Perceived attitudes of family and peers toward same-sex marriage as a distal sexual minority stressor for gay and bisexual men in Taiwan

Lesbian, gay, and bisexual (LGB) individuals have been reported to have a higher risk of mental health problems, such as depression [1, 2], anxiety [2], and loneliness [3], as well as suicide [1], compared with their heterosexual peers. Minority stress theory [4] is the most common theoretical framework used to explain mental health disparities between LGB individuals and heterosexuals. Sexual minority stress is defined as the unique stress experienced by LGB individuals living in a social environment characterized by heterosexualism and consequent prejudice and stigma toward LGB individuals [4]. Sexual minority stressors are broadly divided into distal stressors (e.g., victimization, discrimination, and microaggression against sexual minorities) and proximal stressors (e.g., internalized homonegativity, concealment of sexual orientation, and expectations of rejection) [4]. Research has indicated that sexual minority stressors compromise LGB individuals’ mental health directly or through the mediation of cognitive dysfunction (e.g., rumination) [4‐6].

Perceived social attitudes toward LGB sexual orientation and culture are well recognized as a distal sexual minority stressor for LGB individuals [4]. Research has revealed that perceived unfavorable attitudes toward homosexuality from the public [7, 8] and family members and peers [9, 10] increase the risk of mental health problems among LGB individuals. As societies evolve, the unfavored targets of social attitudes rooted in heteronormativity may change and even expand. Legalization of same-sex marriage (SSM) has been intensely debated in recent decades [11‐13]. As of June 20, 2022, SSM was legal in 29 countries [14]. Legalization of SSM not only extends equal rights to LGB individuals but also yields health benefits for this population [15‐18]. However, unfavorable attitudes toward SSM remain prevalent in society, even in the countries or regions where SSM is legal [12, 19].

The campaign for SSM in Taiwan has been an arduous one. In May 2017, Taiwan’s Council of Grand Justices announced that the prevailing Civil Code that barred SSM was a violation of the human right to equality and was unconstitutional. However, people in Taiwan voted in a referendum to oppose changing the Civil Code to allow SSM. On the basis of the referendum results and the judgment of the Council of Grand Justices, the Taiwan government introduced a special act to legalize same-sex civil unions but not SSM for same-sex couples in May 2019 [20].

Whether perceived attitudes of family and peers toward SSM is a distal sexual minority stressor remains uncertain. According to minority stress theory [4], a distal sexual minority stressor should meet the following conditions: (1) it is specific to a sexual minority population; (2) it is strongly related to existing distal sexual minority stressors; (3) it contributes to the formation of proximal sexual minority stressors; and (4) it results in psychological distress. The stress triggered by perceived attitudes of family and peers toward SSM is specific to LGB individuals. Research has demonstrated that perceived unfavorable attitudes of family and peers toward SSM are associated with mental health problems among LGB individuals [9, 10]. However, perceived attitudes of family and peers toward SSM are not included in the currently used measures for sexual minority stressors (e.g., the 8-item Sexual Minority Stress Scale for Lesbian Women’s Everyday Lives [21], Couple-Level Minority Stress Scale [22], and Daily Sexual Minority Stressors Scale [23]) or sexual stigma (the Neilands Sexual Stigma Scale [24], Sexual Stigma Scale for Lesbian, Bisexual and Queer Women [25], and HIV- and Homosexuality-Related Stigma Scale [HHRS] [26]). Moreover, although research in the United States before the legalization of SSM nationwide indicated that LGB individuals living in states where SSM was banned experienced significantly higher levels of internalized homonegativity than those living in states where SSM was legal [27], the association of perceived attitudes of family and peers toward SSM with internalized homonegativity in LGB individuals has not been examined at the individual level. To elucidate the role of perceived attitudes of family and peers toward SSM as a distal sexual minority stressor, further study should examine its associations with the items of the existing scales measuring sexual stigma and internalized homonegativity.

In this cross-sectional study, we examined the associations of perceived attitudes of family and peers toward SSM with perceived sexual stigma from family and peers, internalized homonegativity, and mental health problems (depression, loneliness, and anxiety) among gay and bisexual men in Taiwan. We hypothesized that perceived attitudes of family and peers toward SSM (1) would have significant correlations with each item measuring the level of perceived sexual stigma from family and peers on the Homosexuality subscale of the HHRS, (2) would be significantly associated with internalized homonegativity, and (3) would be significantly associated with depression, loneliness, and anxiety.

The 400 participants’ demographic information and data on perceived attitudes of family and peers toward SSM, perceived sexual stigma from family and peers, internalized homonegativity, and mental health problems are listed in Table 1. The mean age of the participants was 30.7 years (SD = 5.9 years); 83.2% had an education level of college or above; 83.2% self-identified as gay. The mean scores (SD) for perceived attitudes of family and peers toward SSM, perceived sexual stigma from family and peers, and the Social Discomfort, Sexuality, Identity subscales of internalized homonegativity were 3.1 (0.9), 26.9 (6.8), 19.0 (6.6), 11.3 (3.1), and 10.6 (4.5), respectively. The mean scores for the severity of depression, loneliness, and anxiety were 18.3 (11.1), 43.5 (11.1), and 39.2 (12.5), respectively.

Table 2 presents the ICC results regarding the correlations of perceived attitudes of family and peers toward SSM with perceived sexual stigma from family and peers on each item of the MC-HHRS-H. The ICC values ranged from 0.635 to 0.826, indicating that perceived attitudes of family and peers toward SSM had a moderate to large correlation with the 10 items of perceived sexual stigma from family and peers on the MC-HHRS-H.

The multilinear regression results for the associations of perceived attitudes of family and peers toward SSM (1) with the Social Discomfort, Sexuality, and Identity subscales of internalized homonegativity on the MC-MISS-LG and (2) with depression, loneliness, and anxiety are presented in Tables 3 and 4, respectively. With the effects of age, education level, and sexual orientation controlled for, perceived attitudes of family and peers toward SSM was significantly associated with (1) increased internalized homonegativity on all dimensions of the MC-MISS-LG and (2) increased depression, loneliness, and anxiety severity.

Because that demographics and sexual orientation were significantly associated with some subscales of internalized homonegativity and mental health problems, the interactions between demographics, sexual orientation, and perceived attitudes of family and peers toward SSM were entered into multilinear regression analysis models to examine their associations with internalized homonegativity and mental health problems (Tables 3 and 4). The results indicated that the interaction between age and perceived attitudes of family and peers toward SSM was significantly associated with the Sexual subscale of internalized homonegativity, indicating that the association between perceived attitudes of family and peers toward SSM and the Sexual subscale of internalized homonegativity was stronger among older participants. Education and sexual orientation did not moderate the associations of perceived attitudes of family and peers toward SSM with internalized homonegativity and mental health problems.

Perceived attitudes of family and peers toward SSM were also significantly correlated with each item on the MC-HHRS-H. The MC-HHRS-H measures various aspects of perceived sexual stigma such as lack of acceptance of sexual minority or gender nonconformity, social barriers, familial disappointment, and stereotyping [26]. Perceived sexual stigma from family and peers is a typical distal sexual minority stressor. The significant correlation between perceived attitudes of family and peers toward SSM and perceived sexual stigma from family and peers highlights the role of perceived attitudes of family and peers toward SSM as a distal sexual minority stressor for gay and bisexual men. According to minority stress theory [4], multiple forms of distal minority stressors may successively or simultaneously contribute to the formation of proximal minority stressors and mental health problems. As a specific dimension of sexual minority stressor, perceived attitudes of family and peers toward SSM might be less influential in shaping internalized stigma and mental health problems than perceived general sexual stigma. However, as societies evolve, emerging sexual minority stressors such as perceived unfavorable attitudes of family and peers toward SSM warrant further study.

In this study, perceived attitudes of family and peers toward SSM was significantly associated with internalized homonegativity in gay and bisexual men. According to socioecological theory [40], internalized homonegativity is the result of the interaction between LGB individuals and their environments (e.g., microsystem, mesosystem, exosystem, and macrosystem). Family and peers are the microsystems that gay and bisexual men most frequently interact with. Research has revealed that perceived sexual stigma from family and peers contributes to the development of internalized homonegativity in LGB individuals [41, 42]. Considering that internalized homonegativity is one type of proximal sexual minority stressor, the significant association between perceived attitudes of family and peers toward SSM and internalized homonegativity underscores the role of perceived attitudes of family and peers toward SSM as a distal sexual minority stressor for gay and bisexual men. Moreover, the present study found that the association between perceived attitudes of family and peers toward SSM and the Sexual subscale of internalized homonegativity was stronger among older participants. Gay and bisexual men in Taiwan face the stress from the family obligations mandated in Confucianism to continue the family bloodline. Therefore, older gay and bisexual men may perceive greater attitudes of family and peers against SSM, feel stronger pressure, and develop greater internalized homonegativity regarding intimate gay relationships and sexual behaviors compared with younger gay and bisexual men.

Consistent with the results of previous studies [9, 10], we found that perceived attitudes of family and peers toward SSM was significantly associated with depression, loneliness, and anxiety in gay and bisexual men. Although mental health problems in gay and bisexual men have various etiologies [43], the impact of perceived attitudes of family and peers toward SSM on mental health in gay and bisexual men warrants consideration. For example, research has revealed that perceived attitudes of family and peers toward SSM might partially account for the high rates of suicidal ideation [44] and suicide attempts [45] among LGB individuals during the debate and referendum regarding SSM in Taiwan.

This study has some limitations. First, we used only one question to assess the attitudes of family and peers toward SSM; therefore, we could not identify the sources of attitudes toward SSM, the reasons for not accepting SSM, and the ways to perceive the attitudes. Given that all these characteristics of perceived attitudes of family and peers toward SSM may contribute to the sexual minority stress experienced by LGB individuals, further study is needed to deepen the understanding of perceived attitudes of family and peers toward SSM in LGB individuals. Second, because of the cross-sectional study design, we could not determine the temporal associations between perceived attitudes of family and peers toward SSM and internalized homonegativity and mental health problems. Third, the sample of this study was composed of gay and bisexual men with homogeneous age and education level; therefore, the findings may not be generalizable to all gay and bisexual men. Moreover, whether gay and bisexual men with various ethnicities, social classes, and urban and rural background perceive different levels of unfavorable attitudes of family and peers toward SSM also warrants further study. Fourth, we did not consider the participants’ gender identity; therefore, the interacting effect of sex and gender on perceived attitudes of family and peers toward SSM could not be determined.

The present study is the first one to examine the role of perceived attitudes of family and peers toward SSM as a distal sexual minority stressor. The results of this study did support the potential of perceived attitudes of family and peers towards SSM to be incorporated into a revised scale measuring sexual minority stressors. However, the contents and characteristics of perceived attitudes of family and peers toward SSM warrant further study. Furthermore, most of the items on the scales for sexual minority stressors (e.g., HHRS used in this study) measure perceived general sexual stigma but not the stigmatizing attitudes toward some specific characteristics of LGB individuals such as SSM. Therefore, how to integrate perceived attitudes of family and peers toward SSM into a revised scale measuring sexual minority stressors warrants further study.

Perceived attitudes of family and peers toward SSM was significantly correlated with perceived sexual stigma from family and peers, internalized homonegativity, depression, loneliness, and anxiety in gay and bisexual men. Perceived attitudes of family and peers toward SSM matched the characteristics of a distal sexual minority stressor, as defined in minority stress theory. More research is needed on perceived attitudes of family and peers toward SSM and its associations with other distal minority stressors, proximal minority stressors, and mental health problems in LGB individuals. Mental health professionals should take perceived attitudes of family and peers toward SSM into consideration when developing intervention programs for mental health of LGB individuals.