Psychosocial symptom networks and high-risk sexual behaviors among men who have sex with men: a network analysis

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However, their interconnections—especially the roles of internalized homonegativity and sociosexual orientation—remain underexplored. This study aimed to: (1) model psychosocial symptom networks among MSM; (2) compare network structures across demographic subgroups; and (3) examine how central symptoms relate to high-risk sexual behaviors. Methods A cross-sectional survey was conducted among 405 MSM in Taizhou, China, using venue-based and online snowball sampling. Psychosocial variables—including depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation—were assessed using validated self-report scales. High-risk sexual behavior was measured based on condom use and number of sexual partners. Network analysis was used to examine symptom-level associations, and network comparison tests explored differences across demographic subgroups. Associations between central symptoms and high-risk behaviors were examined using correlation and regression analyses. Results Among 405 MSM, 12.4% reported moderate-to-severe depression and 10.1% had moderate-to-severe anxiety. Network analysis revealed the strongest connections between depressive and anxiety symptoms, as well as between loneliness and the desire for uncommitted sexual relationships. Central symptoms identified included ‘feeling nervous’ , desire for uncommitted sexual relationships, ‘feeling tired’ , ‘lacking companionship’, and ‘no good’ . Significant structural differences were found between participants < 33 years and those ≥ 33 years (p = 0.017), with older individuals showing generally weaker psychosocial connections. Central symptoms were significantly associated with risky sexual behaviors, especially in younger participants. Conclusions Central psychosocial problems—particularly emotional symptoms, low self-esteem, loneliness, and sociosexual desire—play a key role in driving high-risk sexual behaviors among MSM. Targeted, age-specific mental health interventions are essential to mitigate these risks and promote holistic well-being. Psychosocial problems High-risk sexual behaviors Men who have sex with men Network analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Men who have sex with men (MSM) refers to cisgender and transgender men who have sex with other men, regardless of whether or not they also have sex with women or have a personal or social gay or bisexual identity [ 1 ]. Sexual activities between men are associated with a high risk due to the prevalence of unprotected anal intercourse (UAI), involvement with multiple sexual partners (MSP), and engagement in commercial sex or other risk-related behaviors [ 2 , 3 ]. Globally, MSM have up to a 28-fold higher risk of Human Immunodeficiency Virus (HIV) acquisition compared to heterosexual men [ 4 ]. It is well-established that engaging in high-risk sexual behaviors significantly increases the likelihood of acquiring and transmitting sexually transmitted infections (STIs), including HIV [ 5 – 7 ]. MSM are often described as a marginalized and stigmatized population due to their sexual orientation and vulnerability to STIs [ 8 – 11 ]. According to the minority stress framework [ 12 ], stigma and social discrimination act as chronic stressors, contributing to psychosocial challenges among MSM. The prevalence of various psychosocial issues is significantly higher among MSM compared to their heterosexual counterparts [ 12 – 16 ]. These psychosocial problems typically manifest in two dimensions: psychological difficulties and social or relational challenges. At the psychological level, MSM often experience depression, anxiety, low self-esteem, and internalized homonegativity. At the social level, they frequently encounter loneliness, lack of social support, and challenges related to sociosexual orientation. To date, extensive research has documented that depression and anxiety are prevalent psychological problems among MSM [ 17 – 22 ]. A meta-analysis showed that the prevalence of depression among MSM in China was 43.9% (95%CI: 36.9%-48.8%), and the rate was particularly high among HIV-positive MSM [ 21 ]. Anxiety symptoms are also widespread, affecting approximately 32.2% of MSM according to a meta-analysis conducted in China [ 23 ]. Discrimination, minority stress, and concealment-related guilt have all been associated with the development of depression and anxiety among MSM [ 24 – 26 ]. Self-esteem, defined as an individual’s evaluation of personal worth, is another critical psychological factor frequently undermined by perceived and internalized stigma [ 17 ]. Existing studies in China report that 6–7% of MSM experience low self-esteem [ 17 , 27 ], reflecting a lack of self-acceptance due to internalization of societal stigma [ 10 ]. Internalized homonegativity—characterized by negative self-perceptions associated with one’s sexual orientation—is closely linked to depression, anxiety and low self-esteem among MSM [ 18 , 28 , 29 ]. These psychological problems are often intertwined, highlighting the complex nature of mental health within MSM populations. Social relationship problems have long been linked to psychological difficulties. Loneliness, a distressing emotion arising from unmet social relationship needs, is prevalent among MSM due to experiences of social exclusion and isolation. In China, MSM who experience loneliness are more likely to exhibit low self-esteem and moderate-to-severe depressive symptoms[ 17 ]. Furthermore, social support plays a crucial protective role. Deficiencies in social support is strongly associated with higher levels of depression, anxiety, and loneliness [ 30 , 31 ]. Sociosexual orientation is used to describe individual differences in the willingness to engage in casual sexual relationships. Some MSM exhibit an unrestricted sociosexual orientation and a behavioral preference for promiscuity [ 32 ]. Individuals with this orientation tend to engage in sexual activities without emotional attachment, favor one-night stands, and often have multiple sexual partners. Psychosocial problems such as depression [ 33 ], anxiety [ 11 ], internalized homonegativity [ 34 ], loneliness [ 18 ] and unrestricted sociosexual orientation [ 35 ] are closely linked to high-risk sexual behaviors. Psychological distress may drive MSM to engage in condomless sex or maintain multiple sexual partners as coping strategies [ 8 – 10 ]. Depression has been associated with a higher likelihood of condomless sex among MSM [ 18 ], though severe depressive symptoms may sometimes reduce sexual interest, reflecting a complex, nonlinear relationship [ 13 ]. Loneliness is similarly linked to increased sexual risk-taking, particularly unprotected sex [ 18 , 36 ]. Social risk factors have been shown to shape high-risk sexual behaviors by influencing patterns of partner seeking, sexual settings, relationship choices, and condom use decisions [ 30 ]. Previous research has typically investigated psychosocial factors in isolation, often overlooking their complex interactions. Psychosocial problems, however, may be more accurately conceptualized as a network of interconnected symptoms [ 37 ]. Similarly, prior studies on high-risk sexual behaviors have predominantly focused on identifying isolated influencing factors, without considering their associations with central symptoms within the psychosocial network [ 38 ]. Given the known comorbidity and syndemic relationship between psychosocial issues [ 11 , 15 , 39 ], network analysis provides a valuable tool for mapping these multifaceted dynamics. It offers both visual and quantitative insights into symptom associations and enables the identification of central symptoms — those most strongly connected to other symptoms in the network [ 40 ]. Targeting central symptoms in interventions may be more effective in preventing the activation or spread of related symptoms. In addition, few studies have examined internalized homonegativity and sociosexual orientation as central variables within psychosocial networks among MSM, leaving a significant gap in the current literature. Although demographic factors, particularly age, have been shown to influence psychosocial challenges among MSM, little is known about how these factors shape the structure and dynamics of psychosocial networks. Existing research has largely overlooked whether different demographic subgroups exhibit distinct psychosocial patterns, limiting a nuanced understanding of how vulnerabilities and risk behaviors may vary across the MSM population. To address the identified research gap and better understand the complex interplay between psychosocial problems and high-risk sexual behaviors among MSM, a cross-sectional survey was conducted in Taizhou, China, with three primary objectives: (1) to construct a comprehensive network model of psychosocial problems, including depression, anxiety, self-esteem, internalized homonegativity, loneliness, social support, and sociosexual orientation; (2) to compare psychosocial network structures across MSM subgroups defined by age, marital status, educational level, and sexual orientation, identifying subgroup-specific patterns; and (3) to examine the associations between central psychosocial symptoms within these networks and high-risk sexual behaviors across different demographic subgroups. Together, these analyses aim to identify critical psychosocial factors and interrelationships, providing an evidence base for developing targeted interventions to improve mental health and reduce sexual risk behaviors among MSM. Methods Participants A cross-sectional survey was conducted among MSM from January to August 2022 in three districts (Huangyan, Jiaojiang, and Luqiao) of Taizhou, Zhejiang Province, China. Participants were eligible if they: (1) were biologically male; (2) aged 15 years or older; (3) had previously engaged in oral or anal sex with another man; (4) had no severe cognitive or communication impairments; and (5) provided informed consent to participate. The study was approved by the Ethics Committee of Taizhou Central Hospital (2022L-01-18), and all methods were carried out in accordance with relevant guidelines and regulations. Due to the hidden nature of the MSM population, participants were recruited using a combination of convenience and snowball sampling methods. Initially, recruitment was carried out at venues frequently visited by MSM, including bars, nightclubs, saunas, and public parks. To ensure privacy and confidentiality, participants completed questionnaires individually in undisturbed areas within these venues. Trained research staff provided clarification and assistance upon request. Additionally, online advertisements were posted on popular MSM-oriented platforms within Zhejiang Province, including forums, chat rooms, and social networking applications. Participants recruited through these platforms were encouraged to share the questionnaire with their MSM peers, continuing until the desired sample size was reached. A total of 534 MSM completed the psychosocial questionnaire with informed consent. After removing incomplete data, the final analytical sample consisted of 405 participants. Measures Sociodemographic characteristics The sociodemographic variables included age, marital status (never married or previously married, married or cohabiting), educational level (middle school or below, high school or technical school, college or above), and sexual orientation (homosexual, bisexual/heterosexual/unsure). Psychosocial variables Depressive symptoms Depressive symptoms among the MSM population were measured using the Patient Health Questionnaire-9 (PHQ-9) scale, a widely utilized and effective self-report instrument designed to assess depression over the preceding two weeks [ 41 ]. The PHQ-9 consists of nine items, each corresponding to one of the nine DSM-IV diagnostic criteria for depression. Respondents rate their experiences on a four-point scale: "not at all" (0 points), "several days" (1 point), "more than half the days" (2 points), and "nearly every day" (3 points). The possible total score ranges from 0 to 27, with higher scores indicating more severe depressive symptoms. The Chinese version of PHQ-9 has been demonstrated as a valid and reliable tool to screen depression [ 42 ], and the Cronbach’s alpha was 0.88 in this study. Anxiety symptoms Anxiety levels were assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7) [ 43 ]. This scale consists of seven items, each rated on a four-point scale: "not at all" (0 points), "several days" (1 point), "more than half the days" (2 points), and "nearly every day" (3 points). The total score is the sum of the seven items, with a higher score indicating greater anxiety. This scale’s reliability and validity have been proven [ 44 ] and the Cronbach’s alpha was 0.91 in this research. Self-esteem Self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES), one of the most widely used instruments for measuring self-evaluation of personal worth [ 45 ]. The RSES consists of 10 items, five of which are positively worded and five reverse-scored. Respondents rate each item on a four-point scale: "strongly agree" (3 points), "agree" (2 points), "disagree" (1 point), and "strongly disagree" (0 points). The total possible score ranges from 0 to 30, with higher scores indicating higher self-esteem. Previous research validating the Chinese version of the RSES has demonstrated excellent reliability, with Cronbach’s α ranging from 0.911 to 0.942, and omega (ω) values ranging from 0.915 to 0.944 [ 46 , 47 ]. The Cronbach’s alpha was 0.85 in this study. Internalized homonegativity The Short Internalized Homonegativity Scale (SIHS) is a commonly used instrument for measuring internalized homonegativity—namely, the internalization of negative attitudes and assumptions about homosexuality by gay individuals themselves [ 47 ]. The SIHS consists of eight items, which are divided into three subscales: "Social Comfort with Gay Men," "Public Identification as Gay," and "Personal Comfort with a Gay Identity". Higher scores on the scale indicate greater acceptance of one’s sexual orientation and lower levels of internalized homonegativity. The Cronbach’s alpha was 0.76 in this study. Loneliness The 3-item UCLA Loneliness Scale (UCLA-3) was used to assess feelings of loneliness [ 48 ]. This scale consists of three items, each rated on a three-point scale: "hardly ever" (1 point), "some of the time" (2 points), and "often" (3 points). Scores of the scale range from 3 to 9, with higher scores indicating higher levels of perceived loneliness. Previous research has demonstrated that the UCLA Loneliness Scale (Version 3) exhibits high reliability, with internal consistency (Cronbach’s α ranging from 0.89 to 0.94) and test-retest reliability over a one-year period (r = 0.73) [ 49 ]. The Cronbach’s alpha was 0.84 in this research. Perceived social support The Multidimensional Scale of Perceived Social Support (MSPSS) was used to assess individuals' perceived support [ 45 ]. The MSPSS consists of 12 items designed to evaluate perceived social support from three sources: Family, Friends, and Significant Others. Each item is rated on a 7-point Likert scale, ranging from "very strongly disagree" (1 point) to "very strongly agree" (7 points). The average score for each subscale was calculated separately, with higher scores indicating greater levels of social support. The Cronbach’s alpha was 0.93 in this study. Sociosexual orientation The revised Sociosexual Orientation Inventory (SOI-R) was used to assess people’s willingness to engage in uncommitted sexual relationships [ 35 ]. The scale comprises 9 items, which are categorized into three subscales: "Behavior," "Attitudes," and "Desire." Only the latter two dimensions were included in the psychosocial network analysis. The Attitude dimension consists of three items that assess one’s disposition toward uncommitted sexual behavior, reflecting the desired level of emotional closeness before engaging in sex and the moral evaluation of such behavior. The Desire dimension also comprises three items and measures interest in uncommitted sexual activity, characterized by heightened sexual desire often accompanied by subjective arousal and sexual fantasies. Unlike general sexual desire, unrestricted sociosexual desire refers to sexual attraction to potential partners outside of committed relationships. Higher scores indicate a greater degree of unrestricted sociosexual orientation. The Cronbach’s alpha was 0.84 in this study. High-risk sexual behaviors High-risk sexual behavior was assessed using two items: (1) the frequency of condom use during anal sex with male partners in the past six months, and (2) the number of sexual partners in the past 12 months, as measured by an item from the Behavior dimension of the SOI-R. A total score was calculated, with higher scores indicating a greater likelihood of engaging in high-risk sexual behaviors. Statistical analysis Descriptive analysis Descriptive analyses were conducted for participants’ sociodemographic characteristics, psychosocial variables, and high-risk sexual behaviors. Continuous variables were summarized using means and standard deviations, while categorical variables were presented as frequencies and percentages. Independent samples t-tests and chi-square tests (χ²) were used to compare the characteristics of MSM aged < 33 years and those aged ≥ 33 years. Network estimation and centrality Psychosocial variables included in the network structure analysis were depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation. All individual items from the scales measuring depressive symptoms, anxiety symptoms, loneliness, and self-esteem were treated as nodes in the network. In addition, total scores from each dimension of perceived social support (three dimensions), sociosexual orientation (two dimensions), and internalized homonegativity (three dimensions) were also included as network nodes. The network was estimated using the "bootnet" package in R and visualized with the "qgraph" package [ 50 ]. Pairwise Spearman correlations and sparse Gaussian graphical models with graphical lasso were used to estimate the associations between psychosocial variables among MSM. All variables were represented as nodes, and direct associations between variables were displayed as edges. The thickness of each edge reflects the strength of the association. To assess node centrality within the psychosocial network, strength, betweenness, closeness, and expected influence were calculated and visualized [ 51 , 52 ]. Higher centrality values indicated more influential symptoms that were directly connected to a greater number of other symptoms in the network. Strength was defined as the total sum of the absolute edge weights directly connected to a specific node, with higher-strength nodes potentially triggering the activation of other symptoms. Betweenness measured the extent to which a node lay along the shortest paths between pairs of other nodes, suggesting that nodes with high betweenness could act as bridges linking different symptom clusters within the network. Closeness referred to the inverse of the average shortest path length from a given node to all other nodes, meaning that a node with high closeness might be more directly connected to a broader range of symptoms. Expected Influence (EI), a more recent centrality metric, expanded on strength by accounting for both positive and negative edge weights when evaluating a node’s influence in the network [ 53 ]. Network stability was evaluated using a case-dropping subset bootstrap approach with 1,000 iterations. The correlation stability coefficient was used to quantify the robustness of the centrality estimates, with values above 0.5 generally considered indicative of a stable network. Network comparison To compare the psychosocial network structures of MSM across different age groups, marital statuses, educational levels, and sexual orientations, the “NetworkComparisonTest” package in R was employed [ 54 ]. A permutation test with 1,000 iterations was conducted to examine both global and local differences in network edges. Global network structure invariance was assessed by evaluating the maximum difference in edge weights between two networks. Global strength differences were quantified by comparing the weighted sum of all absolute edge values across networks. Local differences were assessed by testing the invariance of each individual edge between the two networks. Association between central symptoms and high-risk sexual behavior To examine whether central symptoms in the psychosocial network were more strongly associated with high-risk sexual behavior, Spearman rank correlation analyses were conducted between each network node and the high-risk behavior score. Higher correlation coefficients indicated a stronger association between the symptom and high-risk sexual behavior. The relationship between centrality and correlation coefficients was evaluated using locally weighted scatterplot smoothing (LOWESS). Linear regression analysis was performed to assess whether nodes with higher centrality values were more strongly associated with high-risk sexual behavior. Results The characteristics of the participants (n = 405) are illustrated in Table 1 . Of the participants with a mean age of 33.4 years (range 16–76), 66.4% were never married or previously married, 33.1% had middle school or lower education, and 58.3% were self-identified as homosexual. Furthermore, 50 (12.4%) participants exceeded the cut-off score of 10 for moderate-to-severe depression and 41 (10.1%) exceeded the cut-off score of 10 for moderate-to-severe anxiety. In total, 27 (6.7%) participants had both clinically relevant depressive and anxiety symptoms. A high percentage of MSM suffered from loneliness (25.7%), 19.3% had unprotected anal intercourse in the last six months and 68.9% had multiple sexual partners in the past 12 months. Compared with younger participants, a higher proportion of MSM aged 33 and older were married or cohabiting, had lower education, and were self-identified as bisexual. The older participants also reported lower self-esteem, poorer social support from family, friends and significant other, and more positive attitude towards unrestricted sociosexual orientation but lower desire for uncommitted sexual relationships. Table 1 Participant characteristics Total sample (n = 405) Age < 33 old (n = 213) Age ≥ 33 old (n = 192) P value Sociodemographic variables Age (16–76) 33.4 (11.5) 24.3 (4.3) 43.6 (7.9) < 0.001 Marital status, n (%) < 0.001 Never married or previously married 269 (66.4) 199 (93.4) 70 (36.5) Married or cohabiting 136 (33.6) 14 (6.6) 122 (63.5) Educational level, n (%) < 0.001 Middle school or below 134 (33.1) 25 (11.7) 109 (56.8) High school or technical school 155 (38.3) 97 (45.5) 58 (30.2) College or above 116 (28.6) 91 (42.7) 25 (13.0) Sexual orientation, n (%) < 0.001 Homosexual 236 (58.3) 167 (78.4) 69 (35.9) Bisexual/heterosexual/unsure 169 (41.7) 46 (21.6) 123 (64.1) Psychosocial variables Depression (0–27) 4.6 (4.4) 4.7 (4.5) 4.5 (4.2) 0.547 Anxiety (0–21) 4.1 (4.1) 4.2 (4.0) 4.0 (4.2) 0.720 Loneliness (3–9) 4.3 (1.5) 4.2 (1.6) 4.3 (1.4) 0.671 Self-esteem (0–30) 20.3 (4.2) 20.8 (4.7) 19.8 (3.6) 0.014 Table 1 Participant characteristics (continued) Total sample (n = 405) Age < 33 old (n = 213) Age ≥ 33 old (n = 192) P value Perceived social support Family support (1–7) 4.7 (1.0) 4.8 (0.9) 4.5 (1.0) 0.003 Friends support (1–7) 4.7 (1.0) 4.8 (0.9) 4.5 (1.0) < 0.001 Significant others support (1–7) 4.7 (1.0) 4.8 (0.9) 4.5 (1.0) < 0.001 Sociosexual Orientation Attitude (3–15) 8.2 (2.1) 7.9 (2.2) 8.7 (2.0) < 0.001 Desire (3–15) 7.3 (3.1) 7.7 (3.2) 7.0 (2.9) 0.021 Internalized homophobia Social comfort with Gay Men (3–21) 12.6 (2.5) 12.4 (2.5) 12.8 (2.5) 0.107 Public Identification as Gay (2–14) 8.0 (2.4) 7.9 (2.4) 8.2 (2.4) 0.307 Personal Comfort with a Gay Identity (3–21) 13.4 (2.8) 13.3 (2.9) 13.6 (2.7) 0.333 High-risk sexual behaviors Unprotected anal intercourse (1–4) 1.9 (0.8) 1.9 (0.7) 1.9 (0.8) 0.628 Multiple Sexual Partners (1–5) 3.0 (1.2) 2.9 (1.1) 3.1 (1.2) 0.144 *Continuous variables were presented as mean (standard deviation), and categorical variables were presented as number (percentage). Network estimation We estimated the overall network including separate items for depressive symptoms, anxiety symptoms, loneliness, self-esteem, and subscale scores for perceived social support from family, friends and significant other, attitude and desire scores for unrestricted sociosexual orientation, and three subscale scores for internalized homonegativity (Fig. 1 ). The items of these measures and their reference names were listed in Table S1 . Within the overall network, we observed strong connections between the items of depressive symptoms and anxiety symptoms, particularly between ‘anhedonia’ and ‘feeling nervous’ (edge weight = 0.23). The loneliness item ‘lacking companionship’ was positively connected with the desire for uncommitted sexual relationships (edge weight = 0.25) and the anxiety item ‘feeling nervous’ (edge weight = 0.09). Among the items of self-esteem, ‘satisfied with myself’ was negatively linked to the desire for uncommitted sexual relationships (edge weight = -0.1), and ‘respect for myself’ was negatively associated with the attitude towards uncommitted sexual relationships (edge weight = -0.1) and social comfort with gay men (SIHSSC) (edge weight = -0.11). Furthermore, social comfort with gay men (SIHSSC) was negatively connected with the desire for uncommitted sexual relationships (edge weight = -0.12), while public identification as gay (SIHSPUBID) was positively associated with the attitude towards uncommitted sexual relationships (edge weight = -0.11), and personal comfort with a gay identity (SIHSPC) was positively linked to family social support (edge weight = 0.08). Detailed edge weights for all the edges in the network can be found in Table S2. Items of depressive symptoms were on average explained for 52.3% by variables in the network that were directly connected to them, for items of anxiety symptoms 61.0%, for loneliness items 54.8% and for self-esteem items 56.5%. Explained variance for perceived social support subscale scores was on average 63.6%, for unrestricted sociosexual orientation 39.9%, and for internalized homonegativity 38.6%. Stability of the network was evaluated using the bootstrap method. The edge weights in the current sample were largely consistent with the bootstrapped sample, indicating relatively stable estimates (see Figure S1 ). The correlation stability coefficients exceeded 0.5 even using 30% of the cases, indicating that the network structure was stable. Network comparison We assessed whether the network structure was significantly different for people of different age, marital status, education or sexual orientation. There was global difference in the network structure between participants < 33 years and those ≥ 33 years (p = 0.017). No global differences were found for the other sociodemographic variables. In addition, local differences existed in several edges for people of different age, and the statistically significant higher and lower correlations are visualized separately in Fig. 2 (p < 0.05). When comparing participants ≥ 33 years with those < 33 years, we observed differences in connections between items of depressive symptoms and items of anxiety symptoms. In MSM ≥ 33 years, there were stronger connections between ‘feeling tired’ and ‘irritable’ , between ‘psychomotor symptoms’ and ‘cannot stop worrying’ and between ‘sleep problems’ and ‘feeling nervous’ , whereas the connections between ‘psychomotor symptoms’ and ‘irritable’ and between ‘sad mood’ and ‘trouble relaxing’ were weaker. The connections between items of emotional symptoms and the other psychosocial problems generally decreased in the older MSM, such as the relations between ‘suicidal thoughts’ and ‘feeling isolated’ and between ‘feeling nervous’ and ‘respect for myself’ . Furthermore, we observed that a number of associations between loneliness, self-esteem, social support, unrestricted sociosexual orientation and internalized homonegativity were significantly weaker in older MSM when compared to the younger group. For example, there were weaker connections between the following nodes: social support from family – ‘worth’ , social support from significant other – ‘proud’, ‘no good’ – desire for uncommitted sexual relationships, and ‘feeling isolated’ – personal comfort with a gay identity. Network centrality Figure 3 shows the network centrality of each item and subscale in the total sample, participants < 33 years and those ≥ 33 years. In the total sample, ‘feeling nervous’ , desire for uncommitted sexual relationships, ‘feeling tired’ , ‘lacking companionship’ and ‘no good’ exhibited high network centrality. The high centrality values of these items implied that their roles in the MSM psychosocial network were important and they were associated with most of the other items in the network. ‘Suicidal thoughts’ , loneliness items and desire for uncommitted sexual relationships showed higher centrality values in participants < 33 years compared to those ≥ 33 years. ‘Feeling afraid’ and ‘satisfied with myself’ showed greater betweenness in participants ≥ 33 years, which might play a key role as mediators between their associated items. Connection value of central symptoms Spearman’s correlations were computed between each psychosocial problem and risky sexual behaviors (see Table S3). Behavior items were coded such that higher scores indicate a higher level of risky sexual behaviors. A high absolute correlation indicates that the severity of the problem was associated with risky sexual behaviors. Depressive symptoms, anxiety symptoms, self-esteem, perceived social support and acceptance of homosexuality negatively correlated with risky sexual behaviors, indicating that individuals with more severe emotional symptoms, higher self-esteem, more social support and greater acceptance of homosexuality were less likely to have risky sexual behaviors. By comparison, the correlation values were positive for loneliness and unrestricted sociosexual orientation, indicating that individuals with more severe loneliness and higher levels of attitude and desire for uncommitted sexual relationships were more likely to have risky sexual behaviors. We refer to the values in Table S3 as connection values . Higher absolute values indicate that the problem has a strong connection with risky sexual behaviors. We then examined whether the centrality of psychosocial problems was associated with connection values. Linear regression results revealed that centrality of problems was significantly associated with connection values for risky sexual behaviors among the total sample (β = -0.144, p = 0.039) and participants < 33 years (β = -0.164, p = 0.022), but not among those ≥ 33 years (β = -0.119, p = 0.218). The results of this analysis are presented in Fig. 4 . The estimation results of LOWESS in Fig. 4 also show that the general tendency between the expected influence strength centrality and the connection value was negative. To properly understand this figure, it is helpful to point out that each point represents a psychosocial problem (i.e., node) in the network. A point towards the right on the x-axis indicates a problem which was highly central. A point large on the y-axis represents a problem which has high connection value. The results thus verified an association between a problem’s centrality and the connection value of that problem with risky sexual behaviors, and the association was stronger in younger participants compared with the older ones. Discussion This study employed network analysis to explore the interrelations among depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation within the MSM population in Taizhou, China. The study also identified central symptoms within the psychosocial network structure and examined their associations with high-risk sexual behaviors. The results revealed significant associations among these psychosocial variables. ‘Feeling nervous’ , desire for uncommitted sexual relationships, ‘feeling tired’ , ‘lacking companionship’ , and ‘no good’ emerged as central symptoms in the network and were significantly associated with high-risk sexual behaviors. Subgroup analyses by age indicated significant differences in the psychosocial network structures across different age groups of MSM. In this study, 12.4% and 10.1% of MSM reported moderate or higher levels of depressive and anxiety symptoms, respectively—rates lower than those reported in prior studies. For example, depression prevalence among MSM was 27.4% in a UK study [ 22 ], 24.9% in a Brazilian multicity study [ 25 ], and 36% among newly diagnosed HIV-positive MSM in China [ 55 ]. Variations in prevalence may be attributed to differences in sample demographics, study periods, measurement tools, and HIV infection status. Regarding sexual risk behaviors, 19.3% of participants reported engaging in condomless anal intercourse in the past six months, and 68.9% reported having multiple sexual partners in the past 12 months. These findings are consistent with international data. A systematic review of MSM in high-income countries documented a substantial increase in condomless anal sex, rising from approximately 35% in 1990 to 55% by 2012, alongside a shift in sexual partner trends: little change between 1992 and 2002, with about 40% of MSM reporting multiple partners, followed by a substantial increase to over 60% during 2003–2013 [ 56 ]. These findings highlight ongoing psychological burdens and sexual risk behaviors among MSM. Further research is warranted to elucidate the psychological, social, and structural factors driving these trends and to inform targeted prevention strategies. In the symptom network linking depression, anxiety, and loneliness, the depressive symptom ‘anhedonia’ exhibited the strongest association with the anxiety symptom ‘feeling nervous’ , followed by ‘feeling tired’ and ‘irritable’ . Among the loneliness symptoms, ‘lacking companionship’ demonstrated a significant correlation with ‘feeling nervous’ . These findings are consistent with previous research in MSM, highlighting the frequent co-occurrence of depression, anxiety, and loneliness [ 17 , 27 ]. Additionally, ‘feeling nervous’ , ‘feeling tired’ and ‘lacking companionship’ emerged as highly central nodes within the psychosocial symptom network in our study. Since centrality identifies symptoms that hold key positions and exert significant influence over the network, targeting these core symptoms in interventions may be an effective strategy to alleviate co-occurring mental health burdens among MSM. In our network analysis, the desire for uncommitted sexual relationships was also identified as a central symptom within the network. Notably, among the associated factors, ‘lacking companionship’ showed the strongest connection with this desire, followed by ‘feeling nervous’ , suggesting that loneliness and anxiety may act as driving forces behind unrestricted sociosexual orientation, potentially serving as coping mechanisms to alleviate feelings of disconnection. Previous research has similarly indicated that MSM experiencing loneliness may seek physical intimacy as a substitute for emotional support [ 18 ]. In line with this, a study of 394 young adults found that individuals with poor mental health experienced temporary relief from depressive and loneliness symptoms following non-restrictive sexual behaviors [ 57 ]. Conversely, other studies have suggested that psychological issues such as depression, anxiety, and loneliness may result from casual sexual encounters. For example, a multi-ethnic study of 3,907 single, heterosexual college students across 30 U.S. universities reported that unrestricted sexual behavior was positively associated with psychological distress and negatively associated with well-being [ 58 ]. In addition, our network analysis revealed that the self-esteem items ‘satisfied with myself’ and ‘respect for myself’ were negatively associated with unrestricted sexual desire and attitudes, respectively. This pattern suggests that a higher level of sociosexual orientation may be linked to lower levels of self-esteem among MSM, consistent with findings in the general population [ 59 ]. However, the causal relationship between low self-esteem and non-restrictive sexual behavior remains unclear and warrants further longitudinal investigation. Internalized homonegativity describes the self-loathing experienced by homosexual individuals. In this study, internalized homonegativity was assessed using three dimensions: social comfort with gay men, public identification as gay, and personal comfort with a gay identity. Network analysis revealed a negative association between social comfort with gay men and the desire for uncommitted sexual relationships. Consistent with prior research, Brian et al. [ 60 ] reported that higher levels of internalized homophobia were associated with stronger sexual urges, which in turn increased the likelihood of engaging in high-risk sexual behaviors. Beyond behavioral consequences, internalized homonegativity has been consistently linked to adverse psychological outcomes. Newcomb et al. [ 61 ] found that internalized homophobia was associated with stronger suicidal ideation, more severe depressive symptoms, and reduced levels of help-seeking and perceived social support. Similarly, Bingham et al. [ 62 ] identified a significant negative association between internalized homophobia and self-esteem. Our network analysis further revealed a positive association between family support and personal comfort with a gay identity, suggesting that familial acceptance may play a protective role against internalized homonegativity. The attitudes and reactions of family members are closely tied to how individuals construct and accept their sexual identities. Negative parental responses to a child's sexual orientation have been shown to hinder self-acceptance and increase the risk of internalized stigma [ 63 ]. These findings highlight the importance of family-inclusive interventions that promote acceptance and understanding, particularly in sociocultural contexts where stigma remains pervasive. This study found that the psychosocial symptom networks varied across age groups among MSM. Specifically, compared to younger participants, older MSM exhibited stronger associations between depressive and anxiety symptoms, such as between ‘feeling tired’ and ‘irritable’ , ‘psychomotor symptoms’ and ‘cannot stop worrying’ , as well as ‘sleep problems’ and ‘feeling nervous’ . In contrast, the interconnections among loneliness, self-esteem, perceived social support, sociosexual orientation, and internalized homonegativity were notably weaker in the older group. In the older MSM network, ‘feeling afraid’ and ‘satisfied with myself’ demonstrated higher betweenness centrality, suggesting that these anxiety and self-esteem symptoms may act as critical mediators of broader psychological distress in this subgroup. Conversely, in the younger group, ‘suicidal thoughts’ , loneliness-related items, and the desire for uncommitted sexual relationships showed higher centrality values than in older participants. These findings indicate that emotional isolation, impulsive sexual behavior, and suicidal ideation are more prominent features in the psychosocial profile of younger MSM, underscoring the need for age-sensitive mental health and behavioral interventions. Importantly, regression analysis in this study demonstrated that central symptoms within the psychosocial network were significantly associated with high-risk sexual behaviors among MSM, with stronger associations observed in younger participants than in older one. This finding suggests that such behaviors may, in part, stem from underlying psychological distress. Conversely, a bidirectional relationship is also plausible, whereby MSM engaging in more high-risk sexual behaviors may subsequently experience greater psychosocial burden. These results align with previous studies among MSM in China, which found that multiple psychosocial problems were associated with unprotected anal intercourse [ 39 ], and that MSM with five or more psychosocial problems had greater odds of having multiple sexual partners compared with those without syndemic conditions [ 27 ]. Several mechanisms may explain the link between psychosocial problems and high-risk sexual behaviors. First, some individuals—particularly youth—may engage in sexual activity as a way to cope with psychological distress, escape unpleasant emotions or circumstances, or seek affirmation of their self-worth [ 64 ]. Second, negative emotional states, such as depression or anxiety, can impair judgment and decision-making, thereby increasing susceptibility to risky sexual encounters [ 65 ]. Even a negative affective state, in the absence of other clusters of depressive symptomatology, can still result in a less severe, but impaired decision making [ 66 ]. Third, MSM experiencing serious psychological distress may have a history of complex trauma in their childhood or adolescent development, which is often associated with a higher likelihood of engaging in unsafe sexual practices [ 67 ]. Such behaviors may serve as maladaptive coping mechanisms the individual has developed over time. Given these findings, targeting central symptoms within the psychosocial network of MSM may serve as an effective intervention strategy to reduce high-risk sexual behaviors and, consequently, lower the risk of HIV and other sexually transmitted infections in this vulnerable population. Integrative interventions that simultaneously address psychological and social factors are essential to effectively mitigate these risks. Strengths and limitations This study has several strengths. To our knowledge, it is among the first to employ network analysis to simultaneously examine seven psychosocial problems within a Chinese MSM population, providing a nuanced understanding of the psychosocial mechanisms underlying high-risk sexual behaviors. The use of age-stratified network analyses further highlights the heterogeneity of psychosocial patterns across subgroups, offering valuable insights for the design of age-tailored interventions. Additionally, the identification of central symptoms linked to high-risk sexual behaviors provides a potential theoretical basis for developing targeted mental health and behavioral interventions. However, several limitations should be acknowledged. First, the cross-sectional design precludes causal inferences regarding the relationships between psychosocial symptoms and high-risk sexual behaviors. Second, participants were recruited through convenience sampling in Taizhou, which may limit the generalizability of the findings to broader MSM populations in China. Third, self-reported data on psychosocial problems and sexual behaviors are subject to recall bias and social desirability bias, which may have led to underreporting of sensitive behaviors. Finally, although network analysis highlights central symptoms and interconnections, it does not capture the temporal dynamics of symptom interactions, which warrant further investigation using longitudinal or ecological momentary assessment designs. Future studies should adopt multi-site, longitudinal, and mixed-method approaches to validate and extend these findings. Conclusions In conclusion, this study mapped the network structure and interconnections among key psychosocial factors—including depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation—across different age groups of MSM. Central symptoms such as ‘feeling nervous’ , desire for uncommitted sexual relationships, ‘feeling tired’ , ‘lacking companionship’ , and ‘no good’ played particularly influential roles within the psychosocial network and were significantly associated with high-risk sexual behaviors. Notably, younger MSM appeared more susceptible to the impact of psychosocial problems on their sexual risk-taking. These findings offer a theoretical foundation for the development of future interventions aimed at improving mental health and reducing high-risk sexual behaviors within the MSM population. Abbreviations MSM Men who have sex with men UAI Unprotected anal intercourse MSP Multiple sexual partners HIV Human immunodeficiency virus STIs Sexually transmitted infections CI Confidence Interval PHQ-9 Patient Health Questionnaire-9 scale GAD-7 Generalized Anxiety Disorder 7-item scale RSES Rosenberg Self-Esteem Scale SIHS Short Internalized Homonegativity Scale UCLA-3 3-item UCLA Loneliness Scale MSPSS Multidimensional Scale of Perceived Social Support SOI-R The revised Sociosexual Orientation Inventory EI Expected Influence LOWESS Locally weighted scatterplot smoothing SIHSSC Subscale of Short Internalized Homonegativity Scale:"Social Comfort with Gay Men" SIHSPUBID Subscale of Short Internalized Homonegativity Scale:"Public Identification as Gay" SIHSPC Subscale of Short Internalized Homonegativity Scale:"Personal Comfort with a Gay Identity" Declarations Acknowledgements We thank all the participants in this study for their time and cooperation, as well as the Taizhou City Center for Disease Control and Prevention. Authors' contributions Nan Lin, Yuan Guo and Yun Chen: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing – Original draft. Yuting Yang and Xiaoxiao Chen: Investigation, Data curation. Tingting Wang: Project administration. Chaowei Fu, Haijiang Lin and Shanling Wang: Methodology, Formal analysis, Writing – Review & editing. Jingyi Wang: Conceptualization, Formal analysis, Methodology, Project administration, Writing – Review & editing. All authors read and approved the final manuscript. Funding Jingyi Wang was sponsored by the China Medical Board (grant number #22–472) and the National Natural Science Foundation of China (grant number 72104053). Haijiang Lin and Xiaoxiao Chen were sponsored by the Special Support Program for High Level Talents in Taizhou (grant number TZ2022-2). Data availability Data and materials are available on request from the corresponding author. Ethics approval and consent to participate The study adhered to the ethical principles outlined in the Declaration of Helsinki. The ethical approval was granted by the Ethics Committee of Taizhou Central Hospital (2022L-01-18). All participants provided informed consent before participation in the study. Informed consent procedures were followed for the collection of all study data. Consent for publication Not applicable. Competing interests The authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article. References UNAIDS. UNAIDS Terminology Guidelines. https://www.unaids.org/sites/default/files/media_asset/2024-terminology-guidelines_en.pdf. Accessed 5 Aug 2025. Cheng W, Tang W, Zhong F, Babu GR, Han Z, Qin F, et al. Consistently High Unprotected Anal Intercourse (UAI) and factors correlated with UAI among men who have sex with men: implication of a serial cross-sectional study in Guangzhou, China. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7315885","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509127395,"identity":"0fcd99d6-9cdd-4b3e-9e87-2d7529679c2c","order_by":0,"name":"Nan Lin","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Lin","suffix":""},{"id":509127396,"identity":"904bbb48-b548-42ab-8db2-f406f7e474e4","order_by":1,"name":"Yuan Guo","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Guo","suffix":""},{"id":509127397,"identity":"aea32ec9-1529-423e-896a-ec80fbb83189","order_by":2,"name":"Yun Chen","email":"","orcid":"","institution":"Yale School of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Yun","middleName":"","lastName":"Chen","suffix":""},{"id":509127398,"identity":"b9c97617-eb70-49f5-8b10-497e2c7e80b3","order_by":3,"name":"Yuting Yang","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yuting","middleName":"","lastName":"Yang","suffix":""},{"id":509127399,"identity":"0b9441d9-63d6-4bd0-bf8b-d8328d789421","order_by":4,"name":"Haijiang Lin","email":"","orcid":"","institution":"Taizhou City Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Haijiang","middleName":"","lastName":"Lin","suffix":""},{"id":509127400,"identity":"dfc58bdd-aa3e-4491-b8c4-a10bb470e2e1","order_by":5,"name":"Xiaoxiao Chen","email":"","orcid":"","institution":"Taizhou Central Blood Station","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxiao","middleName":"","lastName":"Chen","suffix":""},{"id":509127401,"identity":"45a2af17-8697-409f-bed2-8de9e6c9ee28","order_by":6,"name":"Tingting Wang","email":"","orcid":"","institution":"Taizhou City Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Tingting","middleName":"","lastName":"Wang","suffix":""},{"id":509127405,"identity":"78389ae2-3b1d-4e29-bf2f-eb4daf813885","order_by":7,"name":"Chaowei Fu","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Chaowei","middleName":"","lastName":"Fu","suffix":""},{"id":509127406,"identity":"cfcf73fa-a069-4a03-baa6-bcd317ab1237","order_by":8,"name":"Shanling Wang","email":"","orcid":"","institution":"Taizhou City Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Shanling","middleName":"","lastName":"Wang","suffix":""},{"id":509127408,"identity":"cd417bd3-74db-45b3-a919-c3a8039c5cda","order_by":9,"name":"Jingyi Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYBACxmYQaQBhP6hgYAazJIjVwmxwhhgtyIBNgigtzO28h1/zFDAk9s9uv1ZxsM1a3pyB+eBtHga7PNwO40uz5jFgSJxx50zZjYNt6YY7G9iSrXkYkotxa+ExMwZqyW24kZN2+2PbYcYNB3jMpHkYDiQ2ENIyH6il4GDbYfsNB/i/EdJi/BikZcON9GMMQC2JQFvYCNrCOMeAoX7jjRxmiQPn0pM3HGYztpxjkIxTi2H/GeMPb/4wGMvdSH/44UCZte2G480Pb7ypsMOtpYGBTYqH4T+QyQOJUEjUGOBQDwTyQCUff4CZ7A9wKxsFo2AUjIIRDQDtn1jGkuQLQwAAAABJRU5ErkJggg==","orcid":"","institution":"Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Jingyi","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-08-07 07:41:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7315885/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7315885/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-025-03550-x","type":"published","date":"2025-11-12T15:57:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90792726,"identity":"ad550182-ffbb-4c83-9713-7b3623f69d9d","added_by":"auto","created_at":"2025-09-08 08:30:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105071,"visible":true,"origin":"","legend":"\u003cp\u003ePsychosocial network structure in the MSM\u003c/p\u003e\n\u003cp\u003eNetwork of psychosocial health factors in men who have sex with men. The light yellow nodes denote depressive symptoms (PHQ-9 items), the red nodes denote anxiety symptoms (GAD-7 items), the blue nodes denote loneliness (UCLA-3 items), the yellow nodes denote self-esteem (RSES items), the light blue nodes denote perceived social support (MSPSS subscales), the orange nodes denote unrestricted sociosexual orientation (SOI-R subscales), and the grey nodes denote internalized homonegativity (SIHS subscales). The blue edges denote the positive correlations and the red edges denote the negative correlations.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7315885/v1/de84e9ec39f6888453f07d62.png"},{"id":90792735,"identity":"ac452e95-c3ec-4cf4-8c3f-f42810df7bfa","added_by":"auto","created_at":"2025-09-08 08:30:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":98181,"visible":true,"origin":"","legend":"\u003cp\u003eNetwork structure of MSM at age \u0026lt;33 versus age≥33\u003c/p\u003e\n\u003cp\u003eEdges exhibiting significant differences between participants ≥ 33 years and those \u0026lt; 33 years (participants \u0026lt; 33 years as reference). The light yellow nodes denote depressive symptoms (PHQ-9 items), the red nodes denote anxiety symptoms (GAD-7 items), the blue nodes denote loneliness (UCLA-3 items), the yellow nodes denote self-esteem (RSES items), the light blue nodes denote perceived social support (MSPSS subscales), the orange nodes denote unrestricted sociosexual orientation (SOI-R subscales), and the grey nodes denote internalized homonegativity (SIHS subscales). The blue edges denote stronger correlations between items and subscales in the older MSM network when compared with those in the younger MSM network, and the red edges denote weaker correlations. A) Stronger correlations in participants ≥ 33 years compared with those \u0026lt; 33 years; B) Weaker correlations in participants ≥ 33 years compared with those \u0026lt; 33 years.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7315885/v1/fcba3ba4003a4b58222410bd.png"},{"id":90792733,"identity":"4940342f-844a-4bde-a404-16b0562be4f3","added_by":"auto","created_at":"2025-09-08 08:30:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":114587,"visible":true,"origin":"","legend":"\u003cp\u003eNetwork centrality of each node in the network for the total sample, age \u0026lt; 33 years, and age 33 ≥ years\u003c/p\u003e\n\u003cp\u003eNetwork centrality of each node in the networks among the total sample, participants \u0026lt; 33 years and those ≥ 33 years. Strength is the sum of the absolute edge weights directly linked to a focal node in the network. Betweenness refers to the degree that a focal node lies on the shortest path between another two nodes. Closeness is defined as the inverse of the average shortest path length from a focal node to other nodes. Expected influence is an index of strength that accurately calculates a node’s linkage including positive and negative edges.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7315885/v1/3174b89e723ef8a436d921b0.png"},{"id":90793264,"identity":"6125e395-9d18-4bff-9109-fec2a9680b92","added_by":"auto","created_at":"2025-09-08 08:38:31","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32812,"visible":true,"origin":"","legend":"\u003cp\u003eLinear regression analysis of the central node and high-risk sexual behavior\u003c/p\u003e\n\u003cp\u003eAssociation between centrality of psychosocial problems and connection values for risky sexual behaviors. Each point represents a psychosocial problem (i.e., node) in the network. A point towards the right on the x-axis indicates a problem which was highly central. A point large on the y-axis represents a problem which has high connection value. The results verified an association between a problem’s centrality and the connection value of that problem with risky sexual behaviors.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7315885/v1/9e35aed6b6bb40ffdf276195.png"},{"id":96105278,"identity":"b6fb0978-a1df-43f2-a7fa-6d156185516d","added_by":"auto","created_at":"2025-11-17 16:10:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1267399,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7315885/v1/057e9c63-9661-4aff-8f83-ca092632e0f0.pdf"},{"id":90792723,"identity":"f97e0863-718b-456c-a78c-31bd7b9aa526","added_by":"auto","created_at":"2025-09-08 08:30:31","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":120057,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialPsychosocialsymptomnetworksandhighrisksexualbehaviorsamongmenwhohavesexwithmenanetworkanalysis.docx","url":"https://assets-eu.researchsquare.com/files/rs-7315885/v1/d133da2ebd1c9358468bd2fe.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychosocial symptom networks and high-risk sexual behaviors among men who have sex with men: a network analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eMen who have sex with men (MSM) refers to cisgender and transgender men who have sex with other men, regardless of whether or not they also have sex with women or have a personal or social gay or bisexual identity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Sexual activities between men are associated with a high risk due to the prevalence of unprotected anal intercourse (UAI), involvement with multiple sexual partners (MSP), and engagement in commercial sex or other risk-related behaviors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Globally, MSM have up to a 28-fold higher risk of Human Immunodeficiency Virus (HIV) acquisition compared to heterosexual men [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is well-established that engaging in high-risk sexual behaviors significantly increases the likelihood of acquiring and transmitting sexually transmitted infections (STIs), including HIV [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMSM are often described as a marginalized and stigmatized population due to their sexual orientation and vulnerability to STIs [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. According to the minority stress framework [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], stigma and social discrimination act as chronic stressors, contributing to psychosocial challenges among MSM. The prevalence of various psychosocial issues is significantly higher among MSM compared to their heterosexual counterparts [\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These psychosocial problems typically manifest in two dimensions: psychological difficulties and social or relational challenges. At the psychological level, MSM often experience depression, anxiety, low self-esteem, and internalized homonegativity. At the social level, they frequently encounter loneliness, lack of social support, and challenges related to sociosexual orientation.\u003c/p\u003e\u003cp\u003eTo date, extensive research has documented that depression and anxiety are prevalent psychological problems among MSM [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A meta-analysis showed that the prevalence of depression among MSM in China was 43.9% (95%CI: 36.9%-48.8%), and the rate was particularly high among HIV-positive MSM [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Anxiety symptoms are also widespread, affecting approximately 32.2% of MSM according to a meta-analysis conducted in China [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Discrimination, minority stress, and concealment-related guilt have all been associated with the development of depression and anxiety among MSM [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Self-esteem, defined as an individual\u0026rsquo;s evaluation of personal worth, is another critical psychological factor frequently undermined by perceived and internalized stigma [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Existing studies in China report that 6\u0026ndash;7% of MSM experience low self-esteem [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], reflecting a lack of self-acceptance due to internalization of societal stigma [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Internalized homonegativity\u0026mdash;characterized by negative self-perceptions associated with one\u0026rsquo;s sexual orientation\u0026mdash;is closely linked to depression, anxiety and low self-esteem among MSM [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These psychological problems are often intertwined, highlighting the complex nature of mental health within MSM populations.\u003c/p\u003e\u003cp\u003eSocial relationship problems have long been linked to psychological difficulties. Loneliness, a distressing emotion arising from unmet social relationship needs, is prevalent among MSM due to experiences of social exclusion and isolation. In China, MSM who experience loneliness are more likely to exhibit low self-esteem and moderate-to-severe depressive symptoms[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, social support plays a crucial protective role. Deficiencies in social support is strongly associated with higher levels of depression, anxiety, and loneliness [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Sociosexual orientation is used to describe individual differences in the willingness to engage in casual sexual relationships. Some MSM exhibit an unrestricted sociosexual orientation and a behavioral preference for promiscuity [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Individuals with this orientation tend to engage in sexual activities without emotional attachment, favor one-night stands, and often have multiple sexual partners.\u003c/p\u003e\u003cp\u003ePsychosocial problems such as depression [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], anxiety [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], internalized homonegativity [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], loneliness [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and unrestricted sociosexual orientation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] are closely linked to high-risk sexual behaviors. Psychological distress may drive MSM to engage in condomless sex or maintain multiple sexual partners as coping strategies [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Depression has been associated with a higher likelihood of condomless sex among MSM [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], though severe depressive symptoms may sometimes reduce sexual interest, reflecting a complex, nonlinear relationship [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Loneliness is similarly linked to increased sexual risk-taking, particularly unprotected sex [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Social risk factors have been shown to shape high-risk sexual behaviors by influencing patterns of partner seeking, sexual settings, relationship choices, and condom use decisions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious research has typically investigated psychosocial factors in isolation, often overlooking their complex interactions. Psychosocial problems, however, may be more accurately conceptualized as a network of interconnected symptoms [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Similarly, prior studies on high-risk sexual behaviors have predominantly focused on identifying isolated influencing factors, without considering their associations with central symptoms within the psychosocial network [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Given the known comorbidity and syndemic relationship between psychosocial issues [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], network analysis provides a valuable tool for mapping these multifaceted dynamics. It offers both visual and quantitative insights into symptom associations and enables the identification of central symptoms \u0026mdash; those most strongly connected to other symptoms in the network [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Targeting central symptoms in interventions may be more effective in preventing the activation or spread of related symptoms. In addition, few studies have examined internalized homonegativity and sociosexual orientation as central variables within psychosocial networks among MSM, leaving a significant gap in the current literature. Although demographic factors, particularly age, have been shown to influence psychosocial challenges among MSM, little is known about how these factors shape the structure and dynamics of psychosocial networks. Existing research has largely overlooked whether different demographic subgroups exhibit distinct psychosocial patterns, limiting a nuanced understanding of how vulnerabilities and risk behaviors may vary across the MSM population.\u003c/p\u003e\u003cp\u003eTo address the identified research gap and better understand the complex interplay between psychosocial problems and high-risk sexual behaviors among MSM, a cross-sectional survey was conducted in Taizhou, China, with three primary objectives: (1) to construct a comprehensive network model of psychosocial problems, including depression, anxiety, self-esteem, internalized homonegativity, loneliness, social support, and sociosexual orientation; (2) to compare psychosocial network structures across MSM subgroups defined by age, marital status, educational level, and sexual orientation, identifying subgroup-specific patterns; and (3) to examine the associations between central psychosocial symptoms within these networks and high-risk sexual behaviors across different demographic subgroups. Together, these analyses aim to identify critical psychosocial factors and interrelationships, providing an evidence base for developing targeted interventions to improve mental health and reduce sexual risk behaviors among MSM.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eA cross-sectional survey was conducted among MSM from January to August 2022 in three districts (Huangyan, Jiaojiang, and Luqiao) of Taizhou, Zhejiang Province, China. Participants were eligible if they: (1) were biologically male; (2) aged 15 years or older; (3) had previously engaged in oral or anal sex with another man; (4) had no severe cognitive or communication impairments; and (5) provided informed consent to participate. The study was approved by the Ethics Committee of Taizhou Central Hospital (2022L-01-18), and all methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\u003cp\u003eDue to the hidden nature of the MSM population, participants were recruited using a combination of convenience and snowball sampling methods. Initially, recruitment was carried out at venues frequently visited by MSM, including bars, nightclubs, saunas, and public parks. To ensure privacy and confidentiality, participants completed questionnaires individually in undisturbed areas within these venues. Trained research staff provided clarification and assistance upon request. Additionally, online advertisements were posted on popular MSM-oriented platforms within Zhejiang Province, including forums, chat rooms, and social networking applications. Participants recruited through these platforms were encouraged to share the questionnaire with their MSM peers, continuing until the desired sample size was reached. A total of 534 MSM completed the psychosocial questionnaire with informed consent. After removing incomplete data, the final analytical sample consisted of 405 participants.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e\u003cp\u003eThe sociodemographic variables included age, marital status (never married or previously married, married or cohabiting), educational level (middle school or below, high school or technical school, college or above), and sexual orientation (homosexual, bisexual/heterosexual/unsure).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePsychosocial variables\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eDepressive symptoms\u003c/h2\u003e\u003cp\u003eDepressive symptoms among the MSM population were measured using the Patient Health Questionnaire-9 (PHQ-9) scale, a widely utilized and effective self-report instrument designed to assess depression over the preceding two weeks [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The PHQ-9 consists of nine items, each corresponding to one of the nine DSM-IV diagnostic criteria for depression. Respondents rate their experiences on a four-point scale: \"not at all\" (0 points), \"several days\" (1 point), \"more than half the days\" (2 points), and \"nearly every day\" (3 points). The possible total score ranges from 0 to 27, with higher scores indicating more severe depressive symptoms. The Chinese version of PHQ-9 has been demonstrated as a valid and reliable tool to screen depression [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], and the Cronbach\u0026rsquo;s alpha was 0.88 in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eAnxiety symptoms\u003c/h2\u003e\u003cp\u003eAnxiety levels were assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7) [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. This scale consists of seven items, each rated on a four-point scale: \"not at all\" (0 points), \"several days\" (1 point), \"more than half the days\" (2 points), and \"nearly every day\" (3 points). The total score is the sum of the seven items, with a higher score indicating greater anxiety. This scale\u0026rsquo;s reliability and validity have been proven [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] and the Cronbach\u0026rsquo;s alpha was 0.91 in this research.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSelf-esteem\u003c/h3\u003e\n\u003cp\u003eSelf-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES), one of the most widely used instruments for measuring self-evaluation of personal worth [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The RSES consists of 10 items, five of which are positively worded and five reverse-scored. Respondents rate each item on a four-point scale: \"strongly agree\" (3 points), \"agree\" (2 points), \"disagree\" (1 point), and \"strongly disagree\" (0 points). The total possible score ranges from 0 to 30, with higher scores indicating higher self-esteem. Previous research validating the Chinese version of the RSES has demonstrated excellent reliability, with Cronbach\u0026rsquo;s α ranging from 0.911 to 0.942, and omega (ω) values ranging from 0.915 to 0.944 [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The Cronbach\u0026rsquo;s alpha was 0.85 in this study.\u003c/p\u003e\n\u003ch3\u003eInternalized homonegativity\u003c/h3\u003e\n\u003cp\u003eThe Short Internalized Homonegativity Scale (SIHS) is a commonly used instrument for measuring internalized homonegativity\u0026mdash;namely, the internalization of negative attitudes and assumptions about homosexuality by gay individuals themselves [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The SIHS consists of eight items, which are divided into three subscales: \"Social Comfort with Gay Men,\" \"Public Identification as Gay,\" and \"Personal Comfort with a Gay Identity\". Higher scores on the scale indicate greater acceptance of one\u0026rsquo;s sexual orientation and lower levels of internalized homonegativity. The Cronbach\u0026rsquo;s alpha was 0.76 in this study.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLoneliness\u003c/h2\u003e\u003cp\u003eThe 3-item UCLA Loneliness Scale (UCLA-3) was used to assess feelings of loneliness [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. This scale consists of three items, each rated on a three-point scale: \"hardly ever\" (1 point), \"some of the time\" (2 points), and \"often\" (3 points). Scores of the scale range from 3 to 9, with higher scores indicating higher levels of perceived loneliness. Previous research has demonstrated that the UCLA Loneliness Scale (Version 3) exhibits high reliability, with internal consistency (Cronbach\u0026rsquo;s α ranging from 0.89 to 0.94) and test-retest reliability over a one-year period (r\u0026thinsp;=\u0026thinsp;0.73) [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The Cronbach\u0026rsquo;s alpha was 0.84 in this research.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePerceived social support\u003c/h2\u003e\u003cp\u003eThe Multidimensional Scale of Perceived Social Support (MSPSS) was used to assess individuals' perceived support [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The MSPSS consists of 12 items designed to evaluate perceived social support from three sources: Family, Friends, and Significant Others. Each item is rated on a 7-point Likert scale, ranging from \"very strongly disagree\" (1 point) to \"very strongly agree\" (7 points). The average score for each subscale was calculated separately, with higher scores indicating greater levels of social support. The Cronbach\u0026rsquo;s alpha was 0.93 in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSociosexual orientation\u003c/h2\u003e\u003cp\u003eThe revised Sociosexual Orientation Inventory (SOI-R) was used to assess people\u0026rsquo;s willingness to engage in uncommitted sexual relationships [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The scale comprises 9 items, which are categorized into three subscales: \"Behavior,\" \"Attitudes,\" and \"Desire.\" Only the latter two dimensions were included in the psychosocial network analysis. The Attitude dimension consists of three items that assess one\u0026rsquo;s disposition toward uncommitted sexual behavior, reflecting the desired level of emotional closeness before engaging in sex and the moral evaluation of such behavior. The Desire dimension also comprises three items and measures interest in uncommitted sexual activity, characterized by heightened sexual desire often accompanied by subjective arousal and sexual fantasies. Unlike general sexual desire, unrestricted sociosexual desire refers to sexual attraction to potential partners outside of committed relationships. Higher scores indicate a greater degree of unrestricted sociosexual orientation. The Cronbach\u0026rsquo;s alpha was 0.84 in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eHigh-risk sexual behaviors\u003c/h2\u003e\u003cp\u003eHigh-risk sexual behavior was assessed using two items: (1) the frequency of condom use during anal sex with male partners in the past six months, and (2) the number of sexual partners in the past 12 months, as measured by an item from the Behavior dimension of the SOI-R. A total score was calculated, with higher scores indicating a greater likelihood of engaging in high-risk sexual behaviors.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eDescriptive analysis\u003c/h2\u003e\u003cp\u003eDescriptive analyses were conducted for participants\u0026rsquo; sociodemographic characteristics, psychosocial variables, and high-risk sexual behaviors. Continuous variables were summarized using means and standard deviations, while categorical variables were presented as frequencies and percentages. Independent samples t-tests and chi-square tests (χ\u0026sup2;) were used to compare the characteristics of MSM aged\u0026thinsp;\u0026lt;\u0026thinsp;33 years and those aged\u0026thinsp;\u0026ge;\u0026thinsp;33 years.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eNetwork estimation and centrality\u003c/h2\u003e\u003cp\u003ePsychosocial variables included in the network structure analysis were depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation. All individual items from the scales measuring depressive symptoms, anxiety symptoms, loneliness, and self-esteem were treated as nodes in the network. In addition, total scores from each dimension of perceived social support (three dimensions), sociosexual orientation (two dimensions), and internalized homonegativity (three dimensions) were also included as network nodes. The network was estimated using the \"bootnet\" package in R and visualized with the \"qgraph\" package [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Pairwise Spearman correlations and sparse Gaussian graphical models with graphical lasso were used to estimate the associations between psychosocial variables among MSM. All variables were represented as nodes, and direct associations between variables were displayed as edges. The thickness of each edge reflects the strength of the association.\u003c/p\u003e\u003cp\u003eTo assess node centrality within the psychosocial network, strength, betweenness, closeness, and expected influence were calculated and visualized [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Higher centrality values indicated more influential symptoms that were directly connected to a greater number of other symptoms in the network. Strength was defined as the total sum of the absolute edge weights directly connected to a specific node, with higher-strength nodes potentially triggering the activation of other symptoms. Betweenness measured the extent to which a node lay along the shortest paths between pairs of other nodes, suggesting that nodes with high betweenness could act as bridges linking different symptom clusters within the network. Closeness referred to the inverse of the average shortest path length from a given node to all other nodes, meaning that a node with high closeness might be more directly connected to a broader range of symptoms. Expected Influence (EI), a more recent centrality metric, expanded on strength by accounting for both positive and negative edge weights when evaluating a node\u0026rsquo;s influence in the network [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Network stability was evaluated using a case-dropping subset bootstrap approach with 1,000 iterations. The correlation stability coefficient was used to quantify the robustness of the centrality estimates, with values above 0.5 generally considered indicative of a stable network.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eNetwork comparison\u003c/h2\u003e\u003cp\u003eTo compare the psychosocial network structures of MSM across different age groups, marital statuses, educational levels, and sexual orientations, the \u0026ldquo;NetworkComparisonTest\u0026rdquo; package in R was employed [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. A permutation test with 1,000 iterations was conducted to examine both global and local differences in network edges. Global network structure invariance was assessed by evaluating the maximum difference in edge weights between two networks. Global strength differences were quantified by comparing the weighted sum of all absolute edge values across networks. Local differences were assessed by testing the invariance of each individual edge between the two networks.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eAssociation between central symptoms and high-risk sexual behavior\u003c/h2\u003e\u003cp\u003eTo examine whether central symptoms in the psychosocial network were more strongly associated with high-risk sexual behavior, Spearman rank correlation analyses were conducted between each network node and the high-risk behavior score. Higher correlation coefficients indicated a stronger association between the symptom and high-risk sexual behavior. The relationship between centrality and correlation coefficients was evaluated using locally weighted scatterplot smoothing (LOWESS). Linear regression analysis was performed to assess whether nodes with higher centrality values were more strongly associated with high-risk sexual behavior.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe characteristics of the participants (n\u0026thinsp;=\u0026thinsp;405) are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the participants with a mean age of 33.4 years (range 16\u0026ndash;76), 66.4% were never married or previously married, 33.1% had middle school or lower education, and 58.3% were self-identified as homosexual. Furthermore, 50 (12.4%) participants exceeded the cut-off score of 10 for moderate-to-severe depression and 41 (10.1%) exceeded the cut-off score of 10 for moderate-to-severe anxiety. In total, 27 (6.7%) participants had both clinically relevant depressive and anxiety symptoms. A high percentage of MSM suffered from loneliness (25.7%), 19.3% had unprotected anal intercourse in the last six months and 68.9% had multiple sexual partners in the past 12 months. Compared with younger participants, a higher proportion of MSM aged 33 and older were married or cohabiting, had lower education, and were self-identified as bisexual. The older participants also reported lower self-esteem, poorer social support from family, friends and significant other, and more positive attitude towards unrestricted sociosexual orientation but lower desire for uncommitted sexual relationships.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal sample\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;405)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;33 old\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;33 old\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;192)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociodemographic variables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (16\u0026ndash;76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.4 (11.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.3 (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.6 (7.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital status, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNever married or previously married\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e269 (66.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e199 (93.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70 (36.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried or cohabiting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e136 (33.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (6.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e122 (63.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational level, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle school or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e134 (33.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109 (56.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school or technical school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155 (38.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58 (30.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91 (42.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSexual orientation, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHomosexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e236 (58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e167 (78.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69 (35.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBisexual/heterosexual/unsure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e169 (41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (21.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e123 (64.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePsychosocial variables\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression (0\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.6 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.7 (4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.5 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.547\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety (0\u0026ndash;21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.1 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2 (4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.0 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.720\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLoneliness (3\u0026ndash;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.3 (1.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.671\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-esteem (0\u0026ndash;30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.3 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.8 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.8 (3.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e Participant characteristics (continued)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal sample\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;405)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;33 old\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;213)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;33 old\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;192)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived social support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily support (1\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.7 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.8 (0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.5 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFriends support (1\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.7 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.8 (0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.5 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSignificant others support (1\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.7 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.8 (0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.5 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociosexual Orientation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude (3\u0026ndash;15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.2 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.9 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.7 (2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDesire (3\u0026ndash;15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.3 (3.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.7 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.0 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternalized homophobia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial comfort with Gay Men (3\u0026ndash;21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.6 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.4 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.8 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.107\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic Identification as Gay (2\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.0 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.9 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.2 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.307\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersonal Comfort with a Gay Identity (3\u0026ndash;21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.4 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.3 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.6 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.333\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHigh-risk sexual behaviors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnprotected anal intercourse (1\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.9 (0.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.9 (0.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.628\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultiple Sexual Partners (1\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0 (1.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.9 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.1 (1.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.144\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Continuous variables were presented as mean (standard deviation), and categorical variables were presented as number (percentage).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eNetwork estimation\u003c/h2\u003e\u003cp\u003eWe estimated the overall network including separate items for depressive symptoms, anxiety symptoms, loneliness, self-esteem, and subscale scores for perceived social support from family, friends and significant other, attitude and desire scores for unrestricted sociosexual orientation, and three subscale scores for internalized homonegativity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The items of these measures and their reference names were listed in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e. Within the overall network, we observed strong connections between the items of depressive symptoms and anxiety symptoms, particularly between \u003cem\u003e\u0026lsquo;anhedonia\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e (edge weight\u0026thinsp;=\u0026thinsp;0.23). The loneliness item \u003cem\u003e\u0026lsquo;lacking companionship\u0026rsquo;\u003c/em\u003e was positively connected with the desire for uncommitted sexual relationships (edge weight\u0026thinsp;=\u0026thinsp;0.25) and the anxiety item \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e (edge weight\u0026thinsp;=\u0026thinsp;0.09). Among the items of self-esteem, \u003cem\u003e\u0026lsquo;satisfied with myself\u0026rsquo;\u003c/em\u003e was negatively linked to the desire for uncommitted sexual relationships (edge weight = -0.1), and \u003cem\u003e\u0026lsquo;respect for myself\u0026rsquo;\u003c/em\u003e was negatively associated with the attitude towards uncommitted sexual relationships (edge weight = -0.1) and social comfort with gay men (SIHSSC) (edge weight = -0.11). Furthermore, social comfort with gay men (SIHSSC) was negatively connected with the desire for uncommitted sexual relationships (edge weight = -0.12), while public identification as gay (SIHSPUBID) was positively associated with the attitude towards uncommitted sexual relationships (edge weight = -0.11), and personal comfort with a gay identity (SIHSPC) was positively linked to family social support (edge weight\u0026thinsp;=\u0026thinsp;0.08). Detailed edge weights for all the edges in the network can be found in Table S2. Items of depressive symptoms were on average explained for 52.3% by variables in the network that were directly connected to them, for items of anxiety symptoms 61.0%, for loneliness items 54.8% and for self-esteem items 56.5%. Explained variance for perceived social support subscale scores was on average 63.6%, for unrestricted sociosexual orientation 39.9%, and for internalized homonegativity 38.6%.\u003c/p\u003e\u003cp\u003eStability of the network was evaluated using the bootstrap method. The edge weights in the current sample were largely consistent with the bootstrapped sample, indicating relatively stable estimates (see Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). The correlation stability coefficients exceeded 0.5 even using 30% of the cases, indicating that the network structure was stable.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eNetwork comparison\u003c/h2\u003e\u003cp\u003eWe assessed whether the network structure was significantly different for people of different age, marital status, education or sexual orientation. There was global difference in the network structure between participants\u0026thinsp;\u0026lt;\u0026thinsp;33 years and those\u0026thinsp;\u0026ge;\u0026thinsp;33 years (p\u0026thinsp;=\u0026thinsp;0.017). No global differences were found for the other sociodemographic variables. In addition, local differences existed in several edges for people of different age, and the statistically significant higher and lower correlations are visualized separately in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eWhen comparing participants\u0026thinsp;\u0026ge;\u0026thinsp;33 years with those\u0026thinsp;\u0026lt;\u0026thinsp;33 years, we observed differences in connections between items of depressive symptoms and items of anxiety symptoms. In MSM\u0026thinsp;\u0026ge;\u0026thinsp;33 years, there were stronger connections between \u003cem\u003e\u0026lsquo;feeling tired\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;irritable\u0026rsquo;\u003c/em\u003e, between \u003cem\u003e\u0026lsquo;psychomotor symptoms\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;cannot stop worrying\u0026rsquo;\u003c/em\u003e and between \u003cem\u003e\u0026lsquo;sleep problems\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e, whereas the connections between \u003cem\u003e\u0026lsquo;psychomotor symptoms\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;irritable\u0026rsquo;\u003c/em\u003e and between \u003cem\u003e\u0026lsquo;sad mood\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;trouble relaxing\u0026rsquo;\u003c/em\u003e were weaker. The connections between items of emotional symptoms and the other psychosocial problems generally decreased in the older MSM, such as the relations between \u003cem\u003e\u0026lsquo;suicidal thoughts\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;feeling isolated\u0026rsquo;\u003c/em\u003e and between \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;respect for myself\u0026rsquo;\u003c/em\u003e. Furthermore, we observed that a number of associations between loneliness, self-esteem, social support, unrestricted sociosexual orientation and internalized homonegativity were significantly weaker in older MSM when compared to the younger group. For example, there were weaker connections between the following nodes: social support from family \u0026ndash; \u003cem\u003e\u0026lsquo;worth\u0026rsquo;\u003c/em\u003e, social support from significant other \u0026ndash; \u0026lsquo;proud\u0026rsquo;, \u003cem\u003e\u0026lsquo;no good\u0026rsquo;\u003c/em\u003e \u0026ndash; desire for uncommitted sexual relationships, and \u003cem\u003e\u0026lsquo;feeling isolated\u0026rsquo;\u003c/em\u003e \u0026ndash; personal comfort with a gay identity.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eNetwork centrality\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the network centrality of each item and subscale in the total sample, participants\u0026thinsp;\u0026lt;\u0026thinsp;33 years and those\u0026thinsp;\u0026ge;\u0026thinsp;33 years. In the total sample, \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e, desire for uncommitted sexual relationships, \u003cem\u003e\u0026lsquo;feeling tired\u0026rsquo;\u003c/em\u003e, \u003cem\u003e\u0026lsquo;lacking companionship\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;no good\u0026rsquo;\u003c/em\u003e exhibited high network centrality. The high centrality values of these items implied that their roles in the MSM psychosocial network were important and they were associated with most of the other items in the network. \u003cem\u003e\u0026lsquo;Suicidal thoughts\u0026rsquo;\u003c/em\u003e, loneliness items and desire for uncommitted sexual relationships showed higher centrality values in participants\u0026thinsp;\u0026lt;\u0026thinsp;33 years compared to those\u0026thinsp;\u0026ge;\u0026thinsp;33 years. \u003cem\u003e\u0026lsquo;Feeling afraid\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;satisfied with myself\u0026rsquo;\u003c/em\u003e showed greater betweenness in participants\u0026thinsp;\u0026ge;\u0026thinsp;33 years, which might play a key role as mediators between their associated items.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eConnection value of central symptoms\u003c/h2\u003e\u003cp\u003eSpearman\u0026rsquo;s correlations were computed between each psychosocial problem and risky sexual behaviors (see Table S3). Behavior items were coded such that higher scores indicate a higher level of risky sexual behaviors. A high absolute correlation indicates that the severity of the problem was associated with risky sexual behaviors. Depressive symptoms, anxiety symptoms, self-esteem, perceived social support and acceptance of homosexuality negatively correlated with risky sexual behaviors, indicating that individuals with more severe emotional symptoms, higher self-esteem, more social support and greater acceptance of homosexuality were less likely to have risky sexual behaviors. By comparison, the correlation values were positive for loneliness and unrestricted sociosexual orientation, indicating that individuals with more severe loneliness and higher levels of attitude and desire for uncommitted sexual relationships were more likely to have risky sexual behaviors. We refer to the values in Table S3 as \u003cem\u003econnection values\u003c/em\u003e. Higher absolute values indicate that the problem has a strong connection with risky sexual behaviors.\u003c/p\u003e\u003cp\u003eWe then examined whether the centrality of psychosocial problems was associated with connection values. Linear regression results revealed that centrality of problems was significantly associated with connection values for risky sexual behaviors among the total sample (β = -0.144, p\u0026thinsp;=\u0026thinsp;0.039) and participants\u0026thinsp;\u0026lt;\u0026thinsp;33 years (β = -0.164, p\u0026thinsp;=\u0026thinsp;0.022), but not among those\u0026thinsp;\u0026ge;\u0026thinsp;33 years (β = -0.119, p\u0026thinsp;=\u0026thinsp;0.218). The results of this analysis are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The estimation results of LOWESS in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003e also show that the general tendency between the expected influence strength centrality and the connection value was negative. To properly understand this figure, it is helpful to point out that each point represents a psychosocial problem (i.e., node) in the network. A point towards the right on the x-axis indicates a problem which was highly central. A point large on the y-axis represents a problem which has high connection value. The results thus verified an association between a problem\u0026rsquo;s centrality and the connection value of that problem with risky sexual behaviors, and the association was stronger in younger participants compared with the older ones.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study employed network analysis to explore the interrelations among depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation within the MSM population in Taizhou, China. The study also identified central symptoms within the psychosocial network structure and examined their associations with high-risk sexual behaviors. The results revealed significant associations among these psychosocial variables. \u003cem\u003e\u0026lsquo;Feeling nervous\u0026rsquo;\u003c/em\u003e, desire for uncommitted sexual relationships, \u003cem\u003e\u0026lsquo;feeling tired\u0026rsquo;\u003c/em\u003e, \u003cem\u003e\u0026lsquo;lacking companionship\u0026rsquo;\u003c/em\u003e, and \u003cem\u003e\u0026lsquo;no good\u0026rsquo;\u003c/em\u003e emerged as central symptoms in the network and were significantly associated with high-risk sexual behaviors. Subgroup analyses by age indicated significant differences in the psychosocial network structures across different age groups of MSM.\u003c/p\u003e\u003cp\u003eIn this study, 12.4% and 10.1% of MSM reported moderate or higher levels of depressive and anxiety symptoms, respectively\u0026mdash;rates lower than those reported in prior studies. For example, depression prevalence among MSM was 27.4% in a UK study [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], 24.9% in a Brazilian multicity study [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and 36% among newly diagnosed HIV-positive MSM in China [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Variations in prevalence may be attributed to differences in sample demographics, study periods, measurement tools, and HIV infection status. Regarding sexual risk behaviors, 19.3% of participants reported engaging in condomless anal intercourse in the past six months, and 68.9% reported having multiple sexual partners in the past 12 months. These findings are consistent with international data. A systematic review of MSM in high-income countries documented a substantial increase in condomless anal sex, rising from approximately 35% in 1990 to 55% by 2012, alongside a shift in sexual partner trends: little change between 1992 and 2002, with about 40% of MSM reporting multiple partners, followed by a substantial increase to over 60% during 2003\u0026ndash;2013 [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. These findings highlight ongoing psychological burdens and sexual risk behaviors among MSM. Further research is warranted to elucidate the psychological, social, and structural factors driving these trends and to inform targeted prevention strategies.\u003c/p\u003e\u003cp\u003eIn the symptom network linking depression, anxiety, and loneliness, the depressive symptom \u003cem\u003e\u0026lsquo;anhedonia\u0026rsquo;\u003c/em\u003e exhibited the strongest association with the anxiety symptom \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e, followed by \u003cem\u003e\u0026lsquo;feeling tired\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;irritable\u0026rsquo;\u003c/em\u003e. Among the loneliness symptoms, \u003cem\u003e\u0026lsquo;lacking companionship\u0026rsquo;\u003c/em\u003e demonstrated a significant correlation with \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e. These findings are consistent with previous research in MSM, highlighting the frequent co-occurrence of depression, anxiety, and loneliness [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Additionally, \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e, \u003cem\u003e\u0026lsquo;feeling tired\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;lacking companionship\u0026rsquo;\u003c/em\u003e emerged as highly central nodes within the psychosocial symptom network in our study. Since centrality identifies symptoms that hold key positions and exert significant influence over the network, targeting these core symptoms in interventions may be an effective strategy to alleviate co-occurring mental health burdens among MSM.\u003c/p\u003e\u003cp\u003eIn our network analysis, the desire for uncommitted sexual relationships was also identified as a central symptom within the network. Notably, among the associated factors, \u003cem\u003e\u0026lsquo;lacking companionship\u0026rsquo;\u003c/em\u003e showed the strongest connection with this desire, followed by \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e, suggesting that loneliness and anxiety may act as driving forces behind unrestricted sociosexual orientation, potentially serving as coping mechanisms to alleviate feelings of disconnection. Previous research has similarly indicated that MSM experiencing loneliness may seek physical intimacy as a substitute for emotional support [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In line with this, a study of 394 young adults found that individuals with poor mental health experienced temporary relief from depressive and loneliness symptoms following non-restrictive sexual behaviors [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Conversely, other studies have suggested that psychological issues such as depression, anxiety, and loneliness may result from casual sexual encounters. For example, a multi-ethnic study of 3,907 single, heterosexual college students across 30 U.S. universities reported that unrestricted sexual behavior was positively associated with psychological distress and negatively associated with well-being [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. In addition, our network analysis revealed that the self-esteem items \u003cem\u003e\u0026lsquo;satisfied with myself\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;respect for myself\u0026rsquo;\u003c/em\u003e were negatively associated with unrestricted sexual desire and attitudes, respectively. This pattern suggests that a higher level of sociosexual orientation may be linked to lower levels of self-esteem among MSM, consistent with findings in the general population [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. However, the causal relationship between low self-esteem and non-restrictive sexual behavior remains unclear and warrants further longitudinal investigation.\u003c/p\u003e\u003cp\u003eInternalized homonegativity describes the self-loathing experienced by homosexual individuals. In this study, internalized homonegativity was assessed using three dimensions: social comfort with gay men, public identification as gay, and personal comfort with a gay identity. Network analysis revealed a negative association between social comfort with gay men and the desire for uncommitted sexual relationships. Consistent with prior research, Brian et al. [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] reported that higher levels of internalized homophobia were associated with stronger sexual urges, which in turn increased the likelihood of engaging in high-risk sexual behaviors. Beyond behavioral consequences, internalized homonegativity has been consistently linked to adverse psychological outcomes. Newcomb et al. [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] found that internalized homophobia was associated with stronger suicidal ideation, more severe depressive symptoms, and reduced levels of help-seeking and perceived social support. Similarly, Bingham et al. [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] identified a significant negative association between internalized homophobia and self-esteem. Our network analysis further revealed a positive association between family support and personal comfort with a gay identity, suggesting that familial acceptance may play a protective role against internalized homonegativity. The attitudes and reactions of family members are closely tied to how individuals construct and accept their sexual identities. Negative parental responses to a child's sexual orientation have been shown to hinder self-acceptance and increase the risk of internalized stigma [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. These findings highlight the importance of family-inclusive interventions that promote acceptance and understanding, particularly in sociocultural contexts where stigma remains pervasive.\u003c/p\u003e\u003cp\u003eThis study found that the psychosocial symptom networks varied across age groups among MSM. Specifically, compared to younger participants, older MSM exhibited stronger associations between depressive and anxiety symptoms, such as between \u003cem\u003e\u0026lsquo;feeling tired\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;irritable\u0026rsquo;\u003c/em\u003e, \u003cem\u003e\u0026lsquo;psychomotor symptoms\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;cannot stop worrying\u0026rsquo;\u003c/em\u003e, as well as \u003cem\u003e\u0026lsquo;sleep problems\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e. In contrast, the interconnections among loneliness, self-esteem, perceived social support, sociosexual orientation, and internalized homonegativity were notably weaker in the older group. In the older MSM network, \u003cem\u003e\u0026lsquo;feeling afraid\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;satisfied with myself\u0026rsquo;\u003c/em\u003e demonstrated higher betweenness centrality, suggesting that these anxiety and self-esteem symptoms may act as critical mediators of broader psychological distress in this subgroup. Conversely, in the younger group, \u003cem\u003e\u0026lsquo;suicidal thoughts\u0026rsquo;\u003c/em\u003e, loneliness-related items, and the desire for uncommitted sexual relationships showed higher centrality values than in older participants. These findings indicate that emotional isolation, impulsive sexual behavior, and suicidal ideation are more prominent features in the psychosocial profile of younger MSM, underscoring the need for age-sensitive mental health and behavioral interventions.\u003c/p\u003e\u003cp\u003eImportantly, regression analysis in this study demonstrated that central symptoms within the psychosocial network were significantly associated with high-risk sexual behaviors among MSM, with stronger associations observed in younger participants than in older one. This finding suggests that such behaviors may, in part, stem from underlying psychological distress. Conversely, a bidirectional relationship is also plausible, whereby MSM engaging in more high-risk sexual behaviors may subsequently experience greater psychosocial burden. These results align with previous studies among MSM in China, which found that multiple psychosocial problems were associated with unprotected anal intercourse [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and that MSM with five or more psychosocial problems had greater odds of having multiple sexual partners compared with those without syndemic conditions [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Several mechanisms may explain the link between psychosocial problems and high-risk sexual behaviors. First, some individuals\u0026mdash;particularly youth\u0026mdash;may engage in sexual activity as a way to cope with psychological distress, escape unpleasant emotions or circumstances, or seek affirmation of their self-worth [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Second, negative emotional states, such as depression or anxiety, can impair judgment and decision-making, thereby increasing susceptibility to risky sexual encounters [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Even a negative affective state, in the absence of other clusters of depressive symptomatology, can still result in a less severe, but impaired decision making [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Third, MSM experiencing serious psychological distress may have a history of complex trauma in their childhood or adolescent development, which is often associated with a higher likelihood of engaging in unsafe sexual practices [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Such behaviors may serve as maladaptive coping mechanisms the individual has developed over time. Given these findings, targeting central symptoms within the psychosocial network of MSM may serve as an effective intervention strategy to reduce high-risk sexual behaviors and, consequently, lower the risk of HIV and other sexually transmitted infections in this vulnerable population. Integrative interventions that simultaneously address psychological and social factors are essential to effectively mitigate these risks.\u003c/p\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis study has several strengths. To our knowledge, it is among the first to employ network analysis to simultaneously examine seven psychosocial problems within a Chinese MSM population, providing a nuanced understanding of the psychosocial mechanisms underlying high-risk sexual behaviors. The use of age-stratified network analyses further highlights the heterogeneity of psychosocial patterns across subgroups, offering valuable insights for the design of age-tailored interventions. Additionally, the identification of central symptoms linked to high-risk sexual behaviors provides a potential theoretical basis for developing targeted mental health and behavioral interventions.\u003c/p\u003e\u003cp\u003eHowever, several limitations should be acknowledged. First, the cross-sectional design precludes causal inferences regarding the relationships between psychosocial symptoms and high-risk sexual behaviors. Second, participants were recruited through convenience sampling in Taizhou, which may limit the generalizability of the findings to broader MSM populations in China. Third, self-reported data on psychosocial problems and sexual behaviors are subject to recall bias and social desirability bias, which may have led to underreporting of sensitive behaviors. Finally, although network analysis highlights central symptoms and interconnections, it does not capture the temporal dynamics of symptom interactions, which warrant further investigation using longitudinal or ecological momentary assessment designs. Future studies should adopt multi-site, longitudinal, and mixed-method approaches to validate and extend these findings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study mapped the network structure and interconnections among key psychosocial factors\u0026mdash;including depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation\u0026mdash;across different age groups of MSM. Central symptoms such as \u003cem\u003e\u0026lsquo;feeling nervous\u0026rsquo;\u003c/em\u003e, desire for uncommitted sexual relationships, \u003cem\u003e\u0026lsquo;feeling tired\u0026rsquo;\u003c/em\u003e, \u003cem\u003e\u0026lsquo;lacking companionship\u0026rsquo;\u003c/em\u003e, and \u003cem\u003e\u0026lsquo;no good\u0026rsquo;\u003c/em\u003e played particularly influential roles within the psychosocial network and were significantly associated with high-risk sexual behaviors. Notably, younger MSM appeared more susceptible to the impact of psychosocial problems on their sexual risk-taking. These findings offer a theoretical foundation for the development of future interventions aimed at improving mental health and reducing high-risk sexual behaviors within the MSM population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMSM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMen who have sex with men\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUAI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnprotected anal intercourse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMSP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultiple sexual partners\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHIV\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman immunodeficiency virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSTIs\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSexually transmitted infections\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePHQ-9\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient Health Questionnaire-9 scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGAD-7\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneralized Anxiety Disorder 7-item scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eRSES\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRosenberg Self-Esteem Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSIHS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eShort Internalized Homonegativity Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUCLA-3\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e3-item UCLA Loneliness Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMSPSS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultidimensional Scale of Perceived Social Support\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSOI-R\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThe revised Sociosexual Orientation Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eEI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExpected Influence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLOWESS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLocally weighted scatterplot smoothing\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSIHSSC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSubscale of Short Internalized Homonegativity Scale:\"Social Comfort with Gay Men\"\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSIHSPUBID\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSubscale of Short Internalized Homonegativity Scale:\"Public Identification as Gay\"\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSIHSPC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSubscale of Short Internalized Homonegativity Scale:\"Personal Comfort with a Gay Identity\"\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the participants in this study for their time and cooperation, as well as the Taizhou City Center for Disease Control and Prevention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNan Lin, Yuan Guo and Yun Chen: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing \u0026ndash; Original draft. Yuting Yang and Xiaoxiao Chen: Investigation, Data curation. Tingting Wang: Project administration. Chaowei Fu, Haijiang Lin and Shanling Wang: Methodology, Formal analysis, Writing \u0026ndash; Review \u0026amp; editing. Jingyi Wang: Conceptualization, Formal analysis, Methodology, Project administration, Writing \u0026ndash; Review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJingyi Wang was sponsored by the China Medical Board (grant number #22\u0026ndash;472) and the National Natural Science Foundation of China (grant number 72104053). Haijiang Lin and Xiaoxiao Chen were sponsored by the Special Support Program for High Level Talents in Taizhou (grant number TZ2022-2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData and materials are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study adhered to the ethical principles outlined in the Declaration of Helsinki. The ethical approval was granted by the Ethics Committee of Taizhou Central Hospital (2022L-01-18).\u0026nbsp;All participants provided informed consent before participation in the study. Informed consent procedures were followed for the collection of all study data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eUNAIDS. UNAIDS Terminology Guidelines. https://www.unaids.org/sites/default/files/media_asset/2024-terminology-guidelines_en.pdf. Accessed 5 Aug 2025.\u003c/li\u003e\n \u003cli\u003eCheng W, Tang W, Zhong F, Babu GR, Han Z, Qin F, et al. Consistently High Unprotected Anal Intercourse (UAI) and factors correlated with UAI among men who have sex with men: implication of a serial cross-sectional study in Guangzhou, China. 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Child Maltreatment. 2017;22(1):69-78. doi: 10.1177/1077559516674595\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Psychosocial problems, High-risk sexual behaviors, Men who have sex with men, Network analysis","lastPublishedDoi":"10.21203/rs.3.rs-7315885/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7315885/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Psychosocial problems are highly prevalent among men who have sex with men (MSM) and are linked to high-risk sexual behaviors. However, their interconnections—especially the roles of internalized homonegativity and sociosexual orientation—remain underexplored. This study aimed to: (1) model psychosocial symptom networks among MSM; (2) compare network structures across demographic subgroups; and (3) examine how central symptoms relate to high-risk sexual behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e A cross-sectional survey was conducted among 405 MSM in Taizhou, China, using venue-based and online snowball sampling. Psychosocial variables—including depression, anxiety, self-esteem, internalized homonegativity, loneliness, perceived social support, and sociosexual orientation—were assessed using validated self-report scales. High-risk sexual behavior was measured based on condom use and number of sexual partners. Network analysis was used to examine symptom-level associations, and network comparison tests explored differences across demographic subgroups. Associations between central symptoms and high-risk behaviors were examined using correlation and regression analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Among 405 MSM, 12.4% reported moderate-to-severe depression and 10.1% had moderate-to-severe anxiety. Network analysis revealed the strongest connections between depressive and anxiety symptoms, as well as between loneliness and the desire for uncommitted sexual relationships. Central symptoms identified included \u003cem\u003e‘feeling nervous’\u003c/em\u003e, desire for uncommitted sexual relationships, \u003cem\u003e‘feeling tired’\u003c/em\u003e, \u003cem\u003e‘lacking companionship’,\u003c/em\u003e and \u003cem\u003e‘no good’\u003c/em\u003e. Significant structural differences were found between participants \u0026lt; 33 years and those ≥ 33 years (p = 0.017), with older individuals showing generally weaker psychosocial connections. Central symptoms were significantly associated with risky sexual behaviors, especially in younger participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e Central psychosocial problems—particularly emotional symptoms, low self-esteem, loneliness, and sociosexual desire—play a key role in driving high-risk sexual behaviors among MSM. Targeted, age-specific mental health interventions are essential to mitigate these risks and promote holistic well-being.\u003c/p\u003e","manuscriptTitle":"Psychosocial symptom networks and high-risk sexual behaviors among men who have sex with men: a network analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 08:30:26","doi":"10.21203/rs.3.rs-7315885/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-19T12:18:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T21:20:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T15:25:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T20:43:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98065228026773254168073388171404193934","date":"2025-09-04T15:59:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42319909463246520368777184716091354902","date":"2025-09-04T14:15:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19773459542538996094603012774545209685","date":"2025-08-30T04:13:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-27T19:27:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-14T10:55:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-08T03:15:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-08T03:13:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-08-07T07:23:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26875816-09a8-4b43-abda-93040f612f62","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:06:10+00:00","versionOfRecord":{"articleIdentity":"rs-7315885","link":"https://doi.org/10.1186/s40359-025-03550-x","journal":{"identity":"bmc-psychology","isVorOnly":false,"title":"BMC Psychology"},"publishedOn":"2025-11-12 15:57:19","publishedOnDateReadable":"November 12th, 2025"},"versionCreatedAt":"2025-09-08 08:30:26","video":"","vorDoi":"10.1186/s40359-025-03550-x","vorDoiUrl":"https://doi.org/10.1186/s40359-025-03550-x","workflowStages":[]},"version":"v1","identity":"rs-7315885","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7315885","identity":"rs-7315885","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}