Men who have sex with men are two-thirds more likely to have unprotected anal sex in which they receive, a study has found.
Past studies have indicated that gay and bisexual men are more at risk of contracting HIV if they have mental health problems, but the latest findings show the extent of the issue.
Researchers have revealed that of the 507 Chinese people who took part in their study, those “who reported feeling lonely were more likely to have had condomless receptive anal intercourse in the past 6 months.”
The experts, who are based at institutions in California and the Chinese cities of Beijing and Nanjing, said the difference was stark, with lonely subjects 67 percent more likely to have unprotected receptive anal sex.
They are also more than twice as likely to feel “hopeless for the future” when compared to others, according to the study. Out of all the participants, more than a quarter – 26.8 percent – reported moderate-to-severe symptoms of depression, while 35.5 percent said they felt lonely. Read more via Pink News
Depression, Loneliness, and Sexual Risk-Taking Among HIV-Negative/Unknown Men Who Have Sex with Men in China
Su, X., Zhou, A.N., Li, J. et al. Arch Sex Behav (2018) 47: 1959. https://doi.org/10.1007/s10508-017-1061-y
Abstract
Research conducted among men who have sex with men (MSM) in high-income countries has demonstrated that negative mental health is one of the significant drivers of HIV infection, and few studies have examined the status of mental health among MSM in China. We sought to describe depression and loneliness and identify their correlates among Chinese MSM. A cross-sectional study was conducted among HIV-negative or unknown status MSM in 2014. Time–location sampling and online convenience sampling methods were employed. Depression was measured via a short version of CES-D (CES-D 10). Loneliness was measured from a single item in CES-D 10. Multivariable logistic regressions were conducted to identify independent correlates of depression and loneliness. A total of 507 individuals participated in the study. Of them, 26.8 and 35.5% reported moderate-to-severe symptoms of depression and feeling lonely, respectively. Depressed participants were more likely to have a sense of hopelessness for the future (AOR 3.20, 95% CI 1.90, 5.20) and report higher levels of internalized homophobia (AOR 2.32, 95% CI 1.47, 3.67). Participants who reported feeling lonely were more likely to have had condomless receptive anal intercourse in the past 6 months (AOR 1.67, 95% CI 1.08, 2.58) and feel hopeless for the future (AOR 2.40, 95% CI 1.60, 3.70). MSM in China have significant rates of depression and loneliness. HIV prevention efforts should address the mental health needs of Chinese MSM such as providing safe environments for social support and role models.
Discussion
In this study, we found that about one-fourth of the HIV-negative or unknown status MSM participants in China suffered from moderate-to-severe depression and one-third suffered from loneliness. The prevalence of moderate-to-severe depression in our sample, 26.8%, was lower than the rates reported in previous studies of Chinese MSM of various serostatuses, which was 46.1% (Yan et al., 2014), and Chinese MSM who were HIV-positive, which was 36.0% (Tao et al., 2017). The rate was within the range reported by other developing countries, with 11–46.3% experiencing depressive symptoms among general MSM (Ahaneku et al., 2016; Tomori et al., 2016). The results of our study also revealed a high prevalence of other negative psychological states such as hopelessness and internalized homophobia, which were significantly correlated with depression and loneliness among our sample of MSM participants. In general, MSM are disproportionately impacted by mental health issues, such as depression and suicidality (Dyer et al., 2015; Li et al., 2016). These mental health issues may be consequences of stigma and discrimination and may result in adverse behavioral and health outcomes, including HIV infection and poorer health outcomes due to lack of adherence in testing and treatment (Dyer et al., 2015).
A global online survey reported that internalized homophobia was negatively associated with having ever tested for HIV among Chinese MSM (Pyun et al., 2014). As one of the social barriers of HIV care and treatment, internalized homophobia, i.e., negative feelings about one’s own sexual orientation resulting from the internalization of anti-gay stigma and prejudice (Herek, 2004), may cause negative self-worth, increased self-judgment, and the belief that something is wrong with oneself; this may further contribute to minority stress and feelings of depression and ultimately affect health-seeking behaviors such as HIV testing. Therefore, campaigns that focus on destigmatizing homosexuality and promoting acceptance of one’s sexuality may be helpful in reducing internalized homophobia and improving HIV prevention efforts among MSM.
Previous studies reported that the MSM population in China was vulnerable to poor social support and increased depression and loneliness, which are associated with higher rates of suicidal ideation (Li et al., 2016; Yan et al., 2014). Depression and loneliness may arise due to genetic predisposition, personality development (lack of self-esteem and self-worth) and early or later life experiences. Lonely and depressed people are more likely to experience cognitive distortions, such as seeing neutral stimuli as negative and threatening, which then perpetuate the cycle of psychological distress (Blatt, Luyten, & Corveleyn, 2005). Moreover, many MSM in China do not disclose their same-sex behaviors to others, including health care workers, for fear of being rejected and discriminated against (Choi, Lui, Guo, Han, & Mandel, 2006; Wei et al., 2014). This might discourage them from accessing HIV prevention and other services provided by the Chinese government. Furthermore, decreased communication between MSM and their family and friends about their lifestyle and constantly concealing their sexual orientation may further exacerbate their already existing depressive symptoms and loneliness. To alleviate their psychological distress, they may be prone to pursue high-risk sexual behaviors (Martin & Knox, 1997; Shernoff, 2006). Therefore, development of a nuanced HIV prevention program considering psychological, social, and personality issues should be adopted among MSM in China.
An interesting finding in this study is that participants who are cohabiting with other men have greater odds of being depressed. A possible explanation may be that those MSM who are cohabitating with men are doing so out of necessity because they have been rejected by their family and peers. The rejection from family and peers may contribute to higher levels of isolation, shame, loneliness, and depression, which may then lead to increased risky sexual behavior. Another possibility is that MSM who cohabitate with other men may not feel they can do so openly, but rather feel the need to conceal their living arrangements. The additional stress of hiding their home situation may contribute to increased feelings of stress and depression. To corroborate these hypotheses, a previous study among Chinese MSM showed that cohabiting with a male partner was associated with having increased rates of condomless anal sex (Zhang et al., 2015). This finding supports the idea that MSM who cohabitate with men have higher rates of loneliness and depression, which then increases their risk of having condomless receptive anal intercourse.
People feel lonely when they perceive their interpersonal relationships to be deficient, situationally or chronically. A variety of coping strategies, from constructive to highly destructive, have been adopted by people who feel lonely (Woodward & Kalyanmasih, 1990). Loneliness was shown to be associated with instability of self-esteem, avoidance behaviors, and lower social support among MSM (Martin & Knox, 1997). Loneliness may contribute to difficulties with safer sex negotiation and condom use (Vanable, Carey, Blair, & Littlewood, 2006). A recent study showed that a one-unit increase in the UCLA loneliness score was met with a 10% decrease in the odds of condom usage among a sample of HIV-positive MSM (Hubach et al., 2015). In our study, lonely participants were significantly more likely to have condomless receptive anal intercourse, which is consistent with data from previous studies (Hubach et al., 2015; Martin & Knox, 1997). Lonely MSM may engage in condomless sexual behaviors to nurture committed relationships or seek casual sexual encounters to ward off feelings of loneliness and foster a sense of connection with sex partners (de Voux et al., 2016; Pope, Wierzalis, Barrett, & Rankins, 2007). Therefore, when examining barriers to condom use, psychological factors such as loneliness and depression should be strong considerations in addition to the usual access barriers (e.g., obtaining condoms) and usage barriers (e.g., decreased sexual sensation) (Mimiaga et al., 2013). A better understanding of the social context of the MSM community will benefit HIV prevention programs.
Mental health of MSM is influenced by a collection of environmental, social, and individual factors, especially the contexts they are living in. While previous studies have shown that HIV behavioral interventions are effective in reducing the odds of having unprotected anal sex, deeply rooted social problems and inequities, such as poverty, homelessness, racism, stigma and homophobia, and the resulting mental health problems, may affect HIV risk and can impact the effective delivery of prevention programs. Thus, maximizing the effectiveness of these interventions through continued assessment of mental health issues is critical for a sustainable impact on the HIV epidemic (Herbst et al., 2007). Current HIV programming for MSM in China is heavily focused on promoting condom use and HIV testing, and there are no evidence-based interventions addressing the social and mental health contexts of HIV-related sexual behavior in this population. Measures to prevent HIV in China may have limited efficacy if mental and behavioral health are not considered together. Although the attitude of the general public toward MSM populations has improved dramatically in the past decade, MSM- and HIV-related stigma and discrimination are still highly prevalent in the community. Being attuned to psychological barriers to HIV prevention behaviors that stem from depression and loneliness will be crucial to more effectively combat the HIV epidemic in China. To have more impact, HIV prevention programs should not be limited to screening for mental health and psychosocial issues, but also provide a supportive community for MSM via peer-led education and health communication. A comprehensive intervention program addressing the sexual health and overall wellbeing of MSM at both the individual and the community level should be developed and scaled up nationally. Such interventions should focus on the interaction of psychological and behavioral mechanisms for HIV risk and integrate with treatment of mental health problems found among Chinese MSM. Meanwhile, improving competency of screening and identify early mental disorders of patients among health professionals in HIV organizations will strengthen the current health system in coping with HIV epidemic across China and the world.
This study had several limitations. First, participants were recruited from MSM venues and a gay-oriented website in one Chinese Province. Thus, our findings may not be generalizable to MSM who do not frequent these venues, do not visit the website, or live in other parts of China. Second, data were collected via self-report, which is subject to social desirability bias. This bias was decreased by having participants self-administer our survey. In addition, participants were asked to recall information from the past 6 months, which allows for the potential of recall bias. Finally, loneliness was measured from a single item on the CES-D 10, so may be conflated with our measure for depression. Although the single question has face validity, future studies may consider other fully validated short scales measuring loneliness, such as the short version of the UCLA Loneliness Scale, which contains three items measuring three aspects of loneliness (Hughes, Waite, Hawkley, & Cacioppo, 2004).
In summary, our study suggests that MSM in China have significant rates of depression and loneliness. Loneliness may lead to higher rates of sexual behavior that place MSM at risk for becoming infected with HIV. Further exploration of the pathway through which loneliness leads to increased risky sexual behavior is warranted among Chinese MSM. Prevention programs should integrate mental health and behavioral assessments and interventions with HIV and STI screening in order to be maximally effective. Providing a supportive community to address psychosocial and mental health factors may be the critical step in more efficiently reducing HIV transmission among MSM in China.