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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2021  |  Volume : 63  |  Issue : 5  |  Page : 490-494
Psychosocial health and its associated factors among Men who have sex with Men in India: A cross-sectional studyS


Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India

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Date of Submission05-Jan-2021
Date of Decision05-Jun-2021
Date of Acceptance11-Aug-2021
Date of Web Publication12-Oct-2021
 

   Abstract 


Background and Aim: MSM in India experience complex and multiple psychosocial challenges. The current study was conducted with an aim to assess the magnitude and predictors of psychosocial health-related problems including MSM registered in targeted intervention centers in Delhi.
Methods: A cross-sectional study was conducted among 235 MSMs. Burden of psychosocial health issues among MSM including depression, anxiety, substance abuse, and partner violence was assessed using semistructured questionnaire. Chi-square test was used to study the association of sociodemographic characteristics and psychosocial issues among the study participants.
Results: The prevalence of depression, anxiety, substance abuse, and partner violence was 45.1%, 37.8%, 27.6%, and 8%, respectively. Age (<24 years), education up to middle school, and being single had significant association with depression. Being sex worker as occupation had a significant association with anxiety and intimate partner violence.
Conclusions: The study reveals a significant burden of psychosocial problems and throws light toward broadening the spectrum of health assessment among this vulnerable group.

Keywords: Men having sex with men (MSM), psychosocial health, psychosocial problems

How to cite this article:
Thirunavukkarasu B, Khandekar J, Parasha M, Dhiman B, Yadav K. Psychosocial health and its associated factors among Men who have sex with Men in India: A cross-sectional studyS. Indian J Psychiatry 2021;63:490-4

How to cite this URL:
Thirunavukkarasu B, Khandekar J, Parasha M, Dhiman B, Yadav K. Psychosocial health and its associated factors among Men who have sex with Men in India: A cross-sectional studyS. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 22];63:490-4. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/5/490/328103





   Introduction Top


The term “Men who have sex with Men” (MSM) was coined denoting all those men who have sex with other men as a matter of preference or practice, regardless of their sexual identity or sexual orientation and irrespective of whether they also have sex with women or not.[1] India is home to about 3.1 million MSMs which is a very diverse group with subgroups, namely kothis (effeminate receptive partner), panthis (penetrative male partner), and double decker (both).[1]

Prevalence and risk behavior related to HIV/AIDS is only the most researched domain among them which represents only tip of the iceberg. Apart from high risk of transmission of HIV and sexually transmitted infections (STIs), striking evidence in the literature can be seen directing toward higher prevalence of psychological health issues such as substance abuse,[2] partner violence,[3] depression,[4] and childhood sexual abuse[5] among MSM.

Behavioral studies of mental health and depression among MSM in India are extremely sparse. Thus, addressing these mental health issues constitutes an important area of concern among MSM and deserves special attention for the care of MSM. Thus, the current study was conducted with an aim to assess the magnitude and predictors of psychosocial health-related problems including among MSM in Delhi.


   Materials and Methods Top


A cross-sectional study was conducted among 235 MSMs who were registered at targeted intervention (TI) centers under the National AIDS Control Organization, during the study period of November, 2014 to April, 2016. The sample size was calculated on the basis of lowest prevalence of depression as 29%, considering power of 90%, confidence interval of 90%, and nonresponse rate of 10%, using Epi Info (Version 7).[6] The estimated minimum sample size came out to be 215. Out of 16 TIs in Delhi, 5 TI centers were randomly selected. A sample of 250 MSMs (ensuring minimum 50 from each center) was drawn for the study. 235 MSMs were finally enrolled and 15 were excluded for various reasons.

Self-designed, semistructured, and pretested interview schedule to collect information on sociodemographic characteristics, psychological and social factors related to psychosocial problems, sexual preferences and practices of MSM, details of substance abuse, partner violence, and childhood sexual abuse. The Center for Epidemiologic Studies Depression Scale (CES-D Scale)[7] and Generalized Anxiety Disorder-7 Item Scale (GAD-7)[8] were used to assess depression and anxiety, respectively.

The study was carried out after obtaining permission from the National AIDS Control Organization and the Delhi State AIDS Control Society in 5 TI centers. TIs[1] for HRGs offer a “package” of services such as promotion/distribution of free condoms and other commodities (e.g., lubricants for MSM, needles/syringes for IDUs), provision of basic STI and health services, linkages to other health services. Participants were selected by using simple random sampling from the register maintained in TI. The interview was conducted on one-to-one basis in an isolated room to keep them at ease which helped them to disclose their personal details after taking written informed consent. Participant confidentiality was strictly maintained. Those who are not willing to give consent were automatically excluded from the study. Those who were found to be positive on screening on CES-D and GAD-7 scale were notified to the project managers regarding their referral. Permission was obtained from the Institutional Ethical Committee before start of the study.

Data were coded and entered in the IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA). Qualitative data were expressed in proportions while mean, median, and standard deviation were calculated for quantitative data. Chi-square test was used to study the association of sociodemographic characteristics and psychosocial issues among the study participants.


   Results Top


The mean age of study participants was 25.5 years ± 6.60 years. Majority (88%) of the study participants were Hindus, followed by Muslims (22%) and Christians (3%).

Majority of study participants (83.4%) perceived themselves as females, followed by males (10.2%) and transgender (6.4%). Of those who identified themselves as females, 89% were having kothi, as sexual behavior. Twenty (11%) study participants who identified themselves as female acted as double decker. Almost all participants (95%) who perceived themselves as males were panthi and only one served as double decker. All those who identified themselves as transgender were having kothi sexual behavior. One-fifth of the participants (20%) were not suffering from any psychosocial problem (depression, anxiety, substance usage, and partner violence). Forty-two percent, 28%, and 9.5% of the participants had any one, two, or three psychosocial issue, respectively.

Almost half of the study participants (53.6%) had suicidal ideations at least once in lifetime. Among them, 50 participants had attempted at least once for suicide in their lifetime. Out of 19 participants who reported any kind of partner violence in the past 12 months, 79% reported violence by commercial sex partner with more than half (60%) reporting both physical and sexual violence. Any kind of substance(s) abuse included smoking (10.6%), smokeless tobacco (5.1%), and alcohol (22.1%) consumption and other nonintravenous drug (0.9%) usage. Pattern of psychosocial problems among the study participants is shown in [Figure 1]. [Table 1] shows association of sociodemographic characteristics of the study participants with psychosocial health-related problems.
Figure 1: Pattern of psychosocial problems among the study participants (n = 235)

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Table 1: Association of sociodemographic characteristics of the study participants with psychosocial health issues

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More than one-third of the study participants were desperate to change their sexual behavior because of the problems they were facing in day-to-day activities but could not change it and felt really bad that they could not help themselves. About one-third felt sad and hopeless about their life in future because of their sexual behavior. One-fifth of the study participants accepted their sexual behavior and considered themselves as blessed, happy, and unique regarding their sexual orientation, most of the study subjects who were content about their sexual orientation and behavior reported wholehearted acceptance by the family. About 9% of the study subjects had a mixed feeling of whether the sexual behavior that they had adopted was correct or not.


   Discussion Top


A total of 235 MSM who were enrolled in the centers were interviewed. Although a lot of studies had been conducted internationally,[2],[3],[4] limited studies were available in Indian context regarding MSM population. A lower mean age of the study participants in the present study (25.5 years ± 6.60 years) reflects the efficiency of the outreach work carried out in hotspots, thus enrolling the MSM at early age and enabling the usage of services provided to them.

The proportion of kothi's was very high in the present study, as compared to the finding reported by Mimiaga et al.[9] The reason of higher proportion of kothi's could be due to the fact that it is easy for panthi's to hide their identity resulting in their low enrolment at TIs. Furthermore, kothi's are feminine and form majority of MSM registered in TI.

Nearly half of study subjects (45%) screened positive for depression. This finding is comparable to finding reported by Williams et al.[10] Much higher prevalence of psychiatric morbidities and depressive mood disorders were reported by Deb et al.[11] The studies conducted by Sivasubramanian et al.[6] (29%) and Cochran and Mays[12] (8.5%) reported much lower prevalence of major depression. The reason of higher prevalence of depression in this study may be due to factors such as stigma and discrimination toward MSM, lack of support from families, inability to carry on normal jobs due to harassment. The reason for the higher prevalence of depression in younger and those which lower levels of education could be attributed to worry and confusion about their sexual identity, sexual behavior, and lack of acceptance by themselves and also by the society. The current study reported practice of suicidal attempts by 21.3% of the participants who had suicidal ideations (53%), which was comparable to the findings by Sivasubramanian et al.[6] The reason for such a larger prevalence of suicidal thoughts in the present study may be due to the lack of support and acceptance from the family members and friends, experienced discrimination, and societal hatred toward MSM.

Nearly 40% of the study subjects were screened positive for anxiety. However, Deb et al.[11] reported much higher prevalence of 63.9%. The higher prevalence of anxiety may be attributed to various factors such as guilt of hiding their sexual behavior from family, internalized homophobia, poor socioeconomic status, and fear of contracting HIV. The prevalence of anxiety was significantly higher among those involved in commercial sex (P: 0.001) which could be due to the fear of disclosure in the family and stigma attached to the nature of the work.

Only 8% of the study participants reported experiencing partner violence in the past 12 months, which was comparable to findings of the study done by Stephenson et al.[13] in which about 10.2% of the study population reported experiencing physical violence. The lower prevalence in the current study compared to most of the international studies[14],[15] could be due to underreporting of partner violence which we came to know when interviewing their fellow MSMs. The main reason for nonreporting of partner violence and higher prevalence among those practicing commercial sex could have been due to the fact that commercial sex is punishable under Indian judicial system and the paid partners were much aware that no one will dare to complain the incident to police.

Nearly one-fourth of the study participants reported any kind of substance usage in their lifetime. Similar findings were reported by Li et al.[16] (18.2% consuming alcohol) and Mimiaga et al.[17] (28%).


   Conclusions Top


The study reveals a significant burden of psychosocial problems and throws light toward broadening the spectrum of health assessment among this vulnerable group rather than limiting their domain to the diseases due to high-risk behavior. Owing to such a prevalence of the stated psychosocial issues, incorporation of counseling and regular assessment by a psychiatrist at the TI center can help in early identification and management of such issues.

Limitations

Study was carried out in TI centers, and hence, the findings cannot be generalized to MSM in the community. Since there are separate TI centers running, especially for transgender and intravenous drug users, there was lesser proportion of transgender in the study and none of intravenous drug users was found among enrolled MSM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
National AIDS Control Organization. Targeted Interventions Under NACP III Operational Guidelines Volume I Core High Risk Groups. NACO, Ministry of Health and Family Welfare, Govt of India; 2007. Available from: http://naco.gov.in/sites/default/files/NACP-III.pdf. [Last accessed on 2020 Jun 20].  Back to cited text no. 1
    
2.
Cochran SD, Keenan C, Schober C, Mays VM. Estimates of alcohol use and clinical treatment needs among homosexually active men and women in the US population. J Consult Clin Psychol 2000;68:1062-71.  Back to cited text no. 2
    
3.
Greenwood GL, Relf MV, Huang B, Pollack LM, Canchola JA, Catania JA. Battering victimization among a probability-based sample of men who have sex with men. Am J Public Health 2002;92:1964-9.  Back to cited text no. 3
    
4.
Sandfort TG, de Graaf R, Bijl RV, Schnabel P. Same-sex sexual behavior and psychiatric disorders: Findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Arch Gen Psychiatry 2001;58:85-91.  Back to cited text no. 4
    
5.
Paul JP, Catania J, Pollack L, Stall R. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men's Health Study. Child Abuse Negl 2001;25:557-84.  Back to cited text no. 5
    
6.
Sivasubramanian M, Mimiaga MJ, Mayer KH, Anand VR, Johnson CV, Prabhugate P, et al. Suicidality, clinical depression, and anxiety disorders are highly prevalent in men who have sex with men in Mumbai, India: Findings from a community-recruited sample. Psychol Health Med 2011;16:450-62.  Back to cited text no. 6
    
7.
Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging 1997;12:277-87.  Back to cited text no. 7
    
8.
Johnson SU, Ulvenes PG, Øktedalen T, Hoffart A. Psychometric properties of the general anxiety disorder 7-item (GAD-7) scale in a heterogeneous psychiatric sample. Front Psychol 2019;10:1713.  Back to cited text no. 8
    
9.
Mimiaga MJ, Biello KB, Sivasubramanian M, Mayer KH, Anand VR, Safren SA. Psychosocial risk factors for HIV sexual risk among Indian men who have sex with men. AIDS Care 2013;25:1109-13.  Back to cited text no. 9
    
10.
Williams JK, Wilton L, Magnus M, Wang L, Wang J, Dyer TP, et al. Relation of childhood sexual abuse, intimate partner violence, and depression to risk factors for HIV among black men who have sex with men in 6 US cities. Am J Public Health 2015;105:2473-81.  Back to cited text no. 10
    
11.
Deb S, Dutta S, Dasgupta A, Roy S. Hidden psychiatric morbidities and general health status among men who have sex with men and other clients of a sexually transmitted disease clinic of Kolkata: A comparative study. Indian J Community Med 2010;35:193-7.  Back to cited text no. 11
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12.
Cochran SD, Mays VM. Burden of psychiatric morbidity among lesbian, gay, and bisexual individuals in the California Quality of Life Survey. J Abnorm Psychol 2009;118:647-58.  Back to cited text no. 12
    
13.
Stephenson R, Sato KN, Finneran C. Dyadic, partner, and social network influences on intimate partner violence among male-male couples. West J Emerg Med 2013;14:316-23.  Back to cited text no. 13
    
14.
King R, Barker J, Nakayiwa S, Katuntu D, Lubwama G, Bagenda D, et al. Men at risk; a qualitative study on HIV risk, gender identity and violence among men who have sex with men who report high risk behavior in Kampala, Uganda. PLoS One 2013;8:e82937.  Back to cited text no. 14
    
15.
Pantalone DW, Schneider KL, Valentine SE, Simoni JM. Investigating partner abuse among HIV-positive men who have sex with men. AIDS Behav 2012;16:1031-43.  Back to cited text no. 15
    
16.
Li Q, Li X, Stanton B. Alcohol use and sexual risk behaviors and outcomes in China: A literature review. AIDS Behav 2010;14:1227-36.  Back to cited text no. 16
    
17.
Mimiaga MJ, Thomas B, Mayer KH, Reisner SL, Menon S, Swaminathan S, et al. Alcohol use and HIV sexual risk among MSM in Chennai, India. Int J STD AIDS 2011;22:121-5.  Back to cited text no. 17
    

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Correspondence Address:
Kartikey Yadav
Department of Community Medicine, Lady Hardinge Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_18_21

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