Internalized homophobia, mental health, sexual behaviors, and outness of gay/bisexual men from Southwest China

Internalized homophobia is defined as the self-hatred and shame of homosexually oriented individuals that has been incorporated into their belief system [1]; it is also a source of stress. The construct includes negative global attitudes toward homosexuality, discomfort with disclosure of sexual orientation to others, disconnectedness from other lesbian, gay, and bisexual (LGB) individuals, and discomfort with same-sex sexual activity [1, 2]. Accordingly, Meyer has developed the Internalized Homophobia Scale, which has been widely used among sexual minorities in Western countries [3–8].

Social attitudes toward male homosexuals in Western society have improved considerably in the past three decades [9]. The acceptance of legalized same-sex marriage, which almost eliminated partnership differences between homosexual and heterosexual couples in the United States [10, 11] and other developed countries [12, 13], has been accompanied by a decrease in homophobic behavior and internalized homophobia. For example, the number of gay/straight alliances in United States secondary schools rose from 100 in 1995 to more than 3,000 in 2007, and most high school seniors graduating in 2006 favored legalizing same-sex marriage or civil unions [2].

Social attitudes toward male homosexuality in China so far are still not optimistic. First, Chinese traditional values emphasize the continuity of bloodlines. Second, HIV infection has increased at an alarming rate among gay males in recent years [14]. In this context, some Chinese people tend to associate gay men with AIDS [15]. Third, same-sex marriage is illegal and sexual minorities still experience stigma, prejudice, and the occurrence of negative events due to their sexual orientation [16]. Even same-sex behaviors may lead to rejection by one’s family and problems in the work setting [17]. As a result, some gay men choose to conceal their same-sex orientation (especially from their parents) [16] and choose opposite-sex marriage to ease the stress of being members of this minority (i.e., internalized homophobia). A study comparing men who have sex with men (MSM) from outside China with MSM in China using a global online survey found that MSM in China reported higher levels of internalized homophobia [18].

Little empirical information is available about the associations between internalized homophobia, mental health, sexual behavior, and substance use among Chinese gay and bisexual individuals. Previous studies of Chinese MSM have indicated that internalized homophobia was a major barrier to accessing HIV prevention and care services, and it was negatively associated with being tested for HIV [18]. However, that study did not examine the associations between internalized homophobia and mental health. Research studies conducted in developed countries have found that higher levels of internalized homophobia were associated with higher levels of mental health problems (i.e., depression and anxiety) [2, 19]. Additionally, internalized homophobia was found to be associated with practicing HIV at-risk sexual behaviors [1, 20], such as condomless sex, multiple sex partners, and unprotected anal sex among male homosexuals. In addition, previous reviews of studies have reported inconsistent conclusions regarding the relationship between internalized homophobia and substance/alcohol use. Some studies have found an association between higher levels of internalized homophobia and increased alcohol use [21], and substance use [21], such as barbiturates and amphetamines, among male individuals, whereas other studies have reported conflicting findings [22, 23].

Overall, there are differences in cultural and social contexts between Western and Chinese male sexual minorities, especially with respect to the norms and social meanings regarding one’s number of partners (i.e., multiple sex partnerships), which have the potential to affect the expression of individuals’ internalized homophobia. Understanding the issue of internalized homophobia should improve interventions that raise levels of mental health and public health (i.e., HIV risks) among gay and bisexual men. To our current knowledge, two published studies have addressed internalized homophobia among Chinese gay and bisexual men [18, 24], both of which were focused on the associations between internalized homophobia and their rates of HIV testing. However, neither of these studies provided a detailed analysis of internalized homophobia as a risk factor for psychological distress and engaging in unprotected sex among Chinese male sexual minorities.

Previous studies have examined internalized homophobia as a correlate of mental health and health risks in developed countries [3, 5, 7, 21]. Among MSM in China, there has been a dramatic increase in new HIV infections, especially among MSM in Southwest China [14]. Furthermore, MSM could potentially act as a bridge to transmit HIV to the general female population through unprotected sex with females because of their inconsistent condom use [25]. In addition, internalized homophobia has been found to be associated with sexual compulsivity [20, 26]. Thus, we first examined the suitability of the Internalized Homophobia Scale. Second, we examined the associations among internalized homophobia, psychological distress, sexual behaviors, and outness. We hypothesized that internalized homophobia would be positively associated with psychological distress, concealment of sexual orientation, sexual compulsivity, and unprotected sex among Chinese gay and bisexual men. The findings of the study will contribute to a better understanding of internalized homophobia in China, and highlight the need to decrease gay-related psychological stress/distress and improve public health services.

Approximately 75% of the respondents were self-identified as gay, and 25% were bisexual. Forty-three percent disclosed their sexual orientation to others, and 20% possibly disclosed their sexual orientation to their parents. The majority of them had not experienced transactional sex during the previous 6 months (93%). Sixty percent reported having more than one male sex partner during the previous 6 months and 16% reported having female sex partners during the previous 6 months; 55% reported inconsistent condom-use during sex with males and 17% reported inconsistent condom-use during sex with females. In the previous 6 months, 47%, 7%, and 27% reported binge drinking, methamphetamine use, and Rush poppers use, respectively. The mean scores for psychological distress, sexual compulsivity, male sexual attraction, and female sexual attraction were 14.0 (SD = 5.5), 22.1 (SD = 6.3), 4.5 (SD = 0.6), and 2.3 (SD = 1.0), respectively.

Correlations showed that internalized homophobia was significantly and negatively correlated with male sexual attraction (r = −.25, p < 0.001), disclosure of their sexual orientation to others (r = −.36, p < 0.001) or to their parents (r = −.18, p < 0.001), and positively correlated with psychological distress (r = .14, p < 0.01), female sexual attraction (r = .34, p < 0.001), sexual compulsivity (r = .23, p < 0.001), transactional sex (r = .12, p < 0.05), female sex partners (r = .24, p < 0.001), condomless sex with females (r = .18, p < 0.001), and sexual orientation (r = .33, p < 0.001). However, there were no significant correlations between internalized homophobia, substance use, the number of male sex partners, and condomless sex with males.

This descriptive study first examined the suitability of the Internalized Homophobia Scale using confirmatory factor analysis in a sample of Chinese gay and bisexual men. The Chinese version of the instrument was found to have acceptable psychometric properties. More importantly, the study found a relatively high level of internalized homophobia among the Chinese gay and bisexual men, and a positive association between higher levels of internalized homophobia with psychological distress, sexual attraction to females, transactional sex during the past 6 months, having female sex partners and condomless sex with females during the past 6 months, and sexual compulsivity. Higher levels of internalized homophobia were negatively associated with respondents’ disclosure of sexual orientation to other people and their parents, sexual attraction to males, and self-identification as bisexual.

The high levels of internalized homophobia among the gay and bisexual men in this study can be explained by the reality that Chinese social attitudes toward male sexual minorities have been negative [16, 36]. Compared to male sexual minorities outside China [18], those in China, such as gay men, are sometimes considered to be synonymous with HIV/AIDS [15]. Even in Shanghai, a highly cosmopolitan city, MSM reported feeling marginalized and experienced many forms of social discrimination and negative attitudes from multiple groups of people, such as their families, colleagues, and employers [17]. The values of marriage and family responsibilities, which are emphasized in traditional Chinese values, contribute to the development of internalized homophobia among gay and bisexual individuals. The results of this study indicated that more than 30% of the respondents wished they were not gay/bisexual men, would like to be heterosexual, and wished they could develop more erotic feelings about women. As reported in previous studies, individuals with internalized homophobia who were ashamed of their sexual orientation were less likely to have HIV testing and less likely to be exposed to intervention messages or healthcare services targeted to gay/bisexual men [6, 18].

These findings are consistent with our hypothesis that internalized homophobia is positively associated with psychological distress. The hypothesis is also supported by previous studies, which reported that individuals experiencing higher levels of internalized homophobia were more likely to have high levels of psychological distress [19, 37]. According to Meyer’s minority stress theory, gay and bisexual individuals experience conflicting sexual values and a social environment relevant to their same-sex attraction. Once a person self-identifies as being gay, the recognition of their “gay” status has psychologically injurious effects due to social homophobia. Thus, it begins to threaten their psychological well-being [27] and may explain why gay and bisexual individuals are more likely to have suicidal ideation and attempts [38]. In addition, these findings offer an Eastern cultural perspective supporting Southwest Chinese gay and bisexual men and the associations between their internalized homophobia and psychological distress.

After adjusting for the significant confounding variables, internalized homophobia was significantly associated with respondents’ reports of transactional sex during the previous 6 months; and it had, to some extent, a weak association with condomless sex with females and having female sex partners during the previous 6 months. Previous studies have reported a high proportion of transactional sex among MSM in Africa [6, 39], but no associations between internalized homophobia and transactional sex [39]. Although this finding indicates there is a low occurrence of transactional sex among male sexual minorities in China, individuals were more likely to report higher levels of internalized homophobia. Thus, the association between internalized homophobia and transactional sex is inconclusive and might be influenced by race and culture. Unlike the finding of a previous study [40], the present findings suggest that individuals with higher levels of internalized homophobia were more likely to have sex with females, although this finding was not statistically significant but more away from the null. The study also revealed that men with higher levels of internalized homophobia were to some extent more likely to engage in unprotected sex with females. Given the dramatic increase in HIV transmission among Chinese MSM [14, 18], these findings suggest the potential for bridging the transmission between Chinese gay/bisexual men, especially those with higher levels of internalized homophobia, and the general population through female sex partners. However, no relationship was found between internalized homophobia and substance use in this sample. Similar to a previous review, mixed results have been reported in studies of these relationships [41]. Cultural and social consciousness might determine these associations.

Higher levels of internalized homophobia were significantly associated with a lower level of disclosure to others and parents. It is possible that the men with higher levels of internalized homophobia were more likely to experience sexual minority stress, thereby engaging in behaviors to protect themselves from harm [5], such as rejection by parents, relatives, and friends, and threats to employment. They might have also developed coping behaviors to comfort themselves. This information may also be applied to helping members of this population solve problems related to minority stress and to improve the mental health of individuals who cope with concealing their sexual orientation. We also found that respondents with higher levels of internalized homophobia were significantly less likely to report male sexual attraction and more likely to report female sexual attraction. Previous studies showed that sexual orientation was generally consistent with sexual attraction [31]. This finding supports the finding of Vu and Sheehy’s study that MSM who did not identify themselves as gay were more likely to report internalized homophobia [6]. In addition, we found a relationship between internalized homophobia and sexual compulsivity. These findings are consistent with those of past studies that reported a negative association between internalized homophobia and gay/bisexual individuals’ mental health, which includes addictive and psychosomatic symptoms [20, 26].

The study has several limitations. First, the data are cross-sectional; thus, causal relationships cannot be inferred. Additionally, some of the associations were weak, such as the association between internalized homophobia and transactional sex during the previous 6 months. Second, participants were recruited via the Internet, which has the disadvantage of self-selection and might have resulted in the underrepresentation of certain populations, e.g., older respondents. Third, certain topics requiring self-report, such as amphetamine use and transactional sex are sensitive in the Chinese culture, which might have biased the responses due to social desirability [42]. Fourth, measure of the choice of disclosure of sexual orientation to others and parents was not fully conceptualized compared with previous studies [3, 5]. Further studies using an adequate definition and measure of outness are needed to understand the experiences of Chinese male sexual minorities.

This study has important implications because it is the first to examine the prevalence and correlates of internalized homophobia among Chinese gay and bisexual men. It also provides a much-needed cross-cultural perspective, as it was conducted in the context of the Chinese culture. High levels of internalized homophobia were found among Chinese male sexual minorities, and internalized homophobia was positively associated with psychological distress, transactional sex during the previous 6 months, and the concealment of sexual identity to others and parents. The Chinese government’s involvement, such as MSM community-based advocacy efforts as well as government-enforced policies in the prevention of internalizing homophobia among gay/bisexual men, is important to buffer the negative effects of a homophobic society on the mental health of this population. Decreasing their gay-related psychological distress and stress, as well as HIV transmission via male-to-female sex, should improve the public health of all.