A Structural Equation Modeling Approach to Understanding Pathways of Attitudinal Familism, Stressful Life Events, Coping Strategies and Condomless Anal Sex Among Men Who Have Sex with Men in Taiwan

Background: Socially and culturally embedded norms, such as familism, may be one potential key factor associated with practicing condomless anal sex among men who have sex with men (MSM) in Taiwan. Familism, one of the social norms in Taiwanese society, is defined as the belief in “prioritizing the family over the individual, showing respect for elders, and honouring the family name” (Schwartz, 2007, p.102). Utilizing sociological stress-coping theory (Aneshensel, Rutter, & Lachenbruch, 1991) and syndemic theory (Singer, 1996), the purpose of this study is to examine the associations among attitudinal familism, stressful life events (adverse childhood experiences, intimate partner violence, and sexuality-related discriminatory experiences), coping strategies and condomless anal sex in the Taiwanese MSM community.

Methods: From July to September 2017, a cross-sectional, on-line survey was implemented among a convenience sample of MSM recruited from five LGBTQ community-based organizations across Taiwan. Survey items included socio-demographic characteristics, adverse childhood experiences (ACEs), intimate partner violence (IPV), and sexuality-related discriminatory experiences (SDE), 14 coping strategies, and condom use. Structural equation modeling using bootstrapping with 3,000 iterations evaluated the mediating effects of 14 coping strategies between stressful life events and condomless anal sex.

Results: Among participants (n = 1000), 81.6% identified as gay; 92.2% had a university degree or more; 55.9% had a full-time job; 71.4% had a monthly income < $1360 USD; 61.0% were single. As for coping strategies, 54.7% of MSM in Taiwan frequently used problem-focused coping, 47.0% frequently used emotion-focused coping, and 43.5% frequently used dysfunctional coping. The measurement model of stressful life events included ACEs, IPV, and SDE. The model demonstrated acceptable model fit to the data (χ² = 113.90, RMSEA = 0.06, CFI/TLI = 0.95/0.96, SRMR = 0.06). In the construct of stressful life events, childhood emotional abuse had the highest standardized regression coefficient (B = 0.95, p < .001), followed by childhood physical abuse (B = 0.92, p < .001). The results showed that higher levels of attitudinal familism was negatively associated with fewer stressful life events and less condomless anal sex. The results also reveal that lower levels of attitudinal familism was associated with more stressful life events, which were, in turn, directly associated with more substance use coping strategy, which was itself directly associated with more condomless anal sex.

Conclusions: These findings suggest that the substance use coping strategy may mediate the association among attitudinal familism, stressful life events, and condomless anal sex among Taiwanese MSM. This study also provides new evidence regarding the role of attitudinal familism in shaping stressful life events and coping strategies among Taiwanese MSM. Given our findings that attitudinal familism was a protective factor for stressful life events and condomless anal sex, educational programs embedded with components of family support, family connection, and respect for elders may be effective in reducing sexual risk behaviours and dysfunctional coping strategies. In conclusion, an understanding of social norms that nurture health behaviours may be a culturally sensitive way to lead MSM to make the journey from traumatic exposure into resilience.