Men who have sex with men (MSM) is a sexual minority group that is vulnerable to addictive behaviors [1]. For instance, high prevalence of substance use has commonly been reported among MSM [1]. According to the minority stress model, minority groups are more likely than their counterparts to encounter stress arising from prejudice and discrimination due to their minority status, which would trigger maladaptive stress responses leading to negative health outcomes [2]. Addictive behaviors (eg, substance use, gambling, and internet gaming) can be considered as potential maladaptive stress responses [3-5]. Thus, sexual minority stress experienced by MSM may drive them to adopt addictive behaviors as a means of maladaptive coping. Internet gaming disorder (IGD) is an important form of such potential maladaptive responses, as internet and social media use have globally become a part of daily life.

IGD has become a growing public health concern, as it is prevalent and was associated with many potential harms including depression and increased violence [6]. Its significance is reflected by the inclusion in the International Classification of Diseases, 11th Revision as a form of mental disorder [7]. High prevalence of IGD was found in adolescents and emerging adult populations [8,9]. Among emerging adults (university students) in mainland China, the prevalence was 9.9% to 14.8% [8]. Social media are frequently used by MSM for social interactions with peers and seeking sex partners [10]; internet gaming among MSM might sometimes be mixed with such purposes. Despite the significance and high risk of IGD due to their sexual minority status among MSM, no study has specifically looked at the prevalence of IGD among MSM, according to our literature review. Although a study reported higher prevalence of problematic gaming among nonheterosexual than heterosexual participants (26% vs 13%), it did not measure IGD specifically [11]. This study represents a novel exploration of the prevalence and factors of IGD among MSM who are emerging adults (university students) in mainland China.

MSM tend to have high levels of loneliness and hopelessness [12,13]. The positive associations between loneliness/hopelessness and IGD have been well established, both theoretically and empirically in general and student populations [8,14,15]. Understanding such associations among MSM is highly warranted. Theoretically, the minority stress model postulates that stressors arising from experiences of prejudice events, expectation of prejudice reactions, and disharmony between the MSM subculture and the mainstream culture would create loneliness and hopelessness among MSM [2]. Perceived and enacted stigma, lack of social support, and loss of friends and intimate partners due to HIV/AIDS were also associated with loneliness and hopelessness among MSM [2]. Furthermore, previous studies have shown that young MSM are prone to experience greater loneliness than their older counterparts [16,17]. A potential consequence is an elevated risk in developing IGD among more younger than older MSM. Furthermore, the preference for online social interaction model postulates that those experiencing psychosocial problems in real life (loneliness and hopelessness in this case) may use internet-related activities (internet gaming in this case) to compensate their unmet psychosocial needs (eg, self-worth), thus leading to a higher risk in developing specific internet use disorder (IGD in this case) [18].

The mechanism between loneliness/hopelessness and IGD among MSM would be informative for designing effective interventions but has not been studied. Self-control is a potential mediator between loneliness/hopelessness and IGD. Self-control has special relevance as MSM exhibited weaker self-control than non-MSM [19,20]. Theoretically, the deficient self-regulation model postulates that self-control mediates between stress and problematic internet use, as self-control may suppress negative emotions caused by stress [21]. Empirical studies have reported a negative association between loneliness/hopelessness and self-control [22,23], and self-control was negatively associated with IGD [24,25]. A study also reported significant mediation between loneliness and problematic gambling via self-control [26].

This study investigated the prevalence and factors (ie, loneliness, hopelessness, and self-control) of IGD among university students who were MSM in mainland China. It also investigated the mediation effect of self-control between loneliness/hopelessness and IGD. It was hypothesized that loneliness and hopelessness would be positively associated with IGD, loneliness and hopelessness would be negatively associated with self-control, and self-control would be negatively associated with IGD. The direct effects from loneliness and hopelessness to IGD were also tested in this study. The study has special relevance to the MSM population, as they tend to have higher levels of addictive behaviors and loneliness/hopelessness, and a lower level of self-control. The information would facilitate tailored IGD interventions targeting MSM.

This study observed a 13% (39/305) prevalence of IGD among Chinese MSM who were university students, which is relatively high and requires attention. It is unknown whether the prevalence would be higher than that of non-MSM who are university students as this study did not involve the non-MSM group and hence no comparison can be made. Future confirmation is warranted. Nonetheless, the high prevalence deserves attention and warrants interventions, as IGD was associated with mental problems such as depression [37] and addictive behaviors such as substance use [38] that may also increase the risk of HIV infection [1,39], which is a serious concern among Chinese MSM who were university students [40].

Year of study was the only background variable significantly associated with IGD. Year 4 students showed lower prevalence of IGD than other students. Previous studies reported similar results that lower grades (eg, first year) were associated with higher risk of addictive behaviors (eg, substance use) [41]. It is plausible that year 4 students might have less time for internet gaming as they were heavily engaged in job-hunting and graduation arrangements thus were at a lower risk of IGD.

As expected, loneliness and hopelessness were both positively associated with IGD in this study, which corroborates findings of other studies [8,14,15]. It also supports the Preference for Online Social Interaction (POSI) model claiming that psychosocial problems such as loneliness and hopelessness may become an inner drive that would increase the risk of problematic internet gaming [18]. The findings have special implications as previous studies found that MSM were at greater risk of other addictive behaviors (eg, drug use and smoking) than others [3,4]. Furthermore, MSM are in general vulnerable to loneliness and hopelessness due to potential discrimination and stigma related to their sexual identity [2]. The trend might lead to higher prevalence of IGD in MSM who are university students than their counterparts, which needs to be investigated in future studies. Notably, this study was conducted prior to the COVID-19 pandemic. A study reported that loneliness showed a stronger correlation with IGD during the COVID-19 pandemic [42]. Future research should study if this is true for this study population.

A more acceptable social environment is also warranted to reduce risk factors of IGD such as loneliness and hopelessness. In agreement with the socioecological model of health [43], the findings suggest that structural factors such as public discrimination toward MSM are important to influence factors of IGD and might hence increase prevalence of IGD among MSM who are university students. The difficulty in developing same-sex families might also contribute to stronger hopelessness. Same-sex marriage is not legally accepted in China and in many parts of the world. MSM might hence find the hope for establishing a family difficult to fulfill. To prevent IGD among MSM who are university students, according to the findings, interventions may consider reducing loneliness and hopelessness. Although such interventions are available, few of them target sexual minority groups. As an exception, a small one-armed pilot psychoeducation intervention reported mild reduction in the level of loneliness over a 3-month period among MSM [44]. As the reasons of loneliness and hopelessness might partially be attributed to sexual minority experiences, tailored individual-level interventions tackling self-stigma among MSM might be useful. For instance, Moreno’s therapeutic model used sociometry, psychodrama, and group psychotherapy to reduce shame and internalized homophobia and increase social support among MSM living with HIV [45].

Supporting one of the hypotheses of this study, self-control was negatively associated with IGD. The finding was supported by previous theoretical and empirical studies [21,23]. Those with strong self-control might deliberately resist the impulse of playing internet games and find it easier to stop playing [46,47]. Another novel finding of this study revealed that self-control fully mediated between loneliness and IGD. This finding agrees with the deficient self-regulation model that mental distress (loneliness and hopelessness in this case) would diminish self-control, which would increase the risk of IGD [21]. The full mediation between loneliness and IGD implies that the negative impact of loneliness on IGD could be fully explained by reduction in self-control. The significant partial mediation between hopelessness and IGD implies that other potential mediators might exist but had not been included in this study. For instance, hopelessness might lead to depression and adoption of negative coping styles that would increase IGD [5,6,48]. Importantly, the significant mediations suggest that modification of self-control would directly reduce IGD and indirectly alleviate the harmful impacts of loneliness and hopelessness on IGD. In the literature, self-control could be strengthened via trainable strategies such as ways to avoid temptations (eg, healthy distraction), plans made ahead of occurrence of temptations, meditation, and self-reminders about the consequences [49-52].

This study has several limitations. First, due to the cross-sectional study design, no causal and temporal inferences can be claimed. Second, reporting bias (eg, recall bias and social desirability bias) may exist and result in underreported prevalence of IGD and an inflated level of self-control. Third, selection bias may exist; the characteristics between MSM participants and nonparticipants might differ but could not be compared. Fourth, the participating universities were conveniently selected in the studied city; generalization of the results to other regions in and outside China should be cautiously made. Fifth, this study did not investigate other potential determinants of IGD that were closely related to the MSM status (eg, sexual orientation, sexual role, and sexual behaviors). Sixth, other potential mediators of the association between hopelessness and IGD may exist but had not been investigated; some of these factors/mediators of IGD may have special relevance to MSM, such as internalized stigma and cognitive bias [2,53]. Last, a comparison group of non-MSM who are university students had not been included in this study; it is hence unknown whether the levels of IGD, loneliness, hopelessness, and self-control of the participants were different between MSM and non-MSM who are university students. Comparative studies would be informative.

In conclusion, this study observed relatively high prevalence of IGD among MSM who are university students in China, which was significantly associated with loneliness, hopelessness, and self-control. Interventions preventing IGD among MSM who are emerging adults might hence need to simultaneously improve loneliness, hopelessness, and self-control. A novel finding of this study was that self-control significantly (and fully or partially) mediated between loneliness/hopelessness and IGD, respectively. The significant mediation effects highlight the importance of self-control apart from its well-studied direct effect on IGD. It suggests that self-control links up the relationships between commonly found psychological problems (eg, loneliness and hopelessness) and IGD among MSM. Future longitudinal and intervention studies are needed to verify the above findings among MSM and other sexual minority groups.