Childhood Sexual Abuse and Associated Suicidal Ideation and Attempts Among Gay and Bisexual Men in China: A Moderated Mediation Model

Abstract

Childhood sexual abuse (CSA) is a critical risk factor for suicidal ideation and attempts, especially among gay and bisexual men who experience living as a minority. However, whether internalized homophobia (IH) underlies suicide risk and the role of outness to one’s family in this association warrants investigation to inform preventive interventions. Using a cross-sectional survey of 570 gay and bisexual men in China, we examined the relationship between CSA and suicidality in the Chinese context and tested a moderated mediation model in this relationship. Nearly 65.6% of the participants had experienced suicidal ideation and 36.8% had attempted suicide. Participants with a history of CSA had higher suicidal ideation (r = 0.33, p < .01) and attempts (r = 0.48, p < .01). Our bootstrapped mediation analysis showed that IH partially mediated the relationship between CSA and suicidal ideation and attempts. Moreover, outness to one’s family (parents and other family members) strengthened the direct association of CSA and IH, and the indirect relationship between CSA and suicidal ideation and attempts. These findings highlight the significance of identifying risk factors and mechanisms for suicidality among Chinese gay and bisexual men, suggesting the importance of early intervention, especially for those who have experienced CSA, to eliminate their IH and to improve family support for coming out to prevent the onset of suicidal ideation and attempts.

Keywords

childhood sexual abuse suicidal ideation and attempts internalized homophobia outness to one’s family moderated mediation model

Worldwide, gay and bisexual men are at increased risk of suicidal ideation and attempts (Kneale et al., 2020; Riley & McLaren, 2019). Across geographic regions—such as the United Kingdom (Rasmussen et al., 2019), the United States (US, McGraw et al., 2022), and Australia (Swannell et al., 2016)—studies have consistently found that gay and bisexual men experience disproportionately higher rates of suicide risk. In a large systematic review, Hottes et al. (2016) found that 17% of sexual minorities (n = 21,201) had attempted suicide in their lifetime, compared with 4% of heterosexuals (n = 76,239). One explanation for the disparities between heterosexual and gay men could be the minority life stressors regarding sexual orientation experienced by gay and bisexual men (Meyer, 2003). However, this evidence is primarily established in Western countries, this limits the potential utility of the theory to understand and address suicide risk among sexual minority men in China.

Suicidality among gay and bisexual men in China, the world’s most populous country, may be more prominent than previously thought (Sun et al., 2020; Zheng et al., 2020). Several factors have contributed to this grim situation. First, along with the increase in HIV infection rates among Chinese gay and bisexual men in the past two decades, same-sex identity or behavior in Chinese society has been widely rejected and stigmatized (Neilands et al., 2008). Second, due to the traditional culture of emphasizing the continuity of bloodlines and the traditional beliefs of Chinese gender roles, men in China are expected to marry the opposite sex and produce heirs (Xu et al., in press; Zheng et al., 2020). Those who fail to fulfill this duty are inevitably socially marginalized (Wei et al., 2016). Third, same-sex marriage is illegal in China, and Chinese gay and bisexual men still experience minority life stressors related to their sexual orientation, including prejudice, adverse events due to sexual orientation, and internalized homophobia (IH) (Xu et al., 2017a; Yip & Chan, 2022). Therefore, compared with the West, Chinese gay and bisexual men may suffer from a more adverse sociocultural environment, leading to a higher prevalence of suicide risk. A sizable body of research demonstrates that Chinese sexual minority men experience elevated rates of suicidal ideation and attempts; estimated rates range from 26.1 to 45.2% for suicidal ideation and from 3.1 to 12.6% for suicide attempts (Chen et al., 2015; Li et al., 2017; Wei et al., 2020). Consequently, the risk and protective factors of suicidality among Chinese gay and bisexual men must be urgently elucidated to provide empirical support for interventions of suicidal ideation and attempts.

Childhood Sexual Abuse and Suicidal Ideation and Attempts

The minority stress model, one of the most prominent theoretical frameworks of health risks among sexual minority individuals, posits that gay men are at increased risk of potential victimization (Meyer, 2003). During childhood, gay and bisexual men who are gender non-conforming are more likely to be rejected by their parents, which further predicts their emotional neglect, as well as psychological and physical abuse by other family member(s) before adulthood (Bos et al., 2019; Roberts et al., 2013). Cross-sectional and longitudinal studies have consistently shown that gay and bisexual men are at higher risk of childhood maltreatment, including physical abuse (Petering et al., 2021), emotional abuse (Schneeberger et al., 2014), and sexual abuse (Backhaus et al., 2019) compared with their heterosexual peers. Further, children who are sexual minorities are more vulnerable to childhood sexual abuse (CSA), which may lead to the adoption of formal, non-heterosexual identity labels later in life (Roberts et al., 2013; Xu et al., 2020). CSA is a pervasive problem affecting sexual minorities worldwide (Scheer et al., in press; Stoltenborgh et al., 2011). Empirical studies indicate that the prevalence of CSA is much higher among sexual minority men than among heterosexual men (Boroughs et al., 2015; Ironson et al., 2019). In the Chinese context, studies also reveal that sexual minority men experience more frequent CSA than heterosexual individuals (Xu et al., 2018a; Zhao et al., 2021). Specifically, a study of Chinese men who have sex with men found the prevalence of CSA to be 22.6%, which was associated with more risky sexual behaviors in adulthood (Li et al., 2021a, 2021b).

Due to the wide-ranging and long-lasting negative effect of CSA on mental and public health, individuals who suffered CSA tend to engage in risk-taking behaviors (Daray et al., 2016; Scheer et al., in press). Studies that examined the long-term effects of CSA showed strong relationships with several negative health, behavioral, and social outcomes, with suicide risk being the most prevalent (Blosnich et al., 2021; Hailes et al., 2019). Further, this relationship may be more powerful among gay and bisexual men due to minority life stressors. For example, a study conducted in the US showed that gay and bisexual men who experienced forced CSA had the highest levels of suicidal ideation, compared with gay and bisexual men who had consensual childhood sex and had no CSA experience (Arreola et al., 2008). Moreover, a study from China found that sexual minority men who experienced CSA were at greater risk for depressive symptoms (Zhao et al., 2021). However, no study has examined the internal mechanism between CSA and suicidal ideation and attempts, especially in China, beyond reporting rates of suicide risk in gay and bisexual male communities.

Internalized Homophobia as a Mediator

IH refers to “the self-hatred and shame of homosexually oriented individuals that has been incorporated into their belief system” (Meyer & Dean, 1998). IH is thought to stem from negative stereotypes and myths about homosexuality that permeate mainstream society and are absorbed from one’s culture(s) (Shidlo, 1994). The literature on victimology states that those who have experienced CSA often struggle with blaming themselves for engaging or not engaging in specific behaviors and for bringing negative events upon themselves (Janoff-Bulman, 1979; Kennedy & Prock, 2018). They tend to attribute the cause of negative events to themselves and believe they could have avoided it, even if this thinking is illogical (Kline et al., 2021). Because CSA violates social norms, those who experience abuse may experience stigmatization that can be internalized as self-blame, shame, and anticipatory stigma (Kennedy & Prock, 2018). However, as a socially disadvantaged community, gay and bisexual men who have experienced CSA suffer from a more adverse social environment, which includes social stigma (Schnarrs et al., 2019) and thwarted belongingness (Backhaus et al., 2019). According to the sexual minority stress theory (Meyer, 2003), IH is a form of proximal stress shaped by distal stresses such as anti-gay violence and discrimination. These distal stresses associated with the negative identity-related appraisals of gay and bisexual men may lead to increased internalization of external stresses; these stresses involve their own appraisal of the environment as threatening and blaming, due to expectations of rejection and IH (Frost & Meyer, 2009). Indeed, there is robust evidence of a link between CSA and IH among gay and bisexual men (Gemberling et al., 2015; Gold & Marx, 2007; Hequembourg et al., 2015). For example, IH has been found to be directly and positively associated with traumatic experiences, including childhood physical and sexual abuse (Gold & Marx, 2007). A recent study revealed that more severe CSA experiences were linked to higher levels of IH among gay and bisexual men (Sutton et al., 2022). Therefore, CSA experience may be a crucial factor that can be positively linked to higher IH in this marginalized community in China.

The relationship between IH and suicide risk has been theoretically and empirically supported. IH in homosexual men contributes to mental health challenges that increase vulnerability to the risks of suicidal ideation and attempts (Meyer, 2003). Additionally, as a sociocultural cognitive factor, IH may increase stress and risk factor vulnerability, and could further be associated with higher rates of suicide risk among homosexual men (Gibbs & Goldbach, 2015). McLaren (2016) found a significant link between IH and suicidal ideation among Australian gay men. In Asian settings, a positive association between IH and suicidal ideation and attempts also exists among gay men. In a qualitative study conducted in South Korea, Lee et al. (2019) found that lesbian, gay, and bisexual adults with high IH levels were at significantly greater risk of suicidal ideation than those with lower IH levels. Research from China showed that IH was positively associated with depressive symptoms among gay men (Li et al., 2021a, 2021b; Xu et al., 2017). Therefore, IH may be linked to a higher possibility of suicide risk among Chinese gay and bisexual men.

Based on the relationship between CSA and IH, and the relationship between IH and suicide risk, we focused on the mediating effect of IH on the relationship between CSA and suicidal ideation and attempts. To date, no study has explored this mediating model. Given the dearth of research on such processes in the Chinese context, additional research is warranted.

Outness to One’s Family as a Moderator

Outness (also called “coming out”) is “the degree to which sexual minority individuals have disclosed their sexual orientation to families and others” (Knoble & Linville, 2012). Sexual identity development theory argues that outness plays a key role in the development of positive sexual identity (Cass, 1979). Coming out may serve as a buffer to further alleviate the negative influence of distal minority stressors on proximal minority stressors (e.g., IH) on mental health. Specifically, greater outness is associated with positive outcomes such as greater self-acceptance (Meyer, 2003), better self-reported health (Weisz et al., 2016), as well as the connection to potentially positive social support in the gay community (Griffith & Hebl, 2002); these aspects represent valuable resilience processes and strategies that may counteract the negative impact of IH (Jackson & Mohr, 2016; Maciel & Barnett, 2021). A recent Spanish study demonstrated that compared with the identity concealment young homosexual group, the outness group who experienced perceived stress reported significantly less mental suffering (Dueñas et al., in press). However, other studies have found that outness had certain adverse mental health consequences. For instance, Longares et al. (2020) indicated that higher degrees of outness acted as a stressor that exacerbated the link between an insecure attachment style and perpetration of psychological abuse in same-sex couples. Pachankis et al. (2015) found that among sexual minority individuals, those who were out experienced more mental health problems that those whose sexual identity remained concealed. Szymanski (2008) demonstrated that greater outness was associated with a greater likelihood of experiencing heterosexual rejection, discrimination, and violence, which could cause sexual minority men to fall into negative perceptions that increase psychological distress. Coming out may be more complex than the idea that being more “out” equals worse psychological distress (Brewster et al., 2013; Pachankis et al., 2020).

Szymanski and Sung (2010) argued that outness was often contingent on relational (e.g., outness to family) and sociocultural or environmental contexts (e.g., settings or locations). For example, Pachankis and Bränström (2018) found that outness was negatively associated with life satisfaction in structurally homophobic contexts (i.e., laws, policies, and social attitudes are non-supportive of sexual minorities) but not in structurally supportive contexts. China’s laws and policies regarding sexual minorities and its culture generally are very different from the West. Coming out to one’s family, especially to one’s parents, is the biggest challenge faced by many Chinese sexual minority individuals, as Confucian culture is paternalistic and places a heavy emphasis on the family (Koo et al., 2012). Chinese Confucian culture emphasizes the maintenance of traditional gender roles for both sexes and is intolerant of openness about homosexuals (Szymanski & Sung, 2010). For example, one qualitative study regarding East Asian gay men demonstrated that many of their families were conservative and they had difficulty coming out to family members because of being afraid of potential rejection (Chung & Szymanski, 2006). When disclosure leads to family rejection, greater outness may cause inter-parental conflict and ultimately lead to lower self-acceptance and emotional suffering, and even higher suicide risk (Mitrani et al., 2017; Shao et al., 2018). In other words, identity concealment from families may serve as a protective factor to alleviate distal minority stress processes (e.g., abusive experiences) or emotional distress such as IH. For example, a recent study indicated that for Chinese gay men, the negative link between emotional abuse in childhood and depression symptoms in adulthood was stronger than for Chinese bisexual men (Xu et al., 2022), as Chinese bisexual men may have more alternative coping strategies against minority stress conditions, such as engaging in opposite-sex relationships. There is currently limited evidence regarding the role of outness to one’s family, especially in China.

The Current Study

In this study, we had three objectives. First, we aimed to examine the relationship between CSA and suicidal ideation and attempts among gay and bisexual men in the Chinese context. Second, we wanted to establish whether IH mediates the link between CSA and suicide risk. Third, we aimed to determine whether outness to one’s family moderates the indirect relationship between CSA and suicidal ideation and attempts via IH. These objectives form a moderated mediation model that can address both mediation (i.e., How does CSA lead to suicide risk?) and moderation (i.e., When is the link between CSA and IH most potent?) mechanisms underlying the relationship between CSA and suicidal ideation and attempts (Figure 1). Based on the literature review by Arreola et al. (2008) that established a positive association between CSA and suicide risk among sexual minority men in Western countries, we hypothesize that (1) CSA and suicidal ideation and attempts are positively correlated among gay and bisexual men in China. Based on the minority stress theory as well as relevant empirical work (Meyer, 2003; Gibbs & Goldbach, 2015; Gold & Marx, 2007), we hypothesize that (2) IH mediates the relationship between CSA and suicidal ideation and attempts. Further, as previous findings on outness are mixed and limited (Legate et al., 2012; Mitrani et al., 2017), we hypothesize that (3) outness to one’s family (parents and other family members) will moderate the relationship between CSA and IH, and further moderate the indirect relationship between CSA and suicidal ideation and attempts, via IH as a mediator.

Figure 1.

The proposed moderated mediation model.

Methods

Participants and Procedure

We conducted a cross-sectional survey using convenience sampling from March to June 2020. Due to the covert nature of the gay community, we recruited participants through several social networking platforms such as “post-bars” for gay men (Baidu Post-Bar), Douban groups, and Weibo; we also used social networking applications such as WeChat and QQ that target gay people. We asked the participants to complete a questionnaire, available on the professional survey website Wenjuanxing, described in elsewhere (Xu et al., 2017b). There were no missing data in the current study as individual’s information was not obtained if a respondent did not complete or submit the questionnaire. The detailed data collection process was similar to that of prior studies (Xu et al., 2018a, 2018). The eligibility criteria were being a gay or bisexual man, 18 years or older, willing to provide informed consent, and living in mainland China. Upon completion, eligible participants received 15 CNY (nearly 2.5 US dollars) as compensation by leaving their Alipay account number. Participants were required to choose their sexual orientation from the following options: completely heterosexual, mostly heterosexual but also attracted to the same sex, bisexual, mostly homosexual but also attracted to the opposite sex, completely homosexual, asexuality, and others. Based on previous literature (Xu et al., 2019), participants who chose mostly homosexual but also attracted to the opposite sex or completely homosexual were coded as gay men. Participants who chose completely heterosexual (n = 310), mostly heterosexual but also attracted to the same sex (n = 181), asexuality (n = 22), or others (n = 15) were excluded from the analyses. This project was approved by the Ethics Committee of the Sichuan university.

Therefore, the final sample consisted of 570 self-identified gay (n = 502, 88.1%) and bisexual (n = 68, 11.9%) men aged 22.89 years old on average (SD = 4.20), ranging from 18 to 40 years. They varied in terms of education level (11.9% had a middle or high school education, 75.6% had a college education or bachelor’s degree, and 12.5% had postgraduate education or above) and current residence (29.8% lived in mega cities, 31.4% lived in provincial capitals, 25.1% lived in general cities, and 13.7% lived in rural areas or small towns). Further, 47.4% of the participants were enrolled as students, while the other 52.6% were not students. Nearly 65.6% of the participants reported a history of suicidal ideation, and 36.8% reported a history of attempted suicide. Table 1 outlines their demographic characteristics. There were significant differences between gay and bisexual men regarding age, education, current residence, and suicide attempts. Occupation and suicidal ideation did not differ by sexual identity.

Table 1.

Description of the Sample by Sexual Identity.

	Gay	Bisexual	Total Sample	F/χ ²	p
	n = 502	n = 68	N = 570	F/χ ²	p
Age, M (SD)	23.02 (4.25)	21.88 (3.70)	22.89 (4.20)	2.144	.036
Education
Middle or high school	10.8	20.6	11.9	7.575	.023
College or a bachelor’s degree	75.9	73.5	75.6
Postgraduate or above	13.3	5.9	12.5
Current residence
Mega cities	31.7	17.6	30.0	11.437	.010
Provincial capital	30.5	38.2	31.4
General cities	23.5	36.8	25.1
Rural areas or small towns	14.3	7.4	13.5
Occupation
Student	48.4	39.7	52.6	1.818	.178
Not student	51.6	60.3	47.4	1.818	.178
Suicidal ideation
Yes	64.7	72.1	65.6	1.421	.233
No	35.3	27.9	34.4	1.421	.233
Suicide attempts
Yes	34.1	57.4	36.8	13.96	<.001
No	65.9	42.6	63.2	13.96	<.001

Measures

Childhood Sexual Abuse

We measured CSA using the CSA Scale developed in the Chinese cultural context (Chen et al., 2004), which asked participants how many times they experienced any of the 12 CSA events before the age of 18 when they did not want it to happen. The scale includes three items of non-physical contact CSA (e.g., An adult masturbated in front of you) and nine items of physical contact CSA (e.g., An adult touched your genitals with his/her mouth). Items were rated using a 4-point Likert scale (ranging from never to three or more times). The Cronbach’s α for the scale was 0.96.

Internalized Homophobia

We adapted the 9-item IH Scale, created by John Martin and Laura Dean (Meyer, 1995), to measure the extent of gay and bisexual men’s IH. Sample items included “I am willing to seek professional help in order to change my sexual orientation from gay to straight.” Items were rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater levels of IH. This scale has demonstrated good psychometric properties in Chinese samples (Xu et al., 2017a, 2019). The Cronbach’s α for the scale was 0.92 in this study.

Outness to One’s Family

We assessed outness to one’s family using the “out to family” subscale from the Outness Inventory (Mohr & Fassinger, 2000). We applied the two items of outness to one’s parents and the two items of outness to other family members. The question on outness to one’s parents asked: “How much does your mother/father know about your sexual orientation?” The question on outness to other family members asked: “How much do your siblings/extended family know about your sexual orientation?” Each item is measured on a 5-point Likert scale, ranging from 0 (the person definitely does not know about my sexual identity) to 4 (the person definitely knows about my sexual identity), with higher scores indicating that an individual was more “out” to his social networks. It has shown good validity and reliability in Chinese sexual minority men sample (Sun et al., 2020). In this study, the Cronbach’s alpha for outness to one’s family was 0.86.

Suicidal Ideation and Attempts

We assessed about suicidal ideation and attempts in the past 12 months using two items, this measure has been widely used in prior research (e.g., Lee et al., 2022; Schlagbaum et al., 2021). The item on suicidal ideation is “During the last 12 months, have you ever had suicidal thoughts, even if you have not actually done it?” The item on suicide attempts is “During the last 12 months, have you ever attempted to commit suicide?” Each item is gauged on a 4-point Likert scale, similar to prior studies (Ren et al., 2018; Schnitker et al., 2021; Wu et al., 2021), ranging from 0 (did not apply to me at all) to 3 (applied to me most of the time).

Statistical Analyses

We performed data analyses with SPSS, including PROCESS macros created by Andrew Hayes (Hayes, 2013). PROCESS provides ordinary least squares, regression-based path analysis similar to structural equation modeling but offers additional useful statistics and safeguards against irregular sampling distributions (Hayes et al., 2017). We first computed descriptive statistics for the main study variables, and tested bivariate relations with Pearson’s correlations. Then, we evaluated mediation models to assess the potential relationship between CSA and suicide risk, and the mediating role of IH in this relation (hypotheses 1 and 2). Next, we entered the proposed moderator variable into the model and tested for moderated mediation (hypothesis 3). Following Hayes (2013) recommendations, we calculated 95% bootstrap confidence intervals (CI) based on 5000 bootstrapped samples to increase the robustness of the standard errors of the indirect effects.

Results

Preliminary Analyses

Table 2 shows the means, standard deviations, and bivariate correlations for all study variables. As the results suggested, the relationships between all core research variables were statistically significant. Specifically, CSA was positively associated with IH, outness to one’s parents and other family members, suicidal ideation, and suicide attempts. Both outness to parents and other family members were positively associated with IH, suicidal ideation, and suicide attempts. IH was positively associated with both suicidal ideation and attempted suicide. Besides, age was positively associated with outness to other family members; education was negatively associated with CSA, IH, outness to one’s parents and other family members, suicidal ideation, and attempted suicide; current residence was positively associated with CSA and outness to other family members. Therefore, we included age, education, and current residence as covariates in subsequent analyses.

Table 2.

Descriptive Statistics and Correlations Among Variables.

Variables	M	SD	1	2	3	4	5	6	7	8	9	10
1. Age	22.89	4.20	1
2. Education	—	—	.20^**	1
3. Current residence	—	—	.29^**	.08^*	1
4. Childhood sexual abuse	20.17	9.95	.05	−.12^**	.10^*	1
5. Internalized homophobia	22.65	8.89	.00	−.09^*	−.02	.34^**	1
6. Outness to family	8.36	4.71	.09^*	−.15^**	.09^*	.41^**	.20^**	1
7. To parents	4.39	2.77	.07	−.12^**	.06	.32^**	.14^**	.94^**	1
8. To other family members	3.97	2.32	.10^*	−.16^**	.12^**	.44^**	.24^**	.91^**	.71^**	1
9. Suicidal ideation	1.08	0.98	−.04	−.11^*	−.02	.33^**	.24^**	.26^**	.19^**	.25^**	1
10. Suicide attempts	0.61	0.91	−.03	−.18^**	.00	.48^**	.33^**	.39^**	.32^**	.41^**	.56^**	1

Note. ^*p < .05. ^**p < .01.

Testing for the Mediation Effect

First, we analyzed the mediating roles of IH in the links between CSA and suicidal ideation and suicide attempts, separately, controlling for covariates. As presented in Table 3, the findings (see Model 1) first revealed that CSA was positively associated with IH (b = .31, SE = .04, p < .001). Second, the results (see Model 2 and Model 3) implied that IH was positively related to suicidal ideation (b = .01, SE = .01, p < .01) and suicide attempts (b = .02, SE = .004, p < .001). Additionally, the residual direct links of CSA with suicidal ideation (b = .03, SE = .004, p < .001) and suicide attempts (b = .04, SE = .004, p < .001) were significant (see Model 2 and Model 3). Bootstrapping analyses indicated that the indirect links of CSA with suicidal ideation (b = .005, 95% CI = [.001, .008]) and suicide attempts (b = .01, 95% CI = [.003, .009]) through IH were significant. The mediation effect accounted for 14.06% and 13.82% of total effects of CSA and suicidal ideation and suicide attempts, respectively.

Table 3.

Testing the mediation effect of CSA on suicidal ideation and attempts.

Predictors	Model 1 (IH)		Model 2 (Suicidal ideation)		Model 3 (Suicide attempts)
Predictors	b	SE	b	SE	b	SE
Age	.02	.09	−.01	.01	−.01	.01
Education	−.78	.73	−.10	.08	−.21^**	.07
Current residence	−.49	.36	−.03	.04	−.01	.03
CSA	.31^***	.04	.03^***	.004	.04^***	.004
IH			.01^**	.01	.02^***	.004
R ²	.12		.13		.27
F	19.92^***		16.84^***		42.52^***

Note. Each column is a regression model that predicts the criterion at the top of the column. CSA = childhood sexual abuse. IH = internalized homophobia. ^***p < .01, ^***p < .001.

Testing for the Moderated Mediation

Next, with the moderation analysis, we examined the potential conditional effects (moderated mediation) of outness to one’s family (to one’s parents and other family members) on this mediation process. As Table 4 shows, CSA interacted with outness to one’s parents in predicting IH (b = .03, SE = .01, p < .05). Approximately 13% of the variance in IH was explained by the CSA, outness to one’s parents, their interaction, and covariates (R² = .13, p < .001). Further, for descriptive purposes, we plotted CSA on IH separately for low, middle, and high levels of outness to one’s parents (±1 SD; Figure 2). Simple slope tests demonstrated that the unique direct link of CSA with IH was stronger for a high level of outness to one’s parents (+1 SD; b_simple = .36, p < .001) than for middle (0 SD; b_simple = .27, p < .001) and low (−1 SD; b_simple = .20, p < .001) levels of outness to one’s parents. Moreover, increased levels of outness to parents strengthened the indirect link of CSA with both suicidal ideation and suicide attempts via IH (see Table 5). Specifically, for participants with a low level of outness to one’s parents, CSA had significant positive indirect links with suicidal ideation (b = .003, SE = .001, 95% CI = [.001, .006]) and suicide attempts (b = .004, SE = .001, 95% CI = [.001, .007]), through an increase in IH. For participants with a middle level of outness to one’s parents, CSA had significant positive indirect links with suicidal ideation (b = .004, SE = .002, 95% CI = [.001, .007]) and suicide attempts (b = .005, SE = .002, 95% CI = [.003, .008]), through an increase in IH. For participants with a high level of outness to one’s parents, CSA had significant positive indirect links with suicidal ideation (b = .005, SE = .002, 95% CI = [.002, .010]) and suicide attempts (b = .007, SE = .002, 95% CI = [.003, .011]).

Table 4.

Testing the moderated mediation effect of CSA on IH.

	IH
Predictors	b		SE
Age	.05		.09
Education	−.60		.73
Current residence	−.47		.36
CSA	.27^***		.04
Outness to parents	.08		.13
CSA × outness to parents	.03^*		.01
R ²		.13
F		14.48^***
Age	.05		.09
Education	−.40		.73
Current residence	−.56		.35
CSA	.23^***		.04
Outness to other family members	.27		.17
CSA × outness to other family members	.06^***		.02
R ²		.16
F		17.26^***

Note. Each column is a regression model that predicts the criterion at the top of the column. CSA = childhood sexual abuse. IH = internalized homophobia. ^*p < .05, ^**p < .01, ^***p < .001.

Figure 2.

Interaction between CSA and outness to parents on IH. Note. CSA = childhood sexual abuse. IH = internalized homophobia. OTP = outness to parents.

Table 5.

Conditional indirect effects of CSA on suicidal ideation and attempts at different levels of outness to parents and other family members.

Moderators	Conditional indirect effects of CSA on suicidal ideation			Conditional indirect effects of CSA on suicide attempts
Outness to parents	Effect	SE	95% CI	Effect	SE	95% CI
M −1SD	.003	.001	[.001, .006]	.004	.001	[.001, .007]
M	.004	.002	[.001, .007]	.005	.002	[.003, .008]
M +1 SD	.005	.002	[.002, .010]	.007	.002	[.003, .011]
Index of moderated mediation	.001 (Index)	.000	[.000, .001]	.001 (Index)	.000	[.000, .001]
Outness to other family members
M −1 SD	.002	.001	[.000, .004]	.002	.001	[−.001, .005]
M	.003	.001	[.001, .006]	.004	.001	[.002, .007]
M +1 SD	.005	.002	[.002, .010]	.007	.002	[.003, .011]
Index of moderated mediation	.001 (Index)	.000	[.000, .002]	.001 (Index)	.000	[.000, .002]

Note. CSA = childhood Sexual Abuse.

Additionally, like the moderating mechanism of outness to one’s parents, the interaction effect between outness to other family members and CSA was also significant (b = .06, SE = .02, p < .001; Figure 3). Approximately 16% of the variance in IH was explained by the CSA, outness to other family members, their interaction, and covariates (R² = .16, p < .001). Simple slope tests demonstrated that the direct link of CSA with IH was stronger for a high level of outness to other family members (+1 SD; b_simple = .36, p < .001) than for middle (0 SD; b_simple = .23, p < .001) and low (−1 SD; b_simple = .11, p < .05) levels of outness to other family members. Moreover, increased levels of outness to other family members also strengthened the indirect link of CSA with both suicidal ideation and suicide attempts via IH (see Table 5).

Figure 3.

Interaction between CSA and outness to other family members on IH. Note. CSA = childhood sexual abuse. IH = internalized homophobia. OTOF = outness to other family members.

Discussion

Suicide risk is a major public health issue (Pompili, 2018). Although the relationship between CSA and suicidal thoughts and attempts in adulthood has accumulated considerable empirical support (Arreola et al., 2008; Blosnich et al., 2021; Hailes et al., 2019), much less is known about this relationship among gay and bisexual men, especially in the Chinese context. Further, the underlying mediation and moderation mechanisms are less clear. Using a Chinese sample, our findings imply that CSA is significantly and positively associated with suicidal ideation and attempts among gay and bisexual men, and that IH partially mediates this relationship. Moreover, outness to one’s family (parents and other family members) moderates the relationship between CSA and IH, and further moderates the indirect effect of IH on the association between CSA and suicidal ideation and attempts, in that the path from CSA to IH was strengthened in the context of higher levels of outness to one’s family.

Our findings underscore the high burden of suicide risk among Chinese gay and bisexual men. Among the respondents, 65.6% reported a history of suicidal ideation, and 36.8% reported a history of attempted suicide. This finding is largely consistent with previous studies involving gay and bisexual samples of individuals with suicidal ideation (ranging from 54.5 to 59.5%) and attempts (ranging from 34 to 36.5%) conducted in a Western country (McGraw et al., 2022; Rasmussen et al., 2019; Swannell et al., 2016). This supports the claim that the issue of suicidality is a global problem of considerable magnitude. The proportions found in our study were far above the suicidal ideation (ranging from 26.1 to 45.2%) and suicide attempts (ranging from 3.1 to 12.6%) found among Chinese sexual minority men, as estimated by Chen et al. (2015) and Li et al. (2017). This suggests that suicide risk among Chinese gay and bisexual men may be a growing problem. Specifically, it might be explained by the distinctive challenges they face due to a lack of legal recognition and protection, as well as cultural pressures from immediate family members, relatives, work, and their communities in China (Zheng et al., 2020). Another possible explanation is that Internet sampling for surveys such as ours is anonymous and self-selective, and this method might ease the burden of reporting suicide risk. In addition, we conducted the survey from March to June 2020, the same period in which the COVID-19 pandemic swept through China; therefore, related stressors might have also increased suicide risk.

We verified the positive association between CSA and suicide risk, which is in line with the findings of previous studies regarding heterosexual individuals (Blosnich et al., 2021; Hailes et al., 2019) and homosexual men (Arreola et al., 2008). Further, our results support the minority stress theory, which proposes that homosexual men are at increased risk of victimization and, consequently, more likely to develop suicide risk. It is possible that homosexual males who suffered CSA are at high risk for post-traumatic stress disorder, depression, substance abuse, and adult sexual assault (Cabral & Marx, 2013), which may trigger suicidal ideation and attempts in some individuals. Our results are the first to illustrate the long-term association between CSA and suicide risk among Chinese gay and bisexual men. Finally, our findings contribute to a better understanding of the relationship between childhood trauma and mental health in adulthood.

The Mediating Role of IH

Our study also adds to the literature by providing preliminary evidence of the indirect link between CSA and suicide risk, via IH. For the first part of the mediating process, gay and bisexual men who experienced CSA had higher levels of IH. This finding is congruent with that of a previous study (Gold & Marx, 2007). Gay and bisexual men who were subjected to CSA were found to be vulnerable to several socio-cognitive factors such as social stigma, blame, and misunderstandings (Kline et al., 2021; Schnarrs et al., 2019); this led to negative appraisals of themselves, which caused them to further internalize the external stigma. Thus, gay and bisexual men with CSA are more likely to have higher levels of IH. Further, we found that gay and bisexual men with higher levels of IH are more likely to have suicidal ideation and attempts. This outcome supports Meyer’s minority stress theory (2003) and is consistent with the findings of previous studies on the relationship between IH and suicide risk (Gibbs & Goldbach, 2015; Lee et al., 2019; McLaren, 2016). IH has been identified as a key risk factor for psychological distress among homosexual men (Igartua et al., 2003). Further, gay and bisexual men may respond to IH and the resulting stress by using negative coping strategies, such as suicidal ideation and attempts. As such, our study makes a major contribution to better understanding the internal mechanism between CSA and suicide risk.

The Moderating Role of Outness to One’s Family

Outness to one’s family was shown to play a moderating role in the direct association between CSA and IH, and in the indirect association between CSA and suicide risk. Specifically, the moderated mediation model indicated that increased outness to one’s family exacerbates the direct link of CSA with IH, which further strengthens the indirect link of CSA with suicidal ideation and attempts. This finding is consistent with research showing that outness act as a risk factor for minority stress conditions and is associated with low life satisfaction in high-stigma countries (Pachankis & Bränström, 2018; Villicana et al., 2016) and with evidence that showed that outness was positively related to suicide risk among Latino sexual minority men (Mitrani et al., 2017). Two possible explanations exist for these findings. First, due to the Chinese family cultural tradition of emphasizing the continuity of bloodlines and traditional beliefs in Chinese gender roles, men who fail to do so are considered unfilial and are socially marginalized (Wei et al., 2016). Therefore, gay and bisexual men’s disclosure of their sexual orientation to family members is usually rejected, treated non-supportively, or accompanied by greater psychological distress; it could even lead to a greater risk of suicide. Second, there are still common misconceptions about and rejections of gay men in Chinese society (Chan & Huang, 2021; Yip & Chan, 2022). Additionally, China’s laws and policies are relatively less supportive for sexual minority individuals compared with those of the West. At the family level, parents who hold traditional gender roles treat their children’s minority identity as a disgrace, even an illness, and try to help them return to “normal.” Therefore, pressure from their family and society after coming out may cause an inability to develop effective coping strategies that could help them cushion the negative effects of CSA. Taken together, these findings suggest that, as the degree of outness to family increases, IH increases precipitously for gay and bisexual men with high levels of CSA, thereby also increasing their suicide risk. It should be noted that although Chinese social attitudes toward homosexuality cannot yet be described as tolerant, they have become considerably more positive in recent years (Shi et al., 2020). Thus, some families are accepting and supportive of their gay family member(s), which acts as a buffer to alleviate the effect of minority stress (e.g., stigmatization) on psychological distress (Wang et al., 2022). The current results of outness to one’s family may inspire future researchers to distinguish its moderating effect in different cultural contexts, to inform theoretical support and practical interventions for improving gay and bisexual men’s mental health. Future research should further explore the levels of family support for participants’ identities to provide insights into such relationships.

Limitations and Implications

The limitations of the present study must be addressed. First, our study was cross-sectional, so we could not establish causal relationships. Future longitudinal studies should explore how the relationship between CSA and suicidal ideation and attempts in adulthood and the mediating role of IH develop over time. Second, due to the covert nature of the gay community, we recruited the participants through an online survey, which may have increased the possibility of bias in the measured data. Further, our sample was likely not representative of Chinese sexual minority men who are older or do not use the Internet. Third, the study’s retrospective design was another limitation because questions in the study were related to childhood experiences and feelings which, for many participants, occurred a long time ago. Therefore, recall errors could bias the results. Fourth, the sample size of bisexual men was relatively small. Because the current sample did not comprise only gay men or only bisexual men, it may neglect discrepancies between gay and bisexual men in many aspects. Future studies involving separate groups based on sexual identities would be helpful.

The current study makes several theoretical and practical contributions. From a theoretical perspective, we extend previous research by identifying risk factors and confirming the mediating role of IH and the moderating role of outness to one’s family. This will contribute to a better understanding of how and when CSA is correlated with suicide risk in adulthood among gay and bisexual men. In terms of practical value, there are three implications. First, we found that gay and bisexual men with high levels of CSA are more likely to develop suicidal ideation and attempts; this should alert suicide interveners to the need for early targeted approaches for gay and bisexual men, especially those who were sexually abused in childhood. Second, high levels of CSA may increase the risk of suicidal ideation and attempts by strengthening gay and bisexual men’s IH. Hence, effective anti-suicide psychological interventions among gay and bisexual men with high levels of CSA should aim to decrease IH by, for example, providing more social support and encouraging the development of self-identity and a sense of personal security. Third, our results indicated that stronger outness to one’s family may increase IH, thereby further increasing the risk of suicide among gay and bisexual men with high levels of CSA, which is a unique phenomenon in China. This indicates to those who design suicide intervention programs that family support should be increased, and that stress related to coming out should be reduced. Specifically, parents should be taught to give their children unconditional love and support, and help them realize that they have the right to disclose their sexual orientation and pursue happiness.

Conclusion

In summary, although further replication and extension is needed, this study marks an important step in resolving how CSA relates to suicidal ideation and attempts in adulthood among Chinese gay and bisexual men. It shows that IH serves as one potential mechanism through which CSA is associated with suicidal ideation and attempts. The focus on IH brings additional nuances in linking CSA to suicidal ideation and attempts. Importantly, this mediation mechanism is moderated by outness to one’s family. High levels of outness to family lead to a precipitous increase in IH in those with high levels of CSA, thereby increasing suicide risk. These findings suggest that gay and bisexual men’s IH and outness may be key in early prevention and intervention programs involving suicidal ideation and attempts. We hope to inspire future researchers to better understand the risk factors and mechanisms for suicidal ideation and attempts, and to advance the field of suicide research among gay and bisexual men.

Footnotes

Acknowledgments

The authors would like to thank Miss Yuxia Huang for her help in participant recruitment. The authors also thank all participants of this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Fundamental Research Funds for the Central Universities (YJ202011) and Scientific Research Planning Project of Sichuan Psychological Association (SCSXLX H2021006).

ORCID iD

Wenjian Xu

Author Biographies

Shuang Xue is a postgraduate student in the Department of Sociology and Psychology, School of Public Administration, Sichuan University, China. She is interested in the area of childhood maltreatment, as well as the underlying psychological mechanism and intervention of gay/bisexual men’ suicide risk.

Wenjian Xu, PhD, is an associate professor in the Department of Sociology and Psychology, School of Public Administration, Sichuan University, China. His research mainly focuses on LGB Health as well as Personality and Social Psychology. He is also a member of American Public Health Association and the Director of the Institute of Psychology, Sichuan University.

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