Introduction
Intimate partner violence (IPV) is generally defined as physical, sexual, psychological or financial harm by a current or former intimate partners or spouse [
1,
2], which is a significant public health issue among women. However, IPV is not exclusive to opposite-sex relationship. The emergency of research on men who have sex with men (MSM) has demonstrated that IPV occurs in male-male partnerships at rates similar to or higher than opposite-sex relationship [
3]. A recent systematic review concluded that the estimated prevalence of lifetime IPV was 41.2% [95% confidence interval (CI) 32.4–50.1%] among MSM [
3]. Studies in China also documented high prevalence of IPV among MSM: ranging from 18.7 to 51.0% for any form of IPV [
4‐
7], 6.6–16.1% for physical IPV, and 5.5–5.7% for sexual IPV. Some studies also show that IPV prevalence is higher in special groups of MSM, such as male sex workers (57.4%) and men who have sex with men and women (37.6%) [
4,
7]. IPV experiences can result in a variety of high-risk sexual behaviors and health problems, such as substance use, engagement in unprotected anal intercourse, group sex, transactional sex, HIV infection [
6,
7], depression, and suicide behaviors [
3]. For instance, a survey among MSM in UK in the PROUD trial from 2012 to 2014 showed that clinically significant depressive symptom prevalence was approximately three times higher in MSM who reported IPV victimization (adjusted prevalence ratios =2.57, 95% CI = 1.71–3.86,
P < 0.001 for lifetime IPV victimization; adjusted prevalence ratios =2.93, 95% CI = 1.96–4.40,
P < 0.001 for IPV victimization in last year) [
8]. A survey among HIV-negative MSM in Northeastern China in 2014 showed that 18.7% (89/476) of the participants reported being victims of any form of IPV (including physical, psychological and sexual) in the past 3 months and those who had been victims of IPV in the past 3 months were more likely to suffer from symptoms of depression (adjusted odds ratios = 2.8, 95% CI = 1.7–4.5,
P < 0.05) [
6]. Although the issue of IPV and mental health has attracted more attention globally, researches on the relationship between IPV victimization and mental health among MSM in China are still rare. Thus, it is greatly warranted to have a closer look at the association between IPV and depression among MSM population in China.
Although the association between IPV and depression in MSM has been reported in literature, the potential pathways linking IPV and depression have been rarely explored. This is crucial for developing effective interventions to maintain and promote mental health of IPV victims. Lifetime IPV victimization among MSM was strongly associated with self-stigma against sexual minority status, which involves a process of incorporating negative societal views of homosexuality into the self-concept [
8,
9]. According to the minority stress theory [
10,
11], sexual minority people in a heterosexual society are subjected to chronic stress related to their stigmatization, such as self-stigma and perceived stigma, which are prominent determinants of mental health for minority populations. Empirical evidence also suggested that self-stigma was significantly associated with greater risk of depression among Chinese MSM [
12‐
14], especially among HIV-positive MSM. In addition, several studies have demonstrated that self-stigma was a significant mediator in the association between prejudiced experiences such as victimization and mental distress among sexual minorities [
15,
16]. This may suggest a possible mediation effect of self-stigma on the relationship between IPV victimization and depression in MSM [
17].
Another potential mediator is self-efficacy, which denotes the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations [
18,
19]. The perception of having personal control and confidence is one important factor in the study of contributors to mental health after exposure to potentially traumatizing events. Extant literature on self-efficacy in IPV victims were mainly focused on financial self-efficacy and condom negotiation self-efficacy among heterosexual women [
20,
21]. Few studies have explored the impact of self-efficacy on the mental health of MSM with IPV victimization. The experience of IPV could be particularly harmful for self-worth and self-efficacy, due to the role that the interactions with others play in the development of self-representations [
22]. A study conducted among Chinese MSM indicated that a higher level of general self-efficacy was associated with lower levels of depression [
23]. General self-efficacy has been found to be a mediator between stressful life events and depressive symptoms among general population [
24]. Thus, IPV may deteriorate self-efficacy, which in turn may increase the risk of depression. In addition, previous studies among sexual minority population revealed that self-stigma could weaken one’s self-efficacy [
25] and lead to negative health outcomes, such as unhealthy behavior [
26] and adverse psychological problems (e.g., depression) [
27].
Thus, the present study aimed to investigate the association between IPV victimization and depression among Chinese MSM, and to test the extent to which the association between IPV and depression would be mediated by self-stigma and self-efficacy. We hypothesized that: (1) IPV victimization would be associated with higher self-stigma and lower self-efficacy; (2) self-stigma would be negatively associated with self-efficacy and positively associated with depression; (3) self-efficacy would be negatively associated with risk of depression.
Discussion
The study examined the association between IPV victimization and depressive symptoms among Chinese MSM and tested the mediation roles of homosexual self-stigma and self-efficacy. The findings showed that prevalences of lifetime IPV victimization and probable depression were high among Chinese MSM. The mediation model further revealed the association between level of IPV victimization and depression was fully mediated via higher homosexual self-stigma and lower self-efficacy.
The prevalence of IPV victimization was 32.7% (189/578), which was higher than the prevalence reported by two prior surveys among MSM in China (29.8 and 24.3%) [
5,
7]. Different from previous studies, the present study included only eligible participants who had or had ever intimate partners, and used a more comprehensive assessment of IPV that involved five different domains. Thus the result could be partially attributed to the cross-study variations in methodology (e.g., sample characteristics, definition and measurement of IPV). We also found a prevalence of 36.0% of depression in the MSM sample, which is comparable to the prevalence reported in previous studies among MSM in China [
40,
41]. Younger age and lower income level were associated with increased risk of depression, corroborating with prior studies among Chinese MSM [
42,
43]. MSM commonly suffer from stress or rejection due to their sexual identity from family [
44]. A qualitative study also showed that internalized homophobia was higher when the MSM population were younger and concealment strategies are often used by young MSM instead of coming out to avoid discrimination and violence associated with stigmatized identity [
45]. A study showed that Younger MSM had a higher prevalence of anxiety than older MSM [
41], which was also strongly linked to depression. In addition, young MSM were more likely to have sexual risk behaviors and have lower utilization of mental health care, which may further aggravate their psychological problem [
46]. Personal income is also associated with depression, which might be partially explained by the financial hardship, discrimination and social stress related to poverty [
47]. Mental health interventions and services therefore should be prioritized for younger and poorer MSM, who might be more vulnerable and lack of resources to cope with mental distress.
Consistent with previous studies [
48,
49], higher level of IPV victimization was associated with increased risk of depression. The findings further revealed that self-stigma and self-efficacy fully mediated the association between level of IPV and depression. This indicated that IPV experiences increased internalized stigma towards self and was detrimental to self-efficacy, which in turn greatly increased the risk of depression, and psychological interventions to manage negative emotions about one’s sexual minority identity and disrupt negative cognitive appraisals may be helpful to prevent depression in MSM who were IPV victims. Our results provided empirical support for the minority stress model, which posits that self-stigma might be induced by external negative experiences and is an important factor in the development of psychopathology among sexual minorities.
In addition, higher level of IPV and self-stigma was associated with lower self-efficacy and for the first time, self-efficacy was confirmed as a mediator in the association between IPV and depression among MSM population. It seemed that, the violent treatment by intimate partners and negative attitudes towards self could be particularly harmful to the personal sense of competence or confidence in managing problems. These findings corroborate a previous study that supported a similar serial mediation model of self-stigma and self-efficacy in the association between prejudiced events and physical health among sexual minority populations [
50]. In fact, several studies have suggested that general self-efficacy may be a source of resilience for people involved in aggressive intimate relationships [
51]. Thus the results underscored the importance to increase self-efficacy, for example via personal empowerment and cognitive-behavior therapy, in order to reduce the negative impacts of IPV and stigma on mental health in counseling interventions and psycho-educational programming targeted at MSM.
The study has several limitations. First, given the cross-sectional nature of the present study, we cannot infer any conclusive causal relationships which demands longitudinal studies to further reveal the causalities between these variables. Second, the results may not be generalized to other cultures and populations. Third, reporting bias may exist due to the nature of self-reported data. Fourth, although we recruited participants from 15 cities, selection bias may exist as participants were recruited from local gay-friendly organizations using convenience sampling. Local community organizations could be an importance source of social support and thus participants who had close ties to the organization may have better mental health than those who did not. In addition, majority of the study participants were urban residents and may not be representative of general MSM population. Fifth, IPV-GBM used in the present study has not yet been validated in Chinese MSM and further research is warranted to explore the application and psychometric properties in Chinese population.
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