Sex Now is a serial cross-sectional survey of gay and bisexual men administered every 12–24 months since 2002 in the Canadian province of British Columbia. The survey has been offered anonymously online since 2007. The sampling frame was expanded to include all of Canada in 2010. This paper uses data from the 2011 edition of the survey collected from September 2011 to February 2012. The survey was offered in Canada’s two official languages, French and English. Sex Now 2011 was the first large-scale Canadian survey of gay men’s social determinants of health. The questionnaire was developed in collaboration with a group of young investigators, who participated in all phases of the study, including questionnaire development, pilot testing, recruitment, survey administration, data analysis, and communication of results (including the present report). The domains of Sex Now 2011 included: sexual behaviors, health measures, relationships, health care services, working conditions, community participation, social support, and experiences of homophobia.
Participants of Sex Now 2011 were recruited from dating/sex-seeking websites (52.7 %), social media (23.1 %), an email database of previous survey participants (9.9 %), word of mouth (8.7 %), and other promotion activities (5.2 %). The survey protocol was reviewed by the independent Research Ethics Board of the Community-Based Research Centre for Gay Men’s Health.
Measures
Demographic factors
Participants self-reported sexual orientation, partnerships status, education level, income, age, ethnicity, living environment and their province of territory of residence. All variables were categorical with the exception of age which was collected as a continuous variable.
Suicide related ideation and behavior
Two indicators of suicide related ideation and behavior were drawn from the following questions: a) “have you ever thought about suicide?” hereafter referred to as suicide ideation; and, b) “have you ever attempted suicide?” hereafter referred to as suicide attempt. In both cases, participants could report these as having never occurred, as having occurred prior to the last 12 months, within the last 12 months, or both prior to and within the last 12 months.
Marginalization indicators
Data on lifetime experiences of anti-gay marginalization and violence were collected. Participants were asked if they had experienced: a) verbal violence and/or hate talk, b) physical violence, c) anti-gay bullying (i.e. harassment, cyber-bullying) d) sexual violence (i.e. unwanted sex), and e) workplace discrimination based on their sexuality.
Psychosocial health problems
Participants were asked if they had experienced the following in the last 12 months: a) frequent consumption of tobacco (regular/daily smokers), b) use of one or multiple of the following party drugs: cocaine, crystal meth, ecstasy, GHB and ketamine, c) being on medication for depression, d) being on medication for anxiety, e) being diagnosed with one or more of the following sexually transmitted infections (STIs): gonorrhea, chlamydia, syphilis, herpes, HPV or hepatitis C, f) one or more episodes of condomless anal intercourse (insertive or receptive) with a partner (CAI-US), whose HIV status was unknown or discordant. We also asked participants to report whether g) they have ever been diagnosed with HIV.
Analytic plan
The analysis was guided by the syndemic production theory of Stall, Friedman and Cantania [13]. Consistent with this theory and previous syndemic studies [11, 17, 18], the accumulation of social stressors was hypothesized to lead to the development of psychosocial health problems, including suicide ideation and attempts. These health problems were predicted to be interrelated and mutually reinforcing (independently associated) -a “snowball” effect in syndemic theory (as described in Fig. 1). The analytic plan for this study was modeled on a syndemic-based analysis of HIV transmission risk in the 2010 version of the Sex Now survey [24].
First the relationships between lifetime indicators of anti-gay marginalization, suicide ideation and attempted suicide in the last 12 months were explored using logistic regression. Because the effect of marginalization was hypothesized to be additive, we calculated the percentage of respondents who experienced suicide ideation and who attempted suicide in the last 12 months by number of marginalization indicators. These relationships were tested using Chi-Square test for trend with p < 0.05 considered statistically significant.
Second, because suicide related ideation and attempt were hypothesized to be interrelated with and to have mutually reinforcing relationships with other psychosocial health problems, we examined correlations between all psychosocial health problems, including suicide ideation and suicide attempts in the last 12 months. Since those who experience multiple psychosocial health problems (those caught in syndemics) were hypothesized to be at increased risk for suicide ideation and attempts, the percentage of those who reported suicide ideation and attempted suicide in the last 12 months was calculated for each expanding number of psychosocial health problems.
Lastly, associations between individual psychosocial health problems and the count of those problems associated with suicide ideation or having attempted suicide were explored in logistic regression.
All multivariable models were adjusted for demographic variables including sexual orientation, as some researchers have found differences in suicide related ideation and behavior between gay and bisexual men [25]. Ninety-five percent confidence intervals (CIs) were calculated for all odds ratios; 95 % CIs which excluded 1 (p < 0.05) were considered statistically significant, though in interpreting results, emphasis is placed on the magnitude of effect. All analyses were performed using SPSS 20.0.