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Chained multimediator model of sexual orientation disclosure, sexual minority stigma, sexual minority identity, social support, and resilience among ymsms
BMC Public Health volume 22, Article number: 797 (2022)
Abstract
Introduction
This study aimed to investigate sexual orientation disclosure and mental health among young men who have sex with men (YMSMs). To this end, we constructed a chained multimediator model of sexual minority stigma, sexual minority identity, social support, and resilience, with the moderator of sexual orientation disclosure.
Methods
We conducted a cross-sectional survey of 345 YMSMs in Nanning, China. Bivariate analysis was used to evaluate factors associated with sexual orientation disclosure. Sexual minority stigma was used to predict identity, with social support as the step 1 mediator and resilience as the step 2 mediator. Sexual minority identity was analyzed using a chained moderated mediation model; sexual orientation disclosure was included as a moderator in all models to control its confounding effect.
Results
The average age of YMSMs was 20.0 ± 1.3 years. Bivariate analysis indicated that YMSMs who disclosed sexual orientation may have experienced less stigma (15.49 ± 3.02 vs 16.21 ± 2.74), obtained more social support (65.98 ± 11.18 vs 63.19 ± 11.13), had strong psychological resilience (37.40 ± 8.57 vs 35.39 ± 7.73), and had a more positive self-identity (104.12 ± 21.10 vs 95.35 ± 16.67); differences between subgroups were statistically significant (p < 0.05). Sexual minority stigma, perceived stigma, and enacted stigma were significantly associated with social support and resilience. The association between sexual minority stigma and sexual minority identity was significantly mediated by social support (indirect effect [95% CI] = − 3.307 [− 4.782, − 1.907]). Resilience significantly mediated the same association for identity (− 2.544 [− 4.052, − 1.114]). The chained relationship from sexual minority stigma to social support, resilience, and identity was also significant, with an indirect effect of − 0.404 [− 0.621, − 0.249].
Conclusion
Among YMSMs in China, sexual minority stigma affects sexual minority identity through social support and resilience. Given the psychological effects of stigma, social support and resilience must be considered to better promote positive self-identity and mental health among YMSMs.
Introduction
It has been estimated that 83.0% of the global sexual minority population conceals its sexual orientation from all or most people [1]. Such concealment may cause men who have sex with men (MSM) to avoid HIV testing, thereby increasing the risk of HIV infection and interfering with AIDS-related behavioral interventions [2,3,4]. Although the experience of sexual stigma among MSMs in China is well documented [5,6,7,8], little is known about its effect on the psychological well-being of young MSMs (YMSM). YMSMs (aged 15–24) who perceive or experience stigma are in a period of changing and unstable physiology and psychology, and they are therefore more sensitive to stigma and negative evaluations [9,10,11,12]. Yet, few studies have specifically investigated potential moderating and mediating effects in the relationship between sexual stigma and psychological distress among YMSMs in China.
Sexual minority stigma refers to the social and structural devaluation of lesbian, gay, bisexual, and other sexually diverse people and the associated power inequalities, negative attitudes, and stereotypes [13]. “Coming out” can still pose a huge dilemma for sexual minorities in many countries, even with same-sex marriage becoming increasingly common [14,15,16]. The low rate of sexual orientation disclosure can also affect sexual behaviors (e.g., getting tested for sexually transmitted infections) and mental health [17,18,19,20]. Traditional concepts of marriage and childbirth are deeply rooted in China, and sexual minority stress is therefore high among Chinese MSMs [21, 22]. This heteronormative social environment [23] results in severe marginalization and stigma for MSMs [24], who may be exposed to negative experiences, such as social rejection, isolation, diminished social support, discrimination, and verbal and physical abuse [25]. The resulting negative effects for MSMs can include depression, anxiety, tension, and fear, as well as violence and a propensity for suicidal and antisocial behavior [26,27,28,29].
Sexual minority identity refers to one’s sense of belonging to a sexual minority [30]. Previous studies have described identity formation and integration as a process in which individuals strive for congruence in their sexual orientation in areas such as sexual attraction, thought, and fantasy [31,32,33,34,35]. Sexual minority individuals are often raised in communities that are ignorant of or openly hostile toward homosexuality and therefore may have difficulty forming a positive identity [26, 36]. The development of sexual identity is a difficult, complex, multidimensional process [37]. As an important factor of MSMs’ mental health, among different types of sexual minority, the effect of sexual minority identity on risky behavior is different and enhances the rise [38,39,40]. While “coming out” is typically stressful for YMSMs, it is also associated with positive mental health and identity outcomes, especially in the long run [41].
MSM research has consistently shown that parental and peer support are related to good mental health (e.g., high self-esteem, less depression, reduced suicidality), self-acceptance, and overall well-being [12, 42,43,44]. Resilience is the ability to have good psychological outcomes and quality of life despite experiencing stressful environments or other serious adversities [45, 46]. People with high resilience have reported a lower prevalence of psychological distress or disorders [47, 48].
In light of the above, social support and resilience might be considered to mediate the effect of sexual minority stigma perception on identity. This might further suggest a potential chained mechanism by which social support and resilience mediate the relationship between sexual minority stigma and sexual minority identity. In addition to the direct effect, stigma may exert indirect effects on identity by enhancing social support and resilience. To our knowledge, no previous study has investigated this potential chained mediation mechanism.
This study investigated the relationship between mental health and sexual orientation disclosure. It also examined the complex underlying mechanisms linking sexual minority stigma to identity through two chained mediators: social support and resilience. To this end, we analyzed data collected from a probability sample of YMSMs in China. The findings can enhance our understanding of the mechanisms of sexual minority identity and provide a reference for interventions aiming to increase the acceptance and positivity of sexual identity.
Methods
Participants
Participants were recruited from July 2019 to July 2020 with support from the Voluntary Counseling and Testing (VCT) clinic of the Centers for Disease Control and Prevention (CDC), Guangxi, China. Participants were also recruited from nongovernmental organizations (NGOs) (e.g., Rainbow of Green City) in Nanning China. We targeted YMSMs who were aged 18–24, who self-reported receptive or insertive anal intercourse or oral sex with another man in the last six months, who had not previously tested positive for HIV, and who agreed to participate in the study.
Procedure
Each survey site was assigned to two well-trained researchers, who were responsible for recruiting participants and distributing the survey. It was an anonymous self-reported questionnaire survey. After providing informed consent, participants received free HIV testing. We collected participants’ fingertip blood, which was placed on HIV testing reagents. As they waited for the HIV testing results, participants were asked to complete the questionnaires. They filled out the questionnaires independently in a separate room to protect their privacy. In-person assistance was available if participants had any questions about the survey. Most took ~ 30 min to complete the questionnaire. Participants received 50 RMB (approximately USD 8) after completing the questionnaire. Among 350 eligible YMSMs, 345 were retained for analysis after excluding individuals with incomplete data for key variables (completion rate: 98.6%).
Measurement
Demographics
The demographic variables included age, ethnicity, education, employment status, marital status, monthly income, and sexual orientation. Ethnicity was Han, Zhuang, or other minority. Education was high school or below or college or above. Identity was student, employee, farmworker, or unemployed. Marital status was unmarried or married/divorced. Monthly income (in RMB) was ≤ 3000, 3001–5000, or > 5000. Sexual orientation was gay, bisexual, or undecided. For the descriptive analysis, we separated the sociodemographic and measurement scale information according to whether participants had disclosed their sexual orientation.
Mediation model
Mediation model is assumed that there is a causal influence between independent variable X and dependent variable Y, and this influence is realized with the participation of the third variable M. In other words, the influence of independent variable X on dependent variable Y is partly indirect through the intermediate variable M, which is called M as the mediator variable (Fig. 1) [49]. A model that has multiple mediators explaining the effect of an independent variable on a dependent variable is called multiple mediation. compared to a direct effect on the regression analysis and other methods, mediation analysis can further explain the mechanism behind the causal variables.
Predictor
Sexual minority stigma
Sexual minority stigma was evaluated using Neilands’s questionnaire, Assessment of Stigma Toward Homosexuality in China [50]. This scale has been used to measure stigma against the MSM population in China and the US and has good reliability and validity (Cronbach’s alpha: 0.75). We measured two subscales of YMSMs’ sexual minority stigma: perceived stigma and enacted stigma. Items for perceived stigma included “How often have you heard that homosexuals are not normal?”; “How often have you felt that your homosexuality hurt and embarrassed your family?”; and “How often have you had to pretend that you are not homosexual in order to be accepted?” Enacted stigma refers to overt experiences of discrimination, including physical, verbal, and sexual violence and hate crimes. Items included “You’ve been hit, beaten, physically attacked, or sexually assaulted”; “You’ve been fired from your job or denied a job or promotion”; and “You’ve been prevented from moving into a house or apartment by a landlord or realtor.” Each item had four response options: 1 = never, 2 = once or twice, 3 = a few times, and 4 = many times. Mean stigma scores were computed for total stigma and two subscales, such that higher scores reflected more stigma experiences.
Mediator
Social support
Social support was measured using the Multidimensional Perceived Social Support Scale [51]. It includes 12 entries divided into three dimensions: support from families, friends, and others. Sample items included “I can get emotional help and support from my family when I need it,” and “I can rely on my friends in times of trouble.” Response options ranged from 1 (very strongly disagree) to 7 (very strongly agree). The higher the overall score and the higher the score in each dimension, the more social support the individual perceived. The Cronbach’s α coefficient of the scale was 0.96.
Mediator
Resilience
A modified Connor–Davidson Resilience Scale [52] was used to measure psychological resilience. Sample items included “I bounce back after illness or injury” and “Under pressure, I stay focused.” These were divided into three dimensions: target focus, emotional control, and positive cognitive. Responses were given on a five-point scale ranging from 0 (“not at all”) to 4 (“extremely”). A higher total score represented a higher level of resilience. The scale exhibited good internal reliability (Cronbach’s alpha: 0.96).
Moderator
Sexual orientation disclosure
Sexual orientation disclosure was defined as having ever disclosed one’s sexual orientation to anyone other than a sexual partner. Healthcare professional disclosure means disclosing to a doctor or other medical provider. Studies have indicated that the association between sexual minority stigma and sexual minority identity differs by orientation disclosure [25, 53]. To better assess the proposed chained mediation mechanism, this variable was used as a moderator and was assessed as whether sexual orientation was disclosed (yes/no).
Outcome
Sexual minority identity
Sexual minority identity was measured using the Lesbian, Gay, & Bisexual Identity Scale [37]. It is divided into eight dimensions: acceptance of attention (three items), hidden motivation (three items), identity hesitation (four items), internalization homogeneity (three items), difficult process (three items), identity advantage (three items), identity verification (three items), and identity center (five items) (total items: 27). Responses included strongly agree (six points), agree (five points), relatively agree (four points), relatively disagree (three points), disagree (two points), and strongly disagree (one point). The eleventh and twenty-third items were reverse scored. The higher the score, the higher the degree of negative identity. Cronbach’s alpha was 0.72.
Statistical analysis
Descriptive analyses were used to describe the study sample and for bivariate analysis by the sexual orientation disclosure subgroup. We tested the proposed chained mediation model in three steps. In step 1, Pearson’s correlation was used to investigate correlations among the key variables, including sexual minority stigma, social support, resilience, and sexual minority identity. In step 2, moderated mediation modeling was used to test the individual roles of social support and resilience in mediating the association between sexual minority stigma and sexual minority identity (i.e., sexual minority stigma → social support → sexual minority identity, and sexual minority stigma → resilience → sexual minority identity), considering the moderating role of orientation disclosure. As shown in Fig. 2a and 2b, the product of the estimated coefficients a and b (a*b) provided a measure of the indirect effect of sexual minority stigma on identity through social support/resilience. A significant c3’ provided a measure of the moderating effect of orientation disclosure. In step 3, chained mediation modeling with two mediators was conducted. As shown in Fig. 2c and d, the products of the estimated coefficients a1 and b1 (a1*b1), a2 and b2 (a2*b2), and a1, a3, and b2 (a1*a3*b2) provided measures of the indirect effects of sexual minority stigma → social support → sexual minority identity, sexual minority stigma → resilience → sexual minority identity and sexual minority stigma → social support → resilience → sexual minority identity, respectively.
Two investigators used Epidata 3.1 to enter the questionnaire data, save the final database after consistency checks, and import it into SPSS 24.0 for descriptive analysis. Type I error was set at p < 0.05 for statistical inference. Moderated mediation analyses were conducted using Mplus 8.3.
Results
Study sample characteristics
A total of 61.7% of participants were Han, and one-third were Zhuang; 79.1% had a college education or higher; 50.1% were staff; 56.2% made 3000 RMB or more; 67.8% reported their sexual orientation as gay. The chi-squared test showed significant statistical differences in sexual orientation disclosure between the self-reported sexual orientation groups (Table 1).
Bivariate analysis by sexual orientation disclosure subgroup
In the bivariate analysis t-test, there were statistical differences in the scores for sexual minority stigma, social support, resilience, and sexual minority identity between subgroup according to whether sexual orientation was disclosed. YMSMs who disclose sexual orientation might experience less stigma, obtain more social support, have strong psychological resilience, and have a positive self-identity. However, different from perceived stigma, enacted stigma showed no significant statistical difference between subgroups (Table 2). For sexual minority stigma, the subgroup of YMSMs who disclosed sexual orientation had less perceived stigma. For the social support aspect, family support did not play any special role in the effect; YMSMs received more support from friends and others, depending on sexual orientation disclosure. Each dimension of resilience was significantly different between the two subgroups; high scorers tended to be “out.” For sexual minority identity, except for the dimension of internalized homonegativity, identity superiority and identity affirmation played special roles in the effect. Other dimensions showed that with higher scores, YMSMs with a more positive sexual minority identity tended to disclose their sexual orientation.
Correlations among predictors, mediators, moderators, and outcomes
Sexual minority stigma, perceived stigma, and enacted stigma were significantly associated with social support and resilience. Social support was significantly associated with resilience; both were significantly associated with sexual minority identity. This supports the proposed mediation models. Additionally, Table 3 reveals differences in the correlations according to whether participants disclosed sexual orientation, suggesting a need to control this variable as a moderator (Table 3). YMSMs who disclosed sexual orientation reported less perceived stigma but more enacted stigma compared to those who concealed sexual orientation. YMSMs who did not disclose sexual orientation might have experienced less enacted stigma; there was no significant association with sexual minority identity.
Moderated mediation modeling of sexual minority identity
We analyzed data of moderated mediation modeling in Fig. 2b, Social support significantly mediated the association between total sexual minority stigma and sexual minority identity (sexual minority stigma → social support: − 1.027 [− 1.400, − 0.683]; social support → sexual minority identity: 0.597 [0.459, 0.740]; indirect effect = − 0.613 [− 0.886, − 0.394]). Resilience significantly mediated the association between total sexual minority stigma and identity (indirect effect = − 0.790 [− 1.128, − 0.518]). Further analyses showed that resilience mediated the association between perceived stigma and enacted stigma; more details can be found in Table 4. YMSMs with less social support experienced higher sexual minority stigma and were more likely to have a negative sexual minority identity. Additionally, resilience had a positive mediating effect on the path connections of sexual minority stigma and sexual minority identity among YMSMs. Individuals with higher stigma had less resilience, which in turn reduced positive identity.
Chained moderated mediation modeling of sexual minority identity
The results shown in Fig. 3a indicate that total sexual minority stigma was significantly associated with social support (coefficient [95% CI] = − 1.027 [− 1.401, − 0.683]). This in turn was associated with resilience (coefficient = 0.360 [0.303, 0.419]) and further associated with sexual minority identity (coefficient = 1.092 [0.902, 1.276]). The chained two-step indirect effect of sexual minority stigma → social support → resilience → sexual minority identity was − 0.404 [− 0.621, − 0.249]. The results in Fig. 3b show that social support and resilience did not significantly mediate the association between perceived stigma and sexual minority identity. The indirect effect of perceived stigma → social support → resilience → sexual minority identity was − 0.091 [− 0.231, 0.010]. The results in Fig. 3c show the mediating role of employment uncertainty and anxiety between enacted stigma and sexual minority identity. The indirect effect for the path enacted stigma → social support → resilience → sexual minority identity was − 0.083 [− 0.296, 0.002]. In these moderated mediation models, social support was not directly associated with sexual minority identity (0.111 [− 0.185, 0.206] for perceived stigma; 0.008 [-0.192, 0.202] for enacted stigma). Further, resilience was not directly associated with sexual minority identity (0.215 [− 0.041, 0.480] for perceived stigma; 0.224 [− 0.032, 0.496] for enacted stigma).
Discussions
As the concept opens up, we can find the number of YMSMs disclosure sexual orientation has increased, about half of YMSM have told others about self-sexual orientation. Our results revealed a significant relationship between mental health and sexual orientation disclosure among Chinese YMSMs. YMSMs who were “coming out” were more likely to have good mental health, as in previous studies [19]. So, we can adopt more ways to advocate society and YMSMs for greater acceptance of homosexual orientation, education, and promotion of positive values and equality may help decrease psychological distress and develop a healthy mindset for YMSMs [54, 55].
One important finding is the demonstration of the effect mechanism of stigma on sexual minority identity, mediated by social support and resilience. Social support and resilience are two important factors related to self-identity [54, 56]. High levels of resilience better reduce the impact of stigma, for example, counseling or individual psychotherapy could alleviate negative effects on self-perception [57]. Our results indicated support from friends or peer are more effective impact discrimination perception than family support and work colleagues’ support, so peer care and help service is necessary. And stigma is a multifaceted concept [26, 58,59,60]. There are different effects in the mediation model. Perceived stigma refers to expectations of stigma and prejudice, which cause stress by requiring vigilance. It is assessed as a person’s level of awareness of being stigmatized and devalued by their community [61]. Enacted stigma refers to experiences of victimization, harassment, threats, and discrimination in daily life, at work, and in housing situations [62]. For these differences, corresponding interventions require our future research.
Our findings also revealed a chained mediation mechanism in which the relationship between sexual minority stigma and identity was mediated by both social support and resilience. Other studies have also observed indirect effects through the associated mediators of social support and resilience [54, 57, 63, 64]. This chained mediation mechanism highlights the importance of a no-stigma environment and social support for YMSMs in China. Social support from family, friends, communities, and medical institutions can mitigate the effects of stigma and positively affect self-identity. Social support also plays an important role by providing informational, instrumental, and emotional support. Resilience increases self-worth and reduces stress, thus helping YMSMs to have a more positive sexual minority identity and increasing their receptiveness to HIV risk-reduction counseling [65, 66].
A positive sexual minority identity among YMSMs can reduce the effects of perceived stigma; it has chain mediating effects in the two key target variables of social support and resilience. Compared to total stigma, the effects of perceived stigma and enacted stigma were not significant; this warrants additional research in the future.
This study has some limitations. First, it was a cross-sectional study limited to one city in China; caution should be exercised with regard to generalizing the findings. Future studies can use a prospective longitudinal research design and collect data in more cities. Second, the variables were self-reported, and underreporting cannot be ruled out resulting from social desirability bias, Future studies may overcome this limitation through communicating more with the participants and taking feasible and effective measures to gain more trust to strengthen the authenticity of the data. Third, we only considered the comparison of discrimination perception between YMSMs who were in or had been in a marriage and who were not. possibly in future studies, the content of the questionnaire can be improved to create additional category like "Being in a relationship but not marred”.
Conclusions
Our findings highlight the importance of considering social support and resilience in the effect of sexual minority stigma on mental health among YMSMs. Reducing stigma and giving more social support are effective measures for intervening in the mental health of YMSMs. The chain mediating effect results showed that sexual minority stigma, sexual minority identity, social support, and resilience regulate and influence each other and provide a basis for YMSMs’ mental health regulation. Combined with longitudinal data, this study’s findings could be used to inform interventions targeting mental health and HIV prevention among YMSMs in China.
Availability of data and materials
The datasets used and analyzed during the current study available from the corresponding author on reasonable request.
References
Pachankis JE, Branstrom R. How many sexual minorities are hidden? Projecting the size of the global closet with implications for policy and public health. PLoS One. 2019;14(6):e0218084.
Coleman TA, et al. Sexual Orientation Disclosure in Primary Care Settings by Gay, Bisexual, and Other Men Who Have Sex with Men in a Canadian City. LGBT Health. 2017;4(1):42–54.
Tamagawa M. Coming Out of the Closet in Japan: An Exploratory Sociological Study. J GLBT Fam Stud. 2017;14(5):488–518.
Pachankis JE, et al. The Geography of Sexual Orientation: Structural Stigma and Sexual Attraction, Behavior, and Identity Among Men Who Have Sex with Men Across 38 European Countries. Arch Sex Behav. 2017;46(5):1491–502.
Liu Y, et al. Association of recent gay-related stressful events with depressive symptoms in Chinese men who have sex with men. BMC Psychiatry. 2018;18(1):217.
Zhao Y, et al. Non-disclosure of Sexual Orientation to Parents Associated with Sexual Risk Behaviors Among Gay and Bisexual MSM in China. AIDS Behav. 2016;20(1):193–203.
Pachankis JE, et al. Sexual orientation concealment and mental health: A conceptual and meta-analytic review. Psychol Bull. 2020;146(10):831–71.
Tang W, et al. Disclosure of sexual orientation to health professionals in China: results from an online cross-sectional study. J Int AIDS Soc. 2017;20(1):21416.
Yunyong L, et al. Associations between recent gay-related stressful events, emotional distress, social support and unprotected anal intercourse behavior among Chinese men who have sex with men. Aust N Z J Psychiatry. 2016;50(7):659–66.
Cao B, et al. MSM Behavior Disclosure Networks and HIV Testing: An Egocentric Network Analysis Among MSM in China. AIDS Behav. 2019;23(5):1368–74.
Fish JN. Future Directions in Understanding and Addressing Mental Health among LGBTQ Youth. J Clin Child Adolesc Psychol. 2020;49(6):943–56.
Sun S, et al. Addressing Minority Stress and Mental Health among Men Who Have Sex with Men (MSM) in China. Curr HIV/AIDS Rep. 2020;17(1):35–62.
Steward WT, Miege P, Choi KH. Charting a moral life: the influence of stigma and filial duties on marital decisions among Chinese men who have sex with men. PLoS One. 2013;8(8):e71778.
Zhang BC, Chu Quan Sheng. MSM and HIV/AIDS in China. Cell research. 2005;15(11–12):858–64.
Almeida J, et al. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. J Youth Adolesc. 2009;38(7):1001–14.
Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97.
Pachankis JE. The psychological implications of concealing a stigma: a cognitive-affective-behavioral model. Psychol Bull. 2007;133(2):328–45.
Bogart LM, et al. Perceived discrimination and mental health symptoms among Black men with HIV. Cultur Divers Ethnic Minor Psychol. 2011;17(3):295–302.
Wight RG, et al. Stress and mental health among midlife and older gay-identified men. Am J Public Health. 2012;102(3):503–10.
Mustanski B, et al. A syndemic of psychosocial health disparities and associations with risk for attempting suicide among young sexual minority men. Am J Public Health. 2014;104(2):287–94.
Felner JK, et al. Sexual orientation and gender identity disparities in co-occurring depressive symptoms and probable substance use disorders in a national cohort of young adults. Addict Behav. 2021;117:106817.
Tsai AC, Burns BF. Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139:26–35.
Yang X, et al. Intersectional stigma and psychosocial well-being among MSM living with HIV in Guangxi China. AIDS Care. 2020;32(sup2):5–13.
Sun S, Hoyt WT, Pachankis JE. Sexual risk behaviors in the internet age: the case of Chinese men who have sex with men. AIDS Care. 2020;32(3):302–9.
Choi KH, et al. Sexual Stigma, Coping Styles, and Psychological Distress: A Longitudinal Study of Men Who Have Sex With Men in Beijing China. Arch Sex Behav. 2016;45(6):1483–91.
Smith MK, et al. Gender Identity and Sexual Orientation in Chinese Men Who Have Sex with Men: A Latent Class Analysis. Arch Sex Behav. 2020;49(2):721–31.
Chan YF, D M, Funk RR. Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment. J Subst Abuse Treat. 2008;34(1):14–24.
Krueger EA, Meyer IH, Upchurch DM. Sexual Orientation Group Differences in Perceived Stress and Depressive Symptoms Among Young Adults in the United States. LGBT Health. 2018;5(4):242–9.
Lucassen MF, et al. Sexual minority youth and depressive symptoms or depressive disorder: A systematic review and meta-analysis of population-based studies. Aust N Z J Psychiatry. 2017;51(8):774–87.
Liu RT, et al. Suicidal Ideation and Behavior Among Sexual Minority and Heterosexual Youth: 1995–2017. Pediatrics. 2020;145(3):e20192221.
Rosario M, Schrimshaw EW, Hunter J. Ethnic/racial differences in the coming-out process of lesbian, gay, and bisexual youths: a comparison of sexual identity development over time. Cultur Divers Ethnic Minor Psychol. 2004;10(3):215–28.
Cass VC. Homosexual identity formation: a theoretical model. J Homosex. 1979;4(3):219–35.
Chapman BE, Brannock JC. Proposed model of lesbian identity development: an empirical examination. J Homosex. 1987;14(3–4):69–80.
Horowitz JL, Newcomb MD. A multidimensional approach to homosexual identity. J Homosex. 2001;42(2):1–19.
Morgan A, et al. Exploring the Sexual Development Experiences of Black Bisexual Male Adolescents Over Time. Arch Sex Behav. 2018;47(6):1839–51.
Dubé EM, S W.R. Sexual identity development among ethnic sexual-minority male youths. Dev Psychol. 1999;35(6):1389–98.
Chakrapani V, et al. Understanding How Sexual and Gender Minority Stigmas Influence Depression Among Trans Women and Men Who Have Sex with Men in India. LGBT Health. 2017;4(3):217–26.
Mohr JJ, Kendra MS. Revision and extension of a multidimensional measure of sexual minority identity: the Lesbian, Gay, and Bisexual Identity Scale. J Couns Psychol. 2011;58(2):234–45.
la Roi C, Meyer IH, Frost DM. Differences in sexual identity dimensions between bisexual and other sexual minority individuals: Implications for minority stress and mental health. Am J Orthopsychiatry. 2019;89(1):40–51.
Vogel EA, et al. Sexual and gender minority young adults’ smoking characteristics: Assessing differences by sexual orientation and gender identity. Addict Behav. 2019;95:98–102.
Blondeel K, et al. Violence motivated by perception of sexual orientation and gender identity: a systematic review. Bull World Health Organ. 2018;96(1):29-41L.
Russell ST, Fish JN. Mental Health in Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth. Annu Rev Clin Psychol. 2016;12:465–87.
Ryan C, et al. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010;23(4):205–13.
Ryan C, et al. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346–52.
Bosco SC, et al. Relationship Power and Intimate Partner Violence in Sexual Minority Male Couples. J Interpers Violence. 2020:886260520916271.
Guihard G, et al. Psychometric validation of the French version of the Connor-Davidson Resilience Scale. Encephale. 2018;44(1):40–5.
Herrman H, et al. What Is Resilience. Can J Psychiatr. 2011;56(5):258–65.
Zhang M, et al. Prevalence of psychological distress and the effects of resilience and perceived social support among Chinese college students: Does gender make a difference? Psychiatry Res. 2018;267:409–13.
Baron R.M, Kenny D. A. The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51:1173–82.
Dale SK, et al. Correlates of resilience after childhood sexual abuse among men who have sex with men. J Trauma Dissociation. 2020;21(3):365–75.
Neilands TB, Steward WT, Choi KH. Assessment of stigma towards homosexuality in China: a study of men who have sex with men. Arch Sex Behav. 2008;37(5):838–44.
Zimet GD, P S, Farley GK, Werkman S, Berkoff KA. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. J Pers Assess. 1990;55(3 4):610–7.
Notario-Pacheco B, S.-M M, Serrano-Parra MD, Bartolomé-Gutiérrez R, García-Campayo J, Martínez-Vizcaíno V. Reliability and validity of the Spanish version of the 10-item Connor-Davidson Resilience Scale (10-item CD-RISC) in young adults. Health Qual Life Outcomes. 2011;5(9):63.
Gonzales G, Przedworski J, Henning-Smith C. Comparison of Health and Health Risk Factors Between Lesbian, Gay, and Bisexual Adults and Heterosexual Adults in the United States: Results From the National Health Interview Survey. JAMA Intern Med. 2016;176(9):1344–51.
Ding C, et al. Sexual Minority Stigma, Sexual Orientation Concealment, Social Support and Depressive Symptoms Among Men Who have Sex with Men in China: A Moderated Mediation Modeling Analysis. AIDS Behav. 2020;24(1):8–17.
Pachankis JE, Cochran SD, Mays VM. The mental health of sexual minority adults in and out of the closet: A population-based study. J Consult Clin Psychol. 2015;83(5):890–901.
Yan H, et al. Association between perceived HIV stigma, social support, resilience, self-esteem, and depressive symptoms among HIV-positive men who have sex with men (MSM) in Nanjing China. AIDS Care. 2019;31(9):1069–76.
Safren SA, et al. Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trial. Lancet Glob Health. 2021;9(4):e446–55.
Fitzgerald-Husek A, et al. Measuring stigma affecting sex workers (SW) and men who have sex with men (MSM): A systematic review. PLoS One. 2017;12(11):e0188393.
Freeland R, et al. Measurements of Sexuality-Based Stigma among Gay, Bisexual, and Other Men Who Have Sex with Men (GBMSM) in Resource-Poor Settings: A Review. AIDS Behav. 2017;22(5):1614–38.
Broady TR, et al. HIV stigma by association among Australian gay and bisexual men. AIDS. 2020;34(Suppl 1):S53–61.
Krueger EA, et al. Psychological Distress, Felt Stigma, and HIV Prevention in a National Probability Sample of Sexual Minority Men. LGBT Health. 2020;7(4):190–7.
Herek GM. Hate crimes and stigma-related experiences among sexual minority adults in the United States: prevalence estimates from a national probability sample. J Interpers Violence. 2009;24(1):54–74.
Li X, et al. Association between enacted stigma, internalized stigma, resilience, and depressive symptoms among young men who have sex with men in China: a moderated mediation model analysis. Ann Epidemiol. 2021;56:1–8.
Ding C, et al. Association of Adverse Childhood Experience and Attention Deficit Hyperactivity Disorder with depressive symptoms among men who have sex with men in China: moderated mediation effect of resilience. BMC Public Health. 2019;19(1):1706.
Mimiaga MJ, et al. A randomized clinical efficacy trial of a psychosocial intervention to strengthen self-acceptance and reduce HIV risk for MSM in India: study protocol. BMC Public Health. 2018;18(1):890.
Acknowledgements
We thank the YMSMs who participated in this study and contributed their time. We also thank the Guangxi Center of Disease Prevention and Control, the VCT, the Nanning Center for Disease Prevention and Control, the Guangxi Key Laboratory of AIDS Prevention and Control. Finally, we thank the following NGOs in Nanning for their help and support: the Yitongxing Charity Organization, Rainbow of Green City, and Biyun Lake Community Organization.
Funding
This research is part of a cohort follow-up study, supported by the National Natural Science Foundation of China (Grant Nos. 81803295 and 81760602), the Natural Science Foundation of Guangxi (2018GXNSFAA138031), the Youth Science Foundation of Guangxi (2018GXNSFBA281047), the Innovation Project of Guangxi Graduate Education (YCSW2021143), the Opening topic fund of Guangxi Key Laboratory of AIDS Prevention and Treatment (No.gklapt 201902).
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All authors contributed to the design of the study, S.T. and P.C. analyzed the data and wrote the manuscript. T.F., X.Y., Y.Z and M.W. helped with research design, data collection. J.Z. and H.H. helped with data processing. J.M. and C.N. helped with critical revision of manuscript. L.J. supervised all aspects of this study. All authors contributed to and approved the final version for submission.
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The study was approved by the Institutional Review Board of the Guangxi Medical University(no.2019-SB-088). All processes were conducted anonymously. all methods were carried out in accordance with relevant guidelines and regulations’; All participants voluntarily signed the informed consent form, and researchers pledged not to disclose all the participants' information.
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Tan, S., Cen, P., Fang, T. et al. Chained multimediator model of sexual orientation disclosure, sexual minority stigma, sexual minority identity, social support, and resilience among ymsms. BMC Public Health 22, 797 (2022). https://doi.org/10.1186/s12889-022-13231-8
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DOI: https://doi.org/10.1186/s12889-022-13231-8