Structural stigma and sexual minority men's depression and suicidality: A multi-level examination of mechanisms and mobility across 48 countries

Background Sexual minority men are at greater risk of depression and suicidality than heterosexuals. Stigma, the most frequently hypothesized risk factor for this disparity, operates across socioecological levels-structural (e.g., laws), interpersonal (e.g., discrimination), and individual (e.g., self-stigma). However, there is limited data on whether changes in structural stigma, such as when a stigmatized person moves to a lower stigma context, affect mental health, and on the mechanisms underlying this association Methods The current study uses data from the 2017/18 European Men-who-have-sex-with-men Internet Survey (n = 123,428), which assessed mental health and psychosocial mediators. We linked these data to an objective indicator of structural stigma related to sexual orientation in respondents' countries of origin (N = 178) and receiving (N = 48) countries Results Among respondents who moved from higher-to-lower structural stigma countries (n = 11,831), longer exposure to the lower structural stigma environments of their receiving countries was associated with a significantly: 1) lower risk of depression and suicidality; 2) lower odds of concealment, internalized homonegativity, and social isolation; and 3) smaller indirect effect of structural stigma on mental health through these mediators. Conclusions This study provides evidence that structural stigma is associated with the mental health of sexual minority men, both through proximal experiences and as a function of length of exposure to structurally diverse contexts, at least for those who move higher-to-lower structural stigma contexts. Findings suggest the importance of routinely assessing life-course structural influences on mental health and deploying interventions to address those influences.