Discussion

Substance use and depression among recently migrated African gay and bisexual men living in the United States

Adedotun Ogunbajo1, Chukwuemeka Anyamele2, Arjee J. Restar1, Curtis Dolezal2, Theodorus G. M. Sandfort2

1Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island 2HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York

Abstract

Background: Immigrant African gay and bisexual men (GBM) are at risk for substance use and adverse mental health outcomes due to negative experiences in home and host countries. Little is

known about correlates of substance use and mental health outcomes in this population. We

explored pre- and post-migratory factors associated with substance use and depression in recently

migrated African GBM.

Methods: Participants (N=70) were recruited between July-November 2015 in NYC. Eligible participants were administered a structured questionnaire. Correlates of substance use and

depression were identified using bivariate and multivariable analyses.

Results: Factors independently associated with current substance use were age, openness about sexual orientation, homophobic experiences in home country, forced sex in home country, current

housing instability, and internalized homophobia. Factors independently associated with

depression were post-traumatic stress disorder symptoms and alcohol use. Substance use and

depression were associated with negative experiences in home and host country.

Keywords

African Gay and Bisexual Immigrants; Substance Use; Mental Health; Immigrant Health

Background

According to census data, the number of African immigrants in the United States (U.S.) has

doubled every decade since 1970 [1]. Among them are gay and bisexual men (GBM),

Corresponding author: Theodorus Sandfort, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, Tel: 646 774 6946; Fax: 646 774 6955, [email protected].

Author Disclosure Statement No competing financial interests exist.

Disclaimer The findings of this analysis were presented as an oral presentation at the 4th Annual United States Conference on African Immigrant and Refugee Health in East Elmhurst, NY, September 15–18, 2016.

HHS Public Access Author manuscript J Immigr Minor Health. Author manuscript; available in PMC 2020 December 01.

Published in final edited form as: J Immigr Minor Health. 2019 December ; 21(6): 1224–1232. doi:10.1007/s10903-018-0849-8.

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migrating mostly from East and West Africa and settling predominantly in urban

metropolitan cities. As recent studies suggest [2–6] this population is negatively affected by

a variety of health problems, including depression and suicidal ideation. These health

problems can be interpreted from the interacting perspectives of migration and sexual

minority stress.

Migration can be stress inducing in a variety of ways [7]. There are premigration, migration

and postmigration factors that affect mental health [8]. Premigration factors might include

trauma, which also may inform one’s motivation to migrate. Postmigration factors include

various resettlement challenges, including insecurity about one’s immigration status and

economic hardship. Accordingly, migration has been linked to substance use and poor

mental health outcomes [9–12]. In a study of African immigrants, mental health was rated as

a top health concern, with over a third reporting a mental health problem [13]. An

international meta-analysis found that migrants are more likely than non-migrants to

experience mental health problems [14].

The sexual minority stress model proposes that, compared to heterosexual persons, sexual

minorities experience a range of specific distal and proximal stressors, that induce stress and

contribute to health disparities [15, 16]. Distal stressors include various experiences of

homophobia, while proximal stressors include internalized homophobia and concealment of

one’s sexual orientation or practices. Studies have shown that sexual minority stress factors

explain differences in substance use and mental health status among sexual minorities [15,

17, 18].

African gay and bisexual immigrants are likely to have been and to be exposed to both

migration-related and sexual minority stressors. Same-sex sexuality is criminalized in most

African countries, with sentences ranging up to the death penalty [19]. Also, compared to

other parts of the world, countries in Africa are among the least accepting of same-sex

sexuality [20]. Experiences with homophobia, including violence and blackmail, are well-

documented among this population [21, 22]. Such circumstances might cause sexual

minority persons to flee their home country. Persecution based on one’s sexual orientation is

ground for asylum in the U.S. and other countries [23]. Once migrated to the U.S., sexual

minority stressors are likely to continue to affect gay and bisexual immigrants, while their

impact might be exacerbated by challenges related to adapting to a new environment.

In the current study, we explored whether factors related to migration and sexual minority

stress were associated with alcohol and drug use, and depression in GBM who migrated

from East and West Africa to live in New York City, one of the main destinations among

African migrants in the U.S. [33]. Among the factors we explored are sexual minority

stressors, both before and after migration, which have been shown to negatively affect health

outcomes [15, 17, 18]. In terms of potential negative life events, we furthermore explored

the role of having forced sex experiences and engagement in transactional sex, and traumatic

experiences more generally. Related to migration, we explored the impact of migratory grief

(the sense of grief and loss associated with migrating [24, 25]), security of migration status,

and housing and financial instability. As far as these stress factors were associated with

substance use and depression, we further explored whether current health is determined by

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postmigratory factors or whether premigration factors still play a role. Understanding the

factors that affect the health status of African gay and bisexual immigrants is critical to

supporting them in their integration in the U.S. culture.

Methods

Participants

Participants were recruited through referrals from community-based organizations (CBOs),

chain referral through already enrolled participants, social media, and placing study

postcards at spaces frequented by the target population. This recruitment was greatly

facilitated by the fact that one of the authors, as an African gay immigrant himself, had

various connections with informal networks of African gay and bisexual immigrants as well

as the various relevant social service organizations. Further details on recruitment strategy

have been documented elsewhere [6]. Inclusion criteria were: (1) self-identify as male; (2)

18 years or older; (3) speak English or French; (4) identify as gay or bisexual or history of

same-sex sexual practices; (5) migrated to the U.S. from East or West Africa in the last 5

years; and (6) currently reside in NYC. In total, 70 men were interviewed; 13 of the 70

interviews were conducted in French. All participants provided written informed consent.

Procedures

Eligible participants were interviewed face-to-face by trained interviewers, using a

standardized questionnaire programmed on a computer. Questionnaires were available both

in English and French due to some West African countries being French-speaking. The

French language questionnaire was translated from English and back translated to ensure

equivalence. Data collection occurred between July 2015 and November 2015. Upon

completion of the survey, participants were compensated with a $30 gift card. All study

procedures were approved by the Institutional Review Board of the New York State

Psychiatric Institute.

Survey Measures

Demographics.—Participants provided their age on their last birthday; highest grade completed in school (some high school/secondary school, high school/secondary school

graduate, some college/university, technical/vocational education, college/university

graduate, graduate education, and other; education was dichotomized into less than college

and some college or higher); current marital status (never married, legally married, civil

union, legally separated, divorced, widowed; dichotomized into never married and ever

married); HIV status; sexual attraction; and sexual identity.

Pre-migratory factors.—Participants were asked about experiences in their country of origin, prior to arriving in the U.S. We assessed openness about one’s same-sex attraction by

asking whether others, including family members, friends, and work colleagues, knew about

participants’ same-sex attraction; all positive answers were summed resulting in scores

ranging from 0 to 5. To assess homophobic experiences, participants were asked whether the

following things ever happened to them due to their sexual orientation or practices [26]:

“While living in your home country, how often have you:” (1) “Had verbal insults and curses

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directed at you?”; (2) “Been threatened with physical violence?”; (3) “Had your personal

possessions damaged or destroyed?”; (4) “Had objects thrown at you?”; (5) “Been chased or

followed?”; (6) “Been punched, hit, kicked, or beaten?”; (7) “Been blackmailed?”; (8)

“Been denied employment or fired from a job?”; (9) “Been denied a promotion or salary

increase?”; and (10) “Received an unfair work evaluation?” (1=never, 5=very often); a mean

score was calculated. Forced sex was ascertained by: “Has someone ever forced you to have

sex when you did not want to yourself?” (yes/no). Participants were asked about history of

transactional sex: “Have you ever received anything in return for having sex with someone

while you were still living in your home country?” (yes/no).

Post-migratory factors.—Participants were asked about current experiences in the U.S. This included immigration status [green card holder, student visa, undocumented, asylum

seeker, asylee (granted asylum), U.S. citizen, and other], categorized as having an insecure

immigration status if they were undocumented or asylum seekers. Migratory grief was

assessed with seven items from the Migratory Grief and Loss Questionnaire [24],

specifically those dealing with identity discontinuity (e.g., “You feel like a stranger in this

country”) (1=never, 5=always; α=.84; mean score was calculated). Social support was measured using five items that asked if there was someone that the participant could rely on

for money, food, or a place to stay, to talk to if he has problems, to accompany him to a

doctor, or help him if he gets hurt (1=never true, 5=always true; α=.89; a mean score was calculated) [27]. To assess housing instability [28], participants were asked “Since living in

New York City, have you ever”: (1) “Moved in with anyone to share household expenses?”;

(2) “Stayed with friends or family because you had no place to sleep?”; (3) “Slept outside,

on the train, or in a shelter because you had no place to sleep?”; (4) “Looked for sex partners

because you had no place to sleep?”; (5) “Been homeless at any time?”, with possible

responses of yes/no; scores were summed (α=.72). To assess financial instability, participants were asked: “In the last 12 months, how often have you had to borrow money

from a friend or relative to survive financially?” (1=never, 5=almost always). To assess

transactional sex, participants were asked: “Since living in the United States, has a man or a

woman given you anything in exchange for having sex?” (yes/no). Whether people hide their

sexual orientation in NYC was asked with the question: “While living in New York, how

hard do you try to keep your sexual orientation hidden?” Responses included: “Try very

hard”, “Try somewhat hard”, “Do not try, but do not talk about it”, and “I openly talk about

it”.

Internalized homophobia.—Internalized homophobia was assessed using a four-item scale adapted from scales used with comparable populations [29]. Participants were asked to

indicate on a 4-point scale whether they (strongly) agreed or (strongly) disagreed with

statements such as “You feel that being attracted to men is a personal shortcoming for you”.

Mean scores were computed (α=.80).

Post-traumatic stress disorder (PTSD).—Symptoms of post-traumatic stress were assessed using the PTSD Checklist (PCL) [30] consisting of six items identifying how often

participants had been bothered by specific problems (e.g., “Trouble concentrating on things,

such as reading the newspaper or watching television”) over the past two weeks; answers

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were scored on a 5-point scale (0=not at all – 4=nearly every day); a total score was

computed (α=.82).

Substance use.—Participants were asked about current alcohol consumption and drug using habits. Alcohol use was assessed with the AUDIT-C, a 3-item screening test for heavy

drinking or alcohol dependence [31]. The AUDIT-C is scored on a scale of 0 to 12, the

higher the score, the higher the likelihood of hazardous drinking. Cronbach of the AUDIT-C

was .77. Recreational drug use was assessed with a question on how often men had used

drugs in the past year. Possible drug options included: cannabis, cocaine, prescription

stimulants, methamphetamine, inhalants, sedatives, hallucinogens, street opioids, and

prescription opioids. Current recreational drug use was assessed by asking: “In the past year,

how often have you used recreational drugs?” (never, less than monthly, monthly, weekly, or

daily or almost daily; 1–5).

Depression.—Depression was assessed with the PHQ-9 [32], an instrument used to screen for depression. It incorporates depression diagnostic criteria from the DSM-IV [33]. Each of

the 9 items on the scale could be scored from 0 (not at all) to 3 (nearly every day) (α=.84). A total score was calculated.

Data Analysis

Descriptive statistics (percentages and means) were calculated for demographics, pre- and

post-migratory factors, substance use, and depression. We first conducted bivariate

associations (Pearson correlations) of substance use and depression with demographic

factors, pre-migratory factors, and post-migratory factors. Subsequently, forward linear

regressions were utilized with substance use and depression as outcome. Data were analyzed

using IBM SPSS Statistics 23 (IBM Corporation, Armonk, New York).

Results

Demographic characteristics are presented in Table 1. Participants’ ages ranged from 20 and

41 years (M=31.0 years, SD=5.7). Most men had a college degree or higher (58.6%) and identified as gay (69.6%).

Recreational drug use

The mean score on recreational drug use was 2.37 (SD=1.53), with 8.6% of participants using drugs four or more times per week. The bivariate analysis showed that demographic

factors (age, educational attainment, and HIV status) were not associated with current

recreational drug use (Table 2). Pre-migratory factors associated with recreational drug use

included openness about same-sex attraction (r=.35, P<.01), history of forced sex (r=.31, P<. 01), and transactional sex (r=.39, P<.001). Post-migratory factors associated with recreational drug use included insecure immigration status (r=.26, P<.05), social support (r= −.29, P<.01), housing instability (r=.46, P<.001), financial instability (r=.31, P<.01), engagement in transactional sex in NYC (r=.41, P<.001), internalized homophobia (r=.28, P=.01), PTSD symptoms (r=.29, P<.01), alcohol use (r=.54, P<.001), and depression (r=.36, P<.001). Men were more likely to be currently engaged in recreational drug use if they had

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an insecure migration status, experienced housing and financial instability, had less social

support, engaged in transactional sex in NYC, experienced more internalized homophobia

and PTSD symptoms, used more alcohol, or reported more depressive symptoms.

In forward stepwise linear regression, five factors were independently associated with

recreational drug use (Table 3). Current recreational drug use was more frequent among

younger participants (β=−.32, P<.01), and participants who were more open about their same-sex attraction in country of origin (β=.39, P<.01), were currently experiencing housing instability (β=.41, P<.001), and experienced more internalized homophobia (β=.20, P<.05).

Alcohol use

The mean score on the AUDIT-C was 3.29 (SD=2.56), with 42.9% of participants scoring a 4 or higher, indicative of hazardous drinking. Bivariate correlates of alcohol use are

presented in Table 2. Demographic factors (age, educational attainment, and HIV status)

were not significantly associated with alcohol use. Several pre-migratory factors were

associated with alcohol use. Alcohol use was more frequent among participants who were

more open about their same-sex attraction in country of origin (r=.32, P<.01), reported a history of forced sex (r=.36, P<.01), or engaged in transactional sex (r=.32, P<.01). Post- migratory factors associated with current alcohol use included housing instability (r=.26, P<. 05), transactional sex in NYC (r=.31, P<.01), recreational drug use (r=.54, P<.001), and depression (r=.33, P<.01). Men who experienced housing instability in NYC, engaged in transactional sex in NYC, used drugs recreationally, or reported more depressive symptoms

were currently more frequent alcohol users. In forward linear regression, homophobic

experiences in country of origin (β=−.25, P<.05) and experiences of forced sex before migration were independently associated with alcohol use (β=0.36, P<.01) (Table 3).

Depression

The depression scores ranged from 0 to 27 with a mean score of 6.85 (SD=4.81); 25.7% of participants had a score of 10 or higher, indicating moderate to severe depression.

Demographic factors (age, educational attainment, and HIV status) were not significantly

associated with depression (Table 2). Participants who reported forced sex experiences in

country of origin were more likely to report depressive symptoms (r=.42, P<.001). Post- migratory factors associated with depression included migratory grief (r=.38, P<.001), insecure immigration status (r=.32, P<.01), social support (r=.−.27, P<.05), housing instability (r=.25, P<.05), financial instability (r=.33, P<.01), engagement in transactional sex in NYC (r=.28, P<.05), PTSD symptoms (r=.66, P<.001), recreational drug use (r=.36, P<.001), and alcohol use (r=.33, P<.01). Men reported more depressive symptoms if they had an insecure immigration status, experienced more migratory grief, less social support,

housing and financial instability, engaged in transactional sex in NYC, experienced more

PSTD symptoms, and reported more recreational drug and alcohol use. In forward linear

regression, factors independently associated with depression included PTSD symptoms (β=. 62, P<.001) and alcohol use (β=.24, P<.01) (Table 3).

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Discussion

This study of recently migrated African GBM in the U.S. found that both migratory factors

and sexual minority stress factors were significantly associated with current substance use

and depression. Among the migratory factors, both premigratory and postmigratory factors

played a role. Recreational drug use, alcohol use, and depression were also strongly

associated with each other. This is the first known study to assess these factors among this

population in the U.S. and these findings have implications for interventions aimed at

promoting better health behaviors and ultimately achieving optimum health outcomes.

In line with results of studies among sexual minority men [34–37], we found that

experiences of forced sex (in country of origin), transactional sex (in country of origin and in

the U.S.), insecure immigration status, limited social support, current housing instability,

financial instability, and PTSD symptoms were all associated in the expected direction with

at least two of the three health outcomes. Homophobic experiences in the country of origin

was only associated with current alcohol use and internalized homophobia was only

associated with recreational drug use. Migratory grief was only associated with depression,

which is in line with other studies conducted on immigrant groups in the U.S. [25]. That

recreational drug use, alcohol use and depression each had unique, independent predictors in

the multivariate analyses is a result of the statistical test applied, which selected only the

strongest independently associated factors in the final model. It is likely that with a bigger

sample size, more factors would have been selected in the multivariate model.

That openness about one’s same-sex attraction in the country of origin was associated with

both recreational drug use and alcohol use, is opposite of what one would expect, because

concealment instead of openness is usually conceived as a sexual minority stress factor [15,

16]. Openness in the country could reflect original differences in lifestyles among GBM,

including an earlier coming out, greater perceived femininity [29, 38], and earlier exposure

to sexual minority stressors and social marginalization at an earlier age. A more in-depth

exploration of immigrants’ sexual life in the country of origin is needed to better understand

underlying processes.

The observed associations of stress factors with substance use and between substance use

and depression suggest that substance use functions as a way of coping with one’s problems,

as studies among African GBM have suggested [39, 40].

These findings suggest a coherent picture, in which negative experiences in the country of

origin, such as forced sex and engagement in transactional sex, lead to housing and financial

instability, and hamper a successful integration in the host country. High rates of

transactional sex in the sample might be indicative of lack of economic opportunities for this

group. Findings furthermore suggest the need to address the men’s experiences in the

country of origin, because their impact seems to be persistent. Furthermore, efforts aimed at

improving the health of migrant African GBM. should be recognize that promoting healthy

behaviors might be ineffective if structural factors such as unstable housing and joblessness

are not adequately addressed.

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Our findings support the framework, recently developed by Alessi and Kahn [41], for

clinical practice with sexual and gender minority asylum seekers. This framework consists

of three components, including establishing safety and stability in treatment and in the

environment, developing skills for managing the asylum claims process, and providing

strategies for dealing with the challenges of resettlement. The aim of these components is to

help clients to heal from trauma, handle the demands of acculturation, and cope with

minority stress.

Our findings suggest the importance of efforts that go beyond clinical practice, including

reinforcing social support and promoting community building among recently migrated

African GBM. Providing spaces for new migrants to meet each other, discuss common

problems, and identify solutions might help alleviate depression that might occur as part of

the migration process. CBOs that serve this group could provide resume writing, interview

preparation, and job skills training services. Gaining financial independence is likely to have

direct implications for physical and mental health outcomes. It is critical that healthcare

systems and social service programs that intersect with this population have the competence

to identify and address the possible trauma prior to migration as well as the unique

challenges and barriers faced once in the U.S.

Limitations

This study has several limitations. First, the small sample size implies low statistical power,

limiting the ability to detect other significant associations. Second, the cross-sectional study

limits our ability to infer causation or directionality of observed associations. Third, we did

not assess men’s motivation to migrate. While some migrated out of personal choice, many

might have fled their country due to prejudice, discrimination, and even death threats [42].

Understanding their motivation might have shed more light on their current health status.

Fourth, there are additional postmigratory challenges that were not studied here, including

language barriers, economic difficulties, loneliness and social isolation, stress about families

left behind, and possibility of reunification [8, 43]. Fifth, as all participants migrated from

East or West Africa, the findings may not be generalizable to GBM from other African

countries. Sixth, the study included immigrants residing in NYC; immigrants living in other

cities might experience different challenges when adjusting to a new environment. Finally,

only social support was studied as a resilience factor; additional resilience factors, including

spirituality, might have offered more insights in successful adaptation strategies [44].

New Contributions to the Literature and Directions for Future Studies

Substance use and depression among African GBM who migrated to the U.S. were

associated with negative experiences both in the home and host country. Public health

programming that takes a holistic and comprehensive approach to improving health

outcomes among this population is needed. Future studies could tease out to what extent

some of the health disparities result from being a sexual minority person or an immigrant by

testing whether the observed associations exist among GBM immigrants in other contexts

and among immigrant populations other than African GBM. This will provide further

understanding of how intersecting identities and backgrounds affect health outcomes.

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Acknowledgements

The research team would like to acknowledge the brave participants who shared their stories and experiences with us. This research was supported by an HIV Center Pilot grant and a National Institute of Mental Health (NIMH) center grant (P30-MH43520; principal investigator [PI]: Robert H. Remien, PhD). Dr. Anyamele is supported by an NIMH training grant (T32-MH19139 Behavioral Sciences Research in HIV Infection; PI: Theodorus G.M. Sandfort, PhD). Mr. Ogunbajo contributions to this paper were supported by NIMH (R25-MH083620; PI: Amy Nunn, PhD), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2C- HD041020; PI: Susan Short, PhD), and the Robert Wood Johnson Foundation Health Policy Research Scholars Program.

References

1. Gambino CP, Trevelyan EN, Fitzwater JT The foreign-born population from Africa. 2008–2012. 2014: US Department of Commerce, Economic and Statistics Administration, US Census Bureau.

2. Hopkinson RA, Keatley E, Glaeser E, Erickson-Schroth L, Fattal O, Sullivan MN. Persecution experiences and mental health of LGBT asylum seekers. J Homosex. 2017;64(12):1650–66. [PubMed: 27831853]

3. Alessi EJ, Kahn S, Chatterji S. ‘The darkest times of my life’: Recollections of child abuse among forced migrants persecuted because of their sexual orientation and gender identity. Child Abuse Negl. 2016;51:93–105. [PubMed: 26615778]

4. Alessi EJ, Kahn S, Van Der Horn R. A qualitative exploration of the premigration victimization experiences of sexual and gender minority refugees and asylees in the United States and Canada. J Sex Res. 2017;54(7):936–48. [PubMed: 27715333]

5. Alessi EJ, Kahn S, Woolner L, Van Der Horn R. Traumatic stress among sexual and gender minority refugees from the Middle East, North Africa, and Asia who fled to the European Union. J Trauma Stress. 2018: Advance online publication.

6. Sandfort T, Anyamele C, Dolezal C. Correlates of sexual risk among recent gay and bisexual immigrants from Western and Eastern Africa to the USA. J Urban Health. 2017;94:330–8. [PubMed: 28258531]

7. Bhugra D Migration and mental health. Acta Psychiatr Scand. 2004;109(4):243–58. [PubMed: 15008797]

8. Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, Guzder J, Hassan G, Rousseau C, Pottie K. Common mental health problems in immigrants and refugees: general approach in primary care. Can Med Assoc J. 2011;183(12):E959–67. [PubMed: 20603342]

9. Johnson TP, Vangeest JB, Cho YI. Migration and substance use: evidence from the US National Health Interview Survey. Subst Use Misuse. 2002;37(8–10):941–72. [PubMed: 12180572]

10. Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Anderson K. Immigration and lifetime prevalence of DSM-IV psychiatricdisorders among mexican americans and non-Hispanic whites in the United States: results from the national epidemiologic survey on alcohol and relatedconditions. Arch Gen Psychiatry. 2004;61(12):1226–33. [PubMed: 15583114]

11. Gee GC, Ryan A, Laflamme DJ, Holt J. Self-reported discrimination and mental health status among African descendants, Mexican Americans, and other Latinos in the New Hampshire REACH 2010 Initiative: the added dimension of immigration. Am J Public Health. 2006;96(10): 1821–8. [PubMed: 17008579]

12. Blake SM, Ledsky R, Goodenow C, O’donnell L. Recency of immigration, substance use, and sexual behavior among Massachusetts adolescents. Am J Public Health. 2001;91(5):794–8. [PubMed: 11344890]

13. Venters H, Adekugbe O, Massaquoi J, Nadeau C, Saul J, Gany F. Mental health concerns among African immigrants. J Immigr Minor Health. 2011;13(4):795–7. [PubMed: 20549358]

14. Bourque F, van der Ven E, Malla A. A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants. Psychol Med. 2011;41(5):897–910. [PubMed: 20663257]

15. Meyer IH, Frost DM. Minority stress and the health of sexual minorities In: Handbook of Psychology and Sexual Orientation. Patterson CJ, D’Augelli AR, eds. Oxford, U.K.: Oxford University Press; 2013:252–66.

Ogunbajo et al. Page 9

J Immigr Minor Health. Author manuscript; available in PMC 2020 December 01.

A u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t

16. Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995;36:38–56. [PubMed: 7738327]

17. McCabe SE, Bostwick WB, Hughes TL, West BT, Boyd CJ. The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. Am J Public Health. 2010;100(10):1946–52. [PubMed: 20075317]

18. Lea T, de Wit J, Reynolds R. Minority stress in lesbian, gay, and bisexual young adults in Australia: Associations with psychological distress, suicidality, and substance use. Arch Sex Behav. 2014;43(8):1571–8. [PubMed: 24573397]

19. Carroll A, Mendos LR. State-sponsored homophobia. Geneva: Ilga; 2017.

20. Kohut A, Wike R, Bell J, Horowitz JM, Simmons K, Stokes B, Poushter J, Ponce A, Gross EM, Barker C. The global divide on homosexuality. Pew Research Center 2013 4.

21. Thoreson R, Cook S. Nowhere to turn: Blackmail and extortion of LGBT people in Sub-Saharan Africa. New York: International Gay and Lesbian Human Rights Commission; 2011.

22. Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, Beyrer C. HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2009;4(3):e4997. [PubMed: 19325707]

23. Randazzo TJ. Social and legal barriers. Sexual orientation and asylum in the United States, in Queer migrations. Sexuality, U.S. citizenship. and border crossings. In: Luibhèd E, Cantù L Jr., eds. Minneapolis: University of Minnesota Press; 2005:30–60.

24. Casado BL, Hong M, Harrington D. Measuring migratory grief and loss associated with the experience of immigration. Research on Social Work Practice. 2010;20(6):611–20.

25. Casado BL, Leung P. Migratory grief and depression among elderly Chinese American immigrants. J Gerontol Soc Work. 2002;36(1–2):5–26.

26. Hershberger SL, D’augelli AR. The impact of victimization on the mental health and suicidality of lesbian, gay, and bisexual youths. Dev Psychol. 1995;31(1):65–74.

27. Dandona L, Dandona R, Gutierrez JP, Kumar GA, McPherson S, Bertozzi SM, Asci FPP Study Team. Sex behaviour of men who have sex with men and risk of HIV in Andhra Pradesh, India. Aids. 2005;19(6):611–9. [PubMed: 15802980]

28. Burgard SA, Seefeldt KS, Zelner S. Housing instability and health: findings from the Michigan Recession and Recovery Study. Soc Sci Med. 2012;75(12):2215–24. [PubMed: 22981839]

29. Sandfort T, Bos H, Knox J, Reddy V. Gender nonconformity, discrimination, and mental health among black South African men who have sex with men: A further exploration of unexpected findings. Arch Sex Behav. 2016;45(3):661–70. [PubMed: 26067298]

30. Lang AJ, Wilkins K, Roy-Byrne PP, Golinelli D, Chavira D, Sherbourne C, Rose RD. Bystritsky A, Sullivan G, Craske MG. Abbreviated PTSD Checklist (PCL) as a guide to clinical response. Gen Hosp Psychiatry. 2012;34(4):332–8. [PubMed: 22460001]

31. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158(16):1789–95. [PubMed: 9738608]

32. Monahan PO, Shacham E, Reece M, Kroenke K, Ong’or WO, Omollo O, Yebei VN, Ojwang C. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya. J Gen Intern Med. 2009;24(2):189–97. [PubMed: 19031037]

33. First MB, Spitzer RL, Gibbon M, Williams JB. Structured clinical interview for DSM-IV axis I disorders. New York: New York State Psychiatric Institute; 1995.

34. Tobin KE, Yang C, King K, Latkin CA, Curriero FC. Associations between drug and alcohol use patterns and sexual risk in a sample of African American men who have sex with men. AIDS Behav. 2016;20(3):590–9. [PubMed: 26558629]

35. Freeman P, Walker BC, Harris DR, Garofalo R, Willard N, Ellen JM, Adolescent Trials Network for HIV/AIDS Interventions 016b Team. Methamphetamine use and risk for HIV among young men who have sex with men in 8 US cities. Arch Pediatr Adolesc Med. 2011;165(8):736–40. [PubMed: 21810635]

36. Shoptaw S, Weiss RE, Munjas B, Hucks-Orti C, Young SD, Larkins S, Victorianne GD, Gorbach PM. Homonegativity, substance use, sexual risk behaviors, and HIV status in poor and ethnic men who have sex with men in Los Angeles. J Urban Health. 2009;86(1):77–92. [PubMed: 19526346]

Ogunbajo et al. Page 10

J Immigr Minor Health. Author manuscript; available in PMC 2020 December 01.

A u th

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u th

o r M

a n u scrip

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u th

o r M

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t

37. Stall R, Paul JP, Greenwood G, Pollack LM, Bein E, Crosby GM, Mills TC, Binson D, Coates TJ, Catania JA. Alcohol use, drug use and alcohol‐related problems among men who have sex with men: The Urban Men’s Health Study. Addict. 2001;96(11):1589–601.

38. Sandfort TGM, Bos H, Reddy V. Gender expression and mental health in Black South African men who have sex with men: Further explorations of unexpected findings. Arch Sex Behav. 2018;47(8): 2481–90. [PubMed: 29464453]

39. Tafuma TA, Merrigan MB, Okui LA, Lebelonyane R, Bolebantswe J, Mine M, Chishala S, Moyo S, Thela T, Rajatashuvra A. HIV/Sexually transmitted infection prevalence and sexual behavior of men who have sex with men in 3 districts of Botswana: Results from the 2012 biobehavioral survey. Sex Transm Dis. 2014;41(8):480–5. [PubMed: 25013975]

40. McAdams-Mahmoud A, Stephenson R, Rentsch C, Cooper H, Arriola KJ, Jobson G, De Swardt G, Struthers H, McIntyre J. Minority stress in the lives of men who have sex with men in Cape Town, South Africa. J Homosex. 2014; 61(6):847–67. [PubMed: 24392722]

41. Alessi EJ, Kahn S. A framework for clinical practice with sexual and gender minority asylum seekers. Psychol Sex Orientat Gend Divers. 2017;4(4):383–91.

42. Edwards JR. Homosexuals and immigration: Developments in the United States and abroad. CIS Backgrounder. 1999:1–7.

43. Keyes EF Kane CF. Belonging and adapting: Mental health of Bosnian refugees living in the United States. Issues Ment Health Nurs. 2004;25(8):809–31. [PubMed: 15545245]

44. Alessi EJ. Resilience in sexual and gender minority forced migrants: A qualitative exploration. Traumatol. 2016;22(3):203–13.

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Table 1.

Characteristics of Recent Gay and Bisexual Immigrants from East and Western Africa to the USA (N = 70)

M (SD) % (n)

Age, years 31.0 (5.71)

Education

Less than college 41.4 (29)

College or higher 58.6 (41)

Marital status

Never married 87.1 (61)

(Ever) married 12.9 (9)

Sexual attraction

To men only 54.3 (38)

To men and women 45.7 (32)

Sexual identity

Gay 69.6 (48)

Bisexual 30.4 (21)

Self-reported HIV status

Positive 11.4 (8)

Negative 72.9 (51)

Don’t know/Never tested 15.7 (11)

Openness in country of origin a 1.9 (1.45)

Homophobic experiences in country of origin b 1.8 (0.80)

Forced sex before migration

No 64.3 (45)

Yes 35.7 (25)

Transactional sex in country of origin

No 40.0 (28)

Yes 60.0 (42)

Insecure immigration status

No 48.6 (34)

Yes 51.4 (36)

Migratory grief c 1.9 (0.63)

Social support d 3.1 (0.98)

Housing instability in NYC e 3.4 (1.46)

Financial instability in NYC f 3.0 (1.15)

Transactional sex in the USA

No 45.7 (32)

Yes 54.3 (38)

Hiding sexual orientation in NYC g 2.9 (0.76)

Internalized homophobia h 2.6 (0.69)

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M (SD) % (n)

PTSD symptoms i 13.9 (4.57)

Recreational drug use j 2.4 (1.53)

Alcohol use k 3.3 (2.56)

Depression l 6.9 (4.81)

a Openness in country of origin, 0–5

b Homophobic experiences in country of origin, 1–5

c Migratory grief, 1–4

d Social support, 1–5

e Housing instability in NYC, 0–5

f Financial instability in NYC, 1–5

g Hiding sexual orientation in NYC, 1–4

h Internalized homophobia, 1–4

i PTSD symptoms, 6–30

j Recreational drug use, 1–5

k Alcohol use, 0–12

l Depression, 0–27.

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Table 2.

Bivariate Associations (r) with Substance Use and Depressive Symptoms among Recent Gay and Bisexual Immigrants from East and Western Africa to the USA (N=70)

Recreational

Drug Use Alcohol Use Depression

Age −.15 −.10 −.02

Education .03 .21 −.01

HIV infected (self-reported) −.001 .20 −.04

Openness in country of origin a .35** .32** .12

Homophobic experiences, country of origin b −.05 .17 .15

Forced sex before migration .31** .36** .42***

Transactional sex in country of origin .39*** .32** .23

Migratory grief c .09 .22 .38***

Insecure migration status .26* .13 .32**

Social support d −.29** −.14 −.27*

Housing instability e .46*** .26* .25*

Financial instability f .31** .17 .33**

Transactional sex in NYC .41*** .31** .28*

Hiding sexual orientation in NYC g .03 .20 −.13

Internalized homophobia h .28** .03 .15

PTSD symptoms i .29** .14 .66***

Recreational drug use j - .54*** .36***

Alcohol use k .54*** - .33**

Depression l .36*** .33** -

r = Pearson correlation coefficient.

* P < .05

** P < .01

*** P < .001.

a Openness in country of origin, 0–5

b Homophobic experiences, country of origin, 1–5

c Migratory grief, 1–4

d Social support, 1–5

e Housing instability in NYC, 0–5

f Financial instability in NYC, 1–5

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g Hiding sexual orientation in NYC, 1–4

h Internalized homophobia, 1–4

i PTSD symptoms, 6–30

j Recreational drug use, 1–5

k Alcohol use, 0–12

l Depression, 0–27.

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Table 3.

Multivariable Linear Regression Analyses of Characteristics of Substance Use and Depressive Symptoms

among Recent Gay and Bisexual Immigrants from East and Western Africa to the USA (N=70)

Recreational

Drug Use Alcohol Use Depression

β t β t β t

Age −.32 −3.30**

Openness in country of origin a .39 3.14**

Homophobic experiences, country of origin b −.25 −2.21*

Forced sex before migration .36 3.20**

Housing instability in NYC c .41 3.90***

Internalized homophobia d .20 2.08*

PTSD symptoms e .62 7.08***

Alcohol use .24 2.75**

R2 .44 .13 .49

F 10.03*** 10.25** 32.03**

β = standardized beta.

* P < .05

** P < .01

*** P < .001 (1-tailed).

a Openness in country of origin, 0–5

b Homophobic experiences, country of origin, 1–5

c Housing instability in NYC, 0–5

d Internalized homophobia, 1–4

e PTSD symptoms, 6–30

f Alcohol use, 0–12.

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