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), migrating mostly from East and West Africa and settling predominantly in urban metropolitan cities. As recent studies suggest [2,3,4,5,6] 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 [9,10,11,12]. 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 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 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 = 0.84; 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 = 0.89; 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 = 0.72). 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 = 0.80).

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 2 weeks; answers were scored on a 5-point scale (0 = not at all—4 = nearly every day); a total score was computed (α = 0.82).

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 0–12, the higher the score, the higher the likelihood of hazardous drinking. Cronbach of the AUDIT-C was 0.77. 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 nine items on the scale could be scored from 0 (not at all) to 3 (nearly every day) (α = 0.84). 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, NY, USA).

Results

Demographic characteristics are presented in Table 1. Participants’ ages ranged from 20 to 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%).

Table 1 Characteristics of recent gay and bisexual immigrants from East and Western Africa to the USA (N = 70)
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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 = 0.35, P < 0.01), history of forced sex (r = 0.31, P < 0.01), and transactional sex (r = 0.39, P < 0.001). Post-migratory factors associated with recreational drug use included insecure immigration status (r = 0.26, P < 0.05), social support (r = − 0.29, P < 0.01), housing instability (r = 0.46, P < 0.001), financial instability (r = 0.31, P < 0.01), engagement in transactional sex in NYC (r = 0.41, P < 0.001), internalized homophobia (r = 0.28, P = 0.01), PTSD symptoms (r = 0.29, P < 0.01), alcohol use (r = 0.54, P < 0.001), and depression (r = 0.36, P < 0.001). Men were more likely to be currently engaged in recreational drug use if they had 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.

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)
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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 = − 0.32, P < 0.01), and participants who were more open about their same-sex attraction in country of origin (β = 0.39, P < 0.01), were currently experiencing housing instability (β = 0.41, P < 0.001), and experienced more internalized homophobia (β = 0.20, P < 0.05).

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)
Full size table

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 = 0.32, P < 0.01), reported a history of forced sex (r = 0.36, P < 0.01), or engaged in transactional sex (r = 0.32, P < 0.01). Post-migratory factors associated with current alcohol use included housing instability (r = 0.26, P < 0.05), transactional sex in NYC (r = 0.31, P < 0.01), recreational drug use (r = 0.54, P < 0.001), and depression (r = 0.33, P < 0.01). 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 = − 0.25, P < 0.05) and experiences of forced sex before migration were independently associated with alcohol use (β = 0.36, P < 0.01) (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 = 0.42, P < 0.001). Post-migratory factors associated with depression included migratory grief (r = 0.38, P < 0.001), insecure immigration status (r = 0.32, P < 0.01), social support (r = − 0.27, P < 0.05), housing instability (r = 0.25, P < 0.05), financial instability (r = 0.33, P < 0.01), engagement in transactional sex in NYC (r = 0.28, P < 0.05), PTSD symptoms (r = 0.66, P < 0.001), recreational drug use (r = 0.36, P < 0.001), and alcohol use (r = 0.33, P < 0.01). 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 = 0.62, P < 0.001) and alcohol use (β = 0.24, P < 0.01) (Table 3).

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 [34,35,36,37], 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.

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.