Stigma and discrimination have been identified as primary obstacles against effective HIV prevention.1,2 As elsewhere, men who have sex with men (MSM) in China are suffering from stigma and discrimination.3,4
In the past 30 years, Chinese society has experienced dramatic sexual liberation concurrent with adoption of more liberal policies and economic reforms. These changes include increasing pre- and extramarital sex, development of a flourishing sex industry, internet and casual sex, and more openness regarding homosexual behaviors. Increasing numbers of people now regard sexuality as a basic human right, meaning that everyone has the right and freedom to pursue his or her own sexual happiness.5-7 Sodomy, previously condemned as a form of hooliganism, was removed from legislation in 1997,4 and homosexual behaviors were excluded from the China Psychiatrics Classification and Diagnostic Criteria, Version 3, as a psychosis in 2001, indicating an increasing acceptance of MSM in general society.7
Nevertheless, homosexuality is still regarded as deviation from social mores by mainstream society in China. A survey among 3000 college students across China in 1992 revealed that 82.0% of male students and 84.5% of female students believed that homosexual behaviors were a psychopathic disorder.8 When asked how they would react if their best friend were homosexual, 67.5% responded that they would suggest to that friend that he seek treatment, and 11.2% would break off the friendship; if it were a relative, 30.4% said that they would feel ashamed, and 38.6% said that they would consider it to be a serious illness.8 Another study among Chinese students in 2002 had similar results, in which 78.6% of men and 66.4% of women disapproved of the concept that homosexuality should be allowed.6
Due to discrimination against homosexuals, MSM remain a hidden population. Thus, it is difficult to reach MSM with information and intervention programs. Admitting to homosexuality reduces their quality of social life and family support, leads to low self-esteem, increases high-risk behaviors such as sexual aggression and drug or alcohol abuse, often resulting in poor psychologic and physical health.3,9-12 They also have difficulty in negotiating safer sex. The pressure of strong Chinese tradition to marry and have children, intensified by the current 1-child policy, causes many MSM to hide their sexual orientation and get married, putting their wives and children at risk of HIV infection and sexually transmitted diseases (STDs).13,14
Chengdu, one of the major cultural and economic centers in southwest China, is noted for its tolerance and openness. The total number of sexually active MSM has been estimated to be as high as 71,000 in Chengdu.15 The HIV prevalence among MSM increased dramatically from 0.6% in 2003 to 5.8% in 2006.16
To date, only a few studies have been carried out in China about the stigma and discrimination experienced by MSM. In this qualitative study, we document MSM activities and discrimination experienced in Chengdu.
From July to September 2006, a qualitative study was conducted among MSM in Chengdu employing focus group discussions and in-depth interviews. The study protocol was reviewed and approved by the Institutional Review Board of the University of California, Los Angeles, and the Chinese Center for Disease Control and Prevention.
Focus group discussion provided information for mapping of MSM venues and understanding prevalent behaviors. A semistructured guide was used to ensure that the same basic lines of inquiry were pursued with each person interviewed. The information collected included basic demographic information, major venues for homosexual activities, knowledge about HIV/STD, HIV-related risk behaviors, and personal experiences with homophobia, stigma, and discrimination. Participants were recruited from different venues by volunteers from the Chengdu Gay Community Care Organization (CGCCO) or by personal reference. Participants were men, at least 18 years old, had been living in Chengdu in the last 3 months, and had had oral or anal sex with other males in the past. All the interviews were administered by male interviewers in a private room in the office of CGCCO. The conversations were audiorecorded and transcribed in Chinese.
The qualitative data collection and analyses yielded 2 types of findings: (1) high-quality, detailed descriptions of each case, which were useful for documenting uniqueness; and (2) important shared patterns and opinions that cut across cases.17,18 A set of codes was developed to classify the words by categories, from which a matrix to display identified categories by groups of respondents was formulated. After summarizing the data, the shared patterns and opinions that significantly emerged from across cases were summarized into several major points to facilitate conclusions. A combination of direct quotes and paraphrases was used to convey the respondents' main points and representation of their own words. The analysis used ATLAS.ti for data storage, coding, retrieval, comparisons, and linking.
A total of 43 subjects were recruited, among whom 16 participated in the 3 FDG and 27 were interviewed in-depth; one subject was inebriated and withdrew voluntarily. Among the 26 participants in the in-depth interviews, 13 were originally from Chengdu. Their ages ranged from 19.5 to 52 years; 12 were younger than 25 years. Fifteen had at least college-level education. Only 2 participants were currently married, and 4 divorced or separated. Twenty self-identified as homosexual and 6 as bisexual.
MSM Venues in Chengdu
The typical venues for MSM in Chengdu in the 1980s included public squares and plazas, parks, tea bars, and public lavatories. The 2 most famous were the Labor's Culture Palace and the tea garden in Wenshu Temple, where many older MSM were introduced to and participated in homosexual social life. Both places were bulldozed and rebuilt. In the late 1990s, gay bars and money boy (MB) brothels started to appear in Chengdu. We found more than 25 venues, relatively numerous, considering the size of the city, providing many choices for meeting with other MSM.
China has recently experienced booming internet development, which has become one of the most important sources for MSM to find homosexual-related information and sexual partners. Most participants routinely used the internet at home and/or in their offices. Those who did not have a personal computer use low-cost internet cafés. Most online partner seeking has been done through instant chat software or chatrooms on websites. The internet provides anonymity, and is very easy and convenient to use. Three main chatrooms, always full, are typically used. There were also 3 web sites. One participant described the development of online chatrooms in the last few years:
“MSM in Chengdu started to use chatrooms in about 2003. There was no chatroom in 2002, and only one website chatroom called ‘Sunshine’ was established in 2003. Not many people used it at that time. The chatroom had a capacity of 100 persons and it was not usually full. Now we have three, two for 175 persons and one for 100, and they are always jammed by visitors.” (Focus group discussion 1).
When asked why they started to use the internet, most participants cited convenience, anonymity, and safety.
“The main reason to use internet was because of its convenience. Today you can get online anywhere, at home, in the office… You can stay online when you go to work. You don't need to show yourself, you can say what you want to say, and ask anything you want to know, like height, weight, age, and how he wants to do it, before you meet the person. Some questions you can hardly ask face-to-face.” (Focus group discussion 1).
Internet has also expanded the scope and sociality of MSM, and provided many more choices to find friends and sexual partners.
“In bars, choices are limited. You can hang around with and talk to only a few persons. When you find somebody new, you cannot just go to him and say hello. Now it is very easy to add new persons to your QQ [one of the most popular instant online chat software programs in China]. You can communicate with many people at the same time. In traditional venues, you could get to know no more than 100 persons a year. But now, it is very easy to reach the limit of 500 persons for QQ in half a year.” (Focus group discussion 2).
Because of the internet, usual MSM venues in Chengdu are undergoing a transformation. Bars, tea bars, and most public parks are no longer places for hunting for sex partners, but for recreation with friends. MB brothels, public bathhouses, and lavatories are still serving as venues for commercial or quick sex. The price for having sex with MB dropped from 150-300 Yuan (US $20-40) in the late 1990s to 50 Yuan (US $6.5) in 2005. The number of the brothels increased to 7 in 2006, and the average price went up to 100 Yuan (US $15), indicating the increased demands for commercial sex in the MSM community. In the last few years, blackmail occurred among MSM who went to public bathhouses and lavatories, so they are becoming less popular.
“My friends and I used to visit those places (public lavatories) before. But later too many people from outside [of the MSM community] started to appear. Most of them were not homosexual, but wanted to use the gay community to earn a living. They went there and blackmailed people. Later my friends told me that internet was safer and more convenient, so I switched to use internet.” (Focus group discussion 2).
“In my opinion, those places (public bathhouses and lavatories) are really dirty and dangerous. On the one hand, there are many bad people, cheating or even blackmailing others. On the other hand, it is very easy to catch diseases to have sex with people in there.” (I14, single, 20 year-old, college-educated student).
Because sexual activities in public places and commercial sex are illegal, MSM venues are occasionally subject to police inquiry. However, we noticed that there were public lavatories and MB brothels located near police stations. The explanation from a former owner of a MB brothel was
“Nowadays, you cannot be arrested because of homosexuality if you don't do it in public places or announce it publicly. Nevertheless, there are many other menaces to homosexuals out there. If you stay close to the police station, other bad things like robbing or blackmailing are not likely happen to you.” (I17, single, 41 year-old, high school-educated, self-employed, former MB brothel owner).
Homosexual-Related Stigma and Discrimination
Participants' experiences of stigma and discrimination came mainly from 3 sources: general society, family, and within the MSM community.
Because most participants carefully conceal their sexual orientation not many reported discrimination from the general population. Only one participant reported an episode of being put in detention for a few days about 20 years before, and 2 episodes of discrimination from colleagues or the general population because of his feminine physical appearance. Nevertheless, most participants expressed fear of being socially ostracized if their sexual orientation were disclosed. Being single and past the usual age for marriage, having a feminine physical appearance, and/or being present in MSM venues raises suspicions.
“Nobody knows about my status except my homosexual friends. Although it is not directly to me, I feel that discrimination against the MSM population does exist. There is one guy in our company who looks very feminine. I don't know if he is gay or not, but he is really isolated in the workplace… Of course I feel pressure being single. Most of my classmates and friends have girlfriends, some even already got married. Many times my colleagues asked me why I don't have a girlfriend and wanted to set up a date for me. Their enthusiasm really bothered me because I had to make up excuses to refuse their help. To be frank, I really care about how people see me. I don't want them to know (my status).” (Interview #10, single, 24 year-old, college-educated company employee).
“I keep my secret very deep and carefully. I never think of telling anybody else about that [homosexual orientation]. I seldom go to gay cruising spots because I don't want to be seen there. I don't want to do that and be under suspicion.” (#19, single, 21 year-old college-educated, unemployed).
Participants may divide their friends into 2 circles, those who are gay and those who are not, or even give up social life with their nongay friends. Some younger participants chose to tell the truth to trusted friends. There is a possibility that at least some of their close friends also know about their true sexual orientation, but do not confront them with it. In most cases, participants did not feel discrimination or estrangement from their friends after admitting to being gay.
“I have two or three best friends who know about my situation. I told them myself. Before they knew about that, I had felt a gap between us. It was not a problem for them to accept it when I told them about my sexual orientation. Now we can even talk about some topics of homosexuality and make jokes about it.” (Interview #7, single, 20 year-old, high school education, self-employed).
“Maybe one or two friends have suspected. I had brought a few close friends to gay bars to see performances. We've been friends for many years. I think they know about it, but they never asked me.” (Interview #6, married, 52 years old, college-educated company employee).
Although nobody in our study would willingly disclose their sexual orientation to the general population, many of them felt it would not have been a difficult situation to deal with if their friends or colleagues found out about their sexual orientation.
“I think in the current situation in China, it is not a good idea to willingly disclose my status. However, it also does not matter if somebody finds out. I've had no experience of being discriminated against. But I think it is not a big deal. People at work judge me by my ability, not my sexual orientation. It might be used against me in some circumstances. Other than that, I do not think it is a problem.” (Interview #12, divorced, 30 year-old, college-educated businessman).
“People outside my (gay) circle don't know my situation. I am an independent person. It doesn't matter what people think of me. It is good that people in my company don't like to probe into other people's lives. Everybody knows that I am single and have no intention of be married. But nobody should care about that. It is my own business.” (Interview #8, single, 46 year-old, college-educated company employee).
Stigma and discrimination from health care personnel has been identified as one of the major reasons MSM do not use health services.
“It is embarrassing going [to the hospital or CDC] for testing. When you specifically ask for HIV testing, they think you must be a bad person or did something wrong. Last time I came here [CGCCO] for testing. Because we were all the same type of people, I did not feel strange at all.” (Focus group discussion 2).
The primary source of pressure in China that MSM identified is the need to show filial piety and maintain the family lineage. Men who fail to fulfill this obligation are viewed not only as shameful but as selfish and shirking their family responsibilities. As a result, MSM who are not married at the proper age cause great concern to parents, especially in the rural areas. With the 1-child policy in China, the pressure for getting married and having children is greater than ever.
“What I care about most is not the gossip about me, but the feelings of my parents. They raised me up to manhood. The only thing they wish from me is to be somebody and make them proud. I cannot be too selfish and let them down.” (interview #10, single, 24 year-old, college-educated company employee).
“I have been thinking of telling my parents about my status lately. When I was young, I didn't think about that. My parents really want me to get married. The pressure from my family is getting too strong. I tried to find a girlfriend but it did not work out. I really have no interest in women and we just broke up a couple of days ago.” (Interview #8, single, 25 year-old, college-educated teacher).
As a response to pressure, MSM tend to postpone marriage to an inevitable point when they must choose between getting married or disclosing their true sexual orientation to their families. They usually choose to tell a sibling or other relative, usually female, rather than their parents.
“I have told my sister. I was forced to. My parents had once set up a date for me and I refused to go. Since I had done this many times and I am the only son in my family, my mom got frustrated and started to cry. My sister came and asked me why I did not want a girlfriend, and demanded a reason. In that situation I had no choice but to tell her [that I am homosexual]. My sister was stunned. She turned around and left without saying a word. I did not dare to talk to her for two days. But she forgave me anyway and told me it was up to me what life I wanted to live. But there is no way that I can tell my parents. They are from the countryside and are not educated. They would never understand what homosexuality is.” (Interview #11, single, 28 year-old, high school-educated service business worker).
Compared with other family members, it was much harder for parents to accept the truth that their son is homosexual, and they therefore exert enormous pressure on MSM who reveal the truth to them.
“I am the only son in my family. When I told my mom that I am a gay, she cried for almost a week. My mom said it was such shame for them. I told her I could save their face by killing myself. I knelt down before my mom and she got down on her knees too. We both cried. If I had been given another chance, I would never have told my family that I am gay. It was too painful… She still cannot accept this, and always thought that if I can go to find a girlfriend and have sex then I could be normal again.” (Interview #5, single, 29 year-old, college-educated accountant).
When MSM disclose to family members about their sexual orientation, they risk losing the respect and support of their families, which in some cases, leads to low self-esteem.
“My parents have passed away and all my brothers knew about my status. One year during the lunar new year I met a person from Chongqing. It was very cold and he had just been cast out by his parents because they just found out [he was gay]. I felt pity for him and brought him to my oldest brother's house to celebrate the new year. My brother was very angry when I brought a stranger who was gay to his house, and he said something very awful. I got angry too and left with him. I have not spoken to my brother since then. Because I really care about the feelings of my family, I quit my job [which was good] and left Chengdu for many years. I did many bad things to survive, and was put in jail for theft for three years.” (Interview #17, single, 41 year-old, high school-educated, self-employed, former MB brothel owner).
Among those participants who had been married, 2 had told their wives about their sexual orientation before marriage. Both of them mentioned that their wife had the misconception that homosexual was a psychologic ailment that could be rectified by having a normal heterosexual relationship. Nevertheless, acceptance of the marriage by their wives was also an indication of the increased tolerance of homosexuality in the young generation.
“I am divorced. I got married because of family pressure. My ex-wife had been an old friend for many years. She was beautiful and shared the same opinions with me on many things. We understood each other and communicated very well. This is something I don't have with my boyfriends. So I told her about my situation and asked her to marry me. Maybe at that time she thought she could change me, and so she agreed. We got married but it did not work out. Now we are just good friends.” (Interview #12, divorced, 30 year-old, college-educated businessman).
Within the MSM Community
Many participants expressed a negative attitude toward MSM. They felt that MSM are not trustworthy and that homosexual relationships are unreliable. MSM tend to build their own circle of friends based on age, social status, personal interests, etc. Normally there is not much communication and interaction between the different groups. There are certain subpopulations, such as MB, feminine-looking MSM, and those who go to certain places such as public lavatories or public bathhouses who provoke more negative attitudes than others.
"I think it is normal [to be homosexual] as long as you don't think of yourself as a woman. I don't like those who act really girly. I don't like men who behave in feminine ways. I don't like that. (Interview #6, married, 52 year-old, college-educated company employee).
“Those places [public lavatories and bathhouses] are really a mess. People go there only for sex. They definitely have no need for communication. They only want sex.” (Interview #7, single, 41 year-old, high school-educated, self-employed, former MB brothel owner).
Enormous stigma about HIV infection existed among the participants. Most participants thought that only those who had been self-indulgent and had sex with many partners could be the potential victims of HIV infection. Few expressed willingness to go for anonymous testing at the CGCCO because they feared people would know that they had come for HIV testing and would be suspicious. Many participants mentioned an incident that occurred in Chengdu, when a man willingly disclosed his positive result to seek help in the community but ended up committing suicide.
“[People don't come to the CGCCO for HIV testing] because they are afraid that people in the [homosexual] community will learn their test results. If you go to other places for HIV testing, you can choose not to tell anybody regardless of the result. If you come here [CGCCO], many people will know you have been here and will ask about the result. Gossip travels very fast in this population. It will put great pressure on you.” (Focus group discussion 2).
In ancient times, Chinese culture was very tolerant about male homosexual behaviors. As early as the Zhou dynasty (1122-256 B.C.) homosexual activities had been common, at least in the upper class of society. There is an idiom “the passion of the cut sleeve” in Chinese, which is still used to refer to homosexuality. The story originates from a Han dynasty emperor who cut his sleeve on which his adored male lover was sleeping in order not to wake him. Tolerance of homosexuality persisted until the beginning of the last century, when social tolerance of homosexuality declined due to changes in social norms and philosophy, and only sex within marriage for reproductive purposes was accepted.6,19
Sex-related issues have become more private, and returned to the personal sphere in China, beginning in the late 1970s. Homosexual activities have become more visible and exempt from severe legal punishment.4,5 This has given MSM more choices and freedom. Another important factor that has dramatically changed the lives of MSM is popularization of the internet, which provides information about homosexuality and the MSM community, and a source for seeking gay friends and sexual partners without the risk of discovery. The younger generation can simply go to the internet for information that may help them to accept their sexual identity, and to gain access to the MSM community.
Nonetheless, fear of discovery is still a major force that keeps the homosexual population hidden, denying them access to information and intervention programs. MSM tend to disguise their true identities when they are involved in community activities, making outreach more difficult.
Getting married and bearing children remain among the most solemn and important responsibilities for most Chinese men. Traditional beliefs still revile exclusive homosexuality because it interferes with continuation of the family lineage. A homosexual life-style without marriage is considered undutiful and is unacceptable to the family and society. Therefore, when they come out to their family, MSM may face not only the agony they cause in the family but also the possibility of losing support and respect from them and other relatives. Therefore, MSM tend to hide their homosexual activities, postpone getting married, move away from family, or try to find support from other family members, but eventually most get married, causing them to become a potential bridge for HIV transmission to the general population.
Since the late 1990s, HIV intervention programs have been trying to involve MSM. However, because of the distinctions among subgroups within the MSM community, only a portion of the population can usually be reached, even through MSM organizations; most marginalized subgroups such as MB and married MSM are excluded. Another major barrier for HIV prevention is the fear that HIV/STD testing will cause disclosure of both their sexual orientation and their HIV positivity.
Therefore, programs that target MSM must be sensitive to stigma related to both homosexuality and HIV infection. Programs should provide a mechanism to prevent HIV-infected MSM from being discovered not only by general society but also by the MSM community. In China, to get free treatment for AIDS, the patient must register using their real name and address. Considering the universal distrust of MSM for health care institutes, a more effective way of providing follow-up services to HIV-positive MSM might be through MSM organizations. However, for this to be effective, stigma within the MSM community toward HIV/AIDS must also be addressed.
Intervention programs also need to be able to reach the hidden or marginalized subpopulations among MSM such as MB. Programs among MSM in China seldom reach MB, especially those not working in brothels. To reach hidden subpopulations, intervention programs should create a supportive environment and provide relevant information and health services conveniently and confidentially.
Our study had several limitations. The participants were recruited from MSM venues or by personal reference. Therefore, they are not a random sample of MSM in Chengdu. Married MSM were probably under-represented. No participants were recruited directly from public lavatories or bathhouses, although several participants had been involved in MSM activities in such locations. More than half of the participants had college or higher education, and only one participant reported selling sex. Stigma and discrimination experienced by MSM in Chengdu might be different in other parts in China that are not as liberal as Chengdu.
Most MSM in China lead a double life and do not come out, due to stigma and discrimination. Thus, it is difficult to estimate the number of MSM and to obtain adequate and accurate information about them.
Stigma and discrimination related to homosexual activities and HIV/STD infection have been the major barriers to MSM seeking health services. HIV/AIDS programs must be sensitive to issues of stigma both from outside and inside of the MSM community. Confidentiality and supportive follow-up services for HIV-positive MSM are among the first issues that need be guaranteed by HIV intervention programs to persuade more MSM to come for HIV testing.
The authors are grateful to the people who participated in this study. We especially thank Mr. Xiaodong Wang, Jun Wang, and other members of Chengdu Gay Community Care Organization (CGCCO) for their enthusiastic assistance and helpful input for this study. Appreciation also goes to Drs. Abdelmonem Afifi, Thomas Coates, Li Li, Pamina Gorbach, and Marc Bulterys for their review, comments, and inspiring suggestions.