School Bullying Victimization and Emotional Problems in Relation to Sexual Orientation Among High School Students in China (cid:0) A Cross-Sectional Study

Background (cid:0) School bullying has become a global concern for the public as well as a erce battleeld for educational psychologists. And sexual minority youth (SMY) may experience minority stress, a chronic form of stress engendered by negative social experiences such as stigmatization, that is known to impact adversely mental health and well-being. Under the specic cultural background of China, few scholars associate sexual orientation with campus bullying, as well as depression and anxiety symptoms. But in fact, China's sexual minority adolescences face no less diculties than any sexual minority in the world. Methods (cid:0) From April to July 2018, a cross-sectional survey was conducted among senior high school students in Hunan Province, China. A total of 3934 subjects were investigated by multi-stage cluster random sampling. Traditional bullying victimization was surveyed via the suffering subscale of Chinese version of Olweus Bully/Victim Questionnaire (OBVQ). Cyber school bullying was surveyed via a question. The Chinese version of the 9-item Patient Health Questionnaire (PHQ-9) and the Chinese version of the 7-item Generalized Anxiety Disorder Scale (GAD-7) were used to screen depression and anxiety symptoms of participants. Logistic regression model was used to analyze the relationship between sexual orientation and types of bullying victimization , depression and anxiety symptoms. Results (cid:0) Bisexuality accounted for the highest proportion of victims of traditional bullying only and cyber bullying only, at 10.2% and 4.8%, respectively. Homosexuality accounts for the highest proportion of combined bullying, at 18.2%. Homosexuality(OR: 5.833; 95% CI: 3.045 to 11.176), bisexuality(OR: 2.831; 95% CI: 1.354 to 5.923)and uncertainty of sexual orientation(OR: 2.206; 95% CI: 1.435 to 3.392) were signicantly associated with combined bullying. The bisexual group has the highest rate of depression(40.1%) and anxiety(38.1%) symptoms. Compared to heterosexual group, bisexual group has the highest risk of depression(OR: 2.349; 95% CI: 1.664 to 3.316) and anxiety(OR: 3.049; 95% CI: 2.150 to 4.324) symptoms. Conclusions: are at the greatest risk of becoming victims of double bullying(traditional and cyberbullying)and bisexuals are at the greatest risk of depression and anxiety symptoms. study showed reliability of the Chinese of PHQ-9 in children and adolescents population[27]. In the present study, the Cronbach’s alpha of PHQ-9 0.88. rate of high school students suffering from campus bullying in Hunan Province was 12.2%, the positive rate of depressive symptoms was 25.2%, and the positive rate of anxiety symptoms was 19.0%. Among senior high school students, sexual orientation is strongly related to the types of bullying victimization. and emotional problems. These ndings indicate that homosexuals are at the greatest risk of becoming victims of double bullying(traditional bullying and cyberbullying) and bisexuals are at the greatest risk of depression and anxiety symptoms. The two types of teenagers face more pressure than heterosexual teenagers. Although anti-bullying activities are being carried out in developed areas of eastern China, few projects contain specic strategies to reduce stereotypes and prejudices, which are necessary to address stigma-based bullying. Future intervention recommendations should include such strategies to address the problem of bullying stigmatized groups. Finally, we emphasize that reducing LGBT stigmatization and bullying/cyber bullying interventions should be multidirectional. Family education plays a key role in embracing diversity. Schools are the context for anti-bullying activities that focus on vulnerable groups and promote tolerance for diversity.

selected schools, and all the students in the selected classes were selected as the subjects of the survey. Due to the heavy academic tasks of the students in the third grade of senior high school, the acceptance of this survey is low, so only the students in the rst and second grades of senior high school are selected as the objects of this study. Before the eld investigation, we requested permissions from the principals of each school. Once the permissions were granted, investigators conducted the research in each class with the help of the headteachers. A total of 4050 questionnaires were distributed and 3934 valid questionnaires were collected, with an effective response rate of 97.1%.
All participants signed informed consent forms, and the purpose of the study as well as the questionnaire sections were explained to them by investigators.
The students were assured of the anonymity and con dentiality of the information provided in the self-reported questionnaires, and the respondents were free to discontinue their participation at any time of the study. The study received the approval from the ethical committee of Xiangya School of Public Health, Central South University. (XYGW-2017-056).

Data collection and measurements
General characteristic Potential confounding factors were selected based on the literature with regard to the association between bullying victimization, emotional problems and sexual orientation [19][20], which included gender, grade, the type of school (public high schools, or private high schools), school location(rural or urban), family type (single-parent family, Remarriage / foster family, or Complete family), parental education (lower than a bachelor's degree ,or a bachelor's degree and above) and whether the respondent comes from one-child family (yes or no). Besides, parental abuse were considered as confounding variables in this study according to prior work [21]. Parental abuse were measured by asking participants "how often your parents hit or abused you". The frequency coded on a 5point scale in the last half year, ranging from 1 to 5 (1= never happened, 2 = only once or twice, 3 = two or three times a month, 4 = about once a week, 5 = several times a week). Those who chose options 2, 3, 4 and 5 were de ned as being abused by their parents, and those who chose option 1 were de ned as not abused by their parents.

Bullying victimization
Traditional bullying victimization was surveyed via the suffering subscale of Chinese version of Olweus Bully/Victim Questionnaire (OBVQ). The reliability of the subscale is good, and the Cronbach's α coe cient is 0.80 [22]. Second, bulling victimization was assessed by asking that have you ever been bullied by peers in the last 6 months using the following 6 items: (1) Having been hit, kicked, pushed or shoved; (2) Having belongings been taken or damaged; (3) Having been called nasty name; (4) Having been made fun of; (5) Having been kept out of things on purpose, excluded from the group or completely ignored; (6) They told lies or spread rumors about you and/or tried to make others dislike you. The frequency was coded on a 5-point scale ranging from 1 to 5 (1= never happened, 2 = only once or twice, 3 = two or three times a month, 4 = about once a week, 5 = several times a week). Students were considered to be involved in traditionally bullying victimization if the frequency of bullying behavior mentioned above happened more than two or three times a month [23].
Cyber school bullying was surveyed via the question, "In the past six months, have any students ridiculed, abused, threatened you or maliciously spread your privacy on the Internet through electronic products such as text messages, e-mails and chat platforms?. " Students who answered " yes " were classi ed as victims of cyber bullying.
For the analysis, the participants were placed into categories based on their responses to traditional and cyber bullying victimization: 1) no form of bullying, 2) traditional bullying only, 3) cyber bullying only 4) a combination of traditional and cyber bullying.

Depression symptoms
The Chinese version of the 9-item Patient Health Questionnaire (PHQ-9) was used to screen depression of participants [24]. The PHQ-9 has 9 questions with a score ranging from 0 to 3 for each item, and total score ranging from 0 to 27. A higher score indicates that the participant has more depressive symptoms. A total score of 10 or more is considered to meet the criterion of screening for depressive symptoms (1 = Yes, 0 = No) [25,26]. The prior study showed good reliability of the Chinese version of PHQ-9 in children and adolescents population [27]. In the present study, the Cronbach's alpha of PHQ-9 was 0.88.

Anxiety symptoms
The Chinese version of the 7-item Generalized Anxiety Disorder Scale (GAD-7) was used to assess anxiety disorders of children [28]. The GAD-7 has 7 questions with a score ranging from 0 to 3 for each item. Therefore, total score of GAD-7 ranges from 0 to 21 [29]. A total score ≥ 10 of the GAD-7 is considered to meet the criterion of screening for anxiety disorder (1 = Yes, 0 = No) [29,30]. The Chinese version of GAD-7 had good reliability among Chinese population according to early ndings [31]. In this study, the alpha Cronbach for GAD-7 was 0.93.

Sexual orientation
First, participants were provided with a de nition of sexual orientation [32]. Then, sexual orientation was measured using a single item on a 4-point scale.
Participants were asked to circle a number which best describes their sexual orientation, the responses included: 0 = Heterosexual, 1 = Lesbian/gay, 2 = Bisexual, and 3 =Questioning[33]. Sexual minority included adolescents who self-identi ed as lesbian/gay, bisexual, or questioning about their sexual orientation (LGBQ). Statistical analysis EpiData 3.1 and SPSS 19.0 software were used for data entry and statistical analysis. Prevalence of participants involved in different types of bullying victimization , depression and anxiety symptoms were summarized by descriptive statistics [n (%)]. The χ2 test and multinomial logistic regressions were conducted to examine the associations between sexual orientation and traditional, cyber and combined bullying. The χ2 test and multivariate binary logistic regression were conducted to examine the associations between sexual orientation and depression and anxiety symptoms. The crude odds ratio (COR) , adjusted odds ratio (AOR)and 95% con dence intervals (95% CI) were estimated. The gender and grade of the respondent, the type of school, whether the school was rural or urban, parental education , whether the respondent comes from one-child family, whether the respondent was beaten by a parent or guardian were included as covariates in the logistic regression. P values of less than 0.05 were considered statistically signi cant.
Chi-square analysis shows that there were statistically signi cant difference between sexual orientation, gender, education level of parents, whether they were beaten by parents or guardians and bullying victimization (P < 0.05) ( Table 2). And according to Table 3, there were statistically signi cant difference between sexual orientation, family type, education level of parents, whether they were beaten by parents or guardians and bullying victimization (P < 0.05).
The associations between sexual orientation and types of bullying victimization.
Bisexuality accounted for the highest proportion of victims of traditional bullying only and cyber bullying only, at 10.2% and 4.8%, respectively. Homosexuality accounts for the highest proportion of combined bullying, at 18.2% (Table 2).
These six variables were adjusted as confounding variables (Gender, Grade, the type of school, whether the school was rural or urban, parental education , whether the respondent comes from one-child family, whether the respondent was beaten by a parent or guardian). After adjustment, results of logistic regression analyses indicated that homosexuality(OR: 5.833; 95% CI: 3.045 to 11.176), bisexuality(OR: 2.831; 95% CI: 1.354 to 5.923)and uncertainty of sexual orientation(OR: 2.206; 95% CI: 1.435 to 3.392) were signi cantly associated with combined bullying( Table 4).
The associations between sexual orientation and depression and anxietysymptoms.
The bisexual group has the highest rate of depression symptoms (40.1%), followed by the uncertain sexual orientation group(38.2%) , the homosexual group(36.4%) and the heterosexual group(21.7%). And the bisexual group also has the highest rate of anxiety symptoms (38.1%), followed by the the homosexual group(32.5%), the uncertain sexual orientation group(28.3%) , and the heterosexual group(15.9%) ( Table 3).
The logistic binary regression analyses indicated that the homosexual group, the bisexual group and the uncertain sexual orientation group and have a higher risk of depression and anxiety symptoms than heterosexual group. Compared to heterosexual group, bisexual group has the highest risk of depression symptoms (OR: 2.349; 95% CI: 1.664 to 3.316), followed by uncertain sexual orientation group(OR: 2.177; 95% CI: 1.805to 2.625) and homosexual group(OR: 1.906; 95% CI: 1.183to 3.071); at the same time ,bisexual group has the highest risk of and anxiety symptoms (OR: 3.049; 95% CI: 2.150 to 4.324), followed by homosexual group(OR: 2.344; 95% CI: 1.435to 3.829) and uncertain sexual orientation group(OR: 1.991; 95% CI: 1.625to 2.438) ( Table 5).

Discussion
This is the rst time controlled the relevant factors of individual, school and family, and tentatively analyze which kind of sexual orientation of Chinese young children is the most serious when they are bullied by only one kind of bullying (traditional bullying or cyber bullying) or combined bullying. And this study also explores the differences between Chinese sexual minority adolescents and heterosexual adolescents who more likely to have depression and anxiety symptoms. Two key ndings emerge from this study regarding the association between sexual orientation and school bullying victimization, emotional problems via a large and random sample in a non-western country. Firstly, being a victim of both traditional and cyber bullying had the strongest association with sexual orientation, even after controlling potential confounding variables including individual characteristics, family characteristics, and school characteristics. Homosexual, bisexual and uncertain sexual orientation adolescents had a higher risk of combined bullying than heterosexual adolescents.
Among them, homosexual adolescents are likely to have the highest risk of becoming victims of combined bullying. Secondly, compared with heterosexual adolescents, bisexual adolescents have the highest risk of depression and anxiety among non-heterosexual adolescents.
Con rmed our hypothesis, the results point in the same direction as other studies that have shown that the LGBT collective is more vulnerable to bullying and cyberbullying [34][35][36][37][38][39][40][41]. In traditional bullying, some research has revealed data ranging from 51% to 58% of victimization in people with non-normative sexual orientation/identity [42]. In cyberbullying, cybervictimization rates between 10% and 71% have been reported in LGBTs [34,43]. The discrepancies between studies are due to the different ages of the samples and the different behaviors measured. We found that 3.3% of the students in the current sample were victims of cyber bullying only. The nding was lower than a study in Shantou, China[44], where 5.5% of the research object were victims of cyber bullying only. This may be because middle schools in eastern and central China have different regulations for students to bring mobile phones to school. Besides, our study results indicate that there is no statistical difference between the situation of sexual minority adolescents who suffer only one kind of bullying (traditional bullying or cyber bullying) and heterosexual adolescents.
At the same time, our study results indicate that the second highest risk group of depression and anxiety symptoms, after bisexual adolescents were homosexual adolescents, followed by uncertain sexual orientation adolescents. The ndings are consistent with international studies reporting poorer mental health outcomes such as depression, anxiety disorders, and suicide, among lesbian, gay, and bisexual people people[45-51]. One of the rst mental health community surveys analyzing bisexuals as a group separate from gays/lesbians and heterosexuals was published in 2002 [52]. The results of this research, which was conducted in Australia, demonstrated that the bisexual group scored the highest on measures of anxiety, depression, and negative affect. The reasons for higher risks of mental health disorders among GLB people are multifactorial and include health disparities linked to prejudice, discrimination and social stigma as chronic stressors[53-55]. Meyer's minority stress model suggests that members of a minority group, such as a sexual minority, are at higher risk of mental illness because of the unique chronic stressors they encounter as a result of their disadvantaged position in society [54]. The mental health of sexual minority adolescents in China has not been the subject of much study. Since depression and anxiety are such potentially disabling chronic diseases, it is important to identify groups at greatest risk and particular risk factors [56].
The study provides data on the prevalence of being bullied traditionally/cyberbullied also analyzes the emotional problems among sexual minority adolescences in central China. Both aggressive behavior towards sexual diversity and the internalized discrimination that characterizes LGBTs can be considered as the result of a society that is educated by a hetero-normative system. Despite the potential contribution to the literature of sexual minority adolescences, there are several limitations of this study. This is a cross-sectional study, and it is impossible to infer the causal relationship between sexual orientation and campus bullying and depression and anxiety. In addition, although the study was enhanced by the use of a large number of population-based survey samples, the sample size of LGB respondents undermined our ability to conduct additional strati ed analysis (for example, separate effects on gay, lesbian and bisexual puberty).
Finally, we hope to provide some suggestions to school psychologists or parents on intervention measures that can effectively reduce school bullying and better promote children's health, that is, we should focus on vulnerable groups and reduce the stigmatization of sexual minority adolescences, although this is not easy for China, which is deeply in uenced by traditional culture.

Conclusions
This study reported that the positive rate of high school students suffering from campus bullying in Hunan Province was 12.2%, the positive rate of depressive symptoms was 25.2%, and the positive rate of anxiety symptoms was 19.0%. Among senior high school students, sexual orientation is strongly related to the types of bullying victimization. and emotional problems. These ndings indicate that homosexuals are at the greatest risk of becoming victims of double bullying(traditional bullying and cyberbullying) and bisexuals are at the greatest risk of depression and anxiety symptoms. The two types of teenagers face more pressure than heterosexual teenagers. Although anti-bullying activities are being carried out in developed areas of eastern China, few projects contain speci c strategies to reduce stereotypes and prejudices, which are necessary to address stigma-based bullying. Future intervention recommendations should include such strategies to address the problem of bullying stigmatized groups. Finally, we emphasize that reducing LGBT stigmatization and bullying/cyber bullying interventions should be multidirectional. Family education plays a key role in embracing diversity. Schools are the context for anti-bullying activities that focus on vulnerable groups and promote tolerance for diversity.

Declarations
Ethics approval and consent to participate The study has been approved by the Ethics Committee of Xiangya School of Public Health, Central South University (XYGW-2017-056). Written informed consent was obtained from all participants before administering any study procedures.

Consent for publication
Not applicable.

Availability of data and material
Data is currently not available online. But can be made available to any interested person(s)contacting the corresponding author via email.

Competing interests
The authors declare that they have no competing interests.  Data are presented as n (%).
Characters in bold means statistical signi cance p 0.05. Table 3 Distribution of depression and anxiety symptoms with different demographic characteristics. Data are presented as n (%).
Characters in bold means statistical signi cance p 0.05. Table 4 The associations between sexual orientation and types of bullying victimization.