Ethno-racial variations in mental health symptoms among sexually-active gay, bisexual, and other men who have sex with men in Vancouver, Canada: a longitudinal analysis

Sexual minority groups, including gay, bisexual, and other men who have sex with men (gbMSM), are at greater risk of mental health disorders compared with heterosexual individuals [1‐3]. Minority stress theory suggests that these disparities may be explained by the excess stress that individuals from stigmatized groups experience because of their social position [4]. Minority stress may manifest distally (e.g., externalized events such as victimization) or proximally (e.g., internalized social attitudes) [4]. Indeed, research has shown that discrimination, stigma, and internalized homophobia play a role in poor mental health outcomes for gbMSM [5, 6].

However, gbMSM may have multiple marginalized social identities beyond their sexual orientation, including racial or ethnic identity, gender identity, immigration status, socioeconomic status, or HIV serostatus. Indeed, there is extensive literature surrounding the negative impact of racial discrimination on mental health outcomes [7]. Minority identities may be examined through the lens of intersectionality theory, which describes how experiences of oppression from multiple marginalized identities (e.g. racism, heterosexism, classism) interact to produce unique downstream effects [8]. Minority stress theory suggests that sexual minority people of colour experience dual stressors through experiences with both homophobia and racism, also termed the “double jeopardy” hypothesis [9]. However, this diversity of identities can also interact in unique ways, inviting conversations about the contribution of both risk and resilience to mental health [9, 10]. Indeed, many modulating factors, including substance use [11] immigration status [12], may influence mental health outcomes in gbMSM with multiple marginalized identities.

Previous research does not consistently show that people of colour experience more mental health problems compared to their white counterparts, including in sexual minority populations. In the United States (U.S.), the prevalence of mental health disorders is lower in some racial or ethnic minority groups compared with white individuals [13, 14]. Research at the intersection of sexual and ethno-racial minority status is limited, but some U.S. data show that the prevalence of mental health disorders or symptoms is similar or reduced for Black, Latino, and Asian sexual minority individuals compared with white individuals [3, 15‐18]. Conversely, some research has shown an increase in suicide attempts for Black [19], Latino [16, 20], and Alaska Native/Pacific Islander [20] sexual minority individuals compared with white individuals. Outside of the U.S., research in the United Kingdom (U.K.) has shown that the impact of minority sexual identity on mental health, as measured by the GHQ-12, is similar along white individuals and people of colour [17]. Conversely, in Australia, non-Anglo-Celtic gay and bisexual men, particularly Indigenous men, were more likely to show symptoms of depression [21].

In Canada, sexual minority individuals experience a higher prevalence of mental health disorders and lower rates of positive mental health than heterosexual individuals [1, 22]. Among all Canadians, Black, South Asian, and Chinese individuals are less likely to have a diagnosed mental health disorder or have suicidal thoughts than their white counterparts [23]. However, Indigenous individuals experience lower rates of complete mental health (emotional well-being; psychological and social functioning) than non-Indigenous individuals [24]. There is comparatively limited recent research outside the U.S. that has centered ethno-racial identity in examining the mental health outcomes of sexual minority groups, and no studies that have investigated outcomes longitudinally. We developed a study to examine the effect of sexual and ethno-racial minority status on symptoms of anxiety and depression in a sample of sexually-active gbMSM in Metro Vancouver, Canada. In doing so, we compare how multiple marginalized identities may uniquely affect mental health outcomes for gbMSM.

RDS-adjusted descriptive statistics by ethno-racial identity group are shown in Table 1. We found statistically significant differences (p < 0.001) for at least one group for all sociodemographic factors and substance use measures. However, we did not find differences between groups for measures of loneliness (p = 0.994), overall self-esteem (p = 0.376), or collective self-esteem (p = 0.541). We found differences in the distribution of normal, borderline, and moderate/severe depression scores at enrollment across ethno-racial groups (p = 0.003), but the differences in anxiety scores did not reach statistical significance (p = 0.067).

In the univariable analysis of factors associated with moderate/severe HADS anxiety scores, participants who identified as Asian (OR = 0.31; 95% CI: 0.13–0.77) and Latino (OR = 0.23; 95% CI: 0.05–0.97) had decreased odds of moderate/severe anxiety scores compared with white participants (Table 2). This association remained in the multivariable model for Asian participants (aOR = 0.39; 95% CI: 0.18–0.86) but was not retained for Latino participants (aOR = 0.39; 95% CI: 0.09–1.73). We found no other significant differences between ethno-racial groups when changing the reference group to from white to Asian (data not shown). Other factors associated with increased odds of moderate/severe anxiety score in the multivariable model included AUDIT Score (aOR = 1.06; 95% CI: 1.02–1.09), total self-esteem score (aOR = 1.43; 95% CI: 1.33–1.53), and loneliness score (aOR = 1.67; 95% CI: 1.50–1.86). Increasing age was associated with a lower odd of moderate/severe scores (aOR = 0.98 per year; 95% CI: 0.96–1.00).

In univariable analyses of factors associated with moderate/severe HADS depression scores, Latino identity was significantly associated with decreased odds of having moderate/severe HADS depression scores compared to both white (OR = 0.01; 95% CI: 0.01–0.03) (Table 3) and Asian (OR = 0.03; 95% CI: 0.01–0.06) identity (data not shown). This association was retained in the multivariable model for Latino individuals in comparison with both white (aOR = 0.17; 95% CI: 0.08–0.36) and Asian (aOR = 0.07; 95% CI: 0.02–0.20) individuals. No other significant differences were found between ethno-racial groups when we changed the reference category as above (data not shown). Other factors associated with increased odds of moderate/severe depression scores in our multivariable analysis included age (aOR = 1.06; 95% CI: 1.03–1.08), self-esteem score (aOR = 1.55; 95% CI: 1.44–1.67), loneliness score (aOR = 1.78; 95% CI: 1.51–2.11) and unstable housing (aOR = 2.16; 95% CI: 1.19–3.95).

In a longitudinal analysis of 774 sexually-active gbMSM in Vancouver, Canada, we did not find evidence of increased odds of moderate/severe anxiety or depression scores amongst ethno-racial minority men compared to white men. In fact, we found reduced odds of anxiety symptoms for Asian men and depressive symptoms for Latino men when compared to their white counterparts.

Our results are consistent with research in general populations in the United States and United Kingdom, which found similar or lower levels of mental health symptoms, suicidal ideation, or doctor-diagnosed mental health conditions among Black, Hispanic, and Asian individuals compared with white individuals [13, 14, 23]. This has similarly been demonstrated in some large-scale national studies in sexual minority populations in the U.S. and U.K. [3, 15, 17, 18]. Notably, in the U.S. National Latino and Asian American Survey conducted in 2002–2003, Latino and Asian sexual minority individuals had lower levels of depressive, anxiety, substance use, and eating disorders, identified through diagnostic interview, than comparable studies of sexual minorities in general [15]. However, some findings in the extant literature varied with differing mental health indicators (i.e., suicidality) or when evaluating non-white identities individually rather than a composite group. For example, although it was found that non-white lesbian and gay adolescents overall had similar or decreased levels of depressive symptoms, this differed between Black and Asian as compared to Latino, multiracial, and American Native/Pacific Islander youth, the latter ethno-racial groups experiencing increased depressive symptoms [17, 20]. Additionally, some U.S. research has found increased levels of suicidality or suicide attempts among sexual minority people of colour [16, 19, 20]. Indeed, research in the U.S. and Canada has shown that members of ethnic minorities with mental health symptoms or disorders are more likely to have persistent disorders [13], more likely to have unmet mental health care needs [23, 38], and less likely to visit mental health resources [23].

Several hypotheses exist to explain the similar or reduced rates of mental health symptoms among gbMSM of colour, including immigration status, family cohesion, and resilience or stress-related growth. In our study, Latino and Asian men were significantly less likely to be born in Canada. In North America, and specifically in Canada, some research has shown evidence of a “healthy immigrant” effect, at least initially, resulting in better mental health outcomes for immigrants [12]. Family cohesion and support, which may be higher in Latino and Asian communities [39], may also serve as a protective factor against poor mental health outcomes [40]. Finally, the previous experiences of gbMSM of colour may contribute to their resilience against sexual minority-related stigma and discrimination. For example, members of racial and ethnic minority groups can learn mechanisms for coping with minority stress in childhood through family members and close adult figures [31]. GbMSM of color may also acquire coping skills earlier in life through minority stress-related experiences associated with an ethno-racial minority identity [9, 41]. Taken together, these factors may explain the reduced levels of anxiety or depression symptoms among Asian and Latino men in our study.

Some differences in mental health symptoms may also be explained through other factors in the multivariable analysis. We selected variables in our multivariable analysis based on factors found in the literature that may confound mental health outcomes. For example, differences were found in alcohol use (AUDIT score) between ethno-racial groups, with a significant association between AUDIT score and anxiety symptoms. Alcohol use is often comorbid with anxiety [42] or depression [43] symptoms, with a potential causal relationship between alcohol use disorder and major depression [43]. Additionally, significant associations were found between loneliness and self-esteem scores and anxiety and depression symptoms, although differences were not found between groups. Finally, significant differences between ethno-racial groups were found in income and education level, which are important social determinants of mental health that have been found to be associated with poor mental health outcomes or mental health disorders [44]. These variables were largely associated with symptom scores in the univariable analyses but were not retained in our multivariable model. Thus, given that the decreased odds of moderate/severe anxiety scores for Latino men was not retained in the multivariable model, other variables may be involved that may serve as the topic of further research.

A key strength of our study was the use of respondent-driven sampling (RDS), with the inclusion of ethno-racial minority seeds, as our sampling and analysis methodology. RDS has the potential to overcome previous sampling shortfalls and more accurately represent population parameters for the Metro Vancouver gbMSM population. Additionally, it allows for the inclusion of subgroups and communities that may be missed through other recruiting methods and enables the study team to adjust for some known biases that arise through the recruitment process. Our longitudinal analysis also increases our statistical power to examine associations between smaller ethno-racial groups while accounting for non-independence of repeated measures and recruitment chains. This allowed our study to address the limitation of relatively small numbers of participants who identified as racial or ethnic minorities. Additionally, our sample was drawn from gbMSM residing in Metro Vancouver, Canada, and thus may not reflect either rural or other urban contexts elsewhere. Greater Vancouver contains a greater proportion of visible minority individuals than Canada as a whole [45], and research has shown a protective effect of higher immigrant concentration neighborhoods on mental health disorder prevalence for immigrants in Canada [12]. Finally, we used the HADS, which utilizes previously established and validated cut-offs, to measure depression and anxiety symptoms [46]. However, given the limited sample of individuals with moderate/severe depression, scores, this may potentially reduce our power to detect significant effects. Additionally, more research is needed to determine the validity of the HADS scale within ethno-racial minority populations in Canada and the United States.

Further research is needed to understand the distinct social, cultural, and structural mechanisms that modulate mental health for gbMSM of various ethno-racial identities. Moving forward, an important research objective remains in understanding survival and resilience narratives that promote mental health among gbMSM of colour. Healthcare providers should nevertheless be aware of the unique mechanisms of racism and heterosexism interact when working with gbMSM.

Among a sample of urban-residing gbMSM in Vancouver, Canada, ethno-racial minority status was not associated with increased odds of moderate/severe depression or anxiety symptoms. Asian and Latino gbMSM in Metro Vancouver manage multiple minority stressors without higher self-reported burden of mental health symptoms. Of note, gbMSM still experience a higher burden of mental health disorders than the general population in Canada. As such, more research is needed with ethno-racialized minority gbMSM to understand mental health risks and vulnerabilities and to qualify survival and resilience narratives surrounding mental health. Healthcare providers should be aware of the complexity in how racism and heterosexism interact when working with gbMSM.