Men who have sex with men (MSM), including gay, bisexual men, men who identify as transsexual, and men who have sex with men who are heterosexual. Compared to the general population, MSM in China are more likely to suffer from mental health problems, including depression, anxiety, suicidal behavior, and substance dependence (Yu et al., 2013; Sun et al., 2020). A meta-analysis on the mental health of MSM from China showed that 43.2% of participants reported depressive symptoms, 32.2% of participants MSM reported anxiety symptoms, 21.2% had suicidal ideation, 6.2% had suicide plans, and 7.3% had attempted suicide (Wei et al., 2020). In addition, men who have sex with men are also at high risk for HIV infection. The prevalence of depressive symptoms among HIV-positive MSM in China was 44.1% (Zhang et al., 2018). The reasons of mental health problems among MSM are various and may be related to stress and stigma caused by social exclusion (Reisner et al., 2016), self-identity (Zhang et al., 2014), high-risk sexual behavior (Fendrich et al., 2013), and other factors. Despite the bleak state of mental health among MSM, only a small percentage of MSM actively seek and receive appropriate health services.

The contemporary term social capital became popular in the late 1980s with the research of Pierre Bourdieu and James Coleman. In 2000, Putnam proposed the importance of social capital for health outcomes (Rodgers et al., 2019). When the World Health Organization developed a new European policy for health—Health 2020, one of the prominent factors that was identified as a protective and promoting factor was “social capital” (World Health Organization, 2013). Social capital embraces the supportive resources inherent in an individual’s social network and his or her capacity to mobilize them (Yang and Yang et al., 2010; Wu D. et al., 2021). In general, the multidimensional structure of social capital can be divided into cognitive social capital and structural social capital. Cognitive social capital refers to subjective self-assessment of social relationships, such as social trust and perceived reciprocity among neighbors. Structural social capital is assessed through objective indicators such as participation in social organizations, volunteering, social participation, and civic activities (McKenzie et al., 2002). This study focuses on social capital at the individual level, and the assessment of individual social capital consists of cognitive social capital, the social networks that individuals have, and participation in social activities (Lynch et al., 2000; Brune and Bossert, 2009).

Related research has found that social capital interventions can be effective in improving subjective well-being, social support, resilience, sense of community, and quality of life, and reducing loneliness and depression (Flores et al., 2018). A study in Iran showed a significant relationship between mental health and social capital in the workplace; the higher the social capital of workers, the lower the risk of psychological distress, and enhancing social capital can be considered as a means of improving employees’ mental health (Firouzbakht et al., 2018). A Japanese study showed that all three factors of social capital (trust, connection and interaction, and social participation) and happiness were positively correlated (Tsuruta et al., 2019). Although the relationship between social capital and mental health has been well established in other populations, there are still relatively few studies on social capital and mental health in MSM. A study on the relationship between suicidal ideation, stigma, and social capital among MSM in three West African countries showed that social capital can reduce suicidal ideation among MSM (Stahlman et al., 2016). Therefore, social capital may be an important factor influencing mental health in MSM.

In China, influenced by Confucianism, collectivism, and a traditional culture that promotes heterosexual marriage, procreation, and filial piety, sexual minorities may suffer prejudice, stigma, and discrimination because of their sexual orientation (Fu et al., 2020; Yan et al., 2020). A study suggests that the high prevalence of mental health problems such as depression, anxiety, suicidal behavior, and alcohol abuse among Chinese MSM can be explained by minority stress (Sun et al., 2020). MSM are also more likely to suffer from depression during the process of minority stress (Meyer, 2003). A study of gay-related stressful events and emotional distress in MSM from China showed that over a 12-month period, participants had at least three to four times the prevalence of suicidal ideation, suicide planning, and suicide attempts than adult males in the general Chinese population. And an increase in gay-related stressful events significantly increased the risk of suicidal ideation and suicide planning among participants (Yu et al., 2018). Stress refers to the process of adaptation once a person is exposed to external or internal challenges (Chrousos, 2009). Maladjustment to stress not only alters brain function and peripheral physiology and can lead to a range of psychological and organic disorders. Perceived stress can be seen as a result of the interaction between the individual and the environment, is a cognitive evaluation process of the events acting on the individual (Katsarou et al., 2012). There are few studies on the status of perceived stress among men who have sex with men, but perceived stress has been found to be potentially related to mental health in other populations. A study of perceived stress and emotional distress showed a significant positive correlation between perceived stress and emotional distress (Yan et al., 2021). Also, perceived stress had a significant positive predictive effect on depression (Sebena et al., 2012). During the COVID-19 epidemic, higher perceived stress was associated with more emotional distress, including depression, fear, obsessive–compulsive anxiety, neurosis, and hypochondria (She et al., 2021). Based on previous studies, this study suggest that perceived stress may be an important factor affecting the mental health of MSM，and effective regulation and control of perceived stress can reduce the generation of negative emotions, such as anxiety and depression in MSM, and prevent the impact on the mental health of individuals.

In addition, Meyer’s (Meyer, 2003) minority stress model explains the impact of stress on sexual minorities from three aspects: general stressors, distal minority stress, and proximal minority stress. Various factors in the environment can lead to stress (general stress). Stress due to minority status (including sex orientation, race/ethnicity, and gender) is distal minority stress (e.g., prejudice, discrimination, and violence). Stress due to one’s own minority identity is minority proximal stress (e.g., expectations of rejection, concealment, and internalized homophobia). All three aspects of stress can have an impact on mental health.

In conclusions, mental health problems in MSM are persistent and severe, but most research on MSM has focused on HIV infection prevention and intervention, and researchers have often overlooked the importance of mental health. At present, social capital is relatively rare in the study of mental health of MSM. Based on previous research and minority stress models, this study selected appropriate questionnaires and scales to investigate the demographic characteristics, social capital, perceived stress, and mental health status of MSM, and analyzed the influencing factors of the mental health of MSM, so as to provide references for strengthening the psychological intervention and promoting the mental health status of MSM.

In this study, 48.9% of the participants scored between 7 and 15, and 7.1% of them scored >15, indicating poor mental health in this group. Similar to the results of previous studies, a systematic review from China showed that the combined prevalence of depressive or depressive symptoms among MSM was 40.0%, much higher than the reported incidence in the general Chinese male population (0.54–2.2%; Fu et al., 2020). The summary prevalence of anxiety symptoms among all MSM was 12.2–57.6% (Wei et al., 2020). The causes of serious mental health problems among MSM are multiple. In terms of population size, China has the largest homosexual population in the world (Wang et al., 2019), there is an estimated 21 million MSM in the sexually active phase (Wu W. et al., 2021). And on a social level, the status of sexual minorities may make it more difficult for them to seek medical or social help. In addition, influenced by traditional Chinese family values, most sexual minorities may be excluded from their families and lack support from their loved ones and families, which may also lead to poorer mental health status of MSM (Hu, 2016; Wei et al., 2020). Therefore, mental health issues in MSM require special attention.

This study found that relationship status (in relationships) was an important factor in mental health, indicating that MSM in a stable relationship had better mental health than single MSM. Similar to previous studies, a study on the effects of relationship quality and loving attitudes on self-stigma and mental health in HIV-positive MSM showed that MSM who had emotionally involved committed relationships or disclosed their HIV-positive status to their intimate partners had better happiness than other HIV-positive MSM (Yang et al., 2017). It follows that high-quality relationships and positive attitudes toward love provide another source of positive self-perception and well-being (Kim and Hatfield, 2004; Yang et al., 2017). A variety of behaviors in intimate relationships, including emotional contact, companionship, and physical intimacy, can provide feelings of attachment, trust, and satisfaction (Fletcher et al., 2000). A study from the United States and Poland showed that individuals in relationships reported better health, especially if they were in a high-quality relationship (Adamczyk et al., 2021). A stable, high-quality relationship may provide higher levels of psychosocial support, economic resources, health, and self-esteem for each other, leading to higher life satisfaction and coping styles that buffer the effects of adverse life events and promote mental health (Fagan, 2009; Siva Kumar et al., 2019). When intimate relationship is lacking, young people may be at risk for health problems. Although having a stable relationship may be beneficial to the development of MSM’s mental health, most of the MSM in this study were single, and the reason for this situation may be related to the lack of positive self-perception and self-stigma (Yang et al., 2017). There are not many studies on MSM relationship status and mental health, and the next research should focus on exploring what factors influence MSM relationship status and relationship quality, so as to create good conditions for MSM to find a stable and high-quality relationship.

In addition to relationship status, this study found that men who identified themselves as heterosexual, bisexual, or other sexual orientation had poorer mental health compared to homosexual. MSM’s cognition of their sexual orientation is also an important factor in mental health. Men’s mental health status may be influenced by their internal gender identity (Wei et al., 2020). Similar to previous studies, MSM had a high negative self-identification rate of 75.8%, with the majority of MSM not identifying themselves as homosexual (Zhang et al., 2014). A study conducted in urban western and southwestern China showed a 50.9% prevalence of depression among men who have sex with men and women, and 35.2% among men who have sex with men (Hu et al., 2019). Similarly, findings from other countries also suggest that bisexual men face greater mental health problems than homosexual men (Conron et al., 2010; Kipke et al., 2020). The reasons for this discrepancy in China are not yet clear, but studies in other Western countries suggest that poor mental health among bisexuals may be related to bisexual invisibility, erasure, bisexual-specific experiences of discrimination, biphobia in the homosexual community, and lack of support for bisexuality (Ross et al., 2018). It follows that improving MSM’s identification with their sexual orientation can also be a way to promote mental health. Therefore, the public should be called upon to treat MSM with more tolerance, especially the bisexual group among MSM or those with lower sexual orientation identity, and to improve and reduce the bi-phobia and discrimination in the surroundings of MSM. It is also important to strengthen support for MSM from society, community, friends, and family to promote their identification with their sexual orientation and thus improve their mental health.

Social capital to be a significant contributor to mental health outcomes (Bassett and Spencer, 2013; Ehsan and De Silva, 2015). This study found that social capital was positively correlated with mental health, and that social participation and social network were important factors influencing mental health. A study of social capital and suicidal ideation among MSM in West African countries found that participation in social activities, such as church, clubs, or broader community activities, was significantly associated with a reduction in suicidal ideation (Stahlman et al., 2016). Several studies have identified a correlation between social participation, volunteerism, and mental health (Thoits and Hewitt, 2001; Diener and Seligman, 2002). And social isolation can have a negative impact on mental health, especially for stigmatized groups such as MSM (Lackner et al., 1993; Liu and Mustanski, 2012). Many studies have demonstrated that the participation dimension of social capital is associated with mental health status, but not many studies have been conducted on social networks, since only a few disclosed that the network dimension of social capital was related to depressive symptoms (Bassett and Spencer, 2013). A study on uncertainty stress, social capital, and suicidal ideation among Chinese medical students found that participants with smaller social networks were more likely to experience suicidal ideation (Wu W. et al., 2021). In MSM, one study found that in the group of men who have sex with men, coming out without social support or a narrow social network will result in the adverse effect of stress, depression, and suicidal ideation and attempts (Cho and Sohn, 2016).

Therefore, intervention from the perspective of social capital, especially social participation and social networks, may be one of the effective ways to improve the mental health of MSM. First of all, relevant institutions can formulate policies to encourage the development of voluntary organizations and communities of sexual minorities and create a more harmonious environment for these organizations to develop. Secondly, these voluntary organizations or communities can organize more health education and communication activities according to their own situation to provide more social opportunities for MSM. Finally, through publicity and education, gay men can be encouraged to actively Finally, through publicity and education, MSM can be encouraged to participate in activities organized by schools, workplace, voluntary organizations, or communities to enhance social participation, broaden the social circle of MSM, and expand their own social networks, so as to improve the mental health level of MSM. In addition, MSM can positively influence health behaviors by spreading health-related information to each other through the social networks they have, establishing healthy social norms, monitoring and preventing unhealthy behaviors, and fostering personal responsibility for health (Thoits and Hewitt, 2001).

The cognitive component includes perceptions of support, trust, reciprocity, and shared values. But in this study, the results showed that cognitive social capital has no significant effect on mental health among MSM, which might be attributed to: Firstly, in recent years, with the opening and modernization of Chinese society, homosexuality has become increasingly visible in China, but an overall negative perception of MSM currently remains in China (Hu, 2016; Fu et al., 2020). Secondly, communities and non-governmental organizations about sexual minorities are very few in China. Although they hope to find more people who are similar to themselves and share a common language through these organizations, and they are eager to receive more support and care from these organizations. However, because these organizations are not well developed, they are unable to provide enough services to meet their needs for physical or mental health services (Xie et al., 2019). Social capital plays an important role in the health of MSM, further research is needed to discover the specific role of social capital in the mental health of MSM, and it is also important to understand the mechanisms by which social capital affects the mental health of MSM.

In this study 46.1% of participants scored >28 on the PSS, indicating a higher level of perceived stress among MSM. Also, perceived stress is an important factor affecting mental health. A study from Korea showed that the prevalence of perceived stress and depression among MSM was 46.7 and 42.7%, and the perception of the self as a stigmatized and devalued MSM correlated with perceived stress and suicidal ideation (Cho and Sohn, 2016). And a study conducted among sexual minorities found that worse self-assessment of health status was associated with higher perceived stress (Michalski et al., 2021). The reason for the higher perceived stress in MSM may be that MSM experience discrimination, stigma, rejection, and prejudice in their lives because of their sexual orientation. The accumulation and interaction of these pressure sources and the lack of social support can make stress management difficult and lead to mental health problems (Yu et al., 2018). Therefore, a harmonious and friendly environment should be created to reduce the prejudice of others against MSM and to reduce the pressure source in daily life, thus reducing the stress and promoting the mental health of MSM.

(1) This study is a cross-sectional study and causal inferences cannot be made. (2) Men who have sex with men are hidden, and the questionnaire was only distributed and collected online in this study. This leads to the possibility that the sample in this study is not well representative of overall MSM, and the generalizability of its findings is limited. (3) There are many variables that affect the mental health of MSM, but how each variable plays a role in influencing mental health is not clear at present. The next step can focus on the study of the mechanism of influence and discuss the specific relationship between each variable through path analysis.

This study found that relationship status, sexual orientation, perceived stress, and social capital all have important effects on the mental health of MSM. This suggests that it is still important to first call on the general public to treat MSM with a more tolerant attitude, improve the overall social environment, reduce external discrimination and prejudice against MSM, and promote the identification of MSM’s sexual orientation, while reducing the generation of external and internal pressure source and relieving MSM’s perceived stress. Secondly, the development of voluntary organizations and communities for sexual minority should be encouraged, through which more health education and services are provided to MSM to make them feel more belonging. Meanwhile, these organizations or communities can provide more opportunities for MSM to participate in activities, thus expanding the social participation and social network of MSM and improving the level of social capital. Finally, it is important to focus on the mental health problems of MSM, to provide mental health services and interventions for MSM with more targeted and effective approaches according to the different situations of individuals, and to encourage MSM to actively seek mental health services, which is also one of the effective ways to improve the mental health of MSM.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Ethics Committee of the Xuzhou Medical University. The patients/participants provided their written informed consent to participate in this study.

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

This study was supported by Excellent Talents Research Foundation of Xuzhou Medical University (grant number D202026).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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