This is the abstract presentation of Rayner Kay Jin Tan, which took place as part of the first session of #APCRSHR10 #Virtual on the theme of "Addressing barriers to accelerate progress on sexual and #reproductivehealth and rights in Asia and the Pacific" | more details are online at www.bit.ly/apcrshr10virtual1 * Welcome from Dr Chivorn Var, Convener of 10th Asia Pacific Conference on Reproductive and Sexual Health and Rights (APCRSHR10) and Executive Director of Reproductive Health Association of Cambodia (RHAC) * Plenary Speaker: Prof Caroline Homer * Abstract presenter: Caecilia Roth (opportunities for strengthening sexual health education in schools: Findings from a student needs assessment in NSW, Australia) * Abstract presenter: Than Nguyen Phuong Hai (needs Of Comprehensive Sexuality Education (CSE) Of Students In Thai Nguyen University (TNU), Vietnam) * Abstract presenter: Jolly Mae Catalan (an analysis of the age pattern of migration in Metro Manila and its sex differentials, 2005-2010 migration period) * Abstract presenter: Rayner Kay Jin Tan (experienced homophobia and suicide ideation in young gay, bisexual, and queer men: Exploring the mediating role of depressive symptoms, self-esteem, and outness in the Pink Carpet Y Cohort Study) For more information on APCRSHR10 Virtual, go to www.bit.ly/apcrshr10virtual #SRHR #sexualhealth #reproductiverights #familyplanning #womenshealth #LGBT #genderequality #SDGs

1. Experienced homophobia and suicide ideation in young gay,
bisexual, and queer men: Exploring the mediating role of
depression severity, self-esteem, and outness in the Pink Carpet
Y Cohort Study
Rayner Kay Jin TAN B.Soc.Sci (Sociology)
Ph.D. Candidate, Saw Swee Hock School of Public Health, NUS & NUHS
Treasurer, Society of Behavioural Health, Singapore
Perspectives Panel, Sexually Transmitted Infections
Associate Editor, Social Determinants of Health, BMC Public Health
E-mail: rayner.tan@u.nus.edu | Twitter: @raynerT
Timothy Low Qing Ying B.Soc.Sci (Political Science and Sociology)
Research Assistant, Centre for Family and Population Research, FASS, NUS
E-mail: timothylow@nus.edu.sg

2. 2
BACKGROUND
Suicide in Young Gay, Bisexual and Queer Men

3. 3
Suicide as a Public Health Issue1
• In 2016, the global crude suicide mortality rate was at 10.6
per 100,000 persons
• Men (13.5) have higher suicide rates than women (7.7)
• European (15.4) and Southeast Asian (13.2) regions having
higher level of reported suicides compared to other parts of
the world
• Higher income countries (14.3) also had higher suicide
mortality rates as compared to lower middle-income
countries

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

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

6. 6
Research on Young GBQ Men in Singapore
• Risk factors for suicide ideation and attempts in young
GBQ men include:
– Substance use 5,7,10,12,16
– Poor mental health 5,7,10,13,14,15
– Peer victimisation and homophobic bullying 5,13,16,17
– Lack of belonging and support in school 13
– Family problems including absent of parents, poor relations with
family and low family support 10,12,17
– Coming out, disclosure or having sexual identity known by others
7,14,17
– Experience with violence and sexual violence 5,18

7. 7
Suicide in Young Gay, Bisexual and Queer Men
• Sexual relations between men is criminalized in Singapore
(Section 377A of the Penal Code)
• Past studies have found that most Singaporeans perceived
same-sex relationships as being wrong, and are against the
idea of gay marriage; most are also not in favor of the repeal
of Section 377A, the law that criminalizes sexual relations
between men 19,20,21,22
• Not much is known about the mental health of young GBQ
men in Singapore, or the impact of stigma and homophobia on
mental health outcomes.

8. 8
METHODS
The Pink Carpet Y Cohort Study

9. 9
Study Design
As of 31 August 2019:
- 701 participants enrolled
- 570 used in analytic sample
Eligibility Criteria:
- 18 to 25 years old at enrolment
- HIV-negative or unsure of status
- Cis/trans male who identifies as
gay, bisexual, or queer

10. 10
Recruitment

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

12. 12
Analysis
STATA IC 15
- Descriptive statistics at univariate level
- Logistic regression for bivariate and multivariate regression analyses
- Generalized structural equation modeling (gsem command) for path analysis/mediation analysis
- SEM builder function in STATA
ehs
sise
4.7
ε1
2.7
age
cismale
housing_pte
gay ethnic_nc
suicideideabin
Bernoulli
logit
.92
-.022
.049
-.17
-.066
-.043
.14
.13 .27

13. 13
FINDINGS
Experienced Homophobia and Suicide Ideation

14. 14
SampleCharacteristics Table 1. Sociodemographic attributes and description of analytic sample (n=570)
Demographic Variables n % Mean SD
Age 21.9 2.17
Ethnicity
Chinese 478 83.9%
Non-Chinese 92 16.1%
Gender
Cisgender male 525 92.1%
Transgender, genderqueer, or others 45 7.9%
Sexual orientation
Gay 408 71.6%
Bisexual, queer, or others 162 28.4%
Housing Type
Private housing 126 22.3%
Public housing 438 77.7%
Ever contemplated suicide (suicide ideation)
Yes 308 54.0%
No 262 46.0%
Ever attempted suicide (suicide attempt)
Yes 76 13.3%
No 494 86.7%
Experienced homophobia* (Range: 14 to 56) 25.0 12.00
Depression severity* (Range: 0 to 27) 7.0 10.00
Self-esteem (Range: 1 to 7) 4.1 1.66
Outness inventory* (Range: 1 to 7) 2.3 2.00
Abbreviation: SD, Standard Deviation
*Median and Inter-Quartile Range reported

15. 19
MediationAnalyses Multivariable logistic regression for ever contemplating suicide
OR 95% CI p-value aOR 95% CI p-value
Age 0.92 (0.86-1.00) 0.047 0.95 (0.87-1.03) 0.214
Non-Chinese (ref=Chinese) 1.41 (0.89-2.22) 0.144 1.25 (0.74-2.09) 0.404
Cisgender male (ref=Transgender, genderqueer, or others) 0.76 (0.41-1.42) 0.393 1.22 (0.61-2.45) 0.570
Gay (ref=Bisexual, queer, or others) 1.12 (0.78-1.62) 0.544 1.10 (0.72-1.67) 0.670
Private housing (ref=Public housing) 1.00 (0.67-1.49) 0.986 1.13 (0.73-1.74) 0.597
Experience homophobia 1.06 (1.03-1.08) 0.000 1.03 (1.00-1.05) 0.022
Depression severity 1.13 (1.09-1.16) 0.000 1.11 (1.07-1.15) 0.000
Self-esteem 0.83 (0.75-0.92) 0.000 0.95 (0.84-1.08) 0.449
Outness 1.22 (1.08-1.38) 0.002 1.19 (1.03-1.37) 0.015
Notes
Abbreviations: CI, Confidence Interval; OR, Odds Ratio; aOR, Adjusted Odds Ratio
Statistically significant results (p<0.05) are highlighted in bold font
Ever contemplated suicide
Multivariable logistic regression for ever attempting suicide
OR 95% CI p-value aOR 95% CI p-value
Age 0.92 (0.86-1.00) 0.047 0.96 (0.85-1.08) 0.526
Non-Chinese (ref=Chinese) 1.41 (0.89-2.22) 0.144 1.74 (0.91-3.36) 0.097
Cisgender male (ref=Transgender, genderqueer, or others) 0.76 (0.41-1.42) 0.393 1.12 (0.47-2.71) 0.796
Gay (ref=Bisexual, queer, or others) 1.12 (0.78-1.62) 0.544 0.73 (0.41-1.32) 0.303
Private housing (ref=Public housing) 1.00 (0.67-1.49) 0.986 1.08 (0.57-2.04) 0.807
Experience homophobia 1.06 (1.03-1.08) 0.000 1.02 (0.99-1.05) 0.147
Depression severity 1.10 (1.06-1.14) 0.000 1.07 (1.03-1.12) 0.001
Self-esteem 0.87 (0.76-1.01) 0.071 0.93 (0.78-1.11) 0.399
Outness 1.39 (1.18-1.63) 0.000 1.41 (1.17-1.71) 0.000
Notes
Abbreviations: CI, Confidence Interval; OR, Odds Ratio; aOR, Adjusted Odds Ratio
Statistically significant results (p<0.05) are highlighted in bold font
Ever attempted suicide

16. 20
MediationAnalyses
Experienced
homophobia
Suicide
Ideation
Depression
Severity
Direct effect: Coeff= .023 SE= .016
Self-Esteem
Outness
Indirect effect: Coeff= .0064 SE= .0029 *
Total effect: Coeff= .034 SE= .012 **
Indirect effect: Coeff= 0.0011 SE= .0014
Total effect: Coeff= .029 SE= .012 *
Indirect effect: Coeff= .024 SE= .0053 ***
Total effect: Coeff= .052 SE= .013 ***

17. 21
MediationAnalyses
Experienced
homophobia
Suicide
Attempts
Depression
Severity
Direct effect: Coeff= .023 SE= .016
Self-Esteem
Outness
Indirect effect: Coeff= .013 SE= .0043 **
Total effect: Coeff= .035 SE= .016 *
Indirect effect: Coeff= 0.0017 SE= .0021
Total effect: Coeff= .024 SE= .016
Indirect effect: Coeff= .017 SE= .0053 **
Total effect: Coeff= .039 SE= .016 *

18. 22
Discussion
Suicide-related behaviors and experienced homophobia
• Rates of suicide ideation (54.0%) and attempts (13.3%) are high among young
GBQ men in Singapore
• Experienced homophobia is a risk factor for both suicide ideation and attempts
• Relevant for sexual and reproductive health – syndemic of HIV and other STI
Mediation/path analysis
• Depression severity partially accounts for the association between experienced
homophobia and suicide ideation and attempts  plausible, but interpret with
caution due to temporality issues.
– Mean age aware of sexual orientation = 13.2 (SD 3.22)
– Mean age of first suicide ideation and attempt = 16.2 (SD 3.42)/16.8 (SD 3.49)
• Outness partially accounts for the association between experienced
homophobia and suicide ideation and attempts  requires further (qualitative)
study.

19. 23
Limitations and Strengths
• Limitations:
– Present measures of depression severity, self-esteem and outness versus past
suicide-related behaviors; assumes depression severity and outness remains
static  require prospective cohort studies among younger GBQ men.
– Selection bias – those who are more ‘out’ or comfortable with their sexual
orientation are more likely to participate in the study.
– Social desirability bias – several ‘prefer not to say’ responses to suicide ideation
(n=46; 8.2%) or attempts (n=33; 5.86%) were recoded as ‘never
contemplated/attempted suicide’ to be conservative.
• Strengths:
– First study on mental health among GBQ men in Singapore, where sexual
relations between men is criminalized
– Strong evidence for the association between experienced homophobia and
past suicide-related behaviors among GBQ men in Singapore
– Future explorations of the ‘life course’ of suicide among GBQ men

20. 24
Recommendations
• Early interventions in schools
– As young as 13 years old for young GBQ men who are questioning
their sexual and gender identities
– School-based and NGO-based programs to buffer impact of stigma
• Stigma reduction
– General society: More challenging
– Institutionalized: More within the means of policymakers
• Protections from discrimination based on sexual orientation
– Bullying and teasing in school
– Media representation
– Healthcare
– Religious institutions

21. 25
Acknowledgements
Study Team Members:
Sumita Banerjee (AFA)
Chronos Kwok (AFA)
CalvinTan (AFA)
AdrianTyler (AFA)
AvinTan (AFA)
Daniel Tiane Le (NUHS)
A/ProfWong Mee Lian (SSHSPH)
Funding:
Singapore Population Health Improvement
Centre (SPHERiC) Seed Fund (SPHERiC-012)
Ethics Approval:
NUS Institutional Review Board (S-19-007)
Support:
ProfTeoYikYing
A/Prof Alex Cook
Ms Sharon Lee
Dr Mark Chen I-Cheng
Dr Wong Chen Seon
Kenneth Ng (SSHSPH)
KohWee Ling (SSHSPH)
Caitlin O’Hara (YLLSoM)
Eugene Wong (AFA)

22. 26
THANK YOU!
Questions?

23. 27
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