Suicide related ideation and behavior among Canadian gay and bisexual men: a syndemic analysis RESEARCH ARTICLE Open Access Suicide related ideation and behavior among Canadian gay and bisexual men: a syndemic analysis Olivier Ferlatte1,2*, Joshun Dulai2, Travis Salway Hottes2,3, Terry Trussler2 and Rick Marchand2 Abstract Background: While several studies have demonstrated that gay and bisexual men are at increased risk of suicide less attention has been given to the processes that generate the inherent inequity with the mainstream population. This study tested whether syndemic theory can explain the excess suicide burden in a sample of Canadian gay and bisexual men. Syndemic theory accounts for co-occurring and mutually reinforcing epidemics suffered by vulnerable groups due to the effects of social marginalization. Methods: This study used data from Sex Now 2011, a cross-sectional survey of Canadian gay and bisexual men (n = 8382). The analysis measured the extent to which anti-gay marginalization and several psychosocial health problems are associated with suicide related ideation and attempts. Since psychosocial health problems were hypothesized to have an additive effect on suicide related ideation and attempts, the analysis calculated the effect of accumulated psychosocial health problems on suicide behavior. Results: Suicide ideation and attempts were positively associated with each individual marginalization indicator (verbal violence, physical violence, bullying, sexual violence and work discrimination) and psychosocial health problems (smoking, party drugs, depression, anxiety, STIs, HIV risk and HIV). Furthermore, prevalence of suicide ideation and attempts increased with each added psychosocial health problem. Those who reported 3 or more had 6.90 (5.47–8.70) times the odds of experiencing suicide ideation and 16.29 (9.82–27.02) times the odds of a suicide attempt compared to those with no psychosocial health problems. Conclusions: This investigation suggests that syndemics is a useful theory for studying suicide behavior among gay and bisexual men. Moreover, the findings highlight a need to address gay and bisexual men’s health problems holistically and the urgent need to reduce this population’s experience with marginalization and violence. Keywords: Gay men, Bisexual men, Suicide, Syndemic, Homophobia, Violence, Canada Background It has been well established that gay and bisexual men experience disproportionately higher rates of suicide re- lated ideation and behavior. According to a meta-analysis conducted by King and his colleagues, gay and bisexual men are approximately four times more likely to attempt suicide over their lifetime in comparison to heterosexual men [1]. While evidence of this disparity has been accumulating, there has been less attention to the pro- cesses that have generated it [2]. Global theories of suicide, such as the interpersonal psychological theory [3] and clinical model [4], have been described as inadequate on their own for explaining the burden of suicide related ideation and behavior among gay and bisexual men [5]. Therefore, theories that expli- citly take into account the unique experiences of sexual minorities are critical to better understanding the pro- cesses that sustain this inequity. Thus far, minority stress model [6], psychological mediation model [7] and eco- logical systems models [8] have emerged in the suicide lit- erature as three theories that potentially address the * Correspondence: oferlatt@sfu.ca 1Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 11300, 8888 University Drive, Burnaby, BC V5A 1S6, Canada 2Community-Based Research Centre for Gay Men’s Health, Vancouver, Canada Full list of author information is available at the end of the article © 2015 Ferlatte et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ferlatte et al. BMC Public Health (2015) 15:597 DOI 10.1186/s12889-015-1961-5 http://crossmark.crossref.org/dialog/?doi=10.1186/s12889-015-1961-5&domain=pdf mailto:oferlatt@sfu.ca http://creativecommons.org/licenses/by/4.0 http://creativecommons.org/publicdomain/zero/1.0/ http://creativecommons.org/publicdomain/zero/1.0/ unique vulnerabilities of sexual minorities to suicide re- lated ideation and behavior, though few of these have been tested with empirical data [5, 9]. Another conceptual framework that may help explain the excess rate of suicide related ideation and behavior among gay and bisexual men may be found in syndemic theory. The term syndemics was coined by medical anthropologist Merrill Singer in the mid-90s to describe how health problems tend to co-occur, overlap and fuel each other to create a mutually reinforcing cluster of epidemics [10, 11]. More so, according to syndemic the- ory, these intersecting epidemics are understood to be the consequences of social inequity and the unjust exer- cise of power [11]. Syndemic theory distinguishes itself from other theories that link marginalization to negative health outcomes by its holistic lens - rather than seeing health outcomes, such as suicide and suicide related ideation and behavior, in isolation from other health problems, syndemic theory illuminates the synergistic interactions of multiple health problems and how these co-occurring epidemics affect communities and there- fore degrade the overall health status of a population. Syndemic theory has gained momentum in the gay and bisexual men’s health literature in recent years. It was first applied to gay and bisexual men by Stall and colleagues in a random sample survey of nearly 3000 gay and bisexual men in four major US cities. That study found that polydrug use, depression, childhood sexual abuse, and intimate partner violence were highly corre- lated among gay and bisexual men [12]. Furthermore, the study showed that accumulations of these health problems were significantly associated with sexual risk and HIV infection. Since then several other public health studies have sup- ported the existence of syndemics among gay and bisexual men. Stall, Friedman and Catania have also proposed a theoretical framework of syndemic production for gay men-informed by minority stress theory that posits that syndemics are socially produce by early adolescence anti- gay violence and stresses associated with migration to large cities to so called “gay ghettos” [13]. Most syndemic studies, including the theoretical framework of Stall and colleagues, have focused on HIV transmission risks, not suicide [14–24]. One notable exception is the work of Mustanski and colleagues who examined suicide among young gay and bisexual men. That study found that the experience of victimization increased syndemic burden. Syndemic conditions appeared to increase the odds of sui- cide attempts [9]. Those findings suggest that syndemic theory may be a potentially useful framework for the study of suicide among sexual minorities. In this paper, the theory of syndemic will be applied to investigate suicide related ideation and behavior in a sam- ple of Canadian gay and bisexual adult men. Drawing on the theoretical and empirical work above, the excess suicide related ideation and behavior was hypothesized to be socially produced through exposure to multiple forms of violence and highly correlated with other mental health and psychosocial problems common in gay and bisexual men’s lives. The ultimate goal is to understand the factors contributing to higher rates of suicide related ideation and behavior in gay and bisexual men, in order to generate strategies for suicide prevention specific to these groups. Methods Sex Now is a serial cross-sectional survey of gay and bisex- ual 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 develop- ment, 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 participa- tion, 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 envir- onment 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 sui- cide 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 Ferlatte et al. BMC Public Health (2015) 15:597 Page 2 of 9 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 mul- tiple 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, syph- ilis, 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 the- ory 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, in- cluding suicide ideation and attempts. These health prob- lems 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 ana- lysis 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 per- centage of respondents who experienced suicide ideation and who attempted suicide in the last 12 months by number of marginalization indicators. These relation- ships 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 mu- tually 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 in- creased risk for suicide ideation and attempts, the percent- age 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 associ- ated 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. Results 8382 Canadian men participated in Sex Now 2011 and all were included in the analysis. The demographic character- istics of the sample are described in Table 1. Among par- ticipants, 49.9 % (n = 4,180) reported lifetime experience of suicide ideation, while 12.5 % (n = 1,050) reported having attempted suicide in their lifetime. When asked Fig. 1 Conceptual Framework of Suicide Risk within Syndemic Production Ferlatte et al. BMC Public Health (2015) 15:597 Page 3 of 9 about these experiences in the last 12 months, 17.0 % (n = 1,427) reported experiencing suicide ideation, while 1.7 % (n = 145) reported a suicide attempt. 63.13 % (n = 901) of those who reported suicide ideation in the last year reported similar experiences over a year ago, while 71.7 % (104) of those who attempted suicide in the last 12 months also reported a previous attempt over a year ago. Table 2 shows the bivariate relationships between anti- gay marginalization indicators and suicide ideation or having attempted suicide in the last 12 months. All indi- cators were positively associated and statistically signifi- cant (p < 0.05) when adjusted for demographics (OR range from 1.30 to 3.94). The effects of all variables diminished in the multi-indicator model (i.e. with adjust- ment for all indicators of marginalization), though most remained statistically significant with odds ratios in the range of 1.30 to 2.81, among those which remained sta- tistically significant. When adjusted for the other forms of marginalization, the associations between sexual vio- lence and suicide ideation and bullying and suicide at- tempts were no longer statistically significant, and the association between verbal violence and suicide attempts was removed. The cumulative effects of marginalization, suicide ideation and having attempted suicide in the prior 12 months are presented in Fig. 2. For each add- itional form of marginalization reported, there was an increased risk of both ideation and attempted suicide (Chi-square test for trend p < .001). People who reported three or more forms of anti-gay marginalization had twice the rate of suicide ideation compared to those with no marginalization (27.3 % vs 12.6 %), and over 4 times the rate of attempted suicide (3.9 % vs 0.9 %). Table 3 shows that all psychosocial health problems were positively associated and statistically significant (p < .005) with the marginalization indicators at the exception of STIs with sexual violence. The correlations between psychosocial health problems are presented in Table 4; all were correlated with the exception of smok- ing and STI (which did not achieve statistical signifi- cance at p < 0.05). 76.6 % (n = 111) of the 145 men who attempted suicide in the last 12 months reported at least one other health problem while 38 % (n = 55) reported 3 or more psychosocial health problems. Similarly, 66.4 % Table 1 Characteristics of study participants (N = 8382) Characteristics No. (%) Sexual orientation Gay 5406 (64.5) Bisexual 2720 (32.5) Straight 175 (2.1) Other 81 (1.0) Relationship status Single 3675 (43.8) Partnered with a man 2215 (26.4) Partnered with a woman 1798 (21.4) Divorced/Separated/Other 694 (8.3) Age Under 30 1866 (22.43) 30–45 years old 2518 (30.0) Over 45 3998 (47.7) Ethnicity Caucasian 7310 (87.2) Asian 212 (2.5) South Asian 74 (0.9) African/Caribbean 76 (0.9) Latino/Hispanic 112 (1.3) Aboriginal (First Nation/Inuit/Metis) 168 (2.0) Middle Eastern 53 (0.6) Mixed 229 (2.7) Other 136 (1.6) Income (annual, CAD) <10,000 739 (8.8) 10,000–29,9999 1653 (19.7) 30,000–49,9999 1847 (22.0) 50,000–69,0000 1698 (20.2) >70,0000 2444 (29.2) Highest level of Education Completed Some high School 348 (4.2) High School 1131 (13.5) Some College or University 2116 (25.2) College 1607 (19.2) University 3180 (37.9) Province/Territories British Columbia 1804 (21.5) Alberta 1064 (12.7) Saskatchewan 289 (3.4) Manitoba 342 (4.1) Ontario 3366 (40.2) Quebec 1048 (12.5) New-Brunswick 105 (1.3) Table 1 Characteristics of study participants (N = 8382) (Continued) Nova Scotia 223 (2.7) Prince Edward Island 33 (0.4) Newfoundland and Labrador 85 (1.0) Yukon 8 (0.1) Norwest Territories 11 (0.1) Nunavut 4 (0.0) Ferlatte et al. BMC Public Health (2015) 15:597 Page 4 of 9 (n = 948) of the men who reported suicide ideation re- ported at least one co-occurring issue in the prior 12 months, while 15.1 % (n = 216) reported three or more. The associations between psychosocial health prob- lems and suicide ideation and attempts are presented in Table 5. While all associations but one were statistically significant in single indicator models, when entered into a multiple indicator model only some associations remained significant. For suicide ideation, depression [AOR 5.37 95 % CI 4.44 -6.49], anxiety [AOR 1.56 (1.27–1.92)], and sexual risk (CAI-US) [AOR 1.36 (95 % CI 1.18–1.57)] remained significant while for attempted suicide only depression [AOR 4.73 (95 % CI 2.84–7.88)] and anxiety [AOR 2.79 (95 % CI 1.67–4.65)] were significant. Models in Table 6 demonstrate the additive relation- ship between psychosocial health problems and suicide related ideation and suicide attempts. Compared to those reporting no problems, those reporting one [AOR 1.69 (95 % CI 1.44–1.97)], two, [AOR 3.36 (1.44–1.97)] and three or more issues [AOR 6.90 (95 % CI 6.90–5.47– 8.70)] were at increased odds of reporting suicide ideation. Similarly, those experiencing one [AOR 1.25 (0.70–2.23)], two [AOR 3.67 (95 % CI 2.15–6.28)] and three or more issues [AOR 16.29 (95 % CI 9.82–27.02)] were at increased odds of attempted suicide. The same trends were found, though the magnitude of ORs decreased and their confi- dence intervals overlapped, when we removed the two psychosocial health problems (depression and anxiety) which had the strongest individual effect on attempted Table 2 Correlation between anti-gay marginalization and suicide related ideation and attempts (N = 8382) % reporting suicide ideation or attempts No. (%) reporting marginalization indicator Among those with indicator Among those without indicator Single indicator models AOR (95 % CI)a Multi-indicator model AOR (95 % CI)b Suicide ideation in the last 12 months Verbal Violence 3920 (46.8 %) 21.6 % 13.0 % 1.77 (1.55–2.01) 1.30 (1.11–1.51) Physical Violence 1044 (12.5 %) 27.0 % 15.6 % 1.90 (1.62–2.21) 1.36 (1.14–1.61) Bullying 3495 (41.7 %) 22.1 % 13.4 % 1.73 (1.53–2.00) 1.30 (1.12–1.50) Sexual Violence 985 (11.8 %) 20.1 % 16.6 % 1.30 (1.10–155) 1.13 (0.95–1.35) Work Discrimination 1353 (16.1 %) 25.3 % 15.4 % 1.91 (1.65–2.20) 1.47 (1.26–1.71) Attempted suicide in the last 12 months Verbal Violence 3920 (46.8 %) 2.3 % 1.2 % 1.95 (1.35–2.83) 0.95 (0.60–1.53) Physical Violence 1044 (12.5 %) 5.3 % 1.3 % 3.94 (2.76–5.61) 2.81 (1.84–4.31) Bullying 3495 (41.7 %) 2.5 % 1.2 % 2.06 (1.44–3.00) 1.24 (0.80–1.92) Sexual Violence 985 (11.8 %) 4.1 % 1.4 % 2.92 (2.01–4.26) 2.20 (1.48–3.25) Work Discrimination 1353 (16.1 %) 3.5 % 1.4 % 2.71 (1.88–3.90) 1.63 (1.08–2.45) aAdjusted for age, ethnicity, income, education, sexual orientation, living environment and province of residences bAdjusted for the demographic variable above and all other marginalization indicators Fig. 2 Prevalence of suicide related ideation or attempts by number of anti-gay marginalization indicators Ferlatte et al. BMC Public Health (2015) 15:597 Page 5 of 9 suicide (data not shown). The AOR for continuous count of psychosocial health problems was 1.88 (95 % CI 1.76–2.00) for suicide ideation and 2.63 (95 % 2.20–3.14) for attempted suicide. Discussion Our results add further evidence to the existing literature that shows that gay and bisexual are at increased risk of suicide related ideation and behavior as compared with heterosexual men. Lifetime experience of suicide related ideation and behavior was reported by 49.9 % of our sam- ple; this is over 6 times what has been reported among Canadian heterosexual men (7.4 %) [26]. More so, findings of this investigation strongly suggest that experiences of anti-gay violence and marginalization increase suicide ideation and suicide attempts among Canadian gay and bisexual men. Moreover, health problems in our sample were associated with each other and with suicide behavior. This study therefore adds to the growing body of literature showing that health disparities occur in clusters among gay and bisexual men. These results, like those of Mustanski [9], support the notion that syndemic theory has the potential to advance research, theory, and inter- ventions related to suicide in this population. There are some limitations that need consideration when interpreting these results. First of all, since the study relies on an Internet convenience sample it is difficult to know how representative it is of the Canadian gay and bisexual men’s population. Moreover, because the survey was cross- sectional and reliant on self-reported retrospective data, conclusions cannot be drawn about the causality of out- comes, including the relation between marginalization and negative health outcomes. Because these outcomes (both psycho-social mediators and suicide-related out- comes) were measured as currently prevalent (within last 12-months), we may have underestimated the true burden of these issues resulting from early-life marginalization experiences (e.g., if some respondents experienced depres- sion or suicide ideation/attempts after encountering anti- gay bullying/harassment during adolescence but then adapted and recovered from these mental health condi- tions). This misclassification of psychosocial and suicide- related outcomes would result in under-estimation of the associations we present. More so, we modeled our analysis according to Stall’s theory of syndemic production [13] but were unable to account for all the factors that may produce or mitigate negative health outcomes such as internalized stigma and protective factors such a social support. We also combined gay and bisexual men in our analysis; how- ever, experiences of oppressions and syndemics may differ between these groups and should be investigated in future studies. Finally, the cross-sectional survey involved people Table 3 Correlation between marginalization and psychosocial and health issues Unadjusted Odds Ratio (95 % Confidence Interval) N (%) Verbal Violence Physical Violence Bullying Sexual Violence Work Discrimination Smoking 2061 (24.6) 1.20 (1.09–1.33) 1.52 (1.32–1.75) 1.19 (1.08–1.31) 1.68 (1.46–1.94) 1.24 (1.09–1.41) Party Drugs 1279 (15.3) 2.24 (1.98–2.54) 2.28 (1.96–2.66) 2.00 (1.77–2.56) 1.61 (1.37–1.91) 1.50 (1.29–1.74) Depression 945 (11.3) 1.88 (1.65–2.14) 1.97 (1.67–2.32) 1.83 (1.61–2.09) 1.41 (1.18–1.69) 1.90 (1.63–2.21) Anxiety 1081 (12.9) 2.05 (1.78–2.36) 2.26 (1.91–2.68) 2.09 (1.82–2.40) 1.48 (1.22–1.79) 2.13 (1.82–2.50) STIs 661 (7.9) 1.41 (1.20–1.65) 1.80 (1.47–2.21) 1.40 (1.20–1.65) 1.17 (0.92–1.48) 1.59 (1.31–1.93) CAI–US 2515 (30.0) 1.47 (1.34–1.62) 1.65 (1.44–1.88) 1.43 (1.31–1.58) 1.57 (1.37–1.80) 1.59 (1.41–1.80) HIV Positive 667 (8.0) 2.56 (2.16–3.02) 2.58 (2.14–3.12) 2.04 (1.73–2.39) 1.94 (1.58–2.38) 2.71 (2.27–3.22) Table 4 Correlation between psychosocial and health issues Unadjusted Odds Ratio (95 % Confidence Interval) N (%) Party Drugs Depression Anxiety STIs CAI-US HIV Positive Smoking 2061 (24.6) 2.47 (2.18–2.80) 1.39 (1.21–1.60) 1.51 (1.30–1.75) 1.08 (0.90–1.29) 1.14 (1.03–1.27) 1.26 (1.06–1.51) Party Drugs 1279 (15.3) 1.38 (1.17–1.62) 1.58 (1.33–1.87) 2.87 (2.41–3.43) 2.75 (2.43–3.11) 3.45 (2.91–4.10) Depression 945 (11.3) 29.28 (24.84–54 .50) 1.76 (1.44–2.16) 1.35 (1.18–1.54) 2.49 (2.06–3.00) Anxiety 1081 (12.9) 1.88 (1.52–2.31) 1.18 (1.02–1.36) 1.92 (1.56–236) STIs 661 (7.9) 2.58 (2.20–3.03) 3.96 (3.23–4.86) CAI-US 2515 (30.0) 3.48 (2.96–4.09) HIV Positive 667 (8.0) Ferlatte et al. BMC Public Health (2015) 15:597 Page 6 of 9 who had attempted suicide and survived. They may have somewhat different characteristics than those whose sui- cide attempt was fatal. This paper adds to the plea of other syndemic re- searchers, as well as that of community activists, to address gay and bisexual men’s health holistically and to create bet- ter living conditions for sexual minorities. Since many of the health disparities experienced by gay and bisexual men (such as HIV, depression, anxiety, polydrug use, suicide) happen synergistically, it is unlikely that any of these conditions would improve without attending to the others. This is concerning in the current context where HIV and STIs are generally the health issues of gay and bisexual men that receive the most public health atten- tion, while other issues, particularly those related to mental wellbeing, are largely ignored. Suicide preven- tion is notably absent from gay and bisexual public health and community programming. In exploring the particular psychosocial health problems that constitute this syndemic, we found that each was as- sociated with suicide related ideation and behavior, but the largest effect was found in evaluating the cumulative number of problems—as predicted by syndemic theory. It is striking that men who experienced three or more psy- chosocial health problems had approximately seven times the odds of suicide ideation and sixteen times the odds of attempted suicide, compared to those with no problems. When all health problems were included in a single model (multi-indicator), the association with suicide ideation and attempts was removed for most but remained strongest for depression. This should not be surprising, considering that mood disorders are known to convey the highest risk for suicide related ideation and behavior in general popu- lations [27]. This study helps identify some of the potential root causes of suicide related ideation and behavior among gay and bisexual men. The five marginalization indicators Table 5 Association between psychosocial and health issues and suicide related ideation and attempts % with psychosocial or health issue No. (%) reporting health Issues Among those reporting suicide behavior Among those not reporting suicide behavior Single indicator models AOR (95 % CI)a Multi-indicator model AOR (95 % CI)b Suicide ideation in the last 12 months Smoking 2061 (24.6 %) 28.5 % 23.8 % 1.20 (1.04–1.38) 1.06 (0.91–1.24) Party Drugs 1279 (15.3 %) 20.7 % 14.1 % 1.38 (1.17–1.62) 1.19 (0.99–1.43) Depression 1081 (12.9 %) 36.6 % 8.0 % 6.87 (5.88–8.02) 5.37 (4.44–6.49) Anxiety 945 (11.3 %) 27.8 % 7.9 % 4.22 (3.39–4.96) 1.56 (1.27–1.92) STIs 661 (7.9 %) 10.6 % 7.3 % 1.42 (1.15–1.75) 1.11 (0.88–1.40) CAI-US 2515 (30 %) 37.6 % 28.4 % 1.45 (1.27–1.65) 1.36 (1.18–1.57) HIV Positive 667 (8.0 %) 7.5 % 10.2 % 1.37 (1.10–1.70) 0.94 (0.74–1.20) Attempted Suicide in the last 12 months Smoking 2061 (24.6 %) 37.2 % 24.4 % 1.62 (1.10–2.38) 1.27 (0.84–1.92) Party Drugs 1279 (15.3 %) 29 % 15 % 1.95 (1.29–2.94) 1.51 (0.94–2.41) Depression 1081 (12.9 %) 55.9 % 12.1 % 9.13 (6.22–13.39) 4.73 (2.84–7.88) Anxiety 945 (11.3 %) 49.7 % 10.6 % 8.05 (5.50–11.79) 2.79 (1.67–4.65) STIs 661 (7.9 %) 16.6 % 7.7 % 2.21 (1.34–3.65) 1.68 (0.96–2.92) CA-US 2515 (30 %) 40.0 % 29.8 % 1.51 (1.04–2.19) 1.27 (0.85–1.91) HIV Positive 667 (8.0 %) 7.9 % 9.7 % 0.97 (0.51–1.87) 0.57 (0.28–1.16) aAdjusted for age, ethnicity, income, education, sexual orientation, partnership status, living environment and province of residence bAdjusted for the demographic variable above and all other health issues Table 6 Association between the cumulative number of psychosocial issues and suicide related ideation and behavior Number Percent AOR (95 % CI)a Suicide ideation in the last 12 monthsb No issue 4465 53.3 Reference One 2372 28.3 1.69 (1.44–1.97) Two 1098 13.1 3.36 (2.82–4.01) Three or More 447 5.3 6.90 (5.47–8.70) Attempted suicide in the last 12 monthsb No issue 4465 53.3 Reference One 2372 28.3 1.25 (0.70–2.23) Two 1098 13.1 3.67 (2.15–6.28) Three or More 447 5.3 16.29 (9.82–27.02) a Model adjusted for age, ethnicity, income, education, sexual orientation, partnership status, living environment and province of residence b Cumulative effect of depression, anxiety, smoking, party drugs, and STIs Ferlatte et al. BMC Public Health (2015) 15:597 Page 7 of 9 investigated were positively associated with suicide idea- tion and behavior in our sample, and the majority of gay and bisexual men (56.1 %) experienced at least one form of marginalization or anti-gay violence in their lifetime. A previous edition of the Sex Now survey (2010) showed that prevalence of physical violence, sexual assault and workplace discrimination was similar across all age co- horts, but the younger cohort experienced higher levels of sexist harassment than any previous generation [24]. Some of the marginalization indicators this study exam- ined (i.e., physical violence, harassment) were also found associated with suicide related ideation and behavior in previous studies [9]. Workplace discrimination was, how- ever, a novel contribution of this study. Together these findings suggest that, despite the re- cent legal gains such as the availability of gay marriage, adoption and protection from discrimination under the constitution, a substantial number of gay and bisexual men still face homophobia. This is consistent with other data sources such as Statistics Canada research which shows that while hate crimes appear to be on the decline in Canada in general, it is not the case for hate crimes committed against sexual minorities [28]. In addition, hate crimes committed against sexual minorities are more likely to be violent and to result in injuries. Another study of Canadian youth found that 20.4 % s of sexual minority men were verbally harassed weekly because of their sexuality, while 17 % reported being physical assaulted at school [29]. These trends are concerning as those who experienced physical violence had nearly 3 times the odds of attempted suicide in the survey. Efforts to prevent physical assault against gay and bisex- ual men, as well as other forms of violence and discrimin- ation, are therefore urgently needed to ameliorate the social and health condition of this population, including re- ducing the incidence of suicide attempts. However, policies and interventions can be made to increase the safety of sexual minorities. For example a school-based survey in the Canadian province of British Columbia demonstrated that gay and bisexual students attending schools with anti- homophobia policies and gay-straight alliances (GSAs) had lower odds of discrimination, as well as lower odds of sui- cide ideation and attempts [30]. Conclusions This study’s findings suggest that syndemics, that in- clude suicide related ideation and attempts, are occur- ring among Canadian gay and bisexual men. This study also showed that psychosocial health problems have an additive effect on suicide, increasing the odds of suicide ideation and suicide attempts. Those who reported 3 or more psychosocial health problems had 6.9 times the odds of suicide ideation and 16.29 times the odds of a suicide attempt compared to those with no problems and these effects are driven in particular by experiences of depression and anxiety. These results highlight the import- ance of addressing gay and bisexual men’s health problems in a holistic manner rather than addressing each in isola- tion. Since all marginalization indicators increased the odds of suicide ideation and attempts, interventions to reduce social exclusion and violence are urgently needed. These results concur with those of Mustanksi and col- leagues which demonstrated that syndemic is a useful the- ory to advance understanding of suicide among gay and bisexual men. While both studies illuminate some of the pathways and social factors that produce suicide related ideation and behavior in this population, such influences have generally been inadequately attended to in research and remain poorly understood. Therefore suicide re- searchers ought to pay more attention to the pathways of suicide ideation and behavior, as they may be critical to the development of effective prevention interventions. Since the majority of gay and bisexual men experienced violence in our survey but only a small minority reported syndemics, suicide ideation and suicide attempts, an array of protective factors may exist. Identifying those would also be key to prevention and health promotion efforts. Furthermore, as the population of gay and bisexual men is diverse along axes of class, geography, education attain- ment, and ethnicity, researchers should also look at how suicide is experienced and distributed among differently positioned gay and bisexual men. Competing interests The authors declare they have no competing interests. Authors’ contributions OF and JD conceived the research question, performed the analysis and co-authored the first draft of the manuscript. TSH provided support for the statistical analysis and helped developed the manuscript. TT and RM designed and coordinated the Sex Now survey and revised the manuscript. All authors read and approved the final manuscript. Authors’ information OF is a PhD candidate in the Faculty of Health Sciences at Simon Fraser University and Research Education Director at the Community-Based Research Centre for Gay Men’s Health (CBRC). JD is a research assistant at the CBRC. TSH is a doctoral student at the Dalla Lana School of Public Health at the University of Toronto and a board member of the CBRC. TT is research director at CBRC. RM is managing director at CBRC. All the authors are members of the gay community. Acknowledgements The authors thanked the young Investgaytors who helped with the recruitment for this study: Keith Reynolds, Darren Ho, Alex Chen and Daniel Wexel. This study was made possible through a grant from the Vancouver Foundation. Author details 1Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 11300, 8888 University Drive, Burnaby, BC V5A 1S6, Canada. 2Community-Based Research Centre for Gay Men’s Health, Vancouver, Canada. 3Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Received: 17 March 2015 Accepted: 22 June 2015 Ferlatte et al. BMC Public Health (2015) 15:597 Page 8 of 9 References 1. King M, Semlyen J, Tai S, Killaspy H, Osborn D, Popelyuk D, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8(1):70. 2. Haas AP, Eliason M, Mays VM, Mathy RM, Cochran SD, D’Augelli AR, et al. 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Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Ferlatte et al. BMC Public Health (2015) 15:597 Page 9 of 9 http://www.statcan.gc.ca/pub/85-002-x/2013001/article/11822-eng.htm http://egale.ca/wpcontent/uploads/Egale%20Publications/Every%20Class%20In%20Every%20School.pdf http://egale.ca/wpcontent/uploads/Egale%20Publications/Every%20Class%20In%20Every%20School.pdf http://egale.ca/wpcontent/uploads/Egale%20Publications/Every%20Class%20In%20Every%20School.pdf Abstract Background Methods Results Conclusions Background Methods Measures Demographic factors Suicide related ideation and behavior Marginalization indicators Psychosocial health problems Analytic plan Results Discussion Conclusions Competing interests Authors’ contributions Authors’ information Acknowledgements Author details References