Age and Education Disparities in Internalized Homophobia, Social Avoidance, Depressive Symptoms, and Sexualized Drug Use Among Men Who Have Sex with Men in China: A Mediation Analysis.

Men who have sex with men (MSM) in China face heightened risks for poor mental health and high-risk behaviors, often shaped by stigma and sociocultural pressures. Drawing on minority stress theory, this study examined whether social avoidance mediates relationships between dimensions of internalized homophobia (internalized heteronormativity, family-oriented identity, and social-oriented identity) and depressive symptoms and sexualized drug use (SDU), and whether associations varied by age and education. A cross-sectional online survey was conducted via Blued. A total of 486 MSM completed validated measures assessing internalized homophobia, social avoidance, depressive symptoms, SDU, and demographic characteristics. Mediation analyses tested direct and indirect pathways and analyses were stratified by age (< 30 vs. ≥ 30 years) and education (less than bachelor's degree vs. bachelor's degree or above). In the full sample, all three dimensions of internalized homophobia were significantly associated with greater social avoidance. Social avoidance partially mediated the relationship between family-oriented identity and depressive symptoms (indirect β = 0.100, p = 0.006; direct β = 0.244, p = 0.036). Internalized heteronormativity was directly associated with SDU (β = 0.017, p = 0.024). Subgroup analyses showed stronger effects among younger and more educated MSM. Among MSM aged < 30, family-oriented identity was associated with depressive symptoms both directly and indirectly via social avoidance. Internalized heteronormativity remained directly associated with SDU in this group. Findings underscore the mental health burden of internalized homophobia and its role in promoting social avoidance, depressive symptoms, and SDU. Targeted interventions addressing internalized homophobia and safer sex practices are needed for younger and more educated MSM in China.