Violence and depression among men who have sex with men in Tanzania

This study utilized a cross-sectional analytical design. The study was conducted at the Muhimbili Health Information Centre in Dar es Salaam City, Tanzania. The study was conducted for a period of 3 months, from August – October 2014.

The study involved men who have sex with men in Dar es Salaam. Inclusion criteria were Men who have sex with men aged at least18 years.

Estimated sample size of the study was calculated by using the formula:

Where by: N = estimated sample size, Z = confidence level at 95% (standard value of 1.96), P = Prevalence of violence among men who have sex with men 8% [6, 8], d = Margin of error at 3%. Adjusting for non-response, we added 10% of the estimated sample size n = 31.4. Therefore: the minimum estimated and obtained sample size was 345.

The study utilized a respondent driven sampling (RDS) technique. This technique is used to study hidden populations; whereby a subset of members of the population is used to increase the sample size by recruitment of similar members of the group. In this research study, five eligible MSM were identified to serve as seeds. Seeds were chosen from the community based on the convenience of the investigator and were reached individually through phone calls. Each seed was tasked to recruit three participants each, the first and subsequent waves of recruits were similarly tasked to bring three participants until the sample size was attained. Although all interviews took place in a health facility, all participants came from the community. Study interviews were conducted by the principal investigator and two trained research assistants. Participants were given 3000 Tanzanian shillings (US$ 1.37) for their participation and 2000 Tanzanian shillings (US$ 0.91) for each recruit they brought to participate in the study.

Violence was measured using the Revised Conflict Tactic Scale (27 questions). The frequency score ranged from 0 = never, 1 = once, 2 = twice, 3 = 3-5 times, and 4 = 6-10 times, 5 = 11-20 times, 6 = more than 20 times. Three types of violence were assessed: physical, emotional and sexual violence. The scale has been validated in Swahili for use in Tanzania [19]. For our study violence score was dichotomized into “No violence (0) and violence (≥1)”.

Symptoms for depression were assessed by PHQ-9 a validated nine item tool based on the DSM IV diagnostic criteria for depression and it has been used in Sub-Saharan Africa and validated in Swahili language. Each question presented the frequency of the depressive symptoms that one has experienced over the past two weeks, scores ranging from 0 (not at all) to 3 (nearly every day). Scores of 1-4 signified minimal depressive symptoms, 5-9 mild depressive symptoms, 10-14 moderate depressive symptoms and scores of >14 entailed a depressive disorder warranting a combination of antidepressants and psychotherapy in the management [20].

In this present study, we found the prevalence of any form of violence amongst MSM to be 94.2%. Even after categorizing violence by type i.e. physical, emotional and sexual, still each form was experienced by at least three quarters of participants. A study done by Chellan et al. [10] revealed a prevalence of 29.6%, 54.6%, 57% in physical, emotional and sexual forms of non-IPV violence respectively. Another study by [11] in India reported non-IPV sexual violence rates of 18%. A local study by [1] revealed non-IPV rates of physical violence of 29.5%, sexual violence 30%, and emotional violence 48.5%. In the recent times, MSM living in Tanzania has faced even more hostility than ever before. Such hostility includes, arrest, persecution, discrimination, harassments, alienation from family and faith, lack of access to social services [21, 22]. These factors in particular amongst others could offer the explanation as to why the rates of violence observed in this study are significantly higher than the ones observed in the previous published works.

Nearly two thirds of study participants reported their sexual partners as the most common perpetrators, while relatives and friends were reported by over half of MSM. Like other studies [1] it was observed that confidants who under natural circumstances are expected to be the source of hope and strength were the leading perpetrators. Assessment of factors associated with violence in a 6-item ‘age, education, marital status, depressive symptoms, and bottom and versatile sexual positioning’ logistic regression model revealed depressive symptoms were the strongest associated factor.

With respect to burden of violence and depression, our findings echo those of Anderson et al. [1]. However, the magnitude from this current study are appreciably higher compared to Anderson’s [1] data. This difference could probably be explained by the fact that participants in this current study were older than the ones in Anderson’s study and potentially had more years of exposure to violence and depression. Our findings potentially reflect the fact that MSM face more hostility currently than a few years ago. Nevertheless, the rates of depression among MSM remain considerably high, displaying a strong association with violence.

Nearly three quarters of our participants displayed depressive symptoms, with over 90% of these falling in the category of minimal to mild depression. Subjects with violence experience had over 11 times odds of having depressive symptoms compared to violence free participants, (OR 11.5, 95 CI 3.5-48.1, p < 0.001). Studies conducted (by [23, 12, 13, 24, 25, 15]) revealed significantly lower depression rates (18%-61%) than the present study. Violence was found to be the strongest associated factor of depressive symptoms in this study. Other potential factors including age, education, marital status and typology didn’t prove to be significant factors of depression in this set up. A study by Klein et al., [24] produced similar results as far as violence is concerned, however, in contrary to our study, low education was a shared predictor in the (Klein et al., [24] and Hirshfield et al. [13] studies, while marriage to a woman and single status were predictors in the Hirshfield et al. [13] study alone. Being MSM in this setting and similar continues to be a reason for extensive discrimination and abuse; as a result men fail to seek for medical-legal help as expected. This inflames distress in an already distressed population full of fear of disclosing their sexual orientation and depression is inevitably high. This not only complicates the lives of MSM but also does hinder both mental health seeking behaviour and service provision [26, 27].

Due to the observational nature of this study our findings could have potentially be exposed to interviewers’ bias and recall bias. However, all interviewers were qualified personnel working in the department of psychiatry and mental health but also underwent a thorough training to familiarize themselves with study objectives and questionnaire. Although we are not in position to infer causality, our current understanding however is that both violence and depression are strongly interlinked each with a potential to cause or result from one another.