How do Sexual Identity, and Coming Out Affect Stress, Depression, and Suicidal Ideation and Attempts Among Men Who Have Sex With Men in South Korea?

OBJECTIVES: This study investigated the status of sexual identity, perceived stigma, stress, depression, and suicidal ideation and attempts. It also examined how sexual identity and "coming out" affect stress, depression, and suicidal ideation and attempts.
METHODS: Suicidal ideation, psychological health status, and health-related behaviors were assessed using the Internet to maximize the confidentiality of the participants, men who have sex with men (MSM). The data were collected from a total of 873 MSM aged between 19 years and 59 years in 2014.
RESULTS: Only 20.9% of the MSM had come out (18.0% voluntarily and 2.9% by others). The prevalences of perceived stress and depression among MSM were 46.7% and 42.7%, respectively, compared with 20.1% and 7.4% among general men. Approximately 32% of the MSM reported any suicidal ideation, and 3.3% had attempted suicide in the past year. The likelihood of suicidal ideation was significantly associated with being age 30-39 years [odds ratio (OR) = 1.8], high school or less (OR = 1.6), having been outed (OR = 5.2), feeling stressed (OR = 1.8), and feeling depressed (OR = 12.4) after sociodemographic factors and other perceptions were controlled for.
CONCLUSION: The present study provides evidence that MSM are at an elevated risk for suicidal ideation and attempts with high stress and depression. Some risk factors were specific to being gay or bisexual in a hostile environment.

Introduction

Many studies have found that suicidal ideation and attempts among lesbians, gay men, and bisexual persons are higher than among heterosexual individuals (or general populations) 1, 2, 3, 4. In addition, these groups have comparatively higher levels of stress and depression. This may be linked to heterocentric cultures and homophobia; Asian cultures, including South Korea's, have higher stigma related to homophobia. Because South Korean tradition places intense value on lineage, marriage, and children, these expectations are considered normal and thus contribute to stigma, even among the unmarried and divorced as well as homosexuals [5].

Recently, suicide has become a serious public health problem in South Korea [6]. According to a report by the Organization for Economic Co-operation and Development [7], Korea had the highest suicide rate with nearly 30 deaths per 100,000 population. However, homosexuals are more likely to commit suicide than the general population because homosexuality is widely stigmatized in Korea. It is impossible to know the exact suicide rate of homosexuals, because sexuality and gender minorities are often hidden and even unknown. Homosexuals do not come out for fear of being rejected by family and friends or discrimination in employment, promotion, housing, and other basic rights 5, 8. The rate of coming out in Korea is only 13.5%, lower than that of other countries [5]. Many studies that have examined determinants of suicidality that are specific to MSM have focused on both developmental life transitions (e.g., adopting sexual identity or “coming out”) and social and cultural stressors (e.g., perceived stigmatization, antigay hostility). Homosexuals have higher rates of all-cause mortality, and those who live in areas with a higher degree of social stigma towards homosexuality tend to commit suicide at earlier ages [9].

According to Meyer [10], this high prevalence of poor mental health problems and risky behaviors in homosexuals can be explained and understood in terms of minority stress. The stigma, prejudice, and discrimination create a hostile and stressful social environment that causes stress, depression, substance use, and suicidal behavior among minority individuals. They are likely to be subject to such conflicts because the dominant culture, social structures, and norms do not typically reflect those of the minority group. Studies on homosexuals focus on perceived stigma and sexual identity, which affect gay-related stress such as coming out as homosexual. The mechanisms that underlie the associations between sexual identity and stress have been explored in a number of studies with mediation models that affect negative mental health problems such as stress, depression, and suicidal ideation.

Suicide follows several steps: suicidal ideation, plans, and attempts, and suicidal ideation is believed to precede the onset of the plans and attempts. Thus, it has been considered one of the strong predictors of future suicide 11, 12. Preventing suicide requires interventions that prevent the progression of thought to suicide attempt 13, 14. Early identification of suicidal ideation is important for preventing suicide. Many studies have identified characteristics of people who have suicidal ideation; risky behaviors, substance use, and poor mental health have been considered risk factors of suicidal ideation 15, 16, 17.

Men who have sex with men (MSM) have been highlighted as a high-risk group for poor mental health including stress, depression, and suicidal ideation and attempts. However, basic research on mental health, including suicidal behavior in this group in Korea, is both rare in quantity and deficient in quality, particularly with respect to sampling. Because homosexuality is also regarded as difficult and uncomfortable to discuss, research in this group is in a relatively underdeveloped state in Korea [5]. A number of factors combine to put MSM populations at increased risk.

Therefore, the aims of this study were: (1) to identify the status of sexual identity, coming out, perceived stigma, and poor mental health problems among MSM in South Korea; (2) to identify the differences in poor mental health problems between MSM and the general male population; and (3) how do sexual identity and coming-out affect stress, depression, and suicidal ideation and attempts among MSM in South Korea.

Materials and methods

Sample and data collection

In South Korea, homosexuality is heavily stigmatized, which makes it difficult to contact, much less survey, the homosexual subpopulation. Many homosexuals or bisexuals come out to very few people, if any, thus leading to an almost nonexistent gay community in which identities are frequently kept hidden. One of the few ways to approach the gay community is through the anonymity of Internet clubs and membership-driven websites. A self-report, cross-sectional correlational study was undertaken. The recruitment procedures were based upon approaches that had been utilized successfully in previous research [5]. One such website (http://www.ivancity.com) for homosexuals was chosen for recruiting a survey sample. The eligibility criteria for this study were MSM aged 20–59 years who reported ever having had insertive or receptive anal intercourse with another man. The website has a membership list with general information. Dormant accounts (inactive for 6 months), redundant users, those outside of the specified age range, and those with typographical errors in their account ID information were removed. A stratified random sample of 5,000 was ultimately selected. The target sample size was 1,000, but low response rates were expected, so 5,000 participants were included in the initial mailing. The sample population was then stratified by age into four categories: 29–29 years, 30–39 years, 40–49 years, and 50–59 years. Within the age ranges of 20–29 years and 30–39 years, the desired number of individuals was achieved. Additional reminder messages were sent to those within the 40–49 and 50–59 age ranges. A total of 873 MSM completed the questionnaire. Respondents were provided with a small monetary compensation: 7,500 Won for use online. The ethical considerations of this research study were approved (syuirb2013-068). To compare the general population with our study sample, we used the 2013 Korean National Health and Nutrition Examination Survey, a national survey that is jointly conducted by the Korea Institute for Health and Social Affairs and the Korea Health Industry Development Institute and commissioned by the Ministry of Health and Welfare in response to regulations in the National Health Promotion Act.

Measuring the variables

Demographics

The sociodemographic factors that were measured were age, level of education, income, and current marital status. Age was assessed by decades (19–29 years, 30–39 years, 40–49 years, and ≥ 50 years). Education was categorized as ≤ high school degree or ≥ college degree.

Sexual identity

Self-identified sexual identity was assessed as gay, bisexual, transgender, or heterosexual. For further analysis, participants were categorized as gay (0) or other (1) (bisexual, heterosexual, transgender, etc.).

Status of coming out

Status of coming out was coded as involuntarily coming out (outing) (3), voluntarily coming out (2), no coming out with thinking (1), and no coming out and no thinking (0).

Self-perceived stigma among homosexuals

To create the self-perceived stigma scale, four questions were used (e.g., homosexuals have been discriminated against in employment). These questions were also graded on a 5-point Likert scale, and scores ranged from 1 (strongly disagree) to 5 (strongly agree). Answers to each item were combined to generate the self-perceived stigma score, wherein higher values would indicate a higher level of perceived stigma. Reliability, as measured by Cronbach α, was 0.76, which indicates satisfactory reliability.

Perceived stress, depression, and suicidality

To assess mental health problems, the respondents were asked four outcome variables: perceived stress, perceived depression, suicidal ideation, and suicide attempts. The men were asked whether they experienced stress in their daily lives. Perceived stress was measured from “often or very often” to “never or a little.” Depressive thoughts were measured with one question that asked whether they had felt sad or depressed for 2 weeks or more in a row during the past year. Participants were asked whether they had seriously considered attempting suicide and/or had made a suicide attempt during the past 12 months. Responses to perceived depression, suicidal ideation, and suicide attempts were divided into yes or no for each question.

Statistical analysis

All analyses were performed using Stata 12 (StataCorp LP, USA). The significance level was set at p < 0.05. First, reliability analyses were employed to measure the individuals' perceived stigma. Second, the data analysis employed proportions, means, and standard deviations to describe the characteristics of the study sample. Third, Chi-square tests and Pearson correlations were used to examine univariate correlates for the categorical variables. Lastly, logistic regression analyses were used to identify the correlates of perceived stress, depression, and suicidal ideation. The findings are reported using odds ratios (OR) to represent the strength of the relationship between each unique predictor and its outcome.

Results

Sociodemographic factors and prevalence of suicidality

Sample demographics are shown in Table 1 (Column 1). The MSM sample consisted largely of a young and midlife population with an average age of 31.6 years [standard deviation (SD) = 9.2]; the majority were aged between 20 years and 29 years (46.4%) or 30 years and 39 years (30.5%). Nearly two-thirds, 69.9%, had completed a 2-year college or higher degree. The unmarried rate was high; nine out of 10 MSM reported having never married (89.0%). Sixty-six percent of the sample self-identified as gay or homosexual, whereas 28.5% self-identified as bisexual. Only a small number identified as heterosexual (1.5%) or transgender (0.8%). The number of participants who selected “other” or “don't know” was very small (3.2%), and it was suspected that these individuals were most likely bisexual. Only 20.9% of participants had come out (18.0% voluntarily and 2.9% by others), and 64.3% had no intention of doing so.

Table 1

Sample characteristics of men who have sex with men (MSM) respondents and prevalence of suicidality by sociodemographic characteristics (N = 873).*

	Sample		Perceived stress	Perceived depression	Suicidal ideation	Suicidal attempt
	n	%	%	%	%	%
Overall percentage					32.3	3.3
Age (y)
Mean (SD): 31.6 (9.2)			p = 0.04	p = 0.01	p = 0.01	NS
19–29	431	49.4	44.8	41.8	29.2	3.2
30–39	261	29.9	53.6	48.7	40.6	3.4
40–49	135	15.5	40.0	41.5	29.6	3.7
50–59	46	5.3	43.5	21.7	21.7	2.2
Education			p = 0.02	NS	p = 0.02	p = 0.05
High school or less	263	30.1	44.9	44.1	36.9	4.6
2-y college	146	16.7	57.5	44.5	37.0	5.5
≥ 4-y college	464	53.2	44.2	41.4	28.2	1.9
Current marital status			NS	p < 0.001	p = 0.04	NS
Never married	777	89.0	47.6	44.8	33.5	3.6
Married/divorced/separated	96	11.0	38.5	26.0	22.9	1.0
Sexual identity			NS	p = 0.02	p = 0.03	NS
Heterosexual	13	1.5	53.8	30.8	15.4	0.0
Gay/homosexual	576	66.0	46.4	45.7	34.7	3.5
Bisexual	249	28.5	47.0	37.3	27.3	3.6
Transgender	7	0.8	42.9	57.1	42.9	0.0
Not sure/don't know	28	3.2	46.4	32.1	32.1	0.0
Status of coming out			p = 0.03	p < 0.001	p < 0.001	p < 0.001
No, no intention	561	64.3	43.1	36.5	26.6	1.2
No, but thinking	130	14.9	49.2	45.4	36.9	3.8
Yes, voluntarily (coming out)	157	18.0	54.8	59.2	43.3	8.3
Yes, but by others (outing)	25	2.9	60.0	64.0	68.0	16.0

* The sum of the total in a subgroup does not equal the total number of participants in this study because information was not available for a few participants. Outing is the act of disclosing a homosexual's sexual orientation of sexual identity without that person's consent.

SD = standard deviation; NS = not significant.

An increased likelihood of suicidal ideation was found among younger men and men who had less education (high school or less), had never married, identified as gay or transgender, or did not identify themselves as a particular group (i.e., don't know/not sure) compared with heterosexual and bisexual respondents and those who had come out, whether voluntarily or not (Table 1). The highest prevalence of suicidal ideation and attempts was found among men who had involuntarily come out.

Self-perceived stigma to homosexuals

The self-perceived stigmas of homosexual are summarized in Table 2. The respondents reported self-perceived gay-related stigmas. The “strongly agree” and “agree” responses ranged from 61.1% to 81.4% (Table 3). The majority of respondents agreed that homosexuals have been discriminated against (mean = 16.0, SD = 3.1, range 4–20). Most MSM (81.4%) agreed that homosexuals have encountered embarrassing situations or been exposed to ridicule by the public, and ∼80% agreed that homosexuals have been treated with less respect than others and that homosexuals have been discriminated against in employment. Approximately 61% agreed that homosexuals can be avoided by others (see Table 2).

Table 2

Self-perceived stigmas against homosexuals (N = 873).*

I think	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
Homosexuals have been discriminated against in employment	44.9	31.7	13.2	5.6	4.6
Homosexuals have been treated with less respect than others	42.6	37.1	11.3	5.8	3.1
Homosexuals can be avoided by others	23.5	37.6	22.0	13.9	3.1
Homosexuals have encountered embarrassing situations or been exposed to ridicule	40.5	40.9	13.5	3.8	1.3
Mean (SD)	16 (3.1)

* Scores ranged from 1 (strongly disagree) to 5 (strongly agree), SD range: 4–20.

SD = standard deviation.

Table 3

Comparison of perceived stress, perceived depression, suicidal ideation, and suicide attempts between men who have sex with men (MSM) and the general male population.

	2014 MSM survey(N = 873)		2013 KNHNES(N = 2,581)
	n	%	n	%
Perceived stress***	407	46.7	518	20.1
Perceived depression***	373	42.7	190	7.4
Suicidal ideation***	282	32.3	100	3.9
Suicide attempts***	29	3.3	18	0.7

*** p <. 001.

KNHNES = Korea National Health and Nutrition Examination Survey.

Comparison of perceived stress, perceived depression, suicidal ideation, and suicidal attempt between MSM and general men

As shown in Table 3, there were large differences in perceived stress, perceived depression, suicidal ideation, and suicide attempts between MSM and the general male population. The prevalences of perceived stress and depression among the MSM were 46.7% and 42.7%, respectively, compared with 20.1% and 7.4%, respectively, among the general population; the rates were significantly higher among the MSM (p < 0.001). Approximately 32% of the MSM reported any suicidal ideation, and 3.3% had attempted suicide in the past year. By comparison, for the 2013 National Health Nutrition Examination Survey, the prevalences of suicidal ideation and suicide attempts among males were 3.9% and 0.7%, respectively, which were significantly different from those of MSM (p < 0.001). Despite the need for caution in comparing data from different sources, these rates suggest that MSM have more than an eight-fold increased risk of considering suicide and a five-fold increased risk of ever attempting suicide in comparison with their general male counterparts. The differences among the percentages of perceived stress, depression, and suicidal ideation in MSM are not greater in contrast to the greater differences between them and the general male population.

Correlations among the variables

Table 4 shows the correlations for sexual identity, perceived stigma, stress, depression, suicidal ideation, and suicide attempts. Sexual identity as homosexual had a significantly positive correlation with coming out and negative correlations with depression and suicidal ideation (p < 0.05). Coming out had a positive correlation with all mental health variables (p < 0.001). Perceived stigma of homosexuals was positively correlated with stress (p < 0.001) and suicidal ideation (p < 0.05). Stress and depression were positively correlated with suicidal ideation and suicide attempts (p < 0.01).

Table 4

Correlates of variables.*

	Sexual Identity	Status of coming out	Perceived stigma	Stress	Depression	Suicidal ideation	Suicide attempts
Sexual identity	1.00
Coming out	0.23**	1.00
Perceived stigma	0.03	0.11***	1.00
Stress	−0.01	0.19***	0.16***	1.00
Depression	−0.08*	0.19***	0.06	0.44***	1.00
Suicidal ideation	−0.07*	0.19***	0.09*	0.36**	0.56**	1.00
Suicide attempts	−0.01	0.19***	−0.03	0.11**	0.18**	0.25**	1.00

* Sexual identity (0, homosexual; 1, others); coming out: no, no intention (0); no, but thinking (1); yes, voluntarily (coming out) (3); yes, but by others (outing) (4); and depression, suicidal ideation, suicide attempts (0, no; 1, yes).

Multiple logistic regression analyses for mental health outcomes (perceived stress, perceived depression, and suicidal ideation)

The findings from the multiple logistic regression analyses for mental health outcome (perceived stress, perceived depression, suicidal ideation) and sociodemographic characteristics, sexual identity and coming out are presented in Table 5. Because of the small number of suicide attempts, we did not use a multiple logistic regression analysis for that variable. The MSM who were aged 30–39 years (OR = 1.4, p < 0.05), had come out (OR = 1.9, p < 0.01), and perceived high levels of stigma toward homosexuals (OR = 1.1, p < 0.01) were more likely to feel stressed than their counterparts; the MSM who had come out (OR = 2.3, p < 0.001) and who felt stressed (OR = 6.2, p < 0.001) were more likely to report depression. The MSM who were aged 30–39 years (OR = 1.8, p < 0.01), had high school or less (OR = 1.6, p < 0.05), had been outed (OR = 5.2, p < 0.001), felt stressed (OR = 1.8, p < 0.001), and felt depressed (OR = 12.4, p < 0.001) were more likely to have suicidal ideation than their counterparts. These findings show that the status of coming out, especially outing, was a very strong predictor of all mental health outcomes.

Table 5

Multiple logistic regression analyses for mental health outcomes (N = 873).

	Perceived stress		Perceived depression		Suicidal ideation
	OR	95% CI	OR	95% CI	OR	95% CI
Age (y)
19–29	1.00
30–39	1.42*	1.03–1.96	1.28	0.90–1.84	1.79**	1.18–2.71
40–49	0.83	0.55–1.25	1.29	0.82–2.03	1.28	0.76–2.18
50–59	1.04	0.56–1.96	0.37	0.17–0.83	1.40	0.57–3.44
Education
≥ 2-y college	1.00
High school or less	0.92	0.68– 1.25	1.17	0.83–1.65	1.57*	1.05–2.33
Sexual identity
Bisexual/heterosexual/other	1.00
Gay	0.84	0.62–1.13	1.34	0.96–1.87	1.09	0.73–1.62
Status of coming out
No, no intention	1.00
No, but thinking	1.42	0.95–2.12	1.31	0.84–2.05	1.46	0.87–2.45
Yes, voluntarily (coming out)	1.85**	1.27–2.71	2.31***	1.52–3.51	1.48	0.92–2.37
Yes, but by others (outing)	2.07	0.89–4.80	2.48*	0.99–6.19	5.17***	1.74–15.35
Perceived stigma	1.10**	1.06–1.16	1.01	0.96–1.06	1.05	0.99–1.11
Little, none
Very much, much			6.19***	4.54–8.44	1.78**	1.22–2.59
Perceived depression
No
Yes					12.39***	8.35–18.40

95% CI = 95% confidence interval for stress, depression, suicidal ideation vs. none; OR = odds ratio.

Discussion

This study provides further evidence that MSM are a high-risk group for poor mental health, and the seriousness of this health concern remains. Nearly half of the MSM in this study, 46.7%, reported high stress, and 42.7% reported feeling depressed, much higher than the corresponding rates among the general male population (20.1% for stress and 7.4% for depression). The prevalences of suicidal ideation and suicide attempts during the past year were much higher than those in the general population males (3.9% for suicidal ideation and 0.7% for suicide attempts); our finding is in agreement with the findings from studies in other regions of the world where MSM are at much greater risk for suicidal behaviors 1, 18. It is likely that social hostility, stigma, and discrimination toward homosexuality increase stress for MSM and partly explain the higher rates of depression, suicidal ideation, and suicide attempts. In this study, > 80% of MSM agreed that homosexuals have been discriminated against, encountered embarrassing situations or ridicule, and have been treated with less respect than others. Our findings showed that the perception of the self as a stigmatized and devalued MSM correlated with perceived stress and suicidal ideation.

The findings of this study demonstrated that coming out negatively affected the MSM through stress, depression, and suicidal ideation. According to Meyer [10], a minority identity leads to additional stressors related to the individual's perception of the self as a stigmatized and devalued minority. Based on research on external and internal stressors in other minority populations, researchers conceptualized internalized homophobia, stigma, and experiences of discrimination and violence as stressors for homosexuals [10]. Because they involve self-perceptions and appraisals, these minority stress processes are more proximal to the individual, including, as described above for MSM, expectations of rejection, concealment, and internalized homophobia. Psychological benefits derive from openness and a more integrated sense of self, but disclosure of a gay or bisexual identity to others (coming out) can potentially lead to consequent distress and depression. In Korea, the weak sexual identity as homosexual at an individual level led to a lack of gay collective consciousness, and this resulted in a weakened sense of belonging, absence of health norms, and a lack of social support. The social support can serve a buffering effect in mitigating the impact of the stigmatization homosexual experience because of their sexual orientation. Furthermore, the coming out without social support or narrow social networks will result in the adverse effect of stress, depression, and suicide ideation and attempts. The data suggest that coming out, especially involuntarily (outing), increased the risk of stress, depression, and suicidal ideation. However, because there were only a small number of participants who had been outed, the findings for stress and depression were not statistically significant (they were for suicidal ideation).

Culturally, strong stigma and discrimination exist against homosexual and bisexual behaviors, in South Korea, which is easy to understand 5, 10, 19. Suicide is a complex human behavior and many factors have been demonstrated to contribute to it. In this study, our survey analysis showed that addressing mental health issues, such as stress and depression, should be a priority in efforts to prevent suicidal thoughts or attempts. To decrease the risk of suicide in reformatories, regular mental health examinations at facilities should be conducted using valid and reliable instruments. Furthermore, there is also a need for psychiatric services and programs [20]. This study revealed that the risk of suicidal ideation was more prominent in the disclosure of a gay or bisexual identity to others (coming out).

This study had a number of potential limitations. Because there were concerns about representativeness due to Internet access and willingness (selection bias), the results may not be generalizable to all MSM in Korea. As in any society, due to stigmatization and the potential for discrimination, recruiting individuals from a hidden population such as this one is often very difficult. Therefore, rather than attempting to recruit individuals by sampling location, the study used an Internet survey to reach the hidden population. However, further research is needed in different settings. Respondents were not directly asked their reasons for attempting suicide (e.g., whether attempts were related to being gay or bisexual). Our analyses provide only a temporal linkage between factors related to coming out and early suicide attempts rather than an exact etiology of such attempts. Thus, we are at a comparatively early stage of identifying those who are at risk, except in relatively broad terms. Because this was a cross-sectional study, we could not determine causality and directionality in the associations between suicidal ideation and its correlates. Finally, this study did not examine other important factors related to current suicidal ideation (e.g., substance abuse, risky behaviors, social support, social capital, etc.).

Our results are consistent with previous investigations in showing that the risks of stress, depression, suicidal ideation, and suicide attempts are elevated among homosexually active people compared with men in general 10, 18, and conclusions drawn from these data are consistent with and supported by findings of extensive prior research. Because coming out appears to increase suicide risk, it may explain the higher prevalence of suicide attempts that have been reported in previous studies of gay, lesbian, and bisexual persons, especially young people 10, 18.

In conclusion, coming out, perceived stress, and depressive thoughts were significant predictors of suicidal ideation among MSM in South Korea. In order to advance the current knowledge on risk and protective factors for suicidality, more comprehensive sets of psychosocial variables related to suicidality should be integrated into the explanatory model. The effective and efficient management of suicidal risk among MSM requires early detection of men at risk and intervention programs to help address their emotional and behavioral problems.

Conflicts of interest

All authors have no conflicts of interest to declare.