Social and structural factors associated with depression and suicidality among men who have sex with men and transgender women in Nepal

Secondary cross-sectional data [37] were used in this study. Gender and sexual minorities are a large and diverse group of individuals. Therefore, we limited the study population in this study to MSM and TGW. Both MSM and TGW refer to several self-identified gender identities and sexual orientations. A list and definitions of these is available in Table 1.

Of all participants, 59% reached the cutoff score of 16 points on CESD-R. Equal rates of MSM and TGW, 34%, had a depression score between 16 and 21. More than twice as many TGW had severe depression compared to MSM (see Fig. 1 for RDS-weighted rates of depression).

Almost one-third of TGW had ever had suicidal thoughts compared to 5% among MSM. Of the participants reporting ever having had suicidal thoughts, over half of the TGW had made plans to commit suicide, and almost one third had attempted suicide. For comparison between MSM and TGW, see Fig. 2 for RDS-weighted rates of suicidal thoughts.

As seen in Supplementary Table 1, eight different exposures were significant predictors of both depression and suicidality among Nepalese MSM. Two remained significant after including all exposures simultaneously in a multivariable logistic regression (see Table 3). Sex workers were more likely to report depression (AOR: 7.9; 95% CI: 3.4–18.2). The MSM who were evicted by their family based on sexual orientation were more likely to have suicidal thoughts (AOR: 6.2; 95% CI: 1.3–28.8).

Using bivariate logistic regression, we found several exposures that were significant predictors of depression and suicidality among Nepalese TGW (see Supplementary Table 2). As seen in Table 4, sex work (AOR: 6.5; 95% CI: 2.3–18.2) remained significant for depression after multivariable logistic regression. Participants who had been cheated and threatened (AOR: 3.9; 95% CI 1.2–12.5) and forced to marry a female (AOR: 2.2; 95% CI: 1.1–5.1) had higher odds of suicidal thought.

This quantitative study had several strengths, including that the data were collected from a wide age span [17–62] and from municipalities that were both rural and included smaller cities (as opposed to large cities and metropolitan areas). In terms of methodology, the strength of this study is that recruiting participants was done with a validated sampling technique, RDS. The descriptive statistics are RDS- weighted thus providing more generalizable statistics. Besides RDS, even self- perceived discrimination, depression and suicidality were measured with standardized tools.

As for limitations in methodology, alcohol abuse was not measured with a standardized tool. Although RDS as a method has aimed to correct the flaws of its predecessor, that is, the snowball sampling method [38], it has yet to reach its full potential [45].

The cross-sectional nature of data collection for this study also leaves a question of how the psychosocial health issues developed over time in this sample [5]. Another limitation of the current study is that no comparison data from heterosexual cis-men or -women was collected. The findings of our study might be used to plan targeted interventions to improve mental health among gender and sexual minorities in Nepal. Although it is evident that the need for mental health services and prevention programs is great, there are no mental health services for gender and sexual minorities in the Terai region (Personal communication Ram Dev Tharu and Mamta Rai 1 Apr 2019). Furthermore, there is very limited mental health services available in the rest of the country (Personal communication Pinky Gurung 22 Mar 2019; Raju Thakali 25 Mar 2019). This leads to peer counseling often being the only option for help.

As many as 75% of TGW and 54% of MSM had clinically significant depression. Rates of depression are higher in our study compared to similar study in India where 42.7% of TGW and 35.3% of MSM had moderate to severe depression [46]. This study did however illustrate higher rates of depression among TGW compared to MSM. Another study on Indian MSM used CESD-R and found that 55% of participants met the cutoff criteria of 16 points, which is similar to our results [47]. Yet another study from India on psychiatric morbidities among TG showed that 31.2% suffered from current depression and 18.7% of dysthymia [48]. When it comes to suicidality, nearly 1/3 of TGW and 5% of MSM had ever had suicidal thoughts. Similar results in TGW, but higher rates among MSM have been reported by researchers in the U.S. [49, 50].

One significant factor contributing to suicidal ideation among TGW was forced marriage to a female. Not many published studies have found this association. Authors of a study of Kenyan MSM found lower depression scores among MSM who are married to a woman, and discuss the possibility that marriage to a woman could help MSM to conceal their sexual orientation [51]. They do not, however, mention whether or not the marriages are forced by family.

Nepal shares a long open border to India. Crossing this open border for sexual activities is a unique phenomenon that can hardly be expected to be found in many other regions. We found no articles where similar association was studied or found. To gain better understanding, we conducted interviews with individuals associated with gender and sexual minority rights movement in Nepal. In the Terai region, TGW sometimes sign contracts to provide sexual services to Nepali or Indian men, or to act as their partner for a certain period of time in exchange for money, accommodation or food (Personal communication Ram Dev Tharu and Mamta Rai 1 Apr 2019). Often these contracts are broken, possibly leaving TGW vulnerable with neither income nor accommodation. This could be one of the explanations to higher rates of depression and suicidality for individuals crossing the border (see Table 2), and even for sex workers and the ones reporting having been cheated or threatened. Threats and verbal abuse due to gender and sexual minority status, coming both from strangers and close ones, have been found to predict suicidality in other studies [49, 50].

Lack of social support was evident amongst many of the participants. Firstly, they could not openly talk about their own sexuality with their families, and secondly, many had been evicted by their family. Being evicted by family remained a significant risk factor for suicidality among MSM. Family rejection has in previous studies been associated with health problems such as suicide attempts, depression and use of drugs [52]. Evicted individuals in Nepal tended to move to larger cities and live under unstable housing conditions, for instance, with friends. Given that as many as half of the participants perceived discrimination in at least one setting, including the housing and working market, vulnerability for social problems among MSM and TGW is evident.

Unfortunately, this sometimes leaves sex work as the only solution for managing financially. Not only family problems [52] and lack of social support, but also being a sex worker increases the risk of having depression and displaying suicidal behavior. For both MSM and TGW, sex work remained as a significant factor for depression. Our findings support the analysis made in an Indian study, where sex work and depressive symptoms had positive correlation among MSM and TGW [53].

A larger proportion of the TGW experienced discrimination compared to MSM as seen in descriptive statistics (Table 2). A study from the U.S. found a high prevalence of attempted suicide among TG, with discrimination and depression among significant factors [54]. TGW tend to be more open about their sexuality compared to MSM who tend to be more afraid and attempt to hide their sexual identity [19], which could be one explanation to the higher rates of discrimination in our study.

In 2003, Meyer reviewed literature on how stress affects mental health among gender and sexual minorities [55]. Meyer summarized the findings of different (mostly American) studies and coined the minority stress theory. The theory posits that stressors such as adverse family factors and discrimination lead to mental health problems in an additive fashion. Our findings describe some of the possible stressors for Nepalese MSM and TGW. It follows that Meyer’s theory about higher prevalence of mental health problems among minorities, including gender and sexual minorities due to stress based on minority status, might be valid even in low-income, non-English speaking countries.