Liu et al. BMC Psychiatry (2018) 18:217 https://doi.org/10.1186/s12888-018-1787-7 RESEARCH ARTICLE Open Access Association of recent gay-related stressful events with depressive symptoms in Chinese men who have sex with men Yunyong Liu1*, Chao Jiang2, Siyao Li3, Yuan Gu4, Yan Zhou5, Xiaoxia An6, Li Zhao7 and Guowei Pan8 Abstract Background: To assess the association of different gay-related stressful events (GRSEs) with depressive symptoms in Chinese men who have sex with men (MSM). Method: A total of 807 MSM were recruited using respondent-driven sampling from four cities in northeastern China. GRSEs were measured using the Gay Related Stressful Life Events Scale, and depressive symptoms were assessed using the Self-Rating Depression Scale (SDS). Results: A total of 26.0% of study participants experienced GRSEs in the past three months, and the average SDS score was lower than the previously reported national average for China. The study participants had significantly elevated risks of depression (SDS score ≥ 53) due to recent troubles with a boss (OR = 4.92, 95% CI = 1.87–12.97) or a workmate (OR = 3.68, 95% CI = 1.52–8.88), loss of a close friend (OR = 2.41, 95% CI = 1.39–4.18), argument with a close friend (OR = 2.07, 95% CI = 1.33–3.22), and being physically assaulted (OR = 2.08, 95% CI = 0.98–4.43). Arguments with family members or classmates had no significant effect on depression. Multiple logistic regression analysis showed that the number of GRSEs, a lower level of education, more advanced age, and HIV infection significantly increased the risk of depression. Conclusions: There are large differences in the associations of different types of GRSEs with depressive symptoms. Reducing the stigmatization and discrimination toward MSM in all social environments and improving the capability of MSM to cope with different types of GRSEs may improve their emotional wellbeing. Keywords: Men who have sex with men, Gay related stressful event, Depressive symptoms, Social support Background the lifetime prevalence of major depression disorder and Homosexuality has been traditionally stigmatized and suicide attempt were about 2.2 and 5.8 times greater prejudiced in many countries, men who have sex with than that of male adults in the general population of men (MSM) have been identified as a higher risk group China [8, 9]. Social support refers to the provision of for depression as compared with general populations psychological and material resources by people within [1–3]. Many studies reported that MSM experience high one’s social network [10]. As an isolated and marginal- levels of gay-related stressful events (GRSEs) from mul- ized population, MSM has inadequate level of social tiple life domains (e.g.,family, work, school, relationship) support, which has been shown to act as a ‘stress buffer’ because of their gay behaviors or orientation [4–6]. The to mitigate depression [11, 12]. It’s estimated that 77,000 total population of Chinese MSM has been estimated at Chinese MSM have been infected with human immuno- 17.82 million [7], they are particularly vulnerable to psy- deficiency virus (HIV) [13], and many studies have dem- chiatric disorders compared with heterosexual males, onstrated that the health concern about HIV infection has become the most prominent health risk and source * Correspondence: [email protected] of stress of MSM [14]. Some studies suggested that the 1Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Xiaoheyan Road 44, Dadong District, Shenyang 110042, People’s experienced GRSEs, lack of social support and the high Republic of China rate of HIV infection among gay men contributed to Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Liu et al. BMC Psychiatry (2018) 18:217 Page 2 of 7 their higher prevalence of poor mental health [15–18], occurrence of incidents related to sexual orientation and researchers have suggested that these additional over the past three months, including the arguments external stressors may directly lead to psychosocial with friends and relatives; conflicts in the home, society difficulties; or indirectly via internal factors (like in- and workplace; and loss of friends and victimization. ternalized homophobia), through a process termed The total score was calculated by summing the num- minority stress [19]. ber of items checked, and a higher score indicates Previous studies in western countries have identified greater stress. that the type and intensity of GRSEs is related to the ex- tent of psychological dysfunction [1–6, 20, 21]. However, Social support few studies have assessed the associations between dif- Social support was measured by the 10 items Social ferent types of GRSEs and depressive symptoms in Chinese Support Rating Scale (SSRS) [25], which measure sub- MSM. A better understanding of characteristics of the rela- jective support (4 items), objective support (3 items), tionships between various types GRSEs and emotional dis- and support-seeking behavior (3 items). The scores of 3 tress in these men has clear implications for reducing their dimensions of SSRS were added to generate a total score stress and improving their mental health. of 0 to 50, and a higher score indicates stronger social The present study aimed to assess the following hy- support. The SSRS has good reliability and validity [25], potheses regarding Chinese MSM: (1) recent GRSEs cor- the internal consistency (Cronbach’s alpha) was 0.89– relate with depressive symptoms; (2) different types of 0.94 and the test-retest reliability is 0.92. GRSEs have distinct effects on depressive symptoms; (3) concern about HIV infection and lack of social support HIV testing increases the risk for depressive symptoms. HIV was tested with the Chinese national standard pro- tocols and laboratory methods [26]. An enzyme-linked Methods immunosorbent assay (ELISA) method was used to con- We have described the selection of MSM of the study duct the initial screening, and positive results were con- previously [8]. In brief, 807 MSM were recruited from firmed by a western blotting. We defined a result as four cities of Liaoning Province using a standardized positive only if both tests were positive. All laboratory respondent-driven sampling (RDS) procedure. Respon- tests were performed in the AIDS labs of LNCDCP. dents were included if they (1) had oral or anal sexual relations with another man during the previous Statistical methods 12 months, (2) 18 to 65 years-old, (3) agreed to We used SPSS, version 17.0 to conduct the data analysis. complete a questionnaire, (4) provided blood samples We used the analysis of variance (ANOVA) to determine for testing. The trained interviewers used a structured the significance of relationships of demographic charac- questionnaire to interview all subjects, without asking teristics, types of GRSEs, and SDS score. We used a lin- names and other personal information, including per- ear trend test to examine differences in mean changed sonal identification numbers. of SDS scores by the number of GRSEs. We conducted The study was conducted in accordance with the bivariate logistic regression analyses of the presence/ Declaration of Helsinki. Verbal consents were obtained absence of depression (SDS ≥ 53) for calculation of from all subjects prior to interview. The ethics commit- crude odds ratios (ORs) and 95% confidence intervals tee of Liaoning Provincial Center for Disease Control (CIs) to examine the associations with each type of and Prevention (LNCDCP) approved the study. GRSEs with adjustment for age. We conducted step- wise multivariate logistic regression analyses to calcu- Depressive symptoms late the adjusted ORs. Depression symptoms were measured with the 20 items Self-Rating Depression Scale (SDS) [22]. Each item was Results scored from 1 to 4 (never or occasionally, sometimes, Table 1 shows the basic characteristics of the 807 re- often, and most of the time), and multiplied by 1.25 to cruited MSM. A total of 71.3% were younger than obtain a total score of SDS ranging from 25 to 100. The 30 years-old, 13.4% were married to females, 11.4% lived subjects with an SDS score ≥ 53 were classified into the with male partners, 40.3% were bisexual, and 47.2% were depression group, the internal consistency (Cronbach’s gay, and 3.47% were HIV-positive. The average SDS alpha) of the SDS was 0.92 [23]. score was 47.29 ± 11.39, and the overall prevalence of depression (SDS ≥ 53) was 33.09%. Gay-related stressful life events The levels of SDS score had a significant linear increase GRSEs were measured with the 12 items Gay Related with age (p < 0.001), and significant linear decrease with Stressful Life Events Scale [24], which measures the education (p < 0.001) and social support (p < 0.001). Liu et al. BMC Psychiatry (2018) 18:217 Page 3 of 7 Table 1 Comparison of the levels of SDS scores and risks of depression (SDS score