The intersection of sexuality and HIV: Chinese men’s struggles and resilience

While Chinese gay and bisexual men living with HIV experienced the negative impacts of their intersecting identities – especially when it came to stigma – they also described how their identities enabled them to thrive in ways they hadn’t expected, according to a recent qualitative study.

Background

Gay and bisexual men in China continue to face discrimination, much of it rooted in stigma directed towards people from sexual minorities. In fact, homosexuality was only removed from the Chinese Classification of Mental Disorders (CCMS-3) in 2000. Rates of HIV continue to disproportionately impact this population, which adds another layer of stigma to an already ostracised group. Stigma towards communities impacted by HIV creates additional barriers to testing and seeking out treatment, and reduces the quality of life of people living with HIV.

Intersectionality has become a prominent framing in health research over the past few years. This approach discourages simply adding different identity markers to each other to result in increased vulnerability. Instead, the focus is on understanding intertwined webs of oppression and how the intersection of different marginalised identities (such as being gay and living with HIV) can create unique realities that result in distinctive challenges and forms of resilience.

The study

Researchers from the City University of Hong Kong interviewed 21 gay and bisexual men living with HIV in Shenzhen (a prosperous and inclusive city in southern China) in 2021. The men were between the ages of 21 and 56, most identified as gay (86%) while the rest identified as bisexual. Most had never been married although two were divorced. Over half had been diagnosed with HIV for over three years and had started antiretroviral therapy at least a year prior to the study (81%). Most men had completed secondary education (62%), while a third had finished tertiary studies. Most men were employed (72%), with just over half being employed full-time. Approximately two-thirds of the sample stated that they had a stable monthly income.

The semi-structured interviews explored living with dual minority identities: being both gay or bisexual and living with HIV. While some questions focused on challenges related to these identities, the participants also had an opportunity to positive experiences in relation to these identities. Interviews were conducted in Mandarin and translated to English during the data analysis process.

The interplay between sexuality and HIV

For some participants, the presence of HIV added to the existing shame of being gay or bisexual. In this sense, the synergistic effects were worse:

“When I was diagnosed with HIV, I was, like – I hated myself for being gay. [I thought] if I were not gay, I wouldn’t have been infected in the very first place.”

One participant spoke of the practice of asking prospective sexual partners to test for before sex – something that has become more common in Shenzhen due to the high rates of HIV transmission among gay men. He spoke about how this was inherently stigmatising and an invasion of privacy:

“Nowadays, many people do the [rapid] blood test at home. They usually do this before having sex. From my perspective, I can accept that someone will not have sex with me [if I do not test], but I feel my privacy is invaded if they ask me to do a test.”

However, the researchers also describe what they term ‘alleviating’ effects – where the combination of sexuality and HIV led to positive outcomes that would not have otherwise occurred. This mainly related to social support stemming from an HIV diagnosis:

“After starting ART, I participated in [some of the] activities organised by the Centers for Disease Control (CDC). I think they are good and necessary. They provided psychological support for me that helped me adapt to the situation.”

For some, being gay provided the resilience required to deal with HIV. When asked if being gay helped him adapt to HIV, this participant responded:

“Yes, I am stronger. I tell myself to adjust my mindset when I encounter situations where I am stuck with negative emotions and can’t move on.”

Pressures and concerns

The men’s intersecting identities led to unique pressures and concerns. In terms of family expectations, marrying and continuing the family lineage were chief among the worries. This was highlighted as a central aspect of Chinese culture:

“In my mind, it is a tradition to pass the family on. If I [were] not infected with HIV, I definitely would get married [and have children]. Especially when you are [in] your mid-twenties, parents will urge you to go on blind dates. [Even] though I know I like people of the same sex, I still go on such blind dates once or twice a year. However, after I was diagnosed, I became reluctant to go on [with] these blind dates.”

However, some participants also described a release of tension – once their family knew that they were living with HIV:

“I had already told them about my HIV status, and I think there’s no need to tell them about my homosexuality anymore. Since I am HIV-positive, I don’t have to marry…”

Men expressed concerns about their financial security as they got older, especially as they did not have children who would care for them. Several worried about losing jobs due to discrimination or failing workplace medical exams, which would impact their health insurance and access to medical care.

Distress and resilience

High levels of anticipated or expected stigma was evidenced by the fact that some men chose to pre-emptively end friendships:

“I would discriminate against HIV-positive people if I was not infected too. That’s why I rarely contact others [friends] now. I used to have  several good friends. Last year, after I was diagnosed, I turned down their invitation[s] to go out together five or six times. They felt this was weird, but from my point of view, I wasn’t willing to contact them. I thought I was different from them.”

However, with HIV came resilience for some men. While acknowledging the challenges of dealing with their diagnoses, they also embraced a newfound strength. This man started ART in 2019:

“I used to attempt suicide. I was in hospital in 2018 due to complications [from] HIV and almost lost my life. I have been through so much [throughout] these years and survived. Now, I believe everything will pass, and I cherish the moment.”

Conclusion

“By integrating an intersectional framework with an empowerment-based perspective, our study’s approach enables it to provide useful insights into future HIV prevention and mental health promotion priorities,” the researchers conclude. “According to our findings, programmes that confront intersectional stigma while strengthening resilience thereby promoting mental health as well as physical well-being – will likely be effective among sexuality minority men living with HIV in urban settings in China.”