The association between involuntary subordination and common mental disorders among men who have sex with men (MSM) in Shanghai, China

There are much higher rates of depression, anxiety, panic disorders, and substance use disorders in men who have sex with men (MSM) than in heterosexual men [5‐7, 26, 35, 36]. Research shows that 60% of MSM in China exhibit symptoms consistent with negative mood, such as extreme tension, depression, anxiety, panic, and loneliness, and 20% of these individuals report previous suicidal attempts. MSM are a sexual minority group and therefore may not easily be accepted into mainstream society. MSM are subject to institutionalized prejudice, social stress, social exclusion, physical violence, physical harassment, rape, incest, and destruction of personal property, which can negatively affect their psychosocial condition [20, 32]. According to minority stress theory, MSM experience disproportionately burdensome degrees of stigma, prejudice, and discrimination. As a result, they are at risk for increased levels of depression, substance use [27, 28]. Studies have shown that mental disorders like depression and anxiety contribute to human immunodeficiency virus (HIV) vulnerability and suicidal ideation [18, 23, 24].

According to social rank theory, involuntary subordination is a mechanism that switches off fighting behaviors when a losing organism is unable to continue in a struggle (thus saving the organism from injury). A subordinate individual may feel helpless, hopeless, inferior, and inadequate and exhibit inhibition of thought. Involuntary subordination leads to a redirection of behavior toward the pursuit of more realistic goals and a new position in the social hierarchy ([38, 17]). However, if individuals are incapable of escaping from a defeating situation or cannot accept defeat, involuntary subordination becomes prolonged and maladaptive, and then manifests as major depression and anxiety disorders ([38, 39, 42]). Social rank theory views depression as a natural consequence of prolonged involuntary subordination. Sturman and Mongrain found that involuntary subordination predicts the recurrence of major depression [45]. Involuntary subordination has also been linked to anxiety disorders. Anxious people may have a defense system dominated by frequent social comparisons and a readiness to submit [11, 12, 48, 49].

Early conceptualizations of involuntary subordination defined it as a latent variable derived from entrapment (feeling stuck or trapped and wanting to escape) and poor social comparisons (i.e., feelings of perceived inferiority) [45]. This definition was later considered too narrow and subsequent research has expanded the concept of involuntary subordination to include other constructs. For example, submissive behavior may be associated with involuntary subordination. Taylor has suggested, on theoretical grounds, that defeat should be considered another indicator of involuntary subordination [47]. Therefore, involuntary subordination can be regarded as a range of interconnected feelings and perceptions, including the perception that one is of lower status than others (unfavorable social comparison), the feeling that one has been defeated by a dominant other (social defeat), the feeling that one has no chance to escape an uncontrollable set of circumstances (entrapment), and the perception that one wishes to avoid conflict (submissive behavior) [1, 2, 11, 13]. A confirmatory factor analysis supported this four-variable model of involuntary subordination [44]. This model provides the basis for a new empirical involuntary subordination measure, which draws on items from questionnaire measures of the four variables (unfavorable social comparison, social defeat, entrapment, and submissive behavior) to evaluate involuntary subordination in a more comprehensive way.

Defeat, entrapment, submissiveness, and perceived low status (unfavorable social comparison) are associated with different types of psychopathology through maladaptive functioning of involuntary subordination [13, 15]. However, there is little research on these associations. It also remains unclear whether involuntary subordination, as it reflects social adaptive functions, is associated with psychological problems in sexual minority groups. Therefore, a new focus is needed on the psychological correlates of MSM. The purpose of this study was to investigate symptoms of depression and anxiety among MSM in metropolitan Shanghai, China, and to explore the role of involuntary subordination in depression and anxiety. The primary study hypotheses were (1) involuntary subordination is related to depression and anxiety status and (2) involuntary subordination constructs (defeat, entrapment, submissiveness, and low perceived status) are associated with depression/anxiety. Guided by previous research findings, we used a combined theoretical and empirical approach to examine these hypotheses and generate recommendations for diagnosis and intervention strategies for anxiety and depression among MSM.

Table 1 summarizes the associations between sociodemographic characteristics and depression/anxiety among MSM. The 547 MSM who completed the survey had a mean age of 30.5 years (range 17.3–65.3); 79.3% of the participants reported never having been married and 5.7% were divorced or widowed. Most (71.3%) reported being homosexual. HIV test outcomes were 5.9, 80.2, and 13.9% for positive, negative, and unknown, respectively. Binary logistic regression showed a significant relationship between the sociodemographic variable of education level and depression. Individuals with a college level or higher level of education had a lower level of depression (ORu = 0.579, 95% CI = 0.392–0.855). Binary logistic regression showed a significant relationship between the sociodemographic variable of income and anxiety. Individuals earning more than 6000 yuan per month had a lower level of anxiety (ORu = 0.494, 95% CI = 0.257–0.948).

Our findings indicated a high prevalence of psychosocial problems among MSM in Shanghai, China. Almost one third of the participants (30.9%) suffered from depression; the prevalence of depression in the general adult population in China is 2.06%. The findings also showed that anxiety was more prevalent in our sample (12.2%) than in the general population in China (1.32%) [31]. The results of the current study indicate that the MSM population experiences poor mental health. As expected, all ISQ components were related to depression and anxiety among MSM.

The significant associations found here between sociodemographic variables and depression and anxiety support previous findings. MSM who have a higher education level are less likely to have depression symptoms. Education improves well-being in men, because it increases work creativity and a sense of control and provides payoffs, such as feelings of dominance and earning capacity [34]. We found that income was associated with anxiety disorders; a pattern consistent with previous study findings [10]. Previous research indicates that low income is linked to distress, because it functions as an indirect proxy for social rank [9, 52].

Involuntary subordination manifests as clinical depression and anxiety disorders when individuals cannot accept their new social position following failure in competition [38, 39]. Involuntary subordination, as a reflection of social strata at the community level, affects psychological and emotional factors at an individual level. Recent research has clarified the role of social adaptive functions in psychological problems. Depression has been viewed as a mechanism that reduces social risk [3] and social loss [22], and solves social problems through rumination, agitation, and the seeking of social support [51].

All the involuntary subordination variables were associated with both depression and anxiety after adjusting for sociodemographic factors. This could be explained by the relatively high comorbidity of depression and anxiety and the overlap between the symptomatology and neurology of these disorders [30]. Allan and Gilbert have demonstrated that poor social comparison is associated with higher levels of interpersonal sensitivity and depression in both nonclinical student and psychiatric inpatient groups [16]. Sturman and Mongrain [43]. have shown that internal and external entrapment account for about 50% of the variance in self-reported levels of depression. Depressed individuals have a strong desire to escape from aversive thoughts or external circumstances and perceive their situation as uncontrollable. One study found that submissive behavior (labeled as “subassertive”) was associated with various psychological problems (e.g., depression and social anxiety) [21]. One systematic review [46] has confirmed that defeat and entrapment both play a central role in depressive symptoms, anxiety, and suicidality.

The present findings showed that defeat, entrapment, low perceived status, and submissiveness were still significantly associated with depression after adjusting for sociodemographic factors. However, only defeat and entrapment were significantly associated with anxiety in both the univariate and multivariate regression models. Although anxiety and depression may share common evolutionary origins [29], some research indicates that anxiety and depression have different functions in the involuntary subordination process. Whereas depression helps to avoid future defeat, anxiety promotes reconciliation, increases sensitivity to possible threats, and focuses on future attacks that would result in loss of status [37]. The perception of defeat begins with an initial evaluation of the current situation followed by a perception of entrapment (and a decision whether to escape or not). Submissiveness and low perceived status suggest that positive self-appraisals such as self-worth and adequacy are absent, whereas defeat and entrapment indicate that negative cognitions are overactivated. Research suggests that depression is a complex combination of high negative affectivity and low positive affectivity, but that anxiety is only correlated with high negative affectivity [50]. Moreover, we found that submissive behavior was a protective factor for depression in the multivariate regression models. It may be that submissive behavior plays a vital role in group cohesion and the control of agonistic behavior [25], maintains the individual’s social position, and redirects behavior toward more productive pursuits.

These findings could form the basis of a new, integrated, and holistic approach to the identification of high-risk groups and the development of interventions for anxiety and depression among MSM. MSM may improve their social status and increase their self-efficacy and resilience through targeted interventions. Further research like a prospective cohort study can be designed to validate the exact causal relationship between involuntary subordination, anxiety and depression. Randomized controlled trials can be designed to explore intervention strategies for these common mental disorders among MSM. In addition, an open and tolerant social environment is required for MSM and other sexual minority groups.

Our findings provide evidence of the prevalence of specific psychosocial problems among MSM in Shanghai, China. MSM are more likely to be depressed or anxious. This may have implications for mental healthcare services and social support for MSM. This study used an evolutionary framework to understand the relationship between mental disorders and involuntary subordination. As such, it offers a new, innovative perspective on the association between individual psychological problems and social rank problems.