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Abstract
Background and Aim: MSM in India experience complex and multiple psychosocial challenges. The current study was conducted with an aim to assess the magnitude and predictors of psychosocial health-related problems including MSM registered in targeted intervention centers in Delhi.
Methods: A cross-sectional study was conducted among 235 MSMs. Burden of psychosocial health issues among MSM including depression, anxiety, substance abuse, and partner violence was assessed using semistructured questionnaire. Chi-square test was used to study the association of sociodemographic characteristics and psychosocial issues among the study participants.
Results: The prevalence of depression, anxiety, substance abuse, and partner violence was 45.1%, 37.8%, 27.6%, and 8%, respectively. Age (<24 years), education up to middle school, and being single had significant association with depression. Being sex worker as occupation had a significant association with anxiety and intimate partner violence.
Conclusions: The study reveals a significant burden of psychosocial problems and throws light toward broadening the spectrum of health assessment among this vulnerable group.
Keywords: Men having sex with men (MSM), psychosocial health, psychosocial problems
How to cite this article: Introduction 
The term “Men who have sex with Men” (MSM) was coined denoting all those men who have sex with other men as a matter of preference or practice, regardless of their sexual identity or sexual orientation and irrespective of whether they also have sex with women or not.[1] India is home to about 3.1 million MSMs which is a very diverse group with subgroups, namely kothis (effeminate receptive partner), panthis (penetrative male partner), and double decker (both).[1]
Prevalence and risk behavior related to HIV/AIDS is only the most researched domain among them which represents only tip of the iceberg. Apart from high risk of transmission of HIV and sexually transmitted infections (STIs), striking evidence in the literature can be seen directing toward higher prevalence of psychological health issues such as substance abuse,[2] partner violence,[3] depression,[4] and childhood sexual abuse[5] among MSM.
Behavioral studies of mental health and depression among MSM in India are extremely sparse. Thus, addressing these mental health issues constitutes an important area of concern among MSM and deserves special attention for the care of MSM. Thus, the current study was conducted with an aim to assess the magnitude and predictors of psychosocial health-related problems including among MSM in Delhi.
Materials and Methods A cross-sectional study was conducted among 235 MSMs who were registered at targeted intervention (TI) centers under the National AIDS Control Organization, during the study period of November, 2014 to April, 2016. The sample size was calculated on the basis of lowest prevalence of depression as 29%, considering power of 90%, confidence interval of 90%, and nonresponse rate of 10%, using Epi Info (Version 7).[6] The estimated minimum sample size came out to be 215. Out of 16 TIs in Delhi, 5 TI centers were randomly selected. A sample of 250 MSMs (ensuring minimum 50 from each center) was drawn for the study. 235 MSMs were finally enrolled and 15 were excluded for various reasons.
Self-designed, semistructured, and pretested interview schedule to collect information on sociodemographic characteristics, psychological and social factors related to psychosocial problems, sexual preferences and practices of MSM, details of substance abuse, partner violence, and childhood sexual abuse. The Center for Epidemiologic Studies Depression Scale (CES-D Scale)[7] and Generalized Anxiety Disorder-7 Item Scale (GAD-7)[8] were used to assess depression and anxiety, respectively.
The study was carried out after obtaining permission from the National AIDS Control Organization and the Delhi State AIDS Control Society in 5 TI centers. TIs[1] for HRGs offer a “package” of services such as promotion/distribution of free condoms and other commodities (e.g., lubricants for MSM, needles/syringes for IDUs), provision of basic STI and health services, linkages to other health services. Participants were selected by using simple random sampling from the register maintained in TI. The interview was conducted on one-to-one basis in an isolated room to keep them at ease which helped them to disclose their personal details after taking written informed consent. Participant confidentiality was strictly maintained. Those who are not willing to give consent were automatically excluded from the study. Those who were found to be positive on screening on CES-D and GAD-7 scale were notified to the project managers regarding their referral. Permission was obtained from the Institutional Ethical Committee before start of the study.
Data were coded and entered in the IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA). Qualitative data were expressed in proportions while mean, median, and standard deviation were calculated for quantitative data. Chi-square test was used to study the association of sociodemographic characteristics and psychosocial issues among the study participants.
Results The mean age of study participants was 25.5 years ± 6.60 years. Majority (88%) of the study participants were Hindus, followed by Muslims (22%) and Christians (3%).
Majority of study participants (83.4%) perceived themselves as females, followed by males (10.2%) and transgender (6.4%). Of those who identified themselves as females, 89% were having kothi, as sexual behavior. Twenty (11%) study participants who identified themselves as female acted as double decker. Almost all participants (95%) who perceived themselves as males were panthi and only one served as double decker. All those who identified themselves as transgender were having kothi sexual behavior. One-fifth of the participants (20%) were not suffering from any psychosocial problem (depression, anxiety, substance usage, and partner violence). Forty-two percent, 28%, and 9.5% of the participants had any one, two, or three psychosocial issue, respectively.
Almost half of the study participants (53.6%) had suicidal ideations at least once in lifetime. Among them, 50 participants had attempted at least once for suicide in their lifetime. Out of 19 participants who reported any kind of partner violence in the past 12 months, 79% reported violence by commercial sex partner with more than half (60%) reporting both physical and sexual violence. Any kind of substance(s) abuse included smoking (10.6%), smokeless tobacco (5.1%), and alcohol (22.1%) consumption and other nonintravenous drug (0.9%) usage. Pattern of psychosocial problems among the study participants is shown in [Figure 1]. [Table 1] shows association of sociodemographic characteristics of the study participants with psychosocial health-related problems.
Figure 1: Pattern of psychosocial problems among the study participants (n = 235)
Table 1: Association of sociodemographic characteristics of the study participants with psychosocial health issuesMore than one-third of the study participants were desperate to change their sexual behavior because of the problems they were facing in day-to-day activities but could not change it and felt really bad that they could not help themselves. About one-third felt sad and hopeless about their life in future because of their sexual behavior. One-fifth of the study participants accepted their sexual behavior and considered themselves as blessed, happy, and unique regarding their sexual orientation, most of the study subjects who were content about their sexual orientation and behavior reported wholehearted acceptance by the family. About 9% of the study subjects had a mixed feeling of whether the sexual behavior that they had adopted was correct or not.
Discussion A total of 235 MSM who were enrolled in the centers were interviewed. Although a lot of studies had been conducted internationally,[2],[3],[4] limited studies were available in Indian context regarding MSM population. A lower mean age of the study participants in the present study (25.5 years ± 6.60 years) reflects the efficiency of the outreach work carried out in hotspots, thus enrolling the MSM at early age and enabling the usage of services provided to them.
The proportion of kothi's was very high in the present study, as compared to the finding reported by Mimiaga et al.[9] The reason of higher proportion of kothi's could be due to the fact that it is easy for panthi's to hide their identity resulting in their low enrolment at TIs. Furthermore, kothi's are feminine and form majority of MSM registered in TI.
Nearly half of study subjects (45%) screened positive for depression. This finding is comparable to finding reported by Williams et al.[10] Much higher prevalence of psychiatric morbidities and depressive mood disorders were reported by Deb et al.[11] The studies conducted by Sivasubramanian et al.[6] (29%) and Cochran and Mays[12] (8.5%) reported much lower prevalence of major depression. The reason of higher prevalence of depression in this study may be due to factors such as stigma and discrimination toward MSM, lack of support from families, inability to carry on normal jobs due to harassment. The reason for the higher prevalence of depression in younger and those which lower levels of education could be attributed to worry and confusion about their sexual identity, sexual behavior, and lack of acceptance by themselves and also by the society. The current study reported practice of suicidal attempts by 21.3% of the participants who had suicidal ideations (53%), which was comparable to the findings by Sivasubramanian et al.[6] The reason for such a larger prevalence of suicidal thoughts in the present study may be due to the lack of support and acceptance from the family members and friends, experienced discrimination, and societal hatred toward MSM.
Nearly 40% of the study subjects were screened positive for anxiety. However, Deb et al.[11] reported much higher prevalence of 63.9%. The higher prevalence of anxiety may be attributed to various factors such as guilt of hiding their sexual behavior from family, internalized homophobia, poor socioeconomic status, and fear of contracting HIV. The prevalence of anxiety was significantly higher among those involved in commercial sex (P: 0.001) which could be due to the fear of disclosure in the family and stigma attached to the nature of the work.
Only 8% of the study participants reported experiencing partner violence in the past 12 months, which was comparable to findings of the study done by Stephenson et al.[13] in which about 10.2% of the study population reported experiencing physical violence. The lower prevalence in the current study compared to most of the international studies[14],[15] could be due to underreporting of partner violence which we came to know when interviewing their fellow MSMs. The main reason for nonreporting of partner violence and higher prevalence among those practicing commercial sex could have been due to the fact that commercial sex is punishable under Indian judicial system and the paid partners were much aware that no one will dare to complain the incident to police.
Nearly one-fourth of the study participants reported any kind of substance usage in their lifetime. Similar findings were reported by Li et al.[16] (18.2% consuming alcohol) and Mimiaga et al.[17] (28%).
Conclusions The study reveals a significant burden of psychosocial problems and throws light toward broadening the spectrum of health assessment among this vulnerable group rather than limiting their domain to the diseases due to high-risk behavior. Owing to such a prevalence of the stated psychosocial issues, incorporation of counseling and regular assessment by a psychiatrist at the TI center can help in early identification and management of such issues.
Limitations
Study was carried out in TI centers, and hence, the findings cannot be generalized to MSM in the community. Since there are separate TI centers running, especially for transgender and intravenous drug users, there was lesser proportion of transgender in the study and none of intravenous drug users was found among enrolled MSM.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
Correspondence Address:
Kartikey Yadav
Department of Community Medicine, Lady Hardinge Medical College, New Delhi
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/indianjpsychiatry.indianjpsychiatry_18_21
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