Introduction

HIV is rising dramatically among Chinese men who have sex with men (MSM). Recent estimates suggest an incidence rate of 3.5% to 6.7% [1], which is substantially higher than the rates observed in MSM populations elsewhere [2]. Although direct comparisons of disease impact in the Chinese MSM and general populations are limited, one study of individuals seeking services in a sexually transmitted infections (STI) clinic found that gay or bisexual men had nearly 17 times the odds of being HIV-positive than men who were exclusively heterosexual [3]. Because substantial numbers of Chinese MSM report concurrent male and female partners [4], there is concern that the high burden of HIV disease among them could eventually result in increased disease prevalence among heterosexuals [5]–[9].

Stigma constitutes a critical challenge to addressing this emerging epidemic. Experiences of prejudice and discrimination are linked to higher rates of unprotected sex, family pressures to marry and have children, and deferral of testing and treatment [4], [10]. But to fully understand and address the effects of stigma, its diverse manifestations must be considered. At its core, stigma is a socially shared process by which a society discourages specific behaviors and conditions [11]. Such behavioral regulation is accomplished both through actions between people and through thought processes internal to any one individual. Enacted stigma refers specifically to interpersonal acts of discrimination against individuals who have or are perceived to have socially scorned conditions, like same-sex attraction [12], [13]. By contrast, felt normative stigma consists of intrapersonal perceptions about the prevalence of stigma in the local community [12], [13]. It is a belief that others harbor hostile feelings toward, or a willingness to discriminate against, individuals with a scorned condition. Internalized stigma refers to a person’s own prejudicial beliefs about a condition. If that person possesses the stigmatized condition, then internalized stigma is effectively a form of self-stigma [13]–[15].

For stigmatizing conditions that can potentially be hidden from others (what has traditionally been referred to as a “discreditable stigma” [11]), these three manifestations interact in important ways. If looking only at acts of overt discrimination (enacted stigma), stigma can appear to be relatively low [13], [16]. But the absence of discriminatory acts is often due to the intrapersonal, felt normative and internalized, forms of stigmas. Because individuals with a scorned condition believe that others may hold prejudicial beliefs (felt normative stigma) and because they sometimes personally endorse such beliefs (internalized stigma), they go to great lengths to avoid disclosure of their condition [13], [16]. As a result, they infrequently encounter hostility or discrimination. Unfortunately, although such non-disclosure efforts may protect a person from enacted stigma, they also have significant consequences for mental and physical health [10], [13], [17]. The same relationship among stigma manifestations is likely to exist for Chinese MSM. Research has already shown that such men report relatively low levels of enacted stigma [10], [18]. If felt normative and internalized stigmas reduce willingness to disclose same sex attractions, then this absence of discrimination would effectively be a byproduct of the men presenting as heterosexual in most social situations.

Understanding non-disclosure motivations and behaviors among Chinese MSM is likely to be complicated, however, by other cultural constructs and norms common to Eastern societies. One construct of particular relevance is filial piety. Sons are expected to fulfill family obligations to marry, have children, and continue the family name [19]. A second relevant construct is conversational norms. Sex (and, more generally, risk factors for HIV) are sensitive topics not typically considered appropriate to discuss openly with family and friends [20]. Cultural dynamics have already been shown to influence the kinds of stigma concerns of salience to Chinese MSM. Those who are more focused on individual success (e.g., trying to do things better than others) report higher levels of internalized stigma. By contrast, those who are more focused on collective success (e.g., willing to give up personal pursuits to take care of family) report more felt normative stigma [21].

The intersection of stigma and cultural norms may also alter what choices are made in the wake of stigma by placing enhanced attention on one’s obligations to others. Morality has been described as reflecting “prescriptive judgments of justice, rights, and welfare pertaining to how people ought to relate to one another” [22]. Studies have shown that moral assessments can be influenced by individualist considerations (e.g., concerns for fairness and people’s welfare) or collectivist considerations (e.g., respect for authority, in-group loyalty) [23], [24]. Whereas a decision in other settings not to disclose a stigmatized condition might be motivated more exclusively by one’s own welfare (i.e., avoidance of potential discrimination) [13], such choices for MSM in China are likely also to be influenced by their endorsement and understanding of filial duties (a collectivist moral consideration related to authority and in-group loyalty). This would change how men understand and potentially justify their own behaviors.

In this manuscript, we present findings from qualitative interviews with MSM in Beijing. We seek to characterize how stigma and cultural factors influence men’s behaviors and decisions, particularly around disclosure of MSM status and marriage. Although prior survey-based observations have documented associations between stigma and HIV risk behaviors with male and female partners [4], such methods are not able to capture the nuance and complexity of circumstances that ultimately lead to the observed associations. Through the qualitative data we present here, we seek to show that, despite very different choices about marriage and partners, MSM’s actions are motivated by moral considerations, even when those choices may ultimately pose HIV risks for themselves and their partners.

Methods

Our description of the recruitment, data collection, and analytic procedures follows the recommendations of COREQ, the consolidated criteria for reporting qualitative research [25]. We conducted qualitative interviews between October, 2009, and January, 2010, with 30 MSM who were living in Beijing, China. Men were referred to the study by two recruiters who were familiar with MSM social networks within the city. They sought out potential participants through organizations serving MSM or in venues where MSM were known to congregate. At any given location, the recruiter would work with a known contact to help identify men to be approached, and would then briefly describe the study and its procedures to those individuals. The need to use recruiters and their contacts is reflective of the current social context for MSM. Men are unlikely to agree to participate if approached directly by an unknown researcher, nor are they likely to respond to flyers advertising a study. Working through recruiters and their contacts allows the initial offer to come from a person that MSM know and trust.

For men interested in participating, the recruiter arranged a time for them to meet individually with a study investigator in a private office at a local university. We sought to obtain a sample that was diverse in terms of age; self-identification as gay, bisexual, or heterosexual; and migration status. These factors were used because prior MSM samples have had an overrepresentation of young men, previous studies have shown that there are substantial numbers of MSM who have sex with both men and women, and earlier research suggests that large proportions of urban-dwelling MSM are individuals who have migrated from elsewhere in the country [4], [26], [27]. To be eligible to participate, an individual had to be 18 years of age or older, be male, and report having had sex with other men. (The use of recruiters and their contacts precluded the calculation of an overall refusal rate, as investigators were not present for the initial contact with prospective participants. But of the men who presented to the investigative team for interviewing, only one was not enrolled in the study. In that case, the man was believed to be gay by other MSM, including the recruiters and their contacts, because he worked for an organization that offered services to MSM. However, he revealed to an investigator that he was in fact exclusively heterosexual and, thus, not eligible for inclusion in the study.) To preserve anonymity, participants were asked to provide verbal consent, which was documented in study records by the investigator conducting the interview. The men received 150 Yuan (equivalent of approximately US$24) to reimburse them for their time. All procedures for the study, including the use of verbal consent procedures, were approved by the institutional review boards (IRB) at the University of California San Francisco and Beijing Normal University.

Results

Participants varied in their demographic characteristics. Most were between the ages of 20 and 39 (mean: 33.3; range: 21–52). One-fifth of the men were or had been married (16.7% currently married, 3.3% divorced). A little over half (53.3%) had completed college and the vast majority (90%) was employed. Most participants (73.3%) had migrated to Beijing. All reported being Han, which is the majority ethnic group in China.

Discussion

The findings from our qualitative interviews with Chinese MSM are consistent with the pattern of stigma manifestations found in other studies [13], [16]. Men reported relatively few experiences of discrimination. But this was due largely to their unwillingness to disclose their sexual orientation, a decision that was motivated by the perception that others would judge, and potentially discriminate against, them for having attractions to men. However, the interviews also highlighted the strong role that cultural constructs, particularly filial piety, played in men’s choices [19]. For many, the decision not to live openly as a gay man was not simply about the avoidance of discrimination, but also something born out of their considerations to family members or other individuals.

The impact of these cultural constructs was evidenced in the ways in which participants justified their decisions. Despite very different choices, men repeatedly turned to explanations that grounded their actions in social responsibilities and moral considerations [23], [24]. For men who did not want to have a wife, emphasis was placed not only on responsibility to themselves but also on the harm that they felt they would do to a female partner (i.e., individualist moral consideration for the woman’s welfare). By contrast, men who chose to marry women placed greater emphasis on the need to honor their parents, often struggling with the fear that not marrying would bring shame or disappointment to their mothers and fathers (i.e. collectivist moral considerations for respect for authority and in-group loyalty). A small subset of these men attempted to strike a compromise by seeking a lesbian as a wife. For the limited number of men who had chosen this strategy, success was mixed. It provided an avenue for fulfilling parental expectations to marry without posing perceived harms to the female partner. But it did not eliminate all family pressures, such as expectations to have children. Other participants who had (or planned to) marry heterosexual women were left at a loss for how to be faithful to their wives, recognizing that they might ultimately need male partners but not seeing a way to avoid the lifelong tension between family obligations and personal desires.

Taken together, these findings complement the kinds of associations observed in quantitative studies of stigma. Prior research has shown that internalized stigma concerns are salient for Chinese MSM with a more individualist orientation whereas felt normative stigma concerns are salient for those with a more collectivist orientation [21]. Our findings suggest that individualist and collectivist moral considerations also shape the choices MSM make in response to stigma perceptions and culturally prescribed duties, particularly when making decisions about marriage.

It is of course by no means unique to Chinese culture to hear of MSM feeling pressure to marry women. But whereas modern accounts in other societies may situate these experiences more overtly in stigma [29], [30], men’s reasoning in our interviews was notable for the repeated attributions to broader social duties. This is not to say that disapproval of homosexuality played no role in men’s lives. The fact that a society views a man’s duty as including marriage to a woman is itself reflective of the differing value placed on different sex and same sex relationships. But for the participants in our study, their thinking about marriage was often not characterized as a response to stigma, even when they acknowledged perceptions of stigma elsewhere in their interviews. Instead, men understood themselves to have broad social obligations. And society’s lack of acceptance of their homosexuality left them with an unusual challenge of having to reconcile their sexuality with those duties.

These findings have important implications for addressing the emerging HIV epidemic among MSM in China. First and foremost, they caution against blaming MSM for the complicated situations in which they may find themselves. A variety of studies have noted that rising rates of HIV among MSM could pose a risk to wives and girlfriends–and, by extension, to the broader heterosexual population [5]–[9]. But, as reflected in the findings presented here, the concurrence of male and female partnerships is not necessarily a result of neglect or lack of concern. Rather, Chinese MSM struggle with how best to honor their duties. Their selection of a female partner, despite the absence of attraction, often comes from sincere respect for their parents. In turn, this suggests that stigma reduction and HIV prevention interventions cannot focus simply on constructs like self-acceptance. A man can be at peace with his homosexuality but still feel pressure to marry as a part of social duties. Therefore, interventions will likely need to incorporate considerations of family and help men to develop strategies for negotiating filial obligations. This is not necessarily an easy task given the importance of family and the pervasive influence of cultural norms. But the fact that substantial numbers of men in our sample were choosing not to marry while maintaining contact with family suggests that success is possible. In light of this observation, one potential direction would be to use peer-based interventions in which men who have successfully found ways to mitigate pressures to marry could model their approaches for men who are less sure of how to handle such challenges.

Our findings are limited by several aspects of the study design. First, because we recruited only in Beijing, it is possible that the results do not generalize to MSM in other parts of the country. We note, however, that Beijing’s cosmopolitan status and availability of jobs makes it an attractive destination for migrants. Thus, the men in our sample hailed from diverse regions in the country. Second, we worked through recruiters and their contacts to identify participants. This methodological approach was driven by some of the very realities we sought to study. The potential for discrimination and prejudice makes men less likely to agree to participate in a study if approached by an unknown researcher. The use of recruiters enabled us to reach men who might otherwise have refused to participate. But the recruitment approach also has limitations because it relies on specific recruiters’ networks of contacts, which may or may not reach to all subgroups of MSM. To mitigate this risk, we used recruiters of different ages with distinctly different contact networks. Nevertheless, we cannot fully guarantee that our methods reached all types of MSM. Third, as a qualitative study, we sought to gather enriched, contextual data from a small sample of men. Such research allows us to say something about the range of experience, but precludes us from drawing inferences about population-wide trends (e.g., relative prevalence of the different types of experiences). Future work will need to use other methods, such as quantitative surveys, to assess the prevalence of different manifestations of stigma and to test for the significance of associations among stigma manifestations, cultural factors, and HIV risk behaviors.

The growing epidemic among MSM in China requires action from the public health community. As programs and interventions are scaled up to serve these men, it is critical to remember that MSM face the same pressures from culturally normative social duties as heterosexual men. Interventions must find ways to help men navigate a balance between their own needs and the responsibilities they feel toward their parents and others.

Acknowledgments

The authors thank our study staff members who assisted in the recruitment of participants and in the transcription and translation of the interviews, two reviewers who provided comments on an initial draft of this article, and the men who gave of their time to participate in the interviews.