Oral presentation on May 23, 1997, in Ottawa, Ontario, at the Canadian Association for HIV/AIDS Research.

Evidence of Psychologic Distress in a Cohort of Young Gay/Bisexual Men

Steve L. Martindale; Steffanie A. Strathdee, PhD; Robert S. Hogg, PhD; Peter GA Cornelisse, MSc; Mary Lou Miller, RN; Bonnie Devlin; JSG Montaner, MD, FRCP; MV O'Shaughnessy, PhD; MT Schechter, OBC, MD, PhD; for the Vanguard Project; UBC and the BC Centre for Excellence in HIV/AIDS.

Acknowledgements:

I would like to take this opportunity to acknowledge the Principal Investigator of this study, Dr. Martin Schechter; the Co-Investigators as listed on the slide; and the National Health Research Development Program of Health Canada for project funding.

I would also like to acknowledge the work of several individuals, including: volunteer recruiter Garry Johnson; data entry clerk Myrna Reginaldo, participating doctors and nurses, members of the Community Advisory Committee and the participants themselves.

Primary Objective:

The Vanguard Project was launched in May, 1995, as an expansion of the Vancouver Lymphadenopathy-AIDS Study (VLAS) which has been running since 1982. The primary objective of the Vanguard Project is to monitor HIV incidence rates and associated risk factors among young men having sex with men (MSM).

To monitor HIV incidence rates and associated risk factors among young men having sex with men (MSM).

Eligibility Criteria:

Eligible participants are males between the ages of 18 and 30, living in the Greater Vancouver area, who have not previously tested HIV-positive.

The study is open to all men who have sex with men, regardless of whether they self-identify as gay, bisexual or straight.

Eligible subjects who agree to participate are asked to complete an annual self-administered questionnaire and submit a blood sample for HIV antibody testing, for which they provide informed consent. The questionnaire includes demographics, sexual behaviour with regular and casual partners, sex-trade involvement, recreational drug use and psycho-social issues.

• 18 to 30 years old at baseline
• Living in Greater Vancouver area
• Gay, bisexual and/or MSM
• No previous positive HIV test result

Study design:

The study is designed as an open cohort, where individuals can enroll at any time. Subjects have been recruited through a variety of mechanisms, the most successful of which have been through street clinics and through direct outreach into community events and bars. At enrollment and throughout follow-up, participants are also provided with referrals to physicians, counselors, medical clinics, community agencies and support services.

• Open cohort
• Annual HIV antibody test
• Self-administered questionnaire

Objective:

The objective of the present analysis is to describe factors associated with psychologic distress among a prospective cohort of young gay and bisexual men, and to examine the relationship of these factors with sexual risk-taking.

To describe factors associated with psychologic distress among a prospective cohort of young gay and bisexual men.

Follow-up questionnaire information:

Following an analysis of baseline data one year ago, we identified several social determinants - such as sexual abuse and low social support - to be associated with sexual risk-taking. We therefore added detailed questions on several psycho-social variables to the follow-up questionnaire. This analysis focuses on the first 203 men who have completed follow-up questionnaires.

Both baseline and follow-up questionnaires included risk behaviours, social support, depression and non-consensual sex. At follow-up, questions were included on suicide ideation and attempts, history of mental disability or mood disorder, drug and alcohol treatment, self-esteem, gay bashing (which we defined in the questionnaire as "physical abuse as a result of being gay or perceived as gay"), domestic violence (which we defined as "ever being hit or assaulted by a partner or date"), age of "coming out" and level of comfort with self-identified sexual orientation.

• Non-consensual sex
• IES Social Support scale
• CES-D depression scale
• Suicidal ideation and attempts
• Mental disability/mood disorder
• Drug/alcohol treatment
• Rosenberg self-esteem scale
• Gay bashing
• Domestic violence
• Age of first "coming out"
• Comfort level with sexual orientation

Study subjects:

As of April 97, follow-up questionnaires and test results had been completed by 203 participants. To date, the return rate for annual follow-up visits is 76%. The median time since the baseline follow-up visit was 13 months.

Among the subgroup of 203 men, the median age was 27. Like the overall cohort, most were Caucasian (78%), and most reported not being in a primary relationship since their baseline visit (73%).

At the time this analysis was conducted, men who had not yet returned for follow-up did not significantly differ from men who completed baseline questionnaires in terms of ethnicity, relationship status, and number of sexual partners reported in the year prior to baseline, but men who have not yet returned are significantly younger, and are more likely to have reported being paid for sex. Therefore, these findings may not be generalizable to the rest of the cohort.

Median age:	27 yrs
Age range:	25-30 yrs
Caucasian:	78%
Primary relationship:	27%
Education < high school:	9%
Unstable housing:	4%
Paid sex:	7%
Return rate:	76%
Median interval:	13 months
Median number of sexual partners in past year:
Regular:	2
Casual:	7

Note: results refer to period since baseline interview.

Results:

Based on responses at follow-up, median age of coming out was 19. Most participants (77%) reported being comfortable with their sexual orientation.

18% had experienced domestic violence at some point in their lives; 25% had been experienced non-consensual sex; and 11% had been gay-bashed. Over half (55%) had seriously considered suicide at some point in the past, of whom one-third (or 18% of the total sample) had made a suicide attempt. Over one fifth (22%) reported having been diagnosed with a mood disorder or mental illness, most commonly depression. Only 7% reported ever having received drug/alcohol treatment.

Median age of first "coming out":	19 yrs
Comfortable with sexual orientation:	77%
Domestic violence:	18%*
Gay bashing:	11%*
Sexual abuse:	25%*
Suicidal ideation:	55%*
Attempted suicide:	18%*
Diagnosed mood disorder/mental disability:	22%*
Drug/alcohol treatment:	7%*

* ever in lifetime

Definition of risk-takers:

We also attempted to determine whether any of the above variables were associated with sexual risk-taking.

Risk-takers were defined as participants who, since their baseline visit: reported at least one episode of unprotected anal sex (either insertive or receptive)with a casual male partner; or had unprotected anal sex with a known HIV+ partner (either regular or casual).

Non-risk-takers were everyone else, including those who: had unprotected anal sex (either insertive or receptive) with regular partner; had only protected anal sex with known HIV+ partners; didn't have anal sex; or didn't have sex at all.

Sexual risk-takers

• unprotected anal sex with a casual partner
• and/or unprotected anal sex with a known HIV+ partner

Non-risk-takers

• had only regular partners
• 100% condom use with casual partners
• or did not have anal sex

Risk-takers vs. non-risk-takers:

Of our sample, 29% were defined as risk-takers according to our definition, which is identical to the proportion based on enrolment questionnaires. This slide depicts the proportion of risk-takers and non-risk-takers, according to whether or not respondents had reported experiencing any of the following indicators of psychologic distress.

As seen here, risk-takers were significantly more likely to be non-white, and have reported domestic violence, gay bashing, suicide attempts, and sexual abuse under the age of 18. Although risk-takers also tended to more commonly report a diagnosis of mental illness/mood disorders, had a higher depression score, and lower scores for social support and self esteem score, these variables did not significantly differ from non-risk-takers.

	RTs (n=55)	NRTs (n=135)	P-value
Non-white:	33%	18%	0.01
Sexual abuse < 18:	23%	13%	0.08
Domestic violence:	30%	12%	0.004
Gay bashing:	20%	10%	0.04
Suicide attempts:	25%	12%	0.02
Suicidal ideation:	60%	50%	0.21
Mood/mental disorder:	25%	22%	0.67
High depression score:	30%	24%	0.37
Low self esteem:	31%	26%	0.48

Relationship between sexual abuse and domestic violence:

Since some of these variables represent various forms of violence, we hypothesized that some of them might be interrelated.

For example, this table shows that those men reporting sexual abuse under the age of 18, were more likely to also report domestic violence. Almost one third of the men who said they had been sexually abused under 18 had also experienced domestic violence, relative to 14% of men who were not sexually abused (p=0.01). A similar relationship was noted between experience of sexual abuse under the age of 18 and gay bashing.

		Sexually abused < 18
		YES	NO
Domestic  violence	YES	11 (31.4%)	23 (14%)
	NO	24 (68.6%)	142 (86%)

Chi-square p-value = 0.01

Limitations:

The following limitations should be acknowledged when interpreting these data:

We are unable to draw causal associations from these cross-sectional data, since our results are based on findings at follow-up only. However, the prospective nature of this study will allow us to correlate these factors with behavioural trends in the future.

This analysis is based on small numbers and may suffer from selection bias since only those subjects who have returned for follow-up visits were studied here.

In addition, these data are self-reported, and may be limited by differential and non-differential recall. However, there is no reason to expect that factors such as recall bias would differ between risk-takers and non-risk-takers.

• cross-sectional univariate analysis
• small sample size
• possible selection bias
• self-reported data

Conclusions:

A disturbing proportion of young MSM report having considered suicide or made suicide attempts, which is consistent with high levels of depression. Various forms of violence appears to be common among young MSM, which could lead to heightened vulnerability to HIV infection.

In our univariate analyses, a relationship was noted between sexual risk-taking, non-white ethnicity, the experience of domestic violence and gay bashing.

High prevalence of

• suicidal ideation and attempts
• violence (gay bashing, domestic, sexual abuse)
• mood disorders (depression)

Sexual risk-taking significantly associated with the experience of several forms of violence:

• domestic violence
• gay bashing
• sexual abuse

Implications of findings:

There are several implications of these findings. Firstly, HIV prevention efforts should take into account the fact that young MSM are often victims of physical and sexual violence, which may affect attitudes and behaviours surrounding safer sex.

The hypothesis that forms of abuse (eg. sexual abuse) experienced at a young age may predispose towards other forms of violence and HIV vulnerability requires further study.

These data strongly suggest that as a society, we need to foster supportive environments for gay youth. In doing so we may indirectly improve the sexual health of the community.

Thank you.

Need for:

• prevention efforts targeting gay male victims of violence and sexual abuse
• supportive environments for sexual minority youth