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Health-related research on sexual minority populations in China is lacking, and research on sexual and gender minority women (SGMW, including transgender women and persons of other gender identities assigned female at birth of all sexual orientations, and cisgender women with nonheterosexual orientations) is even less. Currently, there are limited surveys related to mental health in Chinese SGMW, but there are no studies on their quality of life (QOL), no studies comparing the QOL of SGMW with that of cisgender heterosexual women (CHW), and no studies on the relationship between sexual identity and the QOL as well as associated mental health variables.
This study aims to evaluate the QOL and mental health in a diverse sample of Chinese women and make comparisons between SGMW and CHW and then investigate the relationship between sexual identity and the QOL through the role of mental health.
A cross-sectional online survey was conducted from July to September 2021. All participants completed a structured questionnaire containing the World Health Organization Quality of Life–abbreviated short version (WHOQOL-BREF), the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Rosenberg Self-Esteem Scale (RSES).
In total, 509 women aged 18-56 years were recruited, including 250 (49.1%) CHW and 259 (50.9%) SGMW. Independent
The SGMW had poorer levels of QOL and a worse mental health status than the CHW. The study findings affirm the importance of assessing mental health and highlight the need to design targeted health improvement programs for the SGMW population, who may be at higher risk of a poor QOL and mental health.
Public health surveillance systems, to date, have focused on cisgender heterosexual (CH) individuals, whose gender identity is consistent with their sex assigned at birth and who are sexually or romantically attracted to people of the opposite sex, while people with other gender and sexual orientation identities have historically been less visible [
A growing body of research has explored health disparities among people of different sexual orientations, and sexual minority populations have consistently been found to report worse health outcomes than their CH peers, especially in the area of mental health [
As emphasized by the World Health Organization (WHO), mental health is “not just the absence of mental disorder” but “a state of well-being in which individuals realize their own potential and can cope with normal stresses of life” [
In addition to mental health, a poor quality of life (QOL) has been shown to be positively associated with adverse mental health outcomes [
Health-related research on SGMW is growing slowly worldwide [
The associations between sexual identity and the QOL as well as mental health vary across studies conducted in different countries, and there are currently no studies aimed at explaining these relationships among Chinese SGM populations, let alone SGMW. Therefore, this study aims to first examine the QOL and mental health of Chinese adult women of different sexual identities, with mental health variables including depression and anxiety as well as self-esteem, and then investigate the relationships between sexual identity and the QOL through the role of mental health variables in the Chinese context. Our main hypotheses were as follows: (1) SGMW in China may report lower levels of the QOL and more mental health disorders compared to CHW, (2) a better mental health status may positively be associated with higher levels of the QOL, and (3) mental health variables mediate the effect of sexual identity on the QOL.
This was a cross-sectional study conducted online in China. Given the relative sensitivity and invisibility of our study population under the influence of traditional Chinese culture, multiple recruitment methods were used, including (1) convenient recruitment via 4 popular nongovernmental organizations (NGOs) serving female or SGM populations in mainland China (TrueSelf, r&B bisexual community, Period Pride China, and the Wuhan LGBT Center); (2) respondent-driven recruitment, where respondents were encouraged to help recruit potential peers through their network of connections [
Eligible participants included Chinese women who were (1) at least 18 years old; (2) self-identified as “female,” either cisgender or transgender women or gender nonbinary individuals whose sex assigned at birth was female; and (3) able to read and understand Mandarin. Data were collected using an online survey platform (Wenjuanxing), and data collection was initiated after informed consent was obtained.
Ethical approval was obtained from the Human Research Ethics Committee (HREC) of the University of Hong Kong (reference no. EA210325). All participants provided informed consent.
Participants who consented to join the study were asked to fill out all the following questionnaires in Mandarin.
The 9-item Patient Health Questionnaire (PHQ-9) is a depression module that measures the presence and severity of depression symptoms over the past 2 weeks according to the
The 7-item Generalized Anxiety Disorder scale (GAD-7) is a self-reported screening tool to identify anxiety symptoms in the past 2 weeks. Each of the 7 items is scored from 0 (not at all) to 3 (nearly every day), and the GAD-7 scale score ranges from 0 to 21 [
The Rosenberg Self-Esteem Scale (RSES) is a 10-item self-report scale evaluating an individual’s self-esteem [
The World Health Organization Quality of Life–abbreviated short version (WHOQOL) is a QOL assessment tool developed by the WHOQOL Group and includes 100 items on a 5-point scale [
All participants completed a set of sociodemographic items, including their basic information (age, employment, race/ethnicity, education level, income, relationship status) and their sexual identity (gender identity and sexual orientation identity).
The sample size calculation was performed using G*Power 3.1 [
Descriptive statistics (counts and percentages, means, and SDs) were used to illustrate participants’ demographic characteristics, QOL, and mental health outcomes.
To compare the scores of mental health variables (PHQ-9, GAD-7, RSES) and the QOL (WHOQOL-BREF) between SGMW and CHW, independent
To examine mediating effects, we used a bootstrapping technique using the PROCESS macro [
As shown in
Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 27.0, and the PROCESS macro version 4.1 for SPSS was used to conduct the mediation analysis [
Proposed parallel mediation model; a: effect of the independent variable (X) on mental health (M1-M3), b: effect of mental health on QOL (Y), c: total effect of X on Y, c’: direct effect of X on Y. M: mediator; QOL: quality of life.
Of the 524 questionnaires collected between July and September 2021, 15 (2.9%) were unqualified since they were cisgender male (9/15, 60%) or less than 18 years old (4/15, 27%) or invalid data with all same answers (2/15, 13%), resulting in a total of 509 (97.1%) adult women enrolled in the study with no missing data. Specifically, 250 (49.1%) were CHW and categorized as the CHW group, while 259 (50.9%) were either sexual orientation or gender minority women and categorized as the SGMW group. The sexual orientation and gender identity of participants are shown in
The mean age of the overall sample was 25.57 (SD 5.77) years, ranging from 18 to 56 years (
Frequency distribution of participants by gender and sexual orientation identity (N=509).
Gender identity | Sexual orientation identity, n (%) | |||||
Homosexual | Heterosexual | Bisexual | Pansexual | Othersa | Total | |
Cisgender women | 51 (10.0) | 250 (49.1)b | 74 (14.5) | 33 (6.5) | 28 (5.5) | 436 (85.7) |
Transgender women | 8 (1.6) | 1 (0.2) | 1 (0.2) | 1 (0.2) | 2 (0.4) | 13 (2.6) |
Gender queer | 10 (2.0) | 1 (0.2) | 4 (0.8) | 12 (2.4) | 1 (0.2) | 28 (5.5) |
Gender fluid | 0 | 0 | 4 (0.8) | 2 (0.4) | 1 (0.2) | 7 (1.4) |
Other gender nonbinaryc | 2 (0.4) | 7 (1.4) | 5 (1.0) | 4 (0.8) | 7 (1.4) | 25 (4.9) |
Total | 71 (13.9) | 259 (50.9) | 88 (17.3) | 52 (10.2) | 39 (7.7) | 509 (100.0) |
aOther minority sexual orientation identities, including asexual, gynephilia/femininity, and all other nonheterosexual orientations.
bThe cisgender heterosexual women (CHW) group in this study comprised 250 (49.1%) women. Correspondingly, the other 259 (50.9%) sexual orientation and gender minority women were categorized as the sexual and gender minority women (SGMW) group.
cThis group included gender questioning (someone who is unsure about or is exploring their gender identity), no gender, and other nonbinary genders that are noncisgender and beyond social norms.
Characteristics of the study sample with comparisons.
Characteristics | Overall (N=509) | SGMWa (n=259, 50.1%) | CHWb (n=250, 49.1%) | |
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18-20 | 94 (18.5) | 61 (23.6) | 33 (13.2) |
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21-30 | 347 (68.2) | 171 (66.0) | 176 (70.4) |
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31-40 | 56 (11.0) | 25 (9.7) | 31 (12.4) |
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41-56 | 12 (2.4) | 2 (0.8) | 10 (4.0) |
Mean age, mean (SD); |
25.57 (5.77) | 24.43 (4.94) | 26.75 (6.31) | |
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0 | 144 (28.3) | 48 (33.3) | 96 (66.7) |
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1-5 | 154 (30.3) | 96 (62.3) | 58 (37.7) |
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6-10 | 74 (14.5) | 50 (67.6) | 24 (32.4) |
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11-20 | 43 (8.4) | 28 (65.1) | 15 (34.9) |
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21-50 | 40 (7.9) | 20 (50.0) | 20 (50.0) |
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51-100 | 27 (5.3) | 12 (44.4) | 15 (55.6) |
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>100 | 27 (5.3) | 5 (18.5) | 22 (81.5) |
Mean numbers of friends around, mean (SD); |
33.44 (108.28) | 20.14 (71.40) | 47.22 (135.14) | |
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High school and below | 33 (6.5) | 21 (8.1) | 12 (4.8) |
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College/bachelor | 284 (55.8) | 167 (64.5) | 117 (46.8) |
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Graduate degree and above | 192 (37.7) | 71 (27.4) | 121 (48.4) |
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Han people | 466 (91.6) | 242 (93.4) | 224 (89.6) |
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Others (Muslim, Zhuang people, etc) | 43 (8.4) | 17 (6.6) | 26 (10.4) |
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Unemployed | 39 (7.7) | 29 (11.2) | 10 (4.0) |
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Full-time student | 222 (43.6) | 118 (45.6) | 104 (41.6) |
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Organization officer | 42 (8.3) | 23 (8.9) | 19 (7.6) |
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Professional/technical personnel | 103 (20.2) | 29 (11.2) | 74 (29.6) |
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Administrative personnel | 17 (3.3) | 7 (2.7) | 10 (4.0) |
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Service personnel | 33 (6.5) | 19 (7.3) | 14 (5.6) |
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Others (famers/freelancers) | 53 (10.4) | 34 (13.1) | 19 (7.6) |
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≤CNY 5000.00/US $743.89 | 282 (55.4) | 162 (62.5) | 120 (48.0) |
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>CNY 5000.00/US $743.89 | 227 (44.6) | 97 (37.5) | 130 (52.0) |
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Have a steady partner | 251 (49.3) | 115 (44.4) | 136 (54.4) |
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Have no steady partner(s) | 258 (50.7) | 144 (55.6) | 114 (45.6) |
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Never drank before | 178 (35.0) | 68 (26.3) | 110 (44.0) |
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Current alcohol user | 331 (65.0) | 191 (73.7) | 140 (56.0) |
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Never used before | 500 (98.2) | 252 (97.3) | 248 (99.2) |
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Have used drug before | 9 (1.8) | 7 (2.7) | 2 (0.8) |
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Never smoked or have quit smoking | 428 (84.1) | 188 (72.6) | 240 (96.0) |
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Current smoker | 81 (15.9) | 71 (27.4) | 10 (4.0) |
aSGMW: sexual and gender minority women. The percentages for this column were all calculated with 259 SGMW as the denominator.
bCHW: cisgender heterosexual women. The percentages for this column were all calculated with 250 CHW as the denominator.
cAll
dCNY 1=US $0.15.
QOLa and mental health of the study participants with comparisons.
QOL and mental health | Overall (N=509) | SGMWb |
CHWc |
Cohen |
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Physical | 14.05 (2.71) | 13.49 (2.87) | 14.63 (2.39) | <.001 | –0.43 |
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Psychological | 13.74 (3.13) | 12.94 (3.35) | 14.57 (2.65) | <.001 | –0.54 |
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Social relationship | 13.62 (3.07) | 13.02 (3.35) | 14.23 (2.61) | <.001 | –0.40 |
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Environment | 13.74 (2.68) | 13.32 (2.90) | 14.18 (2.35) | <.001 | –0.33 |
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Total score | 55.15 (9.90) | 52.77 (10.69) | 57.61 (8.34) | <.001 | –0.50 |
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Depression (PHQ-9e) | 7.85 (5.92) | 9.16 (6.36) | 6.50 (5.11) | <.001 | 0.46 |
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Anxiety (GAD-7f) | 6.00 (5.23) | 6.93 (5.49) | 5.04 (4.77) | <.001 | 0.37 |
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Self-esteem (RSESg) | 28.86 (4.66) | 28.04 (4.95) | 29.72 (4.18) | <.001 | –0.37 |
aQOL: quality of life.
bSGMW: sexual and gender minority women.
cCHW: cisgender heterosexual women.
dWHOQOL-BREF: World Health Organization Quality of Life–abbreviated short version.
ePHQ-9: 9-item Patient Health Questionnaire.
fGAD-7: 7-item Generalized Anxiety Disorder scale.
gRSES: Rosenberg Self-Esteem Scale.
Pearson correlations between the QOL and depression, anxiety, and self-esteem are displayed in
Correlations between the QOLa and mental health variables.
Mental health | QOL (WHOQOL-BREFb) | |||||
Physical | Psychological | Social relationship | Environment | Total score | ||
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r value | –0.66 | –0.67 | –0.52 | –0.47 | –0.68 |
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<.001 | <.001 | <.001 | <.001 | <.001 | |
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r value | –0.56 | –0.55 | –0.42 | –0.45 | –0.58 |
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<.001 | <.001 | <.001 | <.001 | <.001 | |
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r value | 0.60 | 0.75 | 0.53 | 0.52 | 0.71 |
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<.001 | <.001 | <.001 | <.001 | <.001 |
aQOL: quality of life.
bWHOQOL-BREF: World Health Organization Quality of Life–abbreviated short version.
cPHQ-9: 9-item Patient Health Questionnaire.
dGAD-7: 7-item Generalized Anxiety Disorder scale.
eRSES: Rosenberg Self-Esteem Scale.
Regressions of sexual identity on the physical QOLa.
Characteristics | Physical QOL (R-square=7.9%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWb vs SGMWc) | 0.77 | .003 | 0.27 to 1.26 |
Age | 0.00 | .93 | –0.04 to 0.05 |
Alcohol user (yes vs no) | –0.40 | .12 | –0.90 to 0.10 |
Drug user (yes vs no) | 1.00 | .27 | –0.79 to 2.79 |
Current smoker (yes vs no) | –0.84 | .02 | –1.53 to –0.15 |
Income (≥CNY 5000/US $743.89d vs below) | 0.52 | .052 | 0.00 to 1.05 |
Have a steady partner (vs no) | 0.41 | .09 | –0.07 to 0.89 |
aQOL: quality of life.
bCHW: cisgender heterosexual women.
cSGMW: sexual and gender minority women.
dCNY 1=US $0.15.
Regressions of sexual identity on the psychological QOLa.
Characteristics | Psychological QOL (R-square=11.3%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWb vs SGMWc) | 1.13 | <.001 | 0.56 to 1.69 |
Age | 0.02 | .48 | –0.03 to 0.07 |
Alcohol user (yes vs no) | –0.11 | .70 | –0.68 to 0.46 |
Drug user (yes vs no) | 0.63 | .54 | –1.40 to 2.66 |
Current smoker (yes vs no) | –1.38 | .001 | –2.16 to –0.60 |
Income (≥CNY 5000/US $743.89d vs below) | 0.43 | .15 | –0.16 to 1.03 |
Have a steady partner (vs no) | 0.64 | .02 | 0.10 to 1.19 |
aQOL: quality of life.
bCHW: cisgender heterosexual women.
cSGMW: sexual and gender minority women.
dCNY 1=US $0.15.
Regressions of sexual identity on the social relationship QOLa.
Characteristics | Social relationship QOL (R-square=9.7%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWb vs SGMWc) | 0.90 | .002 | 0.35 to 1.46 |
Age | –0.07 | .01 | –0.12 to –0.01 |
Alcohol user (yes vs no) | –0.60 | .04 | –1.16 to –0.04 |
Drug user (yes vs no) | –1.45 | .16 | –3.45 to 0.56 |
Current smoker (yes vs no) | –0.74 | .06 | –1.51 to 0.04 |
Income (≥CNY 5000/US $743.89d vs below) | 0.27 | .37 | –0.32 to 0.86 |
Have a steady partner (vs no) | 1.10 | <.001 | 0.57 to 1.64 |
aQOL: quality of life.
bCHW: cisgender heterosexual women.
cSGMW: sexual and gender minority women.
dCNY 1=US $0.15.
Regressions of sexual identity on the environment QOLa.
Characteristics | Environment QOL (R-square=4.4%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWb vs SGMWc) | 0.67 | .008 | 0.17 to 1.17 |
Age | –0.03 | .20 | –0.08 to 0.02 |
Alcohol user (yes vs no) | 0.01 | .97 | –0.50 to 0.51 |
Drug user (yes vs no) | –0.21 | .82 | –2.01 to 1.59 |
Current smoker (yes vs no) | –0.74 | .04 | –1.44 to –0.05 |
Income (≥CNY 5000/US $743.89d vs below) | 0.41 | .13 | –0.12 to 0.94 |
Have a steady partner (vs no) | 0.30 | .23 | –0.19 to 0.78 |
aQOL: quality of life.
bCHW: cisgender heterosexual women.
cSGMW: sexual and gender minority women.
dCNY 1=US $0.15.
Regressions of sexual identity on the overall QOLa.
Characteristics | Overall QOL (R-square=10.3%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWb vs SGMWc) | 3.47 | <.001 | 1.68 to 5.26 |
Age | –0.08 | .37 | –0.24 to 0.09 |
Alcohol user (yes vs no) | –1.10 | .23 | –2.91 to 0.71 |
Drug user (yes vs no) | –0.02 | .99 | –6.47 to 6.43 |
Current smoker (yes vs no) | –3.70 | .004 | –6.19 to –1.21 |
Income (≥CNY 5000/US $743.89d vs below) | 1.64 | .09 | –0.26 to 3.54 |
Have a steady partner (vs no) | 2.45 | .006 | 0.72 to 4.18 |
aQOL: quality of life.
bCHW: cisgender heterosexual women.
cSGMW: sexual and gender minority women.
dCNY 1=US $0.15.
Regressions of sexual identity on mental health (depression).
Characteristics | Depression (R-square=8.5%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWa vs SGMWb) | -1.74 | .002 | –2.82 to –0.66 |
Age | -0.07 | .16 | –0.17 to 0.03 |
Alcohol user (yes vs no) | 0.86 | .12 | –0.24 to 1.95 |
Drug user (yes vs no) | -2.01 | .31 | –5.91 to 1.89 |
Current smoker (yes vs no) | 2.50 | .001 | 0.99 to 4.00 |
Income (≥CNY 5000/US $743.89c vs below) | -0.03 | .95 | –1.18 to 1.12 |
Have a steady partner (vs no) | -0.42 | .43 | –1.47 to 0.63 |
aCHW: cisgender heterosexual women.
bSGMW: sexual and gender minority women.
cCNY 1=US $0.15.
Regressions of sexual identity on mental health (anxiety).
Characteristics | Anxiety (R-square=6.9%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWa vs SGMWb) | -1.11 | .02 | –2.07 to –0.15 |
Age | -0.03 | .46 | –0.12 to 0.06 |
Alcohol user (yes vs no) | 1.06 | .03 | 0.09 to 2.04 |
Drug user (yes vs no) | -2.34 | .19 | –5.81 to 1.13 |
Current smoker (yes vs no) | 1.87 | .006 | 0.53 to 3.21 |
Income (≥CNY 5000/US $743.89c vs below) | -0.33 | .53 | –1.35 to 0.70 |
Have a steady partner (vs no) | -0.68 | .15 | –1.61 to 0.25 |
aCHW: cisgender heterosexual women.
bSGMW: sexual and gender minority women.
cCNY 1=US $0.15.
Regressions of sexual identity on mental health (self-esteem).
Characteristics | Self-esteem (R-square=7.8%) | ||
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Coefficient | 95% CI | |
Sexual identity (CHWa vs SGMWb) | 1.01 | .02 | 0.15 to 1.86 |
Age | 0.00 | .97 | –0.08 to 0.08 |
Alcohol user (yes vs no) | 0.04 | .92 | –0.82 to 0.91 |
Drug user (yes vs no) | 1.58 | .31 | –1.50 to 4.66 |
Current smoker (yes vs no) | -1.91 | .002 | –3.10 to –0.72 |
Income (≥CNY 5000/US $743.89c vs below) | 1.33 | .004 | 0.42 to 2.23 |
Have a steady partner (vs no) | 0.60 | .16 | –0.23 to 1.43 |
aCHW: cisgender heterosexual women.
bSGMW: sexual and gender minority women.
cCNY 1=US $0.15.
Parallel mediation model for the physical QOL. M: mediator; QOL: quality of life.
Parallel mediation model for the psychological QOL. M: mediator; QOL: quality of life.
Parallel mediation model for the social relationship QOL. M: mediator; QOL: quality of life.
Parallel mediation model for the environment QOL. M: mediator; QOL: quality of life.
Parallel mediation model on the overall QOL. M: mediator; QOL: quality of life.
Mediation effects of mental health on the relationship between sexual identity and the QOLa.
Dependent variable (Y) | Total effect (c) | Direct effect (c’) | X→Mb (a1, a2, a3)c | M→Y (b1, b2, b3)d | Indirect effect (a×b) | |||||||||||||||
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βe | SE | β | SE | β | SE | β | SE | β | SE | 95% CI | |||||||||
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X→M1→Y1 | .74 | .004 | .25 | .20 | .28 | .18 | –1.72 | .002 | .55 | –.21 | <.001 | .03 | .37 | .13 | 0.12 to 0.65 | ||||
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X→M2→Y1 | —f | — | — | — | — | — | –1.12 | .02 | .49 | .00 | .92 | .03 | .00 | .04 | –0.08 to 0.08 | ||||
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X→M3→Y1 | — | — | — | — | — | — | .93 | .03 | .43 | .19 | <.001 | .02 | .17 | .08 | 0.02 to 0.35 | ||||
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X→M1→Y2 | 1.09 | <.001 | .29 | .44 | .02 | .18 | –1.72 | .002 | .55 | –.20 | <.001 | .03 | .35 | .13 | 0.11 to 0.61 | ||||
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X→M2→Y2 | — | — | — | — | — | — | –1.12 | .02 | .49 | .03 | .30 | .03 | –.03 | .04 | –0.12 to 0.03 | ||||
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X→M3→Y2 | — | — | — | — | — | — | .93 | .03 | .43 | .36 | <.001 | .02 | .33 | .15 | 0.03 to 0.63 | ||||
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X→M1→Y3 | .83 | .004 | .28 | .35 | .14 | .24 | –1.72 | .002 | .55 | –.19 | <.001 | .03 | .33 | .12 | 0.11 to 0.59 | ||||
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X→M2→Y3 | — | — | — | — | — | — | –1.12 | .02 | .49 | .05 | .18 | .04 | –.05 | .05 | –0.18 to 0.03 | ||||
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X→M3→Y3 | — | — | — | — | — | — | .93 | .03 | .43 | .23 | <.001 | .03 | .21 | .10 | 0.02 to 0.41 | ||||
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X→M1→Y4 | .60 | .02 | .25 | .21 | .32 | .22 | –1.72 | .002 | .55 | –.07 | .02 | .03 | .12 | .07 | 0.01 to 0.28 | ||||
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X→M2→Y4 | — | — | — | — | — | — | –1.12 | .02 | .49 | –.07 | .04 | .03 | .08 | .06 | 0.00 to 0.20 | ||||
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X→M3→Y4 | — | — | — | — | — | — | .93 | .03 | .43 | .21 | <.001 | .03 | .19 | .09 | 0.02 to 0.37 | ||||
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X→M1→Y5 | 3.26 | <.001 | .91 | 1.20 | .04 | .59 | –1.72 | .002 | .55 | –.68 | <.001 | .09 | 1.17 | .43 | 0.37 to 2.06 | ||||
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X→M2→Y5 | — | — | — | — | — | — | –1.12 | .02 | .49 | .01 | .91 | .09 | –.01 | .11 | –0.26 to 0.21 | ||||
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X→M3→Y5 | — | — | — | — | — | — | .93 | .03 | .43 | .98 | <.001 | .07 | .91 | .42 | 0.09 to 1.75 |
aQOL: quality of life.
bM: mediator.
ca1, a2, and a3 are the effects of the sexual identity (X) on the mental health mediators depression (M1), anxiety (M2), and self-esteem (M3), respectively.
dCorrespondingly, b1, b2, and b3 are the effects of M1, M2, and M3, respectively, on the QOL (Y).
eUnstandardized coefficients (β) are reported. Bootstrap sample size=5000.
fNot applicable.
The QOL is widely used to describe individuals’ perceptions of general and holistic health [
In terms of cultural issues affecting the QOL and mental health of SGMW in China, it is critical to consider the deep-rooted traditional Confucian Chinese culture that highly values family and inheritance. Specifically, being a member of SGM populations in China is associated with internalized homophobia and stressful feelings in the face of social expectations [
Furthermore, despite a similar cultural background, the overall participants in our study (mainly from mainland China) scored lower than SGMW in Taiwan using the same RSES [
Both correlation and regression analyses in this study showed that the overall QOL as well as the QOL in each domain are significantly associated with depression, anxiety, and self-esteem, which is in line with previous studies. Specifically, depression was shown to negatively impact the QOL in our study, as has been seen in similar pathway analysis studies in other populations [
Given the prior neglect of the health status of SGM populations and the worrisome levels of the QOL and mental health among SGMW, the participants in this study, our results also have significant implications for professional practice. It is recommended that health and social care professionals proactively attend to the mental health of people belonging to sexual minorities when designing or providing interventions. Notably, we found that the proportions of current smokers and alcohol users were significantly higher in SGMW than in CHW, which is supported by previous studies [
Although there were no significant associations between having a steady partner and mental health variables in our study, being in a steady relationship was found to be significantly positively associated with the overall QOL, psychological QOL, and social relationship QOL. Such findings that the relationship status could positively affect the QOL are consistent with a published review showing that being in a relationship with a regular partner is a protective factor for health [
Sexual minority populations have been found to experience higher rates of physical and mental health disorders and poorer levels of the QOL [
To sum up, this is the first study to examine both the QOL and mental health among Chinese adult women with diverse sexual identities and also the first to conduct comparisons between SGMW and CHW, showing that SGMW experience worse levels of the QOL and mental health compared to CHW. Although the associations between the QOL and mental health are well established in general populations, there has been little research on these relationships in people of different gender and sexual orientation identities, so this study is also the first to report the interrelationships between sexual identity and the QOL as well as mental health (depression, anxiety, and self-esteem). Moreover, our study is also the first to explore and confirm the mediating role of mental health in the impact of sexual identity on the QOL.
This study had several limitations. First, although the QOL and mental health variables explored in this study are generally investigated as separate constructs, this has certain limitations as the meanings of these concepts are intertwined and may influence each other. Although due to the cross-sectional design of this study, the comprehensive relationships within these concepts could not be adequately explored, further studies using more diverse research methodologies, such as qualitative approaches or longitudinal designs, are needed. Second, most of our study participants were young, and nearly half had no paid employment or were still full-time students; therefore, the results might not be generalizable to the broader Chinese female population. Third, although the sample size was sufficient for comparisons between SGMW as a whole and CHW, subgroup analyses by specific sexual orientation may not be powerful enough. Future studies with larger, more diverse, and representative samples are needed.
This study demonstrated that SGMW have lower levels of the QOL, higher levels of depression and anxiety symptoms, and lower levels of self-esteem than heterosexual women. The overall QOL and QOL in each domain were found to be positively associated with good mental health outcomes, with moderate-to-strong correlations. Multiple linear regressions found that being a sexual or gender minority, current smoker, and woman with no steady partner are associated with a worse overall QOL. Mediation analysis showed that depression, anxiety, and self-esteem play significant mediating roles in the relationship between sexual identity and the QOL in Chinese adult women, affirming the importance of assessing mental health when investigating or improving the QOL. Longitudinal studies and evidence-based intervention programs are further needed, with a particular focus on sexual minority women.
None declared.
Comparisons of quality of life and mental health among 5 sexual orientation groups.
cisgender heterosexual
cisgender heterosexual women
7-item Generalized Anxiety Disorder scale
9-item Patient Health Questionnaire
quality of life
Rosenberg Self-Esteem Scale
sexual and gender minority
sexual and gender minority women
World Health Organization Quality of Life–abbreviated short version
We are grateful to all the participants for sharing their experiences with us. We also thank TrueSelf Shenzhen, Period Pride China, Wuhan LGBT Center, the r&B bisexual community, and all those who helped transfer this survey to their friends for their contribution to the questionnaire distribution.
Publication made possible in part by support from the University of Hong Kong (HKU) Libraries Open Access Author Fund sponsored by the HKU Libraries.