for age and other confounding factors, men in the lowest income bracket had between two and three times the odds of these outcomes relative to men in the highest bracket.

Men with lower levels of education (no A levels) had approximately twice the odds of these outcomes relative to those with degree-level education, after adjustment for income and other confounders.

Men of black ethnicity had elevated rates of depression, self-harm and suicide. Asian men had higher rates of depression.

Bisexual men were more likely to have symptoms of depression or to have self-harmed than gay men.

On the other hand, men who lived with a male sexual partner had half the odds of depression, a third the odds of suicide and lower rates of the other outcomes, compared with men who lived alone. The findings are consistent with studies showing that heterosexual marriage has health benefits for men, linked to companionship and psycho-social support.

Interpretation

The authors note that the most common explanation for poor mental health in men who have sex with men is “minority stress theory”. This suggests that the daily experience of homophobia results in poor mental health. This account has less to say about the differences within the group of gay, bisexual and other men who have sex with men.

The authors suggest three possible explanations for these variations.

  • Homophobia is unequally experienced by MSM, being more prevalent in the lives of younger, poorer, less educated and black men.
  • Men are better able to resist the impact of homophobia if they are relatively privileged in other areas of their lives.
  • In addition to homophobia, men also experience discrimination and marginalisation related to other aspects of their lives, such as poverty and racism.
References

Hickson F et al. Mental health inequalities among gay and bisexual men in England, Scotland and Wales: a large community-based cross-sectional survey. Journal of Public Health, online ahead of print, 2016. (Full text freely available).