Current heterosexual marriage is associated with significantly decreased levels of anxiety symptoms among Chinese men who have sex with men

Background The high heterosexual marriage rate could be a ‘double-edge’ sword for the emotional health of Chinese men who have sex with men (MSM). The aim of this study was to determine if current marriage and breakdown of marriage (divorce) have different effects on the mental health of Chinese MSM. Methods Eight hundred seven MSM were recruited using respondent-driven sampling from four cities in northeastern China. Gay-related stressful events (GRSE) were measured using the Gay Related Stressful Life Events Scale; social support was measured by the Social Support Rating Scale (SSRS); and depressive and anxiety symptoms were assessed using the Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS), respectively. Results Of the study participants, 13.4% were married to women and 4.5% were divorced. The rates of marriage or divorce were 35.3 and 75.8% for participants 30–39 and > 40 years of age, respectively. The current married MSM had the highest SDS (50.0 ± 10.9) and SSRS (35.8 ± 8.6) levels, but the lowest SAS (38.7 ± 12.1) levels. Divorced MSM had the highest SAS (44.4 ± 9.6) and lowest SSRS (30.8 ± 8.1) levels. Age, GESE number, and HIV infection were predictors for SDS and SAS, and current marriage was associated with significantly decreased level of SAS (β = − 0.136, P = 0.001) based on multiple linear analysis. Conclusions Current marriage is associated with significantly decreased levels of anxiety symptoms among Chinese MSM. More studies are needed to understand the mechanisms underlying the effects of different marriage status on the emotional distress of Chinese MSM.

than their counterparts in other countries [1,2]. To avoid the stigma and discrimination associated with homosexuality and to cope with the stressors from family and society, many Chinese MSM marry and conceal their same-sex behaviors from their wives and members of their broader social network [1][2][3][4]. Between one-fourth and one-third of Chinese MSM marry women [3,4] and most keep their homosexuality a secret [1]. The marriage rate is significantly higher in Chinese MSM than MSM in Western countries (3-5%) [5,6]. Such a choice, however, could be a 'double-edge' sword. On the one hand, marrying a woman and having a child would mask homosexual behaviors, meet social expectations, avoid being "outed" to the family, buffer the stressors from parents and family, and avoid experiencing guilt, shame, and anxiety concerning homosexual behaviors [7][8][9]. A few studies have shown that keeping homosexual behaviors a secret could reduce the frequency of gay-related stressful events (GRSEs) among MSM [10,11], but no studies have reported if such a defensive choice could reduce the levels of depression or anxiety symptoms for married MSM. On the other hand, this strategy will result in numerous new problems with significant byproducts for the mental health of MSM [7][8][9]12]. The high level of internal gender role conflict (GRC) stemming from the desire for male partners while living with a wife without personal enthusiasm, fear about being known or disclosing their homosexual orientation and behaviors, and risks of transmitting HIV to their wives and girlfriends [13] all will increase psychological distress and reduce self-esteem. Several studies have reported depression, anxiety, sexual abuse, and other psychological syndemics among MSM in China [11,14], only a few studies have assessed associations between high marriage rates and emotional health [15,16]. Therefore, whether or not married and/or divorced MSM have significantly higher depression and/or anxiety symptoms than un-married MSM has not been established. The present study aimed to determine the following: (1) if current marriage is associated with significantly decreased levels of anxiety symptoms; (2) marriage to a woman may worsen the emotional status, particularly depression symptoms; (3) the dissolution of a marriage will influence the emotional health and increase and/or decrease the levels of anxiety and depression symptoms.

Subjects
The locations of the cross-sectional study areas and selection of MSM were described previously [11,17]. In brief, 807 MSM who lived or worked in four cities of Liaoning Province in northeastern China were recruited using a standardized respondent-driven sampling (RDS) procedure in 2012. Respondents were included if they had oral or anal sexual relations with another man during the previous 12 months. Each subject was interviewed personally by trained interviewers. Sociodemographic characteristics, marriage status, sexual identity, and disclosure of homosexual identity were recorded using a structured questionnaire [17].

Anxiety and depressive symptoms
Subjective feelings of depression and anxiety during the week prior to the interview were quantified using the Self-Rating Depression Scale (SDS) [18] and the Self-Rating Anxiety Scale (SAS) [19]. The details of SDS and SAS has been described in previous paper of the study [17]. Depression and anxiety was defined as scores of SDS over 53 and SAS over 50 [20,21].

Social support
Social support was measured by the Social Support Rating Scale (SSRS) [22], which contains 10 items and measures 3 dimensions of social support: subjective support (4 items), objective support (3 items), and supportseeking behavior (3 items). SSRS scores were added up to generate a score of 0 to 50, with a higher score indicating stronger social support. The SSRS has been used with a wide range of Chinese populations due to its high reliability and validity, and the 2-monthtest-retest reliability of 0.92.

Gay-related stressful life events
GRSEs were measured using the Gay Related Stressful Life Events Scale [23], a 12-item scale that measures the occurrence of incidents related to sexual orientation over the past 3 months. The detailed of SDS and SAS has been described in previous paper [17].

Statistical methods
Data analysis was conducted using SPSS (version 17.0). Analysis of variance (ANOVA) and the Kruskal-Wallis test were used to compare mean values of SAS, SDS, SSRS, and GRSEs by demographic characteristics and marriage status. We used stepwise multivariable linear regression analysis retaining variables with a p value < 0.10 to assess which variables were independently associated with SDS and SAS scores. Age, education, income, sexual orientation, disclosure of homosexual identity, number of GRSE, SSRS score, and HIV infection were included in the stepwise selection procedure. Table 1 shows that a total of 807 MSM were recruited with the following demographics: 71.3% were < 30 years of age; 40.3% were bisexual; 47.2% were gay; 13.4% were married to women; 4.5% have divorced; 22.9% revealed their homosexual identities to their parents and wives; 26.0% experienced GRSEs in the past 3 months; and 3.5% were HIV-positive. The marriage and divorce rates (MD) increased rapidly with age and decreased significantly with decreasing education years, which were 35.3 and 75.8% for those 30-39 and > 40 years of age, respectively, and were significantly higher in those who were HIV-positive (39.3%) than in those who were HIVnegative (17.1%), and significantly lower in those who had disclosed homosexual status (9.2%) than in those who had not disclosed homosexual status (20.4%). Table 2 shows that the SDS means increased significantly with age and decreased significantly with education level. The SSRS score showed an opposite linear trend, unlike the SAS score. When sexual identity was considered, gay had the highest SDS, SAS, and GRSEs means and heterosexual MSM had the lowest levels. When marriage status was considered, the married MSM had the highest SDS and SSRS and lowest SAS, and divorced MSM had the highest SAS and lowest GRSEs and SSRS. The SDS and SAS means were significantly elevated among MSM with HIV infection. The SAS level was borderline increased, but GRSEs levels were significantly decreased, for those who disclosed their sexual identity to others. Table 3 shows that age, GRSE number, and HIV infection were predictors for SDS and SAS, SSRS (β = − 0.242, p < 0.001) and higher education years (β = − 0.119, p < 0.001) were associated with significantly decreased levels of SDS. Sexual identity as gay (β = 0.076, p = 0.031) and current marriage (β = − 0.136, p = 0.001) were significant predictors for SAS.  SDS Self-rating depression score, SAS Self-rating anxiety score, SSRS Social support rating score, GRSE Gay related stressful event

Discussion
The rates of MD were 35.3 and 75.8%, respectively, for those 30-39 and 40-64 years of age in our study, which is consistent with previous reports that Chinese MSM have higher marriage and lower divorce rates than their counterparts in Western countries [1][2][3][4][5][6][7]. The significantly lower rate of disclosing homosexual status among married (10.2%) and divorced (16.7%) than single (24.2%) and co-habiting MSM (32.6%); the significantly lower levels of recently experienced GRSEs among those who conceal their homosexual status (0.36 ± 0.80) than those who have disclosed their homosexual status to family members (0.68 ± 1.18), might support the notion that married MSM tend to keep their homosexual status as a secret. Furthermore, the high marriage and low disclosure rate, as a defense strategy against external and internal stressors, protect Chinese MSM from experiencing conflicts or harm related to sexual minority stress, which is in agreement with previous findings in China [23] and internationally [10]. Similar to previous findings in China, we observed that Chinese MSM had higher SDS and SAS scores, but lower social support compared to their heterosexual counterparts [19]. Age, HIV infection, and number of experienced GRSEs were independent predictors of depression and anxiety symptoms, and these results are consistent with previous studies. The elderly face increasing challenges, such as isolation, more stressors, and increased health problems and disabilities, making them more likely to develop psychological problems [18,24]. Recently experienced GSREs are direct stressors and lead to increased depression and anxiety symptoms [25,26]. HIV infection will make them face serious physical and psychological burdens and threats, rendering them more likely to experience mental health problems [27]. We found better social support is a protective factor for SDS, consistent with the findings that better social and economic status enhances an individual's ability to cope with stressful life events and were less likely to suffer from mental health problems [28].
The currently married MSM had the highest depression symptoms and social support levels, but the lowest anxiety symptoms, and current marriage was associated with significantly decreased levels of SAS (β = − 0.136, p = 0.001) based on multiple linear analysis. The beneficial effect of current marriage on SAS, as well as the significantly decreased GRSE and SAS levels in MSM who did not disclose their sexual identity compared with MSM who did disclose their sexual identity, provides additional evidence that entering into marriage and keeping homosexual status a secret helps them avoid or buffer the internal and external stressors from multiple sources [7,12], which in turn decrease the levels of anxiety. In contrast, reduced worry and anxiety could also serve as main causes contributing to the higher marriage rates in Chinese MSM. The highest anxiety score and the lowest social support levels in divorced MSM further confirmed the effects of losing the protective effects of marriage.
The significantly elevated SDS levels in married (50.0 ± 10.9) and divorced (49.3 ± 12.5) compared with single MSM (46.3 ± 11.3) provided some evidence that continuously struggling with numerous unique challenges related to heterosexual marriage and strong internal gender role conflict (GRC) would waste their emotional energy in maintaining a highly problematic relationship discordant with their erotic desires, resulting in unhappiness and depression [7,12]. Current marriage or divorce was not a significant predictor for SDS in multiple analyses, which was consistent with the findings of a previous study in China [16]. Anxiety and depression symptoms usually co-exist and overlap and should be considered as a continuum spectrum of affective symptoms, with the hallmark of anxiety being worry, while lack of energy, motivation, and sadness prevail for depression. Although anxiety and depression symptoms are considered to be the two main psychological health problems of MSM, limited information is available on what symptoms or aspects are more relevant to the marriage status of MSM. We think our results are in agreement with the cognitive consistency theory that heterosexual marriage could reduce the amount of worry and the level of anxiety, but make the MSM unhappy and fraught with problems, and the dissolution of marriage make MSM more anxious [12,29].
Considering the large number (17.8 million), high marriage rate, growing HIV epidemic, and poor mental health status among Chinese MSM [11-14, 30, 31], it is critical to help MSM navigate a balance between their own needs and the culturally normative social duties as heterosexual men. More efforts are needed to reduce the social stigma toward homosexual behaviors and external pressure to marry, targeting specific HIV-prevention and professional consult services, and skills to cope with marriage-related troubles. Early detection of anxiety and depression symptoms, and implementing pharmacologic and non-pharmacologic treatment could improve their mental health status and provide support for MSM to accept public health services. Nonetheless, more work is needed to validate our findings and to explain the mechanisms behind the "double-edged sword" effects of marriage on the mental health of Chinese MSM, and assess the possible influence of the rapid changes in lifestyle and attitude toward homosexual behaviors and/or marriage in China.
There were some limitations within this study that need to be acknowledged. The temporal misalignment between marriage status (current status), depression and anxiety (in the past week), GRSE (in the past 3 months), and social support (not specified), as well as the selfreported symptoms or events, may bias their associations. The cross-sectional design of this study made it impossible to determine directionality or causality between marriage status and emotional distress. The 807 MSM were selected from 4 cities in northeast China. It is not certain that our findings can be generalized to other regions of China. Previous studies noted that RDS may have included individuals who are more marginalized, have fewer resources, and/or have more time to participate in the study. Attentions should be paid to the possible selections bias when generalizing our findings to the target MSM population.

Conclusion
Age, HIV infection, and number of experienced GRSEs are independent predictors for depression and anxiety symptoms, and current marriage is associated with significantly decreased levels of anxiety symptoms among Chinese MSM. High marriage rates in Chinese MSM may play an important role in shaping the high HIV epidemic among themselves and to their wives, as well as their mental health. New interventions to control the HIV epidemic and improve mental health should accommodate the personal, social, and cultural needs of different marriage subgroups, such as policy development and environment building, to reduce social discrimination toward homosexual behaviors and marriage/co-habitation, increasing the capabilities to buffer or cope with the unique marriage-related stressors and protect themselves and their family members from psychological harm and HIV infection, screening, and early treatment of depression and anxiety. More studies are needed to understand the mechanisms underlying the effects of different marriage status on the emotional distress of Chinese MSM.