Experienced homophobia and suicide ideation in young gay,

bisexual, and queer men: Exploring the mediating role of

depression severity, self-esteem, and outness in the Pink Carpet
Y Cohort Study

Rayner Kay Jin TAN B.Soc.Sci (Sociology)

Ph.D. Candidate, Saw Swee Hock School of Public Health, NUS & NUHS
Treasurer, Society of Behavioural Health, Singapore
Perspectives Panel, Sexually Transmitted Infections
Associate Editor, Social Determinants of Health, BMC Public Health
E-mail: rayner.tan@u.nus.edu | Twitter: @raynerT

Timothy Low Qing Ying B.Soc.Sci (Political Science and Sociology)

Research Assistant, Centre for Family and Population Research, FASS, NUS
E-mail: timothylow@nus.edu.sg
Suicide in Young Gay, Bisexual and Queer Men

BACKGROUND

2
Suicide as a Public Health Issue1
• In 2016, the global crude suicide mortality rate was at 10.6
per 100,000 persons
• Men (13.5) have higher suicide rates than women (7.7)
• European (15.4) and Southeast Asian (13.2) regions having
higher level of reported suicides compared to other parts of
the world
• Higher income countries (14.3) also had higher suicide
mortality rates as compared to lower middle-income
countries

3
Suicide-Related Behaviors
• Not all individuals who contemplate suicide would act upon
such feelings and that it was necessary to differentiate these
two groups of individuals.2 However, there seems to be an
inconsistent conceptualization on suicide and suicide
attempts.3
• Individuals with an intent to die and harm themselves are
classified as having a suicide attempt. 4

4
Suicide in Young Gay, Bisexual and Queer Men
• Young gay, bisexual and queer (GBQ) men are more likely
to exhibit suicide behaviour (e.g. ideation, planning,
attempting and actual suicide death) as compared to their
heterosexual counterparts.5-8
– Young gay and bisexual men > heterosexual counterparts (OR: 2.21),
while transgender youths have greater risk of suicide (OR: 5.87) than
bisexual (OR: 4.87) and homosexual (OR:3.71) youths.9
– Within suicide death in the US, the proportion of younger sexual
minorities was greater than those of older sexual minorities.10
– Young GBQ men in China and South Korea are more likely to have
suicide ideations or attempts than their heterosexual counterparts,
suggesting that greater risk of suicide for young GBQ men is not
specific to Western developed societies.7,11,12

5
Research on Young GBQ Men in Singapore
• Risk factors for suicide ideation and attempts in young
GBQ men include:
– Substance use 5,7,10,12,16
– Poor mental health 5,7,10,13,14,15
– Peer victimisation and homophobic bullying 5,13,16,17
– Lack of belonging and support in school 13
– Family problems including absent of parents, poor relations with
family and low family support 10,12,17
– Coming out, disclosure or having sexual identity known by others
7,14,17

– Experience with violence and sexual violence 5,18

6
Suicide in Young Gay, Bisexual and Queer Men
• Sexual relations between men is criminalized in Singapore
(Section 377A of the Penal Code)
• Past studies have found that most Singaporeans perceived
same-sex relationships as being wrong, and are against the
idea of gay marriage; most are also not in favor of the repeal
of Section 377A, the law that criminalizes sexual relations
between men 19,20,21,22
• Not much is known about the mental health of young GBQ
men in Singapore, or the impact of stigma and homophobia on
mental health outcomes.

7
The Pink Carpet Y Cohort Study

METHODS

8
Study Design

Eligibility Criteria: As of 31 August 2019:

- 18 to 25 years old at enrolment - 701 participants enrolled
- HIV-negative or unsure of status - 570 used in analytic sample
- Cis/trans male who identifies as
gay, bisexual, or queer

9
Recruitment

10
Variable Measures
Demographic Variables
Age, Gender, Sexual orientation, HIV status, Residence status, Ethnicity, Religion, Educational attainment,
Work status, Housing, Gross personal monthly income, Current relationship status, Height and weight

Other Variables of Interest

1. Connectedness to LGBT community scale (Frost & Meyer, 2012)
2. Personal social capital scale (Chen et al., 2012)
3. Outness inventory (Mohr & Fassinger, 2000)
4. Sexual risk behaviors (Age of sexual debut, sexual risk behaviors, substance use, accessing sex etc.)
5. HIV/STI testing behaviors (Frequency, recency of HIV and other STI testing)
6. HIV Pre-exposure prophylaxis (PrEP) and Post-exposure prophylaxis (PEP) knowledge and uptake
7. Perceived homosexual stigma (Smolenski, Ross, Risser, Rosser, 2009)
8. Internalized homosexual stigma (Amola & Grimmett, 2015)
9. Experienced Homosexual Stigma (Bruce, Ramirez-Valles, & Campbell, 2008)
10. Single-Item Self-Esteem Scale (Robins, Hendin, & Trzesniewski, 2001)
11. Patient Health Questionnaire-9 (PHQ-9) (Kroenke, Spitzer, & Williams, 2001)
12. Suicide-related questions

11
Analysis
STATA IC 15
- Descriptive statistics at univariate level
- Logistic regression for bivariate and multivariate regression analyses
- Generalized structural equation modeling (gsem command) for path analysis/mediation analysis
- SEM builder function in STATA

sise ε1 2.7
4.7
-.17
-.022

Bernoulli

ehs suicideideabin
.049 .92
logit
-.066
age
-.043

.14
cismale
.13 .27

housing_pte

gay ethnic_nc

12
Experienced Homophobia and Suicide Ideation

FINDINGS

13
 Table 1. Sociodemographic attributes and description of analytic sample (n=570)
Demographic Variables n % Mean SD
Age 21.9 2.17
Ethnicity
Chinese 478 83.9%
Non-Chinese 92 16.1%
Gender
Cisgender male 525 92.1%
Transgender, genderqueer, or others 45 7.9%
Sexual orientation
Gay 408 71.6%
Bisexual, queer, or others 162 28.4%
Sample Characteristics

Housing Type
Private housing 126 22.3%
Public housing 438 77.7%
Ever contemplated suicide (suicide ideation)
Yes 308 54.0%
No 262 46.0%
Ever attempted suicide (suicide attempt)
Yes 76 13.3%
No 494 86.7%
Experienced homophobia* (Range: 14 to 56) 25.0 12.00
Depression severity* (Range: 0 to 27) 7.0 10.00
Self-esteem (Range: 1 to 7) 4.1 1.66
Outness inventory* (Range: 1 to 7) 2.3 2.00

Abbreviation: SD, Standard Deviation

*Median and Inter-Quartile Range reported

14
 Multivariable logistic regression for ever contemplating suicide

Ever contemplated suicide

OR 95% CI p-value aOR 95% CI p-value

Age 0.92 (0.86-1.00) 0.047 0.95 (0.87-1.03) 0.214
Non-Chinese (ref=Chinese) 1.41 (0.89-2.22) 0.144 1.25 (0.74-2.09) 0.404
Cisgender male (ref=Transgender, genderqueer, or others) 0.76 (0.41-1.42) 0.393 1.22 (0.61-2.45) 0.570
Gay (ref=Bisexual, queer, or others) 1.12 (0.78-1.62) 0.544 1.10 (0.72-1.67) 0.670
Private housing (ref=Public housing) 1.00 (0.67-1.49) 0.986 1.13 (0.73-1.74) 0.597
Experience homophobia 1.06 (1.03-1.08) 0.000 1.03 (1.00-1.05) 0.022
Depression severity 1.13 (1.09-1.16) 0.000 1.11 (1.07-1.15) 0.000
Self-esteem 0.83 (0.75-0.92) 0.000 0.95 (0.84-1.08) 0.449
Outness 1.22 (1.08-1.38) 0.002 1.19 (1.03-1.37) 0.015

Notes
Abbreviations: CI, Confidence Interval; OR, Odds Ratio; aOR, Adjusted Odds Ratio
Statistically significant results (p<0.05) are highlighted in bold font
Mediation Analyses

Multivariable logistic regression for ever attempting suicide

Ever attempted suicide

OR 95% CI p-value aOR 95% CI p-value

Age 0.92 (0.86-1.00) 0.047 0.96 (0.85-1.08) 0.526
Non-Chinese (ref=Chinese) 1.41 (0.89-2.22) 0.144 1.74 (0.91-3.36) 0.097
Cisgender male (ref=Transgender, genderqueer, or others) 0.76 (0.41-1.42) 0.393 1.12 (0.47-2.71) 0.796
Gay (ref=Bisexual, queer, or others) 1.12 (0.78-1.62) 0.544 0.73 (0.41-1.32) 0.303
Private housing (ref=Public housing) 1.00 (0.67-1.49) 0.986 1.08 (0.57-2.04) 0.807
Experience homophobia 1.06 (1.03-1.08) 0.000 1.02 (0.99-1.05) 0.147
Depression severity 1.10 (1.06-1.14) 0.000 1.07 (1.03-1.12) 0.001
Self-esteem 0.87 (0.76-1.01) 0.071 0.93 (0.78-1.11) 0.399
Outness 1.39 (1.18-1.63) 0.000 1.41 (1.17-1.71) 0.000

Notes
Abbreviations: CI, Confidence Interval; OR, Odds Ratio; aOR, Adjusted Odds Ratio
Statistically significant results (p<0.05) are highlighted in bold font

19
 Indirect effect: Coeff= .024 SE= .0053 ***
Total effect: Coeff= .052 SE= .013 ***

Depression
Severity

Indirect effect: Coeff= 0.0011 SE= .0014

Total effect: Coeff= .029 SE= .012 *

Self-Esteem
Mediation Analyses

Indirect effect: Coeff= .0064 SE= .0029 *

Total effect: Coeff= .034 SE= .012 **

Outness

Experienced Suicide
homophobia Direct effect: Coeff= .023 SE= .016 Ideation

20
 Indirect effect: Coeff= .017 SE= .0053 **
Total effect: Coeff= .039 SE= .016 *

Depression
Severity

Indirect effect: Coeff= 0.0017 SE= .0021

Total effect: Coeff= .024 SE= .016

Self-Esteem
Mediation Analyses

Indirect effect: Coeff= .013 SE= .0043 **

Total effect: Coeff= .035 SE= .016 *

Outness

Experienced Suicide
homophobia Direct effect: Coeff= .023 SE= .016 Attempts

21
Discussion
Suicide-related behaviors and experienced homophobia
• Rates of suicide ideation (54.0%) and attempts (13.3%) are high among young
GBQ men in Singapore
• Experienced homophobia is a risk factor for both suicide ideation and attempts
• Relevant for sexual and reproductive health – syndemic of HIV and other STI

Mediation/path analysis
• Depression severity partially accounts for the association between experienced
homophobia and suicide ideation and attempts  plausible, but interpret with
caution due to temporality issues.
– Mean age aware of sexual orientation = 13.2 (SD 3.22)
– Mean age of first suicide ideation and attempt = 16.2 (SD 3.42)/16.8 (SD 3.49)
• Outness partially accounts for the association between experienced
homophobia and suicide ideation and attempts  requires further (qualitative)
study.

22
Limitations and Strengths
• Limitations:
– Present measures of depression severity, self-esteem and outness versus past
suicide-related behaviors; assumes depression severity and outness remains
static  require prospective cohort studies among younger GBQ men.
– Selection bias – those who are more ‘out’ or comfortable with their sexual
orientation are more likely to participate in the study.
– Social desirability bias – several ‘prefer not to say’ responses to suicide ideation
(n=46; 8.2%) or attempts (n=33; 5.86%) were recoded as ‘never
contemplated/attempted suicide’ to be conservative.

• Strengths:
– First study on mental health among GBQ men in Singapore, where sexual
relations between men is criminalized
– Strong evidence for the association between experienced homophobia and
past suicide-related behaviors among GBQ men in Singapore
– Future explorations of the ‘life course’ of suicide among GBQ men

23
Recommendations
• Early interventions in schools
– As young as 13 years old for young GBQ men who are questioning
their sexual and gender identities
– School-based and NGO-based programs to buffer impact of stigma
• Stigma reduction
– General society: More challenging
– Institutionalized: More within the means of policymakers
• Protections from discrimination based on sexual orientation
– Bullying and teasing in school
– Media representation
– Healthcare
– Religious institutions

24
Acknowledgements
Study Team Members:
Sumita Banerjee (AFA)
Chronos Kwok (AFA)
Calvin Tan (AFA)
Adrian Tyler (AFA)
Avin Tan (AFA)
Daniel Tiane Le (NUHS)
A/Prof Wong Mee Lian (SSHSPH)

Funding:
Singapore Population Health Improvement
Centre (SPHERiC) Seed Fund (SPHERiC-012)

Ethics Approval:
NUS Institutional Review Board (S-19-007)

Support:
Prof Teo Yik Ying
A/Prof Alex Cook
Ms Sharon Lee
Dr Mark Chen I-Cheng
Dr Wong Chen Seon
Kenneth Ng (SSHSPH)
Koh Wee Ling (SSHSPH)
Caitlin O’Hara (YLLSoM)
Eugene Wong (AFA)

25
Questions?

THANK YOU!

26
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