Discrimination and mental health in the minority sexual population: Cross-sectional analysis of the first peruvian virtual survey.

OBJECTIVE: This study sought to evaluate the association between discrimination and having mental health problems in the past 12 months in the sexual minority population in Peru.
METHODS: We conducted a cross-sectional analysis of a secondary database corresponding to the first LGBTI survey in Peru in 2017. We included adults who self-identified their sexual orientation as gay, lesbian, bisexual, pansexual, or asexual/others. Both the exposure and dependent variables were self-reported by the participants. Multivariable Poisson regression was used to determine the association by calculating adjusted prevalence ratios (APR) with 95% confidence intervals (95% CI).
RESULTS: Out of 9760 respondents, more than two-thirds of the participants reported having been discriminated against or having experienced violence at some time in their lives (70.3%) and one-fourth reported having mental health problems (23.8%). In the multivariable regression model, the prevalence of mental health problems in the last 12 months was 72% higher for the group of individuals who experienced discrimination when compared with the group that did not experience discrimination (APR = 1.72, 95% CI 1.57-1.88). The association was stronger among who self-identified lesbians (APR = 2.08, 95% CI 1.65-2.64).
CONCLUSION: The prevalence of mental health problems and discrimination was high in this population. In addition, we found a statistically significant association between discrimination and the occurrence of mental health problems in the last 12 months.

Introduction

The LGTBI community (lesbian, gay, bisexual, trans, and intersex) represents people with diverse sexual orientation or gender identities. It constitutes a vulnerable group because they do not fit within society’s conventional ideas regarding sexual orientation, which leads them to be ridiculed, intimidated, and even physically abused. Therefore, currently, the United Nations Organization works to protect the LGBTI community against violence and discrimination and declares that all people have the same freedom and equal rights [1]. Similarly, the United Nations Development Program prohibits discrimination based on sexual orientation and gender identity and discrimination based on LGBTI status [2,3]. In Peru, since January 2017 Legislative Decree 1323 entered into force, including as categories protected against discrimination, gender identity, and sexual orientation, being also considered as aggravating in crimes against LGBTI persons [4].

For several decades, the sexual orientation conception of the LGTBI community has tended to be discriminated against. For that reason, LGBTI activism gained force in the 70s which led to the fact that in 1973 the Board of Directors of the American Psychiatric Association voted to remove the diagnosis of "homosexuality" from the DSM III classification of psychiatric disorders. This event was joined by the American Psychological Association, which since 1975 has been working to eliminate the concept of mental illness that has been associated with the sexual orientation of these individuals [5,6]. Finally, in 1990, the WHO removed homosexuality from the ICD-10. In recent years, the historical antecedents and LGTBI activism have managed to change the opinion of society, which has increasingly opposed discrimination. Nevertheless, hostile expressions are still used towards members of the LGTBI community [7]. In Peru, a country with conservative traits, unions between people of the same sex have not yet been officially recognized. Most of the population rejects the implementation of equal marriage. With a government that prohibits discrimination and incitement to discrimination based on sexual orientation and gender identity, but that still maintains Article 333 subsection 9 of the current Civil Code, where homosexuality is considered as a ground for divorce [8]. It fails to curb the high rates of discrimination suffered by the LGBTI community.

In the LGTBI population of the United States, discrimination was associated with mental health problems such as depression and anxiety which were reported more among people self-identified as gay than bisexual or heterosexual individuals. Within women, the self-identified bisexual population was more likely than lesbians or heterosexuals to report disorders and mental health conditions such as depression and/or anxiety. In addition, within men, the self-identified gay population was more likely than the bisexual population to be discriminated against because of their sexual orientation 50% vs 24.2% (χ2 = 11.3, p < .01), and within women the self-identified lesbian population was more prone than the bisexual or heterosexual population to be discriminated against because of their sexual orientation [9]. Previous studies in the United States have shown that people who are part of this population have a higher prevalence of suicide, depression, anxiety, and substance use disorders [10,11]. Meyer’s conceptual framework addressed the association between these variables and hypothesized that factors such as social support, expectations of rejection, concealment, and internalized homophobia could explain the causal pathway [12].

In Peru, there are no studies that evaluate the predisposition to suffer mental disorders in the LGTBI population. However, we observe that the Peruvian trans population is seriously affected. Violence comes, in some regions, from the general population or the Police and other authorities. This is a very difficult situation because this population may also suffer discrimination when reporting [13].

Hence, we conducted a cross-sectional analysis of a secondary database corresponding to the first LGBTI survey in Peru in 2017 to evaluate the association between discrimination and mental health problems in the sexual minority Peruvian population.

Methods

Setting and population

A cross-sectional analysis of a secondary database from the First Virtual Survey for LGTBI people in Peru was conducted. This survey was carried out by the Peruvian National Institute of Statistics and Informatics (INEI) in 2017. The main aim of this survey was obtained peruvian LGBTI population statisical information who were over 18 years of age. It had a exploratory design and used non-probabilistic sampling due to no prior information being available on the size of this population to select a sample. Data was collected through a virtual survey on the INEI website from May to August of 2017. The clean survey data is publicly available on the INEI website (http://iinei.inei.gob.pe/microdatos/). The National Directorate of Census and Surveys of INEI was in charge of data collection. The web application was designed for the purpose and subsequently validated by a process involving mixed methods. An analysis of the consistency of the information was also carried out before the creation of the final database. Further details of the data collection process can be found on their web page [14]. Target population was adults between 18–60 years old who self-identified their sexual orientation as gay, lesbian, bisexual, pansexual, or asexual/others. The question that assessed sexual orientation did not have transgender and intersex as answers, as both terms refer to sexual identity.

Variables

Past-year mental health disorders were assessed using the following question (P105_3) “In the last 12 months, have you had a mental health problem such as (depression, anxiety)?”. The answer was dichotomous (yes, no). This question involves any degree of symptomatology from a belief of anxiety or depression to a clinical diagnosis. Discrimination was assessed using one item (P201): “Have you ever suffered discrimination and/or violence?”. The answer also was dichotomous (yes, no). Given that there was no question used to measure the type, the frequency, and extent of the discrimination, the understanding is that respondents would report any life experience.

Potential confounding variables were described and included in the multivariable analysis. Sociodemographic variables included education level (university-level studies or not), physiological sex at birth (male, female), race (mestizo, black, white, Indian native), disability (yes, no), and sex work at least once (yes, no) [15-23]. A history of chronic and infectious diseases in the last 12 months was also taken into account with questions "In the last 12 months, have you had any chronic diseases (asthma, chronic bronchitis or emphysema, hypertension, i.e., high blood pressure, diabetes, high blood sugar)" (yes, no) and "In the last 12 months, have you had any infectious diseases (tuberculosis, sexually transmitted infections (syphilis, gonorrhea, etc.), HIV/AIDS)" (yes, no). A question about health insurance had the categories none, SIS = Peruvian Comprehensive Health Insurance and other health insurances.

Statistical analysis

Absolute and relative frequencies were used to describe categorical data. Median and interquartile range was used to describe the age. Prevalence of discrimination and mental health problems were calculated in the total sample and by sexual orientation. The relationship between the key variables and sexual orientation was assessed using the Chi-squared test. We calculated unadjusted and adjusted prevalence ratios (PR) with 95% confidence intervals (95% CI) using Poisson regression with robust variance to examine the association between discrimination and mental health problems. The potential confounding variables described above were included in the adjusted model. In addition, we examined the effect of discrimination and sexual orientation simultaneously on mental health. First, we added the interaction between discrimination and sexual orientation to the adjusted model. Then, we calculated the interaction terms multiplying the prevalence ratios as follows: RP = RP * RP * RP. We choose Poisson regression because the frequency of the outcome event, mental health problems, was greater than 10% and the ORs might overestimate the magnitude of the association [24,25]. A p-value <0.05 was considered significant. All analysis was performed using R, version 3.2.5.

Ethics approval

This study was approved by the Faculty of Health Sciences of the Universidad Peruana Unión (Certificate of Approval: N°00116-2020/UPeU/FCS/CIISA). This was a secondary analysis of a publicly available database. The database does not contain personal data that would allow for the identification of the respondents, and the respondents appear in the database using a user code.

Results

General characteristics of the study sample

Table 1 shows the general characteristics of the population. A total of 12 026 people completed the survey. We excluded 669 participants who identified themselves as heterosexuals, 38 because were older than 60 years old, and 1559 because of missing values on the variables of interest. The final sample size involved 9760 participants. The median age of the sample was 25 IQR [21,30] years and 53.2% were male. Half of participants reported to have some level of higher education (47.9%) and a third reported not having health insurance (29.3%). Regarding sexual orientation, people self-identifying as gay was predominant (43.7%), followed by people self-identifying as bisexual (25.7%). 6.7% reported having done sex work some time. In the last 12 months, 12.9% and 10.6% suffered from a chronic and/or an infectious disease, respectively.

Table 1

General characteristics, mental health problems and discrimination experiences among Peruvian sexual minorities aged 18 to 60 years old (n = 9760).

Characteristics	N (%)
Age (median [IQR])	25 [21,30]
Sex
Male	5196 (53.2)
Female	4564 (46.8)
Education level
No university	5081 (52.1)
University	4679 (47.9)
Health insurance
None	2857 (29.3)
SIS	1327 (13.6)
Other health insurances	5576 (57.1)
Sexual orientation
Gay	4268 (43.7)
Lesbian	2215 (22.7)
Bisexual	2506 (25.7)
Pansexual/Asexual/Other	771 (7.9)
Race
Indian native	515 (5.3)
Black	470 (4.8)
White	1729 (17.7)
Mestizo	6804 (69.7)
Other	242 (2.5)
Disability
No	9468 (97.0)
Yes	292 (3.0)
Sex work at least once
No	9109 (93.3)
Yes	651 (6.7)
Chronic diseases in the last 12 months
No	8493 (87.0)
Yes	1267 (13.0)
Infectious diseases in the last 12 months
No	8704 (89.2)
Yes	1056 (10.8)

IQR = Interquartile range.

SIS = Peruvian Comprehensive Health Insurance.

Mental health problems and discrimination experiences

Discrimination/violence was reported by 70.3% of individuals and mental health problems in the last 12 months were reported in 23.8% of respondents. Stratifying by sexual orientation, the prevalence of discrimination was higher in participants who identified themselves as gay (74.6%), followed by pansexual, asexual and other (73.9%), lesbian (70.6%), and bisexual (61.6%). Regarding mental health problems, the prevalence was higher in who identified themselves as pansexual, asexual, and other (39.8%), followed by bisexual (29.6%), lesbian (19.8%), and gay (19.6%).

Prevalence of mental health problems in the last 12 months by characteristics of the study population

Table 2 presents the bivariate analysis that relates the general characteristics of the population to mental health. A statistically significant difference (p<0.05) was observed with all variables, except with race (p = 0.096). The prevalence of mental health problems was higher in women compared with men (27.2% vs 20.8%, p<0.001). Concerning sex work, 28.4% of individuals who engaged in such practices reported mental health problems, and in those who did not, the prevalence of problems was lower (23.5%). The prevalence of mental health problems in participants who reported discrimination and/or violence experiences was almost double compared with those who did not (27.2% vs 15.8%, p<0.001).

Table 2

Mental health problems in the last 12 months by characteristics of the Peruvian sexual minority aged 18 to 60 years old (n = 9760).

Variables	Mental health problems in the last 12 months
	No	Yes	P*
	N = 7438	N = 2322
Discrimination and/or violence experiences			<0.001
No	2438 (84.2%)	458 (15.8%)
Yes	5000 (72.8%)	1864 (27.2%)
Age (median [IQR])	25 [22,30]	23.0 [20,28]	<0.001
Sex			<0.001
Male	4115 (79.2%)	1081 (20.8%)
Female	3323 (72.8%)	1241 (27.2%)
Education level			<0.001
No one/Primary/Secondary	3667 (72.2%)	1414 (27.8%)
Superior	3771 (80.6%)	908 (19.4%)
Sexual orientation			<0.001
Gay	3433 (80.4%)	835 (19.6%)
Lesbian	1776 (80.2%)	439 (19.8%)
Bisexual	1765 (70.4%)	741 (29.6%)
Pansexual/Asexual/Other	464 (60.2%)	307 (39.8%)
Race			0.096
Indian native	379 (73.6%)	136 (26.4%)
Black	353 (75.1%)	117 (24.9%)
White	1358 (78.5%)	371 (21.5%)
Mestizo	5166 (75.9%)	1638 (24.1%)
Other	182 (75.2%)	60 (24.8%)
Disability			<0.001
No	7304 (77.1%)	2164 (22.9%)
Yes	134 (45.9%)	158 (54.1%)
Sex work at least once			0.005
No	6972 (76.5%)	2137 (23.5%)
Yes	466 (71.6%)	185 (28.4%)
Health insurance			<0.001
None	2039 (71.4%)	818 (28.6%)
SIS	995 (75.0%)	332 (25.0%)
Other health insurances	4404 (79.0%)	1172 (21.0%)
Chronic diseases in the last 12 months			<0.001
No	6540 (77.0%)	1953 (23.0%)
Yes	898 (70.9%)	369 (29.1%)
Infectious diseases in the last 12 months			0.012
No	6600 (75.8%)	2104 (24.2%)
Yes	838 (79.4%)	218 (20.6%)

IQR = Interquartile range.

SIS = Peruvian Comprehensive Health Insurance.

*p values were calculated by Pearson’s Chi-squared test for categorical variables and by Wilcoxon rank sum test with continuity correction for the age.

Association between mental health problems in the last 12 months and discrimination experiences

The prevalence of mental health problems in the last 12 months was 72% higher in the group who experienced discrimination compared with the group that did not experience discrimination (APR = 1.72, 95% CI 1.57–1.88). Stratifying by sexual orientation, the association was stronger in the people self-identifying as gay and lesbian and a little weaker in people self-identifying as bisexual and pansexual/asexual/other. Those who identify themselves as lesbian and experienced discrimination had more than twice the prevalence of mental health problems in the last 12 months (APR = 2.08, 95% CI 1.65–2.64) compared with the overall average. Table 3 presents all the results of the multivariable analysis.

Table 3

Association between discrimination experiences and mental health problems in the last 12 months in the Peruvian sexual minorities.

	Prevalence of mental health problems	Unadjusted a			Adjusted a, b
	N (%)	PR	95% CI	p	PR	95% CI	p
All sample (n = 9760)
Without discrimination and/or violence experiences	473 (15.4%)	ref.			ref.
With discrimination and/or violence experiences	1929 (27.2%)	1.72	1.57–1.88	<0.001	1.72	1.57–1.88	<0.001
Gay (n = 4268)
Without discrimination and/or violence experiences	125 (11.6%)	ref.			ref.
With discrimination and/or violence experiences	710 (22.3%)	1.93	1.62 – 2.30	<0.001	1.8	1.51 – 2.15	<0.001
Lesbian (n = 2215)
Without discrimination and/or violence experiences	71 (10.9%)	ref.			ref.
With discrimination and/or violence experiences	368 (23.5%)	2.16	1.70 – 2.73	<0.001	2.08	1.65 – 2.64	<0.001
Bisexual (n = 2506)
Without discrimination and/or violence experiences	202 (21.0%)	ref.			ref.
With discrimination and/or violence experiences	539 (34.9%)	1.66	1.44 – 1.91	<0.001	1.63	1.42 – 1.88	<0.001
Pansexual/Asexual/Other (n = 771)
Without discrimination and/or violence experiences	60 (29.9%)	ref.			ref.
With discrimination and/or violence experiences	247 (43.3%)	1.45	1.15 – 1.83	0.002	1.39	1.11– 1.74	0.004

a PR calculated using Poisson regression with a robust error variance.

b Prevalence ratio was adjusted for age, education level, health insurance, sex, race, disability, sex work, chronic diseases, infectious diseases.

95% CI = 95% confidence interval.

In Table 4, we tabulated the PR of the model with interaction. In this model, the effect of discrimination on mental health problems increased (APR, 2.87; 95% CI, 1.70–4.86). People self-identified as gay, lesbian, bisexual, and pansexual who experienced discrimination had a 3.01, 2.38, 3.50, and 4.23 times higher prevalence of having mental health problems than heterosexuals who did not experience discrimination (Table 4).

Table 4

Association between discrimination on mental health problems in the last 12 months adding the interaction of sexual orientation.

	PR a	95% CI	p
Discrimination and/or violence experiences
No	Ref.
Yes	2.87	1.70–4.86	<0.001
Sexual orientation
Heterosexual	Ref.
Gay	1.64	0.98–2.74	0.059
Lesbian	1.15	0.68–1.96	0.604
Bisexual	2.14	1.30–3.51	0.003
Pansexual/Asexual/Other	3.07	1.82–5.18	<0.001
With interaction
Discrimination experience * Heterosexual	Ref.
Discrimination experience * Gay	0.64	0.37–1.11	0.109
Discrimination experience * Lesbian	0.72	0.40–1.23	0.261
Discrimination experience * Bisexual	0.57	0.33–0.99	0.044
Discrimination experience * Pansexual/Asexual/Other	0.48	0.29–0.84	0.011

a PR calculated using Poisson regression with a robust error variance. The model included the interaction between sexual orientation and discrimination and adjusted for age, education level, health insurance, sex, race, disability, sex work, chronic diseases, infectious diseases.

95% CI = 95% confidence interval.

Discussion

This is the first study that assessed the association between discrimination and mental health in a sexual minority Peruvian population. Previous studies have shown that discrimination is associated with internalization disorders, i.e. mental health disorders, and externalization disorders, such as substance use disorders, in sexual minorities [26]. In the context of our study, we only addressed the mental health problems reported by the population studied, which was defined as having presented problems of depression or anxiety in the last 12 months.

Interestingly, the prevalence of discrimination was reported by 70% of the individuals. In England, Jackson et al., found the rate of perceived discrimination in adults self-identifying as gay, lesbian, and bisexual was 47.4%, even this reported that 23.7% received poor treatment by doctors or hospitals [27]. The difference between the prevalence of discrimination may be due to in developing countries the probability of acceptance of this sexual minority is lower [28]. Particularly, this alarming rate could be explained analyzing the Peruvian society context where acts of discrimination, in general, are quite common. In Peru, since 2017, as promulgated in the Legislative Decree 1323, acts of discrimination are forbidden, as well as incitement to discrimination based on gender identity and sexual orientation. Nevertheless, the prevalence of discrimination remains high. This is a permanent challenge for organizations such as the Homosexual Movement of Lima and More Equality Peru, that have sought not only to defend LGTBI victims of discrimination, even to raise awareness in Peruvian society about the damage these acts of discrimination produce in all aspects of their lives. In Peru, mainly the media contribute to reducing discrimination against the LGTBI community, which have received a lot of rejection, however, nowadays they have achieved higher acceptation and awareness about the consequences of discrimination and also, in several open forums, respect for the LGTBI community is highlighted

Previous studies have shown that the LGBT community, compared to heterosexual population, have lower scores on several mental health indicators such as the remarkable higher need and use of mental health services, higher levels of smoking, as well as psychiatric diagnoses such as major depression, generalized anxiety disorders, and substance abuse [29-31]. In the present study, 23.8% of the analyzed population had mental health problems. In Ethiopia,in a population identified as gay, lesbian, and bisexual, 10.7% had depression, 14% stress and 20.8% anxiety or panic attacks [32].

Logie et al. evaluated the relationship between sexual stigma and depression in the LGBT population, and they found that 60.1% of respondents reported symptoms of depression. They also found low social support, low self-esteem, and economic insecurity mediated the relationship between sexual stigma and depressive symptoms [33].

Concerning anxiety, previous literature suggests that chronic experiences of discrimination based on sexual orientation may negatively alter the ability to regulate emotional responses, which may ultimately contribute to psychological symptoms and disorders [34]. In addition, tolerance to distress has been studied as a key vulnerability factor associated with high anxiety symptoms [35].

In the multivariable analysis, the discriminated sexual minority population had a 72% higher prevalence of mental health problems compared to the group that did not report discrimination. This association could be mediated by higher levels of victimization, depressive symptoms, and suicidal tendencies [36]. Other important factors are the self-concealment of sexual identity, the expectations of rejection, the lack of social support and the internalized homophobia [12,37]. Additionally, other factors such as discrimination type and frequency could be implicated in the association with mental health. A previous study in the LGBT population found that perceived discrimination in everyday life was associated with higher odds of depressive symptoms (OR = 2.30, 95% CI 1.02 to 5.21), loneliness (OR = 3.37, 95% CI 1.60 to 7.10), and lower quality of life (B = -3.31, 95% CI -5.49 to -1.12) [27]. Other study estimated that the odds of suffering any mental health disorder among those who reported gender discrimination was 2.28 times (AOR = 2.28, 95% CI 1.09 to 4.78) that of those who reported no discrimination. They also found that those individuals who suffered discrimination due to sexual orientation, gender discrimination, and racial discrimination were 3.31 times more likely to present any mental health disorder compared to those who did not report discrimination (AOR = 3.31, 95% CI 1.45 to 6.74) [9]. These findings suggest that within the sexual minority community there are subpopulations at risk for other types of discrimination that may increase the likelihood of mental health disorders. However, in the present study, we did not evaluate the type of discrimination or the extent and frequency of discrimination.

Another interesting finding in the multivariable subgroup analysis was that people who identified as lesbians were the population most affected by discrimination (APR = 2.08, 95% CI 1.65–2.64), followed by people who identified as gay (APR = 1.80, 95% CI 1.51–2.15). Despite the different studies that have been carried out to understand how discrimination affects mental health in the LGBT population, most chose only to analyze the association between discrimination and mental health in the entire LGBT sample [9,30]. Few studies carry out analyses among subgroups, i.e., among the population self-identifying as lesbian, gay, bisexual, and pansexual. This makes it difficult to compare the results found with previous literature. More studies that analyze how discrimination affects each of the aforementioned subgroups and the difference between these are needed because the social interactions of each subgroup are different, i.e. transgenders are not too accepted as gay populations among Peruvian LGTB community and the rest of society. In addition, knowledge of the characteristics and implications of discrimination in each subgroup would lead to proposal future strategies for an adequate and timely approach to the mental problems associated with discrimination in the LGBT community.

All the studies mentioned agree that discrimination in the sexual minority population leads to mental health problems [9,26-37]. In the present study, the effect of discrimination on mental health found in the general sample was not as high as in the studies cited. These differences may be since most previous studies have used odds ratios to measure the effect. However, when the prevalence of the outcome of interest in the population is greater than 10%, this statistical test tends to overestimate the effect. Another possible explanation is that the effect found is different from the real one because of other unmeasured variables such as internalized homonegativity, sensitivity to rejection, social support, social network, belonging to an LGB community, perceived stress, and child gender dissatisfaction [38].

In the present study, we evidence the association between discrimination and self-reported mental health problems. New strategies focused on reducing discrimination in these vulnerable populations should be implemented, since the current ones are apparently not effective. Especially in those subpopulations with a greater association with mental health problems should be protected. We recommend that future studies explore this association evaluating the type, frequency, and extent of the discrimination. Also, mental health problems should be evaluated with validated tools for depression (PHQ-9) and anxiety (GAD-7). Other outcomes such as suicidal ideation could be addressed. Ideally, prospective studies should be performed.

Strengths and limitations

Some limitations must be highlighted. First, this is a secondary analysis, which not only focuses on mental health and discrimination topics; thus, some variables have not been considered. Second, we could not assess causality between the evaluated variables due to the cross-sectional nature of our study. Third, a non-probabilistic sampling was made due to no prior information being available on the size of this population to select a sample. Fourth, the survey had no details regarding the type, frequency, or extent of the discrimination. Fifth, the mental health variable was by self-report and the survey did not include a validated instrument to detect mental health symptoms. Nevertheless, despite these limitations, this study analyzes the first national survey of the Peruvian sexual minority population and has a large sample. Thus, our findings could serve as the basis for developing and strengthening public health policies to decrease discrimination in sexual minority populations in Peru.

Conclusion

This study found a high prevalence of discrimination and mental health problems in the last 12 months in the sexual minority population. Additionally, an association between both conditions was determined. The problem of discrimination in this population was very common, demonstrating the need for educational and socio-cultural interventions that can reduce this alarming figure. Furthermore, this population presented a high prevalence of mental health problems so it is important to increase efforts for the diagnosis and necessary treatment of these conditions. In addition, it is recommended that new prospective studies be carried out as far as possible to determine other risk factors, as well as to evaluate other mental health problems.

14 Dec 2021

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Additional Editor Comments (if provided):

This is an interesting paper and provide important insights into the mental health issues among sexual minority population. I have couple of observations:

1. Provide more details on the data collection process, its management and quality assurance process. Clarify, if any incentive was provided to participants.

2. I feel the Table 2 is not adding any value when I look at Table 3. You should include a table that provides prevalence of mental health problems by experience of discrimination for each category of sexual identity that would enable making sense of odds ratios presented in Table 4.

3. I think discussion is missing the critical interpretation on what does the prevalence of mental health and discrimination mean for Peru and programs working on sexual minorities, how the high prevalence of mental health higher for some groups even if the prevalence of discrimination is lower? There are multiple things to discuss.

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Reviewer #1: Additional comments: It would be helpful to know if any of the research team/authors on the paper, are part of the sexual or gender minority populations under study (in alignment with the notion "nothing for us without us"). Some of the language, as written, comes off as "othering", so I suggest a modest revision when describing populations of transgender experience, and less use of the words they/them in reference (although this is could be an interpretation). Explicitly state in the abstract and the intro or methods that this is a secondary analysis for further clarity on the methodology and type of study undertaken. This is a very important topic and I am grateful this research was undertaken - it is potentially lifesaving. Clarity is needed on the definition of "mental health problems" as only including experience of depression and/or anxiety - did this mean by a clinical definition of depression and/or anxiety inclusive of severe symptoms such as panic attacks, or just generally that the person reported feeling depressed or anxious in the past year (as these are drastically different since all humans experience depression and/or anxiety and are not "mental health problems" as a stand alone, but whether or not symptoms are debilitating and chronic - this needs to be clarified from what the original survey intended). Please provide further clarification on justifying the two different time frames used in the original survey, and how this was accounted for in your secondary analysis regarding association: having "ever" experienced discrimination and experienced mental health problems "in the past 12 months." For the discrimination variable(s), is there a scale or additional questions to specify the type/experience/extent/frequency of discrimination experienced? This seems important to understand better if the suggestion is a direct association between discrimination (as the exposure) and mental health problems, and is it possible to make this association in a non-randomized sample - or do the interpretation of findings suggest that the "exposure" of discrimination doesn't matter for it to impact anxiety and depression specifically? This should be clarified. Consider adding a sample of the original survey questions that were asked for discrimination and mental health to make these points more clear. The majority of the Discussion is focused on previous studies in different countries, and little on the findings of this secondary analysis. The background literature is useful for context, but not for comparison of findings. Consider revising the Discussion to go into more detail about the findings from the secondary analysis. Limitation of not being able to assess causality was listed, but the findings seem to imply that ever experiencing discrimination is associated with recent anxiety and/or depression; suggest elaborating on what this association may imply and to make suggestions on further research needed to explore this further (since not possible to know causality at this stage/with these methods) - elaborate on recommendations as written, they are too vague especially when referring to the need for "new prospective studies" [276-277]. This is a very important study with important findings on a population in need of support of services - recommendation is to revise and resubmit.

Reviewer #2: This paper examines the relationship between discrimination and mental health in a Peruvian sexual minority population. This is an important topic that merits additional research. Below I provide several comments that can help strengthen the analysis and writing of the paper.

Introduction:

- The authors provided a lot of context for sexual minority in the U.S. but very little for those in Peru. More of the social and historical context for Peru (the study setting) is needed.

- I strongly advise the authors to consider the use of a theory or conceptual framework for their study question.

Methods:

- More information is needed about how this sample of 12000+ sexual minority individuals was recruited.

- Please justify the use of the non-validated question to measure mental health. There are several options that could have been used (e.g., PHQ-9). The use of unvalidated instrument is a significant limitation of this paper.

- Please justify why the question about experiences of discrimination only asked about general discrimination and did not specify discrimination based on sexual orientation.

- Please harmonize and be consistent about how you present the questions and the answer options. Currently some are presented in parentheses, some in a different sentence, etc.

- Please correct “multivariate” to “multivariable” throughout the paper.

Results:

- Please be mindful of some language (e.g., you should say “people self-identifying as gay” instead of “the gay population”). Please be consistent with capitalizing or not capitalizing sexual orientation (e.g., Gay, Lesbian)

- The table 4’s header does not make it clear that the outcome is mental health. I suggest a revision.

- A major issue is the subgroup analysis. You are analyzing data separately for subsamples and then comparing effect sizes of separate subsamples. This is not an appropriate practice – I suggest instead the use of interaction terms.

Discussion:

- Similar to the introduction, more discussion of the implications of your findings in the Peruvian context is needed.

**********

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Reviewer #1: No

Reviewer #2: No

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16 Mar 2022

Response to Reviewers

Journal Requirements:

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Reply: Thanks for the observation, we modified the style according to the journal.

2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section

Reply: Thank you. We have added the number of the grant that supports the corresponding author.

EDITOR:

1. Comment: Provide more details on the data collection process, its management and quality assurance process. Clarify, if any incentive was provided to participants.

Reply:

Thank you for the comment. We have detailed the data collection process, its management and quality assurance process in the methods section using the details that the Peruvian National Institute of Statistics brings on their website.

2. Comment: I feel the Table 2 is not adding any value when I look at Table 3. You should include a table that provides prevalence of mental health problems by the experience of discrimination for each category of sexual identity that would enable making sense of odds ratios presented in Table 4.

Reply: Thank you, we have added the prevalence of mental health problems by the experience of discrimination for each subgroup in a new table 3 and we deleted the past table 2.

3. Comment: I think discussion is missing the critical interpretation on what does the prevalence of mental health and discrimination mean for Peru and programs working on sexual minorities, how the high prevalence of mental health higher for some groups even if the prevalence of discrimination is lower? There are multiple things to discuss.

Reply: We thank the comment, to solve this lack of context, we added the following in the discussion: “Particularly, this alarming figure could be explained observing the context that surrounds Peruvian society where acts of discrimination, in general, are quite common. In Peru, since 2017, as promulgated in Legislative Decree1323, acts of discrimination are prohibited as well as incitement to discrimination based on gender identity and sexual orientation. Nevertheless, even with this measure, we observe that the prevalence of discrimination remains high. This is a constant challenge for associations such as the Homosexual Movement of Lima and More Equality Peru that have sought not only to defend LGTBI victims of discrimination but also to raise awareness in Peruvian society of the damages that these acts of discrimination generate in health and integral life these acts of discrimination. Important support in Peru to reduce discrimination against the LGTBI community is the media, which began receiving a lot of rejection, however, today they have achieved a better understanding of the consequences of discrimination and in the different open forums, comments improve and respect for the LGTBI community is encouraged.”

REVIEWER #1:

4. Comment: It would be helpful to know if any of the research team/authors on the paper, are part of the sexual or gender minority populations under study (in alignment with the notion "nothing for us without us").

Reply: In the research team, none of the authors is part of the sexual minority population.

5. Comment: Some of the language, as written, comes off as "othering", so I suggest a modest revision when describing populations of transgender experience, and less use of the words they/them in reference (although this is could be an interpretation).

Reply: Thanks for the suggestion. We changed the sentence in the introduction to avoid using they/them: “This is a very difficult situation because this population may also suffer discrimination when reporting. [10]”

6. Comment: Explicitly state in the abstract and the intro or methods that this is a secondary analysis for further clarity on the methodology and type of study undertaken. This is a very important topic and I am grateful this research was undertaken - it is potentially lifesaving.

Reply: We appreciate the comments, and we added this information in the abstract and in the methods. Abstract: “We conducted a cross-sectional analysis of a secondary database corresponding to the first LGBTI survey in Peru in 2017.” Methods: “This study is a cross-sectional analysis of a secondary database from the First Virtual Survey for LGTBI people in Peru carried out by the Peruvian National Institute of Statistics and Informatics (INEI) in 2017.”

7. Comment: Clarity is needed on the definition of "mental health problems" as only including experience of depression and/or anxiety - did this mean by a clinical definition of depression and/or anxiety inclusive of severe symptoms such as panic attacks, or just generally that the person reported feeling depressed or anxious in the past year (as these are drastically different since all humans experience depression and/or anxiety and are not "mental health problems" as a stand alone, but whether or not symptoms are debilitating and chronic - this needs to be clarified from what the original survey intended).

Reply: Thank you, we clarified this in the variables section in methods. We added, “This question involves any degree of symptomatology from a belief of anxiety or depression to a clinical diagnosis.” Regarding the terminology, we use the “mental health problem” term throughout the manuscript because it is the one mentioned by the question with which the outcome was evaluated.

8. Comment: Please provide further clarification on justifying the two different time frames used in the original survey, and how this was accounted for in your secondary analysis regarding association: having "ever" experienced discrimination and experienced mental health problems "in the past 12 months." For the discrimination variable(s), is there a scale or additional questions to specify the type/experience/extent/frequency of discrimination experienced? This seems important to understand better if the suggestion is a direct association between discrimination (as the exposure) and mental health problems, and is it possible to make this association in a non-randomized sample - or do the interpretation of findings suggest that the "exposure" of discrimination doesn't matter for it to impact anxiety and depression specifically? This should be clarified. Consider adding a sample of the original survey questions that were asked for discrimination and mental health to make these points more clear.

Reply: We added in the methodology that: “Given that there was no question used to measure the type, the frequency and extent of the discrimination, the understanding is that respondents would report any life experience.”

9. Comment: The majority of the Discussion is focused on previous studies in different countries, and little on the findings of this secondary analysis. The background literature is useful for context, but not for comparison of findings. Consider revising the Discussion to go into more detail about the findings from the secondary analysis.

Reply: In the discussion, we added more context about the Peruvian setting and the implications of the results.

10. Comment: Limitation of not being able to assess causality was listed, but the findings seem to imply that ever experiencing discrimination is associated with recent anxiety and/or depression; suggest elaborating on what this association may imply and to make suggestions on further research needed to explore this further (since not possible to know causality at this stage/with these methods) - elaborate on recommendations as written, they are too vague especially when referring to the need for "new prospective studies" [276-277]. This is a very important study with important findings on a population in need of support of services - recommendation is to revise and resubmit.

Reply: We appreciate the suggestion, we added recommendations for future research at the end of the discussion.

REVIEWER #2:

11. Comment: Introduction: The authors provided a lot of context for sexual minority in the U.S. but very little for those in Peru. More of the social and historical context for Peru (the study setting) is needed.

Reply: Thanks for the observation, we added the following sentences in the introduction to fill this gap. “In Peru, since January 2017 Legislative Decree 1323 entered into force, including as categories protected against discrimination, gender identity, and sexual orientation, being also considered as aggravating in crimes against LGBTI persons. (("Peruvian Penal Code 2021 updated"))” and “In Peru, a country with conservative traits, unions between people of the same sex has not yet been officially recognized. Most of the population rejects the implementation of equal marriage. With a government that prohibits discrimination and incitement to discrimination based on sexual orientation and gender identity, but that still maintains Article 333 subsection 9 of the current Civil Code, where homosexuality is considered as a ground for divorce. It fails to curb the high rates of discrimination suffered by the LGBTI community.”.

12. Comment: Introduction: I strongly advise the authors to consider the use of a theory or conceptual framework for their study question.

Reply: We appreciate the suggestion. We used the Meyer conceptual framework (Minority stress processes in lesbian, gay, and bisexual populations).

13. Comment: Methods: More information is needed about how this sample of 12000+ sexual minority individuals was recruited.

Reply: Thank you. We have added in the method section the details about data collection.

14. Comment: Methods: Please justify the use of the non-validated question to measure mental health. There are several options that could have been used (e.g., PHQ-9). The use of unvalidated instrument is a significant limitation of this paper.

Reply: Thank you. Yes, is an important limitation. We have clarified this in the limitations section. However, there is no other available database with data of this nature.

15. Comment: Methods: Please justify why the question about experiences of discrimination only asked about general discrimination and did not specify discrimination based on sexual orientation.

Reply: Thank you. The survey and dataset do not include details about the cause of discrimination. That is why we could not evaluate that aspect. We added this concern to the limitations section.

16. Comment: Methods: Please harmonize and be consistent about how you present the questions and the answer options. Currently some are presented in parentheses, some in a different sentence, etc.

Reply: We modified the sentences to use only parentheses.

17. Comment: Methods: Please correct “multivariate” to “multivariable” throughout the paper.

Reply: We changed the term to multivariable.

18. Comment: Results: Please be mindful of some language (e.g., you should say “people self-identifying as gay” instead of “the gay population”). Please be consistent with capitalizing or not capitalizing sexual orientation (e.g., Gay, Lesbian)

Reply: We agree with the comment, we homogenize the terms throughout the manuscript.

19. Comment: Results: The table 4’s header does not make it clear that the outcome is mental health. I suggest a revision.

Reply: Thank you. We have clarified the outcome on the new table 3.

20. Comment: Results: A major issue is the subgroup analysis. You are analyzing data separately for subsamples and then comparing the effect sizes of separate subsamples. This is not an appropriate practice – I suggest instead the use of interaction terms.

Reply: Thank you for the suggestion. We have complemented the analysis with a regression model with interaction to evaluate the effect of discrimination and sexual identity on mental health problems (table 4).

Comment: Discussion: Similar to the introduction, more discussion of the implications of your findings in the Peruvian context is needed.

Reply: Thanks for the comment. We added more details about the Peruvian context and the implications of the results.

Submitted filename: Response final.docx

Click here for additional data file.

9 May 2022

Discrimination and Mental Health in the minority sexual population: Cross-sectional analysis of the First Peruvian Virtual Survey

PONE-D-21-30055R1

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26 May 2022

PONE-D-21-30055R1

Discrimination and Mental Health in the minority sexual population: Cross-sectional analysis of the First Peruvian Virtual Survey

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