Abstract
Bullying is a form of violence characterized as an aggressive behavior that is unprovoked and intended to cause harm. Prior studies have found that lesbian, gay, bisexual, and transgender (LGBT) youth experience high levels of bullying related to their sexuality and this harassment can lead to engagement in risk behaviors, depression, and suicide. Ethnic/racial minority young men who have sex with men (YMSM) may experience dual levels of stigma and maltreatment due to both their sexuality and their race. The aim of the current study was to assess the prevalence and perceptions of racial and sexual identity-based abuse among a sample of minority YMSM, and whether this maltreatment plays a role in the emotional distress of these youth. We found that overall 36% and 85% of participants experienced racial and sexuality-related bullying, respectively. There was a significant association between experiencing a high level of sexuality-related bullying and depressive symptomatology (p=0.03), having attempted suicide (p=0.03), and reporting parental abuse (p=0.05). We found no association between racial bullying and suicide attempts. In a multivariable logistic regression model, experiencing any racial bullying and high sexuality-related bullying were significant predictors of having a CES-D score ≥16; adjusted odds ratio (OR) 1.83 and 2.29, respectively. These findings contribute to the existing literature regarding the negative experiences and daily stressors facing LGBT youth with regard to both their minority status and LGBT identities. Future interventions for racial/ethnic minority YMSM should provide assistance to achieve a positive view of self that encompasses both their racial and sexual identities.
Introduction
T
Bullying is a form of violence characterized as an aggressive behavior that is unprovoked and intended to cause harm. 10 Both cross-sectional studies and systematic reviews indicate that there is an increased risk of suicidal ideation and/or suicide attempts associated with bullying behavior, 13,14 including an association between victimization by violence and suicide attempts among LGBT-identified youth. 15,16 In the 2005 Massachusetts Youth Risk Behavior Survey, students who were bullied at school in the prior year were more likely than their peers who were not bullied to have considered or attempted suicide (24% vs. 9% and 12% vs. 5%, respectively). Sexual minority youth, compared to their peers, were significantly more likely to have skipped school because they felt unsafe (13% vs. 3%), had been bullied (44% vs. 23%), threatened or injured with a weapon at school (14% vs. 5%), and to have experienced dating violence (35% vs. 8%) or sexual contact against their will (34% vs. 9%). 2
Harassment or discrimination due to one's racial identity can lead to negative health outcomes, including increased levels of anxiety and depression, increased drug use, and low self-esteem. 17 –20 Further, there is evidence of racial discrimination within LGBT communities, as well as reports of anti-LGBT discrimination within communities of color. The aim of the current study was to assess the prevalence and perceptions of racial and sexual identity-based maltreatment among a sample of racial/ethnic minority young men who have sex with men (YMSM), and whether this abuse plays a role in the emotional distress of these youth.
Methods
Study participants
Special Projects of National Significance (SPNS) Initiative participants were enrolled at one of eight SPNS-funded demonstration sites (Bronx, NY; Chapel Hill, NC; Chicago, IL; Detroit, MI; Houston, TX; Los Angeles, CA; Oakland, CA; and Rochester, NY), each with its own outreach, linkage, and retention strategies. 21 Interventions at the sites varied based on local program design. To be eligible for this study, participants had to be: (a) born male; (b) HIV-infected and not currently in care; (c) had sex with males or had intent or wish to have sex with males; (d) self-identified as nonwhite and nonheterosexual; (e) between 13 and 24 years at the time of the interview; and (f) able to provide written informed consent.
Procedures
Eligible participants were administered a standardized face-to-face interview by local study staff. Baseline data collected between June 1, 2006 and August 31, 2009 were analyzed. De-identified data were entered into a secure web-based data portal maintained by the evaluation center staff, who analyzed the pooled data for the eight sites. All participants provided written informed consent to participate. All instruments and protocols were approved by local Institutional Review Boards (IRBs), and The George Washington University IRB.
Measures
Racial and sexuality-based harassment
Two items were used to measure Racial Bullying: “How often have you been made fun of or called names because of your race or ethnicity?” and “How often have you been hit or beaten up because of your race or ethnicity?” Youth who answered either “once or twice”, “a few times,” or “many times” to either or both of these questions were considered to have experienced racial bullying.
Three items were used to measure Sexuality-Related Bullying. The first two items were “How often have you been made fun of because of your sexuality?” and “How often have you been treated rudely or unfairly because of your sexuality?” Participants could answer “never (0 points),” “once or twice (1 point),” “a few times (2 points),” or “many times (3 points).” Responses to each question were summed and a composite score was generated. A score of 0 indicated the participant experienced no bullying; 1–4: the participant experienced a low/medium level of bullying; and 5–6: the participant experienced a high level of sexuality-related bullying. If a respondent answered anything other than “never” to a third item, “How often have you been hit or beaten up because of your sexuality?” they were included in the “high level” category.
Depressive symptomatology and additional indicators of emotional distress
The Center for Epidemiologic Studies Depression Scale (CES-D) has been used extensively to measure depressive symptomatology in HIV-infected populations, and minority and LGBT youth. 22 –26 The CES-D is a self-report scale with 20 items, each of which is rated on a 4-point scale, with a minimum score of 0 and a maximum score of 60. Individuals are asked to report the frequency of how they felt in the previous week on parameters such as crying spells, loneliness, self-esteem, and sleep. Scores of 16 or greater on the CES-D are traditionally interpreted as suggestive of clinically significant depression.
In addition, we used two other indicators to measure emotional distress. Youth were asked about suicidal ideation (“Have you ever made a plan for committing suicide? I mean, have you ever figured out a specific way of ending your life?”) and prior acts of self-harm (“Have you ever tried to take your own life?”). Both items had “yes” and “no” as response options.
Family and friendship-based social support
Support from family was measured with 2-items, scored “never,” “sometimes,” “most of the time,” and “always.” “How often have you had serious disagreements with your family about things that were important to you?” and “How often do your feel your parent(s)/guardian(s) care about your well-being?” An additional item, “Do you feel you have a good relationship with your family?” had “yes” and “no” as response options. A final item measured how frequently participants see/hear from family and was scored “less than once a month,” “monthly,” “a few times a month,” “a few times a week,” or “daily.” Support from close friends was measured with a single item, “How often do you see/hear from close friends?” This item was scored “less than once a month,” “monthly,” “a few times a month,” “a few times a week,” or “daily.”
Parental abuse
A single item assessed for parental abuse, “When your parent or primary caretaker has disagreements with you, do they ever…(a) Hurt your feelings/emotionally abuse you? (b) Kick, bite, or hit you with a fist? (c) Hit or try to hit you with an object? (d) Beat you up? (e) Burn or scald you? (f) Threaten you with a knife? (g) Threaten you with a gun? (h) Touch you in a way that made you uncomfortable? and/or (i) Threaten your life in some other way?” Participants could choose more than one response.
Statistical analysis
Uni- and bivariate analyses were used to describe participants and potential confounders. A logistic regression model to identify significant predictors for having a CES-D score ≥16 was performed. Variables significant at the 0.10 level and those known to be related to depressive symptoms were included in the model. In addition, age was included as a confounding variable. An analysis of the association of race with CES-D score showed that race is not significantly associated with CES-D score (p=0.75) and was not included in the model. All analyses were performed in SAS Version 9.1 (Cary, NC).
Results
Descriptive statistics
The cohort consisted of 351 racial/ethnic minority YMSM with a mean age of 20.4 years. Two-thirds of the sample (67.5%) identified as African-American, 20.2% as Latino, and 12.3% as multiracial. Most of the sample identified as gay (65.5%) or bisexual (20.5%). A majority (92.9%) of the cohort reported being comfortable or very comfortable with their sexual orientation. The mean age of sexual debut with a man was 14.6 years.
Twenty-three percent (n=79) of the cohort had made a plan to commit suicide, and almost all of those who had made a plan (96%, n=76) had attempted at least once. Among those youth with suicide plans, 45% (n=34) had attempted suicide more than once.
Racial bullying
Overall, 36.3% (n=128) of participants reported being made fun of or called names because of their race or ethnicity and 4.6% (n=16) reported being beaten up. Experiencing racial bullying was more common among multiracial and African-American young men compared with Latinos (p=0.05).
There was a significant association between being bullied due to race or ethnicity and depressive symptomatology (CES-D score ≥16, p=0.007) and having a period of at least one week of feeling sad (p=0.002) (Table 1). While use of any drugs was not associated with experiencing racial bullying, lifetime use of sedatives (p=0.05) and sedative use within the last three months (p=0.04) were associated with racial bullying.
Excludes alcohol.
Sexuality-related bullying
Overall, 74.1% (n=260) of the cohort reported being made fun of because of their sexuality, with more than half (55.0%) reporting that these experiences were somewhat or very stressful. Fifty-eight percent (n=205) of the young men reported ever being treated rudely or unfairly because of their sexuality, and nearly two-thirds (62.4%) found these events to be somewhat or very stressful. Fifty-seven participants (16.2%) reported being hit or beaten up because of their sexuality, with 7 of these young men experiencing this physical violence many times. The composite scores for bullying related to sexuality showed that 14.8% (n=49) of the cohort experienced no bullying; 54.1% (n=179) experienced a low/medium level of bullying; and almost one-third, 31.1% (n=103) experienced a high level of bullying. Sixteen participants did not identify as male, with 5 identifying as transgender, 3 as female, 1 as butch queen, 1 as realness, and 6 as other. Overall, 75% of these nonmale identified participants experienced some form of sexuality-related bullying.
There was a significant association between experiencing a high level of sexuality-related bullying and depressive symptomatology (p=0.03); ever having a period of at least 1 week of feeling sad (p=0.004); having attempted suicide (p=0.03); having serious disagreements with family (p<0.0001); and experiencing parental abuse (p=0.05) (Table 2).
Excludes alcohol.
Multivariable analysis
Experiencing any racial bullying and high sexuality-related bullying were significant predictors of having a CES-D score≥16 in a logistic regression model, with adjusted odds ratios (ORs) of 1.83 (95% C.I. 1.06, 3.14, p=0.0293) and 2.29 (95% C.I. 1.01, 5.20, p=0.0474), respectively (Table 3). Measures of the closeness of family and friend relationships were also included in this model to control for the level of social support experienced. The odds ratios of 2.29 for high sexuality-related bullying indicates that the odds that racial/ethnic minority YMSM reporting significant depressive symptomatology would report high sexuality-related bullying was more than two times greater than that of youth not reporting depressive symptomatology.
Likelihood ratio chi-square=69.25 (p<0.0001).
Discussion
Prior studies have found that being gay or bisexual is a major predictor of suicidality, 27,28 and rates of suicidal ideation and attempts in this cohort of HIV-infected raical/ethnic minority YMSM were similarly found to be significantly higher than those in heterosexual youth. 29 Gay youth who have been exposed to high levels of victimization have higher rates of past-year suicide attempts compared with heterosexual youth exposed to similar levels of victimization 16 and one study found that gay and bisexual men may be more vulnerable to suicidal thoughts and actions as depressive symptoms increase, compared to heterosexual men. 27
Despite some modest gains in acceptance of gays and lesbians over the decades since removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), national policies are indicators of the social climate and homophobia remains pervasive in today's society. The hateful rhetoric used in national debates over same sex marriage and "don't ask, don't tell" continue to fuel the problem, creating a potentially harmful environmental context for LGBT persons that may result in negative health outcomes. The debate over same-sex marriage is one of the most visible and highly contested political issues impacting LGBT communities. A recent study showed that psychiatric disorders increased significantly in LGBT individuals living in states that banned same sex marriage in the 2004 and 2005 elections. There was a 36.6% increase in mood disorders, a 248.2% increase in generalized anxiety disorder, and a 42% increase in alcohol use disorders. 30
At first glance, equal rights for the LGBT community may appear to be peripheral to the issue of suicide among LGBT youth, but the policy environment has direct bearing on internal and interpersonal factors, including internalized homophobia and reduced self-worth for YMSM. This can lead to shame, self-hatred, and social isolation. In their study of African-American, YMSM, Stokes and Peterson proposed that the negative experiences these men have with regard to their race, sexuality, and gender are internalized and result in decreased self-esteem and self-worth. 31 As in other studies, this was related to deep-seated external and internalized stigma around sexuality, race, and gender. Internalized homophobia is also associated with demoralization, guilt, suicidal thoughts, sexual problems, and traumatic responses to HIV-related stress. 32 –36
In this study, we found an association between experiencing a high level of bullying related to sexuality and both depressive symptoms and attempting suicide. The extreme nature and devastating consequences that harassment has on gay youth may be related to a lack of social support to buffer these negative experiences and daily stressors, as well as high levels of parental abuse. More than two-thirds of the young men in this sample experienced some form of parental abuse, and more than a quarter of those experiencing abuse had cuts, burns, or broken bones as a result of those incidents. Other studies have found that LGBT adolescents who reported higher levels of family rejection were at least three times more likely to use illegal drugs compared to their peers who reported no or low levels of family rejection. 37 There is also the added effect of race, with racial/ethnic minority YMSM more often reporting negative family reactions to their sexual orientation compared to white YMSM. 37 African-American and Latino YMSM may also experience homophobia from their respective racial/ethnic communities. How YMSM cope with this homophobia becomes important, given that racial/ethnic minority YMSM who are able to achieve a positive integrated identity related to being a LBGT person of color have higher self-esteem, stronger social support networks, greater levels of life satisfaction, and lower levels of psychological distress than young men who do not achieve this identity. 38,39 Taken together, these findings suggest interventions that help families and communities become more accepting of LGBT members may have beneficial health effects, including decreased depression, drug use, and attempts at self-harm.
The association of suicide attempts and sexuality-related bullying, but not racial bullying, may be due to social support and having a strong sense of racial identity that can buffer these negative experiences. 40 –42 Diaz et al. reported that in a sample of Latino MSM, family acceptance and community involvement reduced the effects of sexuality-based discrimination. 43 Unlike their experiences surrounding race, minority YMSM are not likely to have grown up in a home with parents who shared their stigmatized gay identity. Thus, there is little to no appropriate gay role modeling or protection against negative views toward homosexuality. If negative stereotypes are constantly reinforced with children who grow up to be gay, they may become a part of the children's perceptions of what it means to be a gay person in society. Interestingly, despite experiencing high rates of both physical and emotional abuse related to their sexuality, most of the young men in this study expressed high levels of comfort with their sexual identity, documenting a high level of resilience within this population, an important consideration in designing future interventions.
This study is not without limitations. Despite being a large, geographically diverse sample, we only included HIV-infected racial/ethnic minority YMSM who were being linked to care. Thus, the most disenfranchised youth may not be represented and our findings may underestimate the magnitude of the problem. Further, we cannot differentiate the effect that HIV had on levels of depressive symptoms or suicide attempts. However, among the 76 youth who had ever attempted suicide and for whom we had a date of HIV diagnosis, and an age at first (or only) suicide attempt (n=65), 59 (90.8%) had attempted suicide at or before the age of their HIV diagnosis. In addition, our survey did not identify who the bully or bullies were or when the bullying took place (e.g., home, school), although it should be noted that only 38% of our sample was enrolled in school at the time of the interview. Future research should focus not just on the prevalence of racial and sexuality-related bullying but who are the perpetrators of the abuse and the context in which the abuse occurs.
The positive impact of LGBT support groups (e.g., Gay-Straight Alliances) and other efforts to improve the climate for LGBT high school students has been documented.
44
Anti-bullying campaigns such as the recently launched “It Gets Better” (
Footnotes
Author Disclosure Statement
This study was made possible by a grant through the U.S. Department of Health and Human Services, Health Resources and Services Administration. The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the U.S. Government.
