Suicide is the 13th leading cause of death worldwide  but is the 5th leading cause of death in China ; it is estimated that nearly half of the global suicide cases are from China, India and Japan. In the general population in China, the overall lifetime prevalence of suicidal ideation was 2.3% (2.8% in the rural sample versus 1.8% in the urban sample) and the prevalence of suicidal attempt was 1.0% (1.3% in the rural sample versus 0.9% in the urban sample) . In the present survey, we found that 26.01% (398/1530) of MSM who responded to the question regarding suicide ideation reported suicide intent and 192 (12.55%) of these respondents had actually attempted parasuicide at least once. Apparently, the prevalence of either suicidal ideation or attempt in the unique population of MSM in China, is significantly higher than that in the general Chinese population; our finding is in agreement with the findings from studies in other regions of the world where homosexual and bisexual men are at a far greater risk of suicidal behaviors [6,9-11].
Suicide is a complex human behavior which is hardly predictable. Nevertheless, a variety of factors have been demonstrated to contribute to suicide. In this study, our survey analysis showed that romantic relation breakup with gay partner(s) was the single most important trigger of suicidal behaviors in MSM in China and 33.67% Chinese MSM involved in our survey had ever considered suicide when their romantic gay relationships were broken up (Table 1). This is in contrast to the results from a recent study on the causes of suicide behaviors in the general population in China where Marriage/Love (51.3%) after Family/Home (60.7%) and Health/Hospital (53.8%) was found to be the third most common categories of negative life events preceding suicide attempts in the rural Chinese youth . Based on the traditional Chinese moral standard, gay, lesbian, bisexual, and transgender individuals as well as those who are sexually active are generally and collectively regarded as “dissolute” and “irresponsible” in China. Apparently, our finding suggests that MSM may be the same or even more serious about their romantic gay relationships as married heterosexual couples about their marriage instead of being “dissolute” and “irresponsible” as previously thought.
The second most important trigger of suicide behaviors in MSM in China as demonstrated in this study was the self-unacceptance of or self-objection to homosexuality. Culturally, strong stigma and discriminations exist against homosexual and bisexual behaviors in China, which is easy to understand. However, to our surprise, the survey data in this study showed that 120 (30.77%) out of the 390 MSM thought about suicide because they could not accept their homosexuality themselves. This finding implies that health professionals, social workers and all others including parents and relatives who do care about the well-being of MSM should pay more attention to the psychological health of this particular group of people to minimize their suicide attempts.
Other causes of suicide behaviors in the MSM surveyed in this study include difficulties in finding gay partners or in getting used to heterosexual marriage life, pressure from being forced to marry a woman, sudden emotional stress from unexpected events, illegal status of gay marriage in China and disclosure of homosexuality to others. All these causes have been also reported in various previous studies.
While elevated suicidal ideation in MSM has been reported to be associated with the positive HIV tests in some studies [17,18], Gibbie et al. has observed no positive correlation between psychological problems including suicide behaviors and HIV status in MSM . Supporting the observation of Gibbie et al., we found no difference in the rate of HIV infection between MSM who had suicide behaviors and those who had no suicide behaviors (2.6% vs 2.3%, P > 0.05).
Sociodemographic data of the subjected analyzed in this study were presented in one of our previous papers . In the present study, we did not include sociodemographic variables like income, education, profession, etc. in our analysis of reasons for suicide attempts in MSM in China. This is the major limitation of this study.