Health and Lifestyle, Safety, Relationship and Personality Factors Influence Gender, Sex and Sexuality Issues among Youth—A Case Record Analysis from Youth Mental Health Promotion Clinics in Karnataka, India

Abstract

Promoting positive identity and seeking early support for gender, sex and sexuality (GSS) issues among youth is vital. Understanding and addressing factors associated withGSS among them is critical. We assessed four-year case records (January 2017–December 2020) of all first visit youth mental health promotion clinic (YMHPC) clients (15–35 years) for factors associated with GSS issues in Karnataka. Overall, prevalence of GSS issues was 1.8% (189/10,340). Increased risk of GSS issues was observed among clients reporting suicidality (AOR = 4.27, 95% CI = 2.70–6.74) and relationship issues (AOR = 3.63, 95% CI = 2.36–5.57), followed by issues of safety (AOR = 2.56, 95% CI = 1.72–3.81), personality (AOR = 2.48, 95% CI = 1.60–3.85), health and lifestyle (AOR = 2.27, 95% CI = 1.77–4.19), smokers (AOR = 2.30, 95% CI = 1.24–4.27), and those who felt depressed (AOR = 2.10, 95% CI = 1.43–3.09) and worthless (AOR = 2.08, 95% CI = 1.28–3.39). Clients aged 21–25 years (AOR = 1.80,95% CI = 1.27–2.54), male (AOR = 1.72, 95% CI = 1.20–2.46) and who had been married (AOR = 2.32, 95% CI = 1.51–3.57) had a higher risk of GSS issues than those aged 15–20 years and other counterparts, respectively. Clients who drank alcohol (AOR = 0.49, 95% CI = 0.30–0.81) had reduced risk of GSS issues. The findings re-iterate the importance of early recognition of factors (essential precursors) of GSS issues among youth. The study highlights the importance of promoting awareness and improving primordial prevention of possible GSS issues in later life. This study has important implications on youth mental health promotion programs, especially in countries like India.

1. Introduction

Nearly 16% of the world’s total population (~1.2 billion) is youth (15–24 years) [1]. India has the largest youth population in the world [2] with nearly 40% aged between 13 and 35 years [3]. Youth in Karnataka (a South Indian state) constitute nearly 39% of the population [2]. This period is characterized by rapid physical, psychological and social development and maturation [4] that affect the gender, sex and sexuality(GSS) of an individual. Physical changes like the onset of menstruation and development of secondary sexual characteristics and psychological changes like body image perception andself-understanding of sexual identity and role occur along with changes in social behaviours, like being independent; exploratory behaviours (smoking, violence, sexual perversions), development of social and financial autonomy; intimate relationships, etc. [5].

During this phase of transition, youth become more aware of GSS issues. Gender, sex and sexuality encompass a wide range of topics like gender roles, perspectives, discrimination, gender-based violence, child sexual abuse, sexually transmitted diseases/infections, etc. These issues need to be addressed during adolescence and youth to ensure healthy adulthood. Issues related to these are not well understood. Norms and expectations related to gender, sex and sexuality often differ between sexes and are set by societies; deviations are often sanctioned [6]. Most societies and communities are conservative in discussing GSS openly. Mainstreaming of GSS is mainly attempted through sex education aspart of the academic curriculum. However, in conservative societies like in India, most teachers are not comfortable doing this [7]. Furthermore, associated societal norms, taboos, myths and misconceptions add to the problem. This leads youth to explore social media and internet for GSS related information and confront established social structures, taboos and norms within their societies.

Gender, sex and sexuality (GSS) are crucial determinants and antecedents of mental health [8], especially among youth during their formative years. GSS issues are known to be associated with a variety of harmful mental health consequences, including depression and attempted suicide affecting education and careers [9]. Existing cultural norms and social discrimination may discourage young people from discussing their GSS issues with others. The disclosure of a stigmatized identity might also lead to rejection and thereby impact the mental health of an individual [10].

Promoting and integrating positive identity and seeking early support related to GSS issues among youth arevital. In this context, it is critical to understand factors associated with GSS and address them during adolescence and youth. Considering the challenges faced by youth, Yuva Spandana (meaning responding to youth), a youth mental health promotion program is being implemented by the Department of Youth Empowerment and Sports (DYES), Government of Karnataka (GoK), with technical support from the Department of Epidemiology, NIMHANS. Trained Yuva Samalochakas and Yuva Parivarthakas (Youth Change Agents) provide guidance and counselling services through youth mental health promotion clinics named Yuva Spandana Kendras (meaning youth response centres) established at every district stadium in Karnataka [11]. Youth with any issue (including issues related to GSS) visit these clinics and avail themselves of guidance/counselling and referral services. The present study aims to assess factors associated with gender, sex and sexuality issues amongst youth attending youth mental health promotion clinics in Karnataka.

2. Materials and Methods

Case record analysis from a tailor-made real-time computerized data management system specifically developed for Yuva Spandana was performed. All registration and first visit case records of beneficiaries aged between 15–35 years utilizing services through Yuva Spandana Kendras between 1 January 2017 and 31 December 2020 in Karnataka were considered for the analysis.

Registration details included socio-demographic details (district, locality, age and gender, level of education, marital status) and habits of beneficiaries. The visit details included issues reported by beneficiaries namely, health and life style issues, education and career, relationship issues, safety, personality and gender, sex and sexuality issues. Gender, sex and sexuality issues included issues related to gender roles, gender discrimination, gender-based violence, child sexual abuse andsexually transmitted diseases/infections. The visit form was filled out based on face-to-face clinical interview conducted in the clinic and included questions like “Haveyou face any issues related to gender role, gender discrimination, gender-based violence and sexually transmitted diseases?”. Since the Yuva Spandana program focuses on providing mental health services, the questions were customized based on the client’s needs, which facilitated counselling sessions. Specifically, gender roles were defined based on the WHO definition [12]. Gender discrimination was identified based on the client’s response to the question of whether he/she felt discriminated against based on their gender, either at workplace, socially orwithin the family. Gender-based violence constituted any form of violence (physical, psychological or sexual) like being punched, hit, kicked, insulted, ignored, yelled at, made tofeel ashamed or forced/coerced to perform sex or touched inappropriately by anyone [13,14] during the past year and was based on self-reporting. Sexually transmitted diseases (including HIV) were reported based on the self-reporting of symptoms, mainly genital ulcers, discharge, swelling, a previous diagnosis of STIs or history of syndromic case management. It also included those who reported issues related to myths and misconceptions related to STIs and HIV [15]. In addition, the visit form had a set of 18 closed-ended yes/no questions related to the beneficiary’s experience of different emotions or feelings like feeling depressed, anxious, lonely, tired, or helpless, excessively worried, a loss of interest in work, unableto make decisions and forgetfulness, as well as concentration-related problems, suicidal ideation and guilt. This was accompanied by information on the client’sawareness of parents/friends attempting suicide.

Statistical Analysis

A total of 10,664 beneficiaries were registered during the study period. Out of this, 10,340 beneficiaries who were aged 15–35 years with both registration and first-visit forms available were included for analysis. Various factors associated with gender, sex and sexuality issues amongst youth attending Yuva Spandana Kendra in Karnataka were hypothesized. Various issues were reported, and experience of different emotions along with socio-demographic characteristics and habits (as listed in Table 1, Table 2 and Table 3) were considered exposure variables.

Binary and multiple logistic regression analyses were performed with self-report of having gender, sex and sexuality issues as the dependent variable. All exposure variables that were significantly associated with GSS issuesat a 10% level (p < 0.10) in the binary analysis were considered eligible to be included in the final multiple logistic regression model. These variables were included in the multivariable model one after the other using a forward stepping process. Those variables which changed the measure of effect (odds ratio) of at least one preceding variable by 10% and significant at 5% (p < 0.05) wereretained in the model. In addition, the significance of including a variable in the model was tested using a likelihood ratio test, comparing the previous model without the variable. The goodness of fit for the final multivariate model was assessed using the Hosmer–Lemeshow test, and a ROC curve was drawn to check the discrimination ability of the final multivariate logistic regression model. All the descriptive analysis was performed using Microsoft Excel 2007. Logistic regression analysis was performed using Stata 12.0 software for windows.

Appropriate Ethical approval for the study was obtained from the Institutional Ethics Committee at NIHMANS, Bangalore vide letter No. NIMH/DO/ETHICS COMMITTEE MEETING/2018, Dated 10 January 2019.

3. Results

Overall, 189 (1.8%) beneficiaries reported having gender, sex and sexuality issues. Most of them were males (67.72%), aged 15–20 years (43.9%) and from rural areas (71.4%). A majority of the clients reporting gender, sex and sexuality issues had more than 10 years of schooling (72%) and hadnever been married (72.48%). All the socio-demographic characteristics except locality were significantly associated with GSS issues (Table 1).

Table 1. Socio-demographic characteristics and gender, sex and sexuality issues among beneficiaries attending youth mental health promotion clinics in Karnataka. (2017–2020) (N = 10,340).

Variables	Gender, Sex & Sexuality Issues				Total		Crude Odds Ratio
	Present (189)		Absent (10,151)		N = 10,340		OR [95% CI]	p-Value
Age in Completed Years	n	%	n	%	N	%
15–20	83	43.9	6244	61.5	6327	61.2	Reference
21–25	54	28.6	2252	22.2	2306	22.3	1.80 [1.27–2.54]	<0.001
26–30	35	18.5	1088	10.7	1123	10.9	2.42 [1.62–3.61]	<0.001
31–35	17	9.0	567	5.6	584	5.6	2.25 [1.32–3.82]	0.003
Gender
Female	61	32.3	4518	44.5	4579	44.3	Reference
Male	128	67.7	5633	55.5	5761	55.7	1.68 [1.23–2.28]	<0.001
Locality
Urban	54	28.6	3308	32.6	3362	32.5	Reference
Rural	135	71.4	6843	67.4	6978	67.5	1.20 [0.87–1.66]	0.243
Years of schooling
<7 years	22	11.6	747	7.4	769	7.4	Reference
8–10 years	31	16.4	1669	16.4	1700	16.4	0.63 [0.36–1.09]	0.102
>10 years	136	72.0	7735	76.2	7871	76.1	0.59 [0.37–0.94]	0.027
Occupation
Students	109	57.7	7237	71.3	7346	71.0	Reference
O Others	80	42.3	2914	28.7	2994	29.0	1.82 [1.36–2.44]	<0.001
Marital Status
Never married	137	72.5	9194	90.6	9331	90.2	Reference
Ever married	52	27.5	957	9.4	1009	9.8	3.64 [2.63–5.05]	<0.001
Total	189	1.8	10,151	98.2	10,340	100

OR—Odds Ratio; CI—Confidence Interval.

Table 1. Socio-demographic characteristics and gender, sex and sexuality issues among beneficiaries attending youth mental health promotion clinics in Karnataka. (2017–2020) (N = 10,340).

Variables	Gender, Sex & Sexuality Issues				Total		Crude Odds Ratio
	Present (189)		Absent (10,151)		N = 10,340		OR [95% CI]	p-Value
Age in Completed Years	n	%	n	%	N	%
15–20	83	43.9	6244	61.5	6327	61.2	Reference
21–25	54	28.6	2252	22.2	2306	22.3	1.80 [1.27–2.54]	<0.001
26–30	35	18.5	1088	10.7	1123	10.9	2.42 [1.62–3.61]	<0.001
31–35	17	9.0	567	5.6	584	5.6	2.25 [1.32–3.82]	0.003
Gender
Female	61	32.3	4518	44.5	4579	44.3	Reference
Male	128	67.7	5633	55.5	5761	55.7	1.68 [1.23–2.28]	<0.001
Locality
Urban	54	28.6	3308	32.6	3362	32.5	Reference
Rural	135	71.4	6843	67.4	6978	67.5	1.20 [0.87–1.66]	0.243
Years of schooling
<7 years	22	11.6	747	7.4	769	7.4	Reference
8–10 years	31	16.4	1669	16.4	1700	16.4	0.63 [0.36–1.09]	0.102
>10 years	136	72.0	7735	76.2	7871	76.1	0.59 [0.37–0.94]	0.027
Occupation
Students	109	57.7	7237	71.3	7346	71.0	Reference
O Others	80	42.3	2914	28.7	2994	29.0	1.82 [1.36–2.44]	<0.001
Marital Status
Never married	137	72.5	9194	90.6	9331	90.2	Reference
Ever married	52	27.5	957	9.4	1009	9.8	3.64 [2.63–5.05]	<0.001
Total	189	1.8	10,151	98.2	10,340	100

OR—Odds Ratio; CI—Confidence Interval.

A majority reported health and lifestyle (79.4%) and personality issues (79.4%). All the other issues, except education and academic issues, were significant during binary logistic regression analysis. Those who had ever attempted or had thoughts of suicide and those with substance use were significantly associated with gender, sex and sexuality issues (Table 2).

Table 2. Issues reported, suicidal attempts, substance use and gender, sex and sexuality issues among beneficiaries attending youth mental health promotion clinics during 2017–2020 in Karnataka (N = 10,340).

Variables	Gender Sex & Sexuality Issues				Total		Odds Ratio
	Yes (189)		No (10,151)		N = 10,340		OR [95% CI] *	p-Value
	n	%	N	%	n	%
Issues Reported
Health and lifestyle issues	150	79.4	2465	24.3	2615	25.3	11.99 [8.40–17.10]	<0.001
Personality issues	150	79.4	2507	24.7	2657	25.7	18.05 [13.07–24.93]	<0.001
Education and academic issues	153	81.0	8048	79.3	8201	79.3	11.72 [8.22–16.72]	0.575
Safety issues	108	57.1	765	7.5	873	8.4	1.11 [0.77–1.60]	<0.001
Relationship issues	136	72.0	1263	12.4	1399	13.5	16.35 [12.15–22.02]	<0.001
Suicidal Attempts Among
Family members	33	17.5	427	4.2	460	4.4	4.81 [3.26–7.09]	<0.001
Friends	32	16.9	465	4.6	497	4.8	4.24 [2.87–6.27]	<0.001
Self	45	23.8	172	1.7	217	2.1	18.13 [12.55–26.17]	<0.001
Substance Use
Tobacco chewing	13	6.9	298	2.9	311	3.0	2.44 [1.37–4.34]	0.002
Tobacco smoking	17	9.0	205	2.0	222	2.1	4.79 [2.85–8.04]	<0.001
Drinking	28	14.8	387	3.8	415	4.0	4.38 [2.90–6.63]	<0.001

* OR—Odds Ratio; CI—Confidence Interval.

Table 2. Issues reported, suicidal attempts, substance use and gender, sex and sexuality issues among beneficiaries attending youth mental health promotion clinics during 2017–2020 in Karnataka (N = 10,340).

Variables	Gender Sex & Sexuality Issues				Total		Odds Ratio
	Yes (189)		No (10,151)		N = 10,340		OR [95% CI] *	p-Value
	n	%	N	%	n	%
Issues Reported
Health and lifestyle issues	150	79.4	2465	24.3	2615	25.3	11.99 [8.40–17.10]	<0.001
Personality issues	150	79.4	2507	24.7	2657	25.7	18.05 [13.07–24.93]	<0.001
Education and academic issues	153	81.0	8048	79.3	8201	79.3	11.72 [8.22–16.72]	0.575
Safety issues	108	57.1	765	7.5	873	8.4	1.11 [0.77–1.60]	<0.001
Relationship issues	136	72.0	1263	12.4	1399	13.5	16.35 [12.15–22.02]	<0.001
Suicidal Attempts Among
Family members	33	17.5	427	4.2	460	4.4	4.81 [3.26–7.09]	<0.001
Friends	32	16.9	465	4.6	497	4.8	4.24 [2.87–6.27]	<0.001
Self	45	23.8	172	1.7	217	2.1	18.13 [12.55–26.17]	<0.001
Substance Use
Tobacco chewing	13	6.9	298	2.9	311	3.0	2.44 [1.37–4.34]	0.002
Tobacco smoking	17	9.0	205	2.0	222	2.1	4.79 [2.85–8.04]	<0.001
Drinking	28	14.8	387	3.8	415	4.0	4.38 [2.90–6.63]	<0.001

* OR—Odds Ratio; CI—Confidence Interval.

Table 3. Distribution of emotions experienced and gender, sex and sexuality issues among beneficiaries attending youth mental health promotion clinics during 2017–2020 in Karnataka. (N = 10,340).

Variables	Gender Sex & Sexuality Issues				Total		Odds Ratio
	Yes (189)		No (10,151)		N = 10,340		OR [95% CI] *	p-Value
	N	%	N	%	n	%
Feel anxious	109	57.7	2120	20.9	2229	21.6	5.16 [3.82–6.91]	<0.001
Feel depressed	68	36.0	699	6.9	767	7.4	7.59 [5.59–10.32]	<0.001
Not interested indoing any work	61	32.3	765	7.5	826	8.0	5.84 [4.27–8.00]	<0.001
Feel tired or helpless	64	33.9	835	8.2	899	8.7	5.71 [4.19–7.78]	<0.001
Worry about problems	54	28.6	762	7.5	816	7.9	4.92 [3.56–6.81]	<0.001
Feel like lost everything in life due to their problems	36	19.0	400	3.9	436	4.2	5.73 [3.93–8.35]	<0.001
Feel incapable of making decisions or solving problems	61	32.3	845	8.3	906	8.8	5.24 [3.83–7.17]	<0.001
Feel lonely	51	27.0	574	5.7	625	6.0	6.16 [4.42–8.59]	<0.001
Unable to trust anyone	32	16.9	260	2.6	292	2.8	7.75 [5.19–11.56]	<0.001
Forgetfulness	23	12.2	313	3.1	336	3.2	4.35 [2.77–6.83]	<0.001
Difficulty in concentration	32	16.9	318	3.1	350	3.4	6.30 [4.24–9.36]	<0.001
Feel like running away from everyone	23	12.2	159	1.6	182	1.8	8.70 [5.47–13.83]	<0.001
Feel like committing suicide	24	12.7	99	1.0	123	1.2	14.76 [9.21–23.67]	<0.001
Feel like it would have been good to have died	26	13.8	94	0.9	120	1.2	17.06 [10.76–27.06]	<0.001
Angry with people around	28	14.8	376	3.7	404	3.9	4.52 [2.98–6.84]	<0.001
Feel like failed in managing responsibilities	27	14.3	275	2.7	302	2.9	5.98 [3.91–9.15]	<0.001
Feel guilty	30	15.9	451	4.4	481	4.7	4.05 [2.71–6.06]	<0.001
Feel worthless	34	18.0	349	3.4	383	3.7	6.16 [4.18–9.06]	<0.001

* OR—Odds Ratio; CI—Confidence Interval.

Table 3. Distribution of emotions experienced and gender, sex and sexuality issues among beneficiaries attending youth mental health promotion clinics during 2017–2020 in Karnataka. (N = 10,340).

Variables	Gender Sex & Sexuality Issues				Total		Odds Ratio
	Yes (189)		No (10,151)		N = 10,340		OR [95% CI] *	p-Value
	N	%	N	%	n	%
Feel anxious	109	57.7	2120	20.9	2229	21.6	5.16 [3.82–6.91]	<0.001
Feel depressed	68	36.0	699	6.9	767	7.4	7.59 [5.59–10.32]	<0.001
Not interested indoing any work	61	32.3	765	7.5	826	8.0	5.84 [4.27–8.00]	<0.001
Feel tired or helpless	64	33.9	835	8.2	899	8.7	5.71 [4.19–7.78]	<0.001
Worry about problems	54	28.6	762	7.5	816	7.9	4.92 [3.56–6.81]	<0.001
Feel like lost everything in life due to their problems	36	19.0	400	3.9	436	4.2	5.73 [3.93–8.35]	<0.001
Feel incapable of making decisions or solving problems	61	32.3	845	8.3	906	8.8	5.24 [3.83–7.17]	<0.001
Feel lonely	51	27.0	574	5.7	625	6.0	6.16 [4.42–8.59]	<0.001
Unable to trust anyone	32	16.9	260	2.6	292	2.8	7.75 [5.19–11.56]	<0.001
Forgetfulness	23	12.2	313	3.1	336	3.2	4.35 [2.77–6.83]	<0.001
Difficulty in concentration	32	16.9	318	3.1	350	3.4	6.30 [4.24–9.36]	<0.001
Feel like running away from everyone	23	12.2	159	1.6	182	1.8	8.70 [5.47–13.83]	<0.001
Feel like committing suicide	24	12.7	99	1.0	123	1.2	14.76 [9.21–23.67]	<0.001
Feel like it would have been good to have died	26	13.8	94	0.9	120	1.2	17.06 [10.76–27.06]	<0.001
Angry with people around	28	14.8	376	3.7	404	3.9	4.52 [2.98–6.84]	<0.001
Feel like failed in managing responsibilities	27	14.3	275	2.7	302	2.9	5.98 [3.91–9.15]	<0.001
Feel guilty	30	15.9	451	4.4	481	4.7	4.05 [2.71–6.06]	<0.001
Feel worthless	34	18.0	349	3.4	383	3.7	6.16 [4.18–9.06]	<0.001

* OR—Odds Ratio; CI—Confidence Interval.

All 18 variables related to emotions experienced by the beneficiaries were significantly (<0.001) associated with self-reporting of gender, sex and sexuality issues. Among these, most beneficiaries reported feeling anxious (57.7%), followed by feeling depressed (36%), feeling tired or helpless (33.9%) and feeling incapable of making decisions or solving the problems (32.3%).

Multiple logistic regression analysis (

Table 4. Multiple logistic regression analysis for factors associated with gender, sex and sexuality issues among beneficiaries attending youth mental health promotion clinics (2017–2020) in Karnataka. (N = 10,340).

Variables		Adjusted Odds Ratio (AOR)
	Crude Odds Ratio [95% CI]	AOR [95% CI] *	p-Value
Age in Completed Years
15–20	Reference	Reference
21–25	1.80 [1.27–2.54]	1.54 [1.05–2.27]	0.027
26–30	2.42 [1.62–3.61]	1.30 [0.80–2.12]	0.276
31–35	2.25 [1.32–3.82]	0.82 [0.43–1.59]	0.573
Gender
Female	Reference	Reference
Male	1.68 [1.23–2.28]	1.72 [1.20–2.46]	0.003
Marital Status
Never Married	Reference	Reference
Ever Married	3.64 [2.63–5.05]	2.32 [1.51–3.57]	<0.001
Types of Issues Reported
Health and lifestyle issues	11.99 [8.40–17.10]	2.27 [1.77–4.19]	<0.001
Relationship issues	16.35 [12.15–22.02]	3.63 [2.36–5.57]	<0.001
Personality issues	18.05 [13.07–24.93]	2.48 [1.60–3.85]	<0.001
Safety issues	1.11 [0.77–1.60]	2.56 [1.72–3.81]	<0.001
Ever attempted suicide	18.13 [12.55–26.17]	4.27 [2.70–6.74]	<0.001
Substance Use
Tobacco smoking	4.79 [2.85–8.04]	2.30 [1.24–4.27]	0.008
Drinking	4.38 [2.90–6.63]	0.49 [0.30–0.81]	0.005
Emotions Experienced
Feel depressed	7.59 [5.59–10.32]	2.10 [1.43–3.09]	<0.001
Feel worthless	6.16 [4.18–9.06]	2.08 [1.28–3.39]	0.003

* OR—Odds Ratio; CI—Confidence Interval. Hosmer–Lemeshow test statistics = 7.09. Area under the ROC curve is 0.89 implies that our model is 89% good.

) revealed that male beneficiaries (AOR = 1.72, 95% CI = 1.20–2.46) had 1.72 times higher risk of GSS issues compared to female beneficiaries. Beneficiaries who were married (AOR = 2.32, 95% CI = 1.51–3.57) had twice the risk of GSS issues compared to those who had never been married. Youth reporting health and lifestyle issues (AOR = 2.27, 95% CI = 1.77–4.19), relationship issues (AOR = 3.63, 95% CI = 2.36–5.57), personality issues (AOR = 2.48, 95% CI = 1.60–3.85) and safety issues (AOR = 2.56, 95% CI = 1.72–3.81) were associated with increased risk ofGSS issues. Beneficiaries attempting suicide (AOR = 4.27, CI = 2.70–6.74) had 4 times increased risk of GSSissues. Beneficiaries who had the habit of smoking tobacco (AOR = 2.30, CI = 1.24–4.27) had 2.3 times increased risk of GSS issues compared to those who didnot smoke. Youth who felt depressed (AOR = 2.10, 95% CI = 1.43–3.09) and worthless (AOR = 2.08, 95% CI = 1.28–3.39) were associated with increased risk of GSS issues. Interestingly, every unit increase in drinking (AOR = 0.49, 95% CI = 0.30–0.81) was associated with 51% reduction in gender, sex and sexuality issues.

4. Discussion

Overall, among 10,340 youth clients of Yuva Spandana, 189 (1.8%) had gender, sex and sexuality issues. Age, gender, marital status, issues reported, suicidality, substance use and feeling depressed or worthless wereassociated with risk of GSS issues among youth in Karnataka. Youth reporting suicidality and relationship issues had the strongest association of increased risk of having GSS issues among clients. Youth with safety issues, personality issues, and health and lifestyle issues also had increased risk of GSS issues. Clients who felt depressed and worthless were associated with increased risk of GSS issues. Clients aged 21–25 years, males, and those thathad been married had a significantly higher risk of GSS issues compared to those aged 15–20 years, females, and those that had never been married, respectively. Tobacco smoking was associated with increased risk, while drinking alcohol was associated with reduced risk of GSS issues.

Our study focused on GSS issues, which includes gender roles, discrimination, GBV, STIs and child abuse related issues. Most studies focus on individual GSS issues like sexual violence [16]; GBV [17]; STIs [18], etc., and on vulnerable populations like LGBT [19], sex workers [20], children [21], migrants [22], women [23] and conflict settings [24]. To our knowledge, studies focusing on multiple GSS issues amongst youth are minimal/rare. Addressing GSS issues during youth through health promotion islikely to be beneficial to prevent health issues in later life, especially mental health issues. It is known that the cost of population level health promotion interventions issignificantly lesser than the cost of individual interventions [25]. The period of youth is the right time to invest in health promotion since youth are mostly healthy and free of disease. Furthermore, in a country like India, youth form >1/3rd of the demographic dividend and investing intheir health is likely to yield better results.

Clients with issues related to health and lifestyle, relationships, personality and safety had higher risk of gender, sex and sexuality issues compared to those without issues.It is well known that gender and sexuality haveinfluence on overall health status, care seeking and access to health [26,27]. There is strong and clear evidence regarding gender-based violence affecting physical and psychological health [28,29,30] as well as relationships [31]. It also influences the social, economic, spiritual, and emotional well-being of individuals [32]. Personality issues are also associated significantly with GSS issues. One of the 5 personality traits, neuroticism, is related to issues with sexuality like sexual guilt [33,34], sexual depression and anxiety, as well as reduced sexual satisfaction [35], thus further affecting sexual orientation. Safety issues are also associated with gender, sex and sexuality issues in the current study. While disclosing their genderpreference to others or when the information is disclosed by others, concerns regarding safety issues take an important role. Absence of protective environments is considered as one of the problems related to vulnerability in health-related areas among sexual minority groups [36].

Association between GSS issues and gender is inconclusive. It was observed that male clients (1.72 times) are at higher risk of GSS issues compared to female clients. In contrast, some studies report women having higher risk and prevalence of sex and sexuality issues like sexual violence [37] and sexual victimization [38]. These studies have focused on sexual violence. Other GSS issues are rarely addressed. This might be the reason for contrasting observations in this analysis. In addition, social desirability might influence men reporting issues related to gender roles, GBV and discrimination more than women. Societal acceptance, patriarchy and the prevalence of male dominated social ecosystems might normalize these issues among women, leading to lack of perception of such issues and thereby reduced reporting among women [39]. However, qualitative studies looking at these interrelationships to understand gender and GSS issues are needed.

Similarly, the association between marital status and GSS seems complex. It was observed that married clients had twice the risk of GSS issues compared to unmarried clients. Gender-based violence is considered acceptable and in-practice among married couples in Indian families [40]. However, another study suggested that gender-based violence is less likely to be associated with marriage [41]. This needs further exploration and understanding. However, public health interventions such as YuvaSpandana (being a health promotion program) can serve as effective platforms to reduce risk of violence among married couples

This analysis, furthermore, adds to the existing strong evidence that suicidality increases risk of GSS issues, in particular, issues related to sexual orientation [42], gender-based violence [43] and gender discrimination [44,45,46]. Stigma, social norms and taboos associated with disclosure and lack of opportunities for open discussion of GSS issues might contribute to suicidality among those with GSS. Being a cross sectional assessment, the temporality of association is difficult to assess.

Smoking tobacco (2.30 times) was associated with increased risk of GSS issues, thus supporting previous study findings [47]. Interestingly, in this study, drinking alcohol was associated with a 51% reduction in GSS issues. Some studies infer that an individual’s false perception that alcohol reduces stress and increases physical pleasure and sexual enjoyment [48] increases his/her ability to cope with distress and to escape reality [49] and thereby influences lack of perception of GSS issues, resulting in under-reporting of GSS issues. There are studies highlighting stronger association between partner violence and partner excessive alcohol use [50], sex related alcohol expectancies to sexual behaviour and alcohol consumption [51]

Mental health problems and GSS issues are closely associated [52]. Depression and anxiety disorders are known to be strong markers of GBV [17,52], gender discrimination [53], sexual issues [54] and STIs [55]. Youth who felt depressed (2.10 times) and worthless (2.08 times) had significantly increased risk of GSS issues in this analysis. Significantly high rates of depression have been associated with individuals in the emerging sexual and gender minority categories [56]. There is also strong association between stigma related to STI, gender non-conformity and depression [57] Unsafe environments; unsympathetic, unwilling and unapproachable attitudes of others; and severe victimization with respect to GSS issues might make youth believe that their isolation or rejection is chronic and thus consider suicide, a severe criteria for depression, as a viable option [58]. Under Yuva Spandana, all clients are asked about the co-existence of 18 feelings/emotions (Table 3) during their visits. However, the remaining 16 emotions or feelings were not associated with GSS amongst youth in Karnataka in the adjusted analysis. This enquiry has brought to light the association of mental health issues and GSS in this study. Furthermore, with respect to mental health issues and suicidality as associated factors with GSS issues, it is more likelythat GSS issues are antecedents to mental health problems rather than vice versa, especially amongst youth [59]. It is important to evaluate mental health issues among those reporting with GSS issues or vice versa.

The current study is part of a first-of-its-kind youth mental health promotion program in India. The uniqueness of the study lies with identification of risk factors of GSS issues such as personality issues, relationship issues, safety issues, health and lifestyle issues, and emotional experiences amongst youth. These prevalent and critical yet neglected issues of youth health and wellbeing are observed contributing to GSS issues, which are known antecedents of mental health problems in the future. The study comprehensively looks at GSS issues among youth rather than focusing on individual/specific components of GSS. This facilitates provision of early intervention and shows the importance of looking upstream. This study has utilized real-time data of all clients visiting Yuva Spandana Kendras covering the entire state of Karnataka. In addition, a large sample size from across 30 districts of Karnataka is a strength of this study. Real-time digital data entry minimizes data entry errors and ensures standardized data entry, unlike other programmatic data. Guidance is provided by trained Yuva Samalochakas, ensuring adequate privacy and confidentiality and reducing the possibility of information bias. Furthermore, built-in systems to ensure the quality of data collected within the program safeguard the reliability of study findings.

5. Limitations

Certain limitations of this study need specific mention. By design, this is a cross sectional study. The temporality of association is difficult to ascertain between GSS issues and its risk factors. However, youth mental health promotion services such as this could incorporate these factors for assessment while providing services. Information related to GSS and its risk factors are sensitive and subject to social desirability bias. However, trained counsellors, maintaining adequate confidentiality and privacy are likely to minimize social undesirability. This study doesnot consider timelines for any of the issues reported. It only assesses currently prevailing issues and emotions.

6. Conclusions

Despite these limitations, the findings of this study re-iterate thesignificance of early recognition of factors that are essential precursors of gender, sex and sexuality issues among youth. The study throws light on the importance of promoting awareness regarding gender, sex and sexuality issues and ensuring primordial prevention of possible gender, sex and sexuality related problems in later life, especially mental health. Interventions need to focus on societal interventions aiming to achieve open attitude towards GSS issues, breaking existing harmful societal norms and taboos, and facilitating disclosure of GSS issues within the society. Interventions focused on gender sensitization, co-existence of mental health issues, suicidality, and other issues related to health and lifestyle, personality, safety and relationships among those with GSS issues or vice versa need to be implemented. Further research onempowering societies and individuals through health promotion related to these issues islikely to yield cost-effective outcomes. This study has important implications foryouth mental health promotion programs especially in India and countries like India.