Racial and Sexual Identity-Related Maltreatment Among Minority YMSM: Prevalence,Perceptions,and the Association with Emotional Distress

Introduction

T here is considerable evidence that lesbian, gay, bisexual, and transgender (LGBT) youth experience increased levels of depression and commit more acts of self-harm compared to their heterosexual peers. ^{1 –5} Some of this may be aggravated by perceived and actual discrimination, as well as verbal and physical abuse. ^{6 –9} Sexual-minority and questioning youth are more likely than heterosexual youth to be victims of bullying, ¹⁰ peer sexual harassment, and dating-partner physical abuse ^8,11 and much of this maltreatment has strong anti-gay overtones. ⁶ Moreover, gay and lesbian youth are two to four times more likely to consider or attempt suicide compared to heterosexual youth ^4,7 and gay youth are more likely to skip school due to fear of being harassed. ¹²

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

Measures

Results

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” (http://www.itgetsbetter.org) are important first steps but must be backed by strict and enforceable hate-crime and anti-bullying legislation at the local and national levels. Future interventions for racial/ethnic minority YMSM should provide assistance in achieving a positive view of self that encompasses both their racial and sexual identities. Additionally, programs that deconstruct negative views of homosexuality in the larger society, and particularly in the Black and Latino communities, are vital, since many of the negative views of homosexuality held by the young men originated from their families and communities of origin. The use of mental health services and counseling in both individual and group form provides an opportunity for these young men to cope with the discrimination directed at them and to redevelop their ideas of what it means to be a young gay Black/Latino person in America. The goal is that these young men will emerge with a more positive, integrated view of themselves, which has been shown to improve health outcomes, lessen depression, and hopefully in turn decrease needless deaths due to suicide in this population. ³⁸