Self-reported sexual orientation , relationships pattern , social connectedness , disclosure , and self-esteem in Indian men who use online gay dating website

1Assistant Professor, Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India, 2Senior Resident, Department of Psychiatry, Govind Ballabh Pant Institute of PostGraduate Medical Education and Research, New Delhi, India, 3Assistant Professor, Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India, 4Professor and Head, Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India


INTRODUCTION
Expression of sexual identity and subsequent behaviour remains a taboo in Indian culture, reinforced by law and societal values.[1] Although in recent times, public perception of the lesbian, gay, bisexual, transgender, and queer (LGBT and Q) community has changed and become more acceptable, a large section of Indian society still has a hostile attitude towards people with gender non-conformity.[2] Recent debate on Section 377 of the Indian Penal Code, criminalising homosexuality has brought attention to gender-related issues to the forefront.[3] This community is forced to conceal their identity out of fear of abuse and rejection from family, peers, and society at large.[4] Further, studies have shown that LGBT people struggle with self-esteem and loneliness attributable to minority stress in the form of struggle to conceal one's sexual orientation and/or identity.[5] Although concealing their sexual orientation helps gay men in dealing with stigma, some of them choose to be open and disclose their orientation to the society, a process aptly named "coming out of the closet" or simply "coming out".[6] The LGBT community remains hidden due to factors such as stigmatisation, victimisation, social rejection, and isolation leading to difficulties in research.[7] Little research has been done on this group in India.[8][9][10][11] This study is an attempt to throw light on aspects of coming out, disclosure, and self-esteem in men having sex with men (MSM).

Aims of the study
a. To describe the pattern of sexual orientation, relationships, social connectedness, and disclosure in men using a gay dating internet website.b.To assess self-esteem and find out the association, if any with coming out in this community.

MATERIALS AND METHOD Design
This was a cross-sectional observational study of Indian men who use a gay dating website.

Recruitment of participants
An advertisement inviting participants for the study was displayed on a gay dating website.This advertisement was visible to 100000 "impressions" (user log-ins) only from India, during the month of December 2015.Users clicking on the advertisement were led to the study's survey website.Information regarding the aim and scope of the study was displayed before users could begin the survey.Participants were also informed that no personal identifiers would be collected from them and their responses would be kept confidential.This study also employed the respondent-driven method for recruitment by encouraging participants to forward the link to the study's survey website, to their gay or bisexual friends and acquaintances.
Clearance was obtained from the institutional research and ethics committees.Informed consent was obtained in the prescribed format from the participants.

Instruments used
A. Sociodemographic proforma to gather sociodemographic data B. Questions on disclosure, relationships, and social support This included questions enquiring about coming out of the closet, with whom they were out with, experiences regarding same.We also enquired into social support with question -Do you think you have people in your life that you can talk to and depend upon for help regarding important matters and health concerns?The responses were in the form of yes/no.Questions were asked regarding whether they lack companionship or feel left out with responses in the form of -often, sometimes, and hardly.
[Appendix] C. Kinsey scale for sexual orientation [12] This scale, more commonly known as "The Kinsey Scale" was developed by Drs.Alfred Kinsey, Wardell Pomeroy, and Clyde Martin (the Heterosexual-Homosexual Rating Scale).The scale was based on the research findings that people did not fit into exclusive heterosexual or homosexual categories."Zero" implies those reporting exclusively heterosexual behaviour or attraction while "six" implies exclusively homosexual behaviour or attraction.Those reporting varying levels of attraction or sexual activity with either sex fall in the range of one to five.D. Rosenberg Self-Esteem Scale (RSES) [13] A widely used ten-item scale that measures global selfworth by measuring feelings about the self.The items on this scale are answered using a four-point Likert scale that ranges from strongly agree to strongly disagree.
The RSES demonstrates a Guttman scale coefficient of reproducibility of 0.92, indicating excellent internal consistency.Test-retest reliability over a period of two weeks reveals correlations of 0.85 and 0.88, indicating excellent stability.[13]

Statistical analysis
Statistical analysis was done using Minitab 17 statistical software.Mean, standard deviation, and percentage were used for descriptive statistics and Kruskal-Wallis test was used to find out the significance of association between variables.

RESULTS
Over a period of two months, 290 subjects participated in the study.Data from 13 individuals had to be discarded due to incomplete or repeat data.This study is part of a larger project that explored the relationship patterns and mental health issues in homosexual men.The sociodemographic data of the sample is already published.[14] The mean age of the study sample being 30.31 years (SD±8.58).A majority of them were salaried, had higher education, and belonged to Hindu religion.On the spectrum of sexual orientation as measured on the Kinsey scale, most of the subjects expressed their orientation as either exclusively or predominantly homosexual (72%) followed by men with bisexual orientation (18%).
Table 1 describes the relationship patterns and social connectedness of the subjects.Relationship status displayed was a wide range of spectrum with majority being single and not in relationship, while some were in relationship with a man, and some married and not in any kind of relationship.Majority were single (61%) and 20% of the subjects were married to a woman.Those who were in relationship, 35% reported to be of less than five years duration.Among those in relationship, equal number reported being satisfied with the relationship (40%) and felt socially connected (53%).However, majority of them (70-80%) had a feeling of missing companionship and being left out.

Disclosure
Majority of them (61%) were not always open about their orientation in front of others.Most of the subjects were not open at workplace (82%) and with the family (80%).Most of them had disclosed their sexual orientation outside their social circle, i.e. to others (62%) followed by friends (42%) and lesser number to parents or workplace colleague.
The average age of coming out of the closet (n=232) was 19.71 years (SD±6.67).Majority of them first came out to friends (57%), 28% to others, and a lesser percentage to family members.Most of the subjects described the experience of coming out as mixed (47%) or positive (38%).
Tables 2 and 3 show coming out and disclosure.

Self-esteem
The mean score on RSES of the entire sample was 28.49 (SD±5.55).There was no association between age of coming out and self-esteem scores (Spearman rho=0.005,p=0.938).Self-esteem scores were significantly lower in subjects who were in the closet (H=16.20,p<0.001,Kruskal-Wallis test) [In the closet (median=27.00),sometimes (median=29.00), and always (median=31.00)].

DISCUSSION
The response to the survey helped us get new insights into the pattern of disclosure and social relationships in this much-hidden community in India.The respondents were adults with a wide age group from 18 years to 60 years.Majority of the surveyed respondents belonged to a highly educated and higher income group.Representation from Hindu religion was highest followed by atheists, Muslims, and Christians.The sociodemographic distribution is expected since access to and knowledge about Internet dating services would be more amongst people with higher education and economic status.

Sexual orientation and relationship patterns
Sexual orientation, as defined by the American Psychological Association [15] refers to the sex of those to whom one is sexually and romantically attracted.The response for sexual orientation in our study showed a wide spectrum on the Kinsey scale emphasising a wider spectrum of human sexual preferences.Majority of the respondents were either exclusively or predominantly homosexual followed by 18% representation from the bisexual group.This emphasises the fact that although categorisation of human sexual orientation into groups such as heterosexuals, bisexuals, and homosexuals is widely used, sexual orientation occurs on a continuum, [12] and people perceived as LGB may identify in various ways and not necessarily by such discrete categories.[16] The relationship pattern reported by subjects was varied and complex.Although most of the subjects reported being single, others had a complex relationship from being married to a woman and being in a relationship with a man, to having relationships with both men and women.Studies have shown that in this community, monogamy and the pattern of relationships are affected by various factors including age, duration of relationship, socioeconomic status, religion, ethnicity, and society's attitude towards sex in general.Depending on how it is classified or defined, or where studies are conducted, between one and two-thirds of gay men may be thought to be in monogamous relationships at any time.[17] Some gay men live their relationships flexibly, view their desires and needs as changeable, and lack a strong ideological attachment to monogamy or non-monogamy.[18] In our study, only six per cent had relationship duration of more than five years.Lack of legal status to same-sex marriages and criminalisation of homosexuality may affect the pattern and the chances of being in a relationship in long term.Along with lack of security of social contract, Indian men are also faced with factors such as social and family pressure in the form of criticism and ridicule, fear of disclosure, and internalised homophobia.Lack of recognition of their relationship may affect the satisfaction and fulfillment one expects from such a relationship.[19] Not surprisingly, half of the subjects who reported being in a relationship, expressed dissatisfaction with their current relationship in our study.For some individuals, difficulty in coping with a climate in which one's relationship is devalued and marginalized, results in a state of chronic secrecy about their sexual orientation, leading to decreased social support, considerable stress, and ultimately, decrease in overall well-being.
The need to belong and form healthy and sustained social relationships is inherent in all human beings.Healthy and satisfying social relationships form an important protective factor against stress and poor mental health.[20,21] In our study, many of the subjects (44%) had the feeling of being socially isolated and left out.Previous studies have also shown that sexual minority adults have fewer social relationships, including with romantic partners, children, and other family members.[22]

Openness and disclosure
Coming out is an important aspect of gay person's identification and social acceptance.Research has shown that outness can be positively associated with outcomes of stress unique to minorities such as depression and anxiety.[23] Adolescents, on average, disclose non-heterosexual identity to parents and loved ones between the ages of 16 and 18 years, [24][25][26] with gay men coming out earlier than lesbian and bisexual women.This finding is similar to our study, where the mean age of coming out was 19.7 years.
The issue of disclosure or coming out does not neatly fit into the category of whether the person has identified his sexual orientation in front of others or not.It involves negotiating the social world by giving information on one's hidden identity to different people in different ways.More than 60% of our study subjects had not disclosed their sexual orientation.Nearly 80% were not open in front of their families and at the workplace.The number of responses to each of the questions was variable since being out of the closet is a fluid concept and outness of a particular person varies with situation and individuals.
The motivation for disclosing or not disclosing one's sexual orientation depends on several factors such as the situation or the proximity to a particular individual, past experiences, and stigma-both societal and internalised.[27] In our study, most of the subjects came out first to friends (56%) with only three per cent coming out to parents or siblings (nine per cent).Only 12% had disclosed their status to fathers, 16% to mother or sibling, and 42% to friends, which is less compared to previous studies.
Remafedi [28] found that 62% of a small sample of gay adolescents had told their mothers, but that only 34% had told fathers; parents generally reacted negatively to the disclosure.Savin-Williams [29] reported that 73% of mothers of the young people in the sample knew, compared to 66% of fathers.Using a college sample of gay men, D' Augelli [30] found that fewer than half had told their families; over onefourth (27%) had told fathers and over one-third (39%) had told mothers.Disclosure to family members was associated with threats, rejection, and with verbal and physical abuse.[30] The avoidance of such negative outcomes may be a primary motivator for concealment in Indian gays.Despite the change of opinion and attitudes of scientific community towards LGBT & Q groups, the heteronormative concept of human sexuality is still deeply entrenched in our society.In a recent survey, 68% of the world population said that they (78% Africa, 77% Asia, 64% Americas, 61% Europe, 44% Oceania) would be upset ('very' or 'somewhat') if their child told them that they were in love with someone of the same sex.[2] The difficulties and uncertainty of parental support they experience in telling parents can be seen in the finding that hardly any of the respondents in this study first disclosed to a parent.[24] Kurdek [31] studied general social support in 69 gay and 50 lesbian couples.He found that friends were the most frequent providers of social support, followed by partners, family, and co-workers.High social support, particularly by partners and friends, was positively related to psychological adjustment.[31] For those who choose to reveal their sexual orientation to others, research has found that the impact on relationship satisfaction depends on whether the disclosure is met with acceptance or rejection by important others, i.e. a person's past experiences.In our study, the experience of coming out was either mixed or positive reaction.This may indicate the changing attitude of our society towards the acceptance of gay people.
Negative criticism from previous instances of disclosure may reinforce internalised stigma leading to concealment.It may also lead to discrimination and job dissatisfaction which may further lead to greater psychiatric morbidity risk in such individuals.[32,33]

Self-esteem and its association with disclosure
In our study sample, the self-esteem scores were higher (mean score, 28.49).Research comparing minority with nonminority groups have returned equivocal results regarding minorities exhibiting lower scores of overall self-esteem.[5] Higher ratings of self-esteem were observed only after affiliation with other members of a shared, identified minority.Additionally, the actual experience of low self-esteem in itself was negatively correlated with the visibility of the specific minority; the lower the self-esteem scores, the higher the concealment.[34] Higher educational and socioeconomic status of the respondents may explain the higher self-esteem scores in our study.
In the present study, there was no correlation between self-esteem scores and age of coming out.Being in the closet and the negative experiences of coming out were significantly associated with lower self-esteem scores.It is known that self-concept is often based on the reflected views of others, along with the stigmatisation of homosexuality throughout our society.Therefore, it is no surprise that many LGB people receive and internalise the message that they are "not normal".Even before one develops a sense of sexual identity, boys and girls assimilate the societal message that there is something wrong with homosexuality.[35] In a study on the relationship between self-esteem and coming out to parents among gay and lesbian youth, Savin-Williams [29] found that among gays, self-esteem was associated with a positive relationship with both their mother and their father.
The stress caused due to efforts on concealment and disclosure of their sexual orientation takes a toll on these individuals.Studies have also shown that low self-esteem, a lack of self-care/self-love, hopelessness, depression, and suicidal thoughts all contributed to unsafe sexual behaviours.[36] The way to reduce stress on the LGBT population and positive mental health is to address the stigmatisation of sexual orientation among family, peers, and society at large, and abolishment of medieval laws such as criminalising homosexuality, so that this community can integrate better with the society.
There are no previous studies, to the best of our knowledge, on disclosure of sexual orientation among MSM and its association with self-esteem.Since the study population was limited to MSM who used a dating website, it might not be representative of the LGBT population in India.As discussed above, outness is a fluid concept and the cross-sectional nature of this study may not have fully grasped the extent of this concept.Also, fear of disclosure may have limited the responses of the study participants.The other limitations of this study were that social connectedness questions were unidimensional and psychological morbidity was not assessed.

Conclusion
This study sought to address the lacuna existing in MSM research in India.Patterns and satisfaction in sexual relationships and social support among MSM has provided unique insights into their lifestyle.Importantly, disclosure of sexual orientation to the society (coming out) was assessed.Although majority of the respondents in our study were single, there was a wider pattern of relationship revealed as discussed above.Nearly half of the study subjects were satisfied with their relationships and perceived adequate social support but a large number still had the feeling of missing companionship and being left out.Majority of the respondents had not disclosed their orientation either at home or workplace.They were more open about their orientation in front of friends and other individuals rather than family or parents.The self-esteem scores were higher among the study population but being in closet and experiencing negative reaction on disclosing their orientation was significantly associated with lower self-esteem.The results of this study point that there is a need for more focused therapy for helping this community deal with issues of coming out of the closet, loneliness and its subsequent impact on self-esteem.More research needs to be directed towards this community considering their unique mental health needs.

Table 1 :
Relationship satisfaction and social support

Table 2 :
Coming out of the closet and degree of openness