Behind the Rainbow, "Tongqi" Wives of Men Who Have Sex With Men in China: A Systematic Review

'Surviving and thriving': intersectional stigma and resilience of dual minority identities among Chinese gay and bisexual men living with HIV

Intersectionality has facilitated an understanding of the complexities of the adversities and challenges faced by individuals with multiple disadvantaged identities, including gay and bisexual men living with HIV. This study used deficiency- and empowerment-based perspectives together with an intersectionality lens to examine the intersections between sexuality minority and HIV-related stigma and resilience, as well as their compound effects on Chinese gay and bisexual men living with HIV. We conducted in-depth interviews with 21 gay and bisexual men living with HIV in Shenzhen, identifying two overarching themes and six subthemes in the provided accounts via thematic analysis. The theme of 'Interplay between Minority Identities' comprised aggravating effects and alleviating effects at the intrapersonal, interpersonal, community and structural levels. The theme of 'Compound Impact of Intersecting Identities' was contributed to by the subthemes 'the pressure to continue family lineage', 'persistent health concerns', 'financial concerns', and 'heightened psychological distress and resilience'. Integrating deficiency and empowerment perspectives, our findings highlight the importance of addressing intersectional stigma and identifying resilience resources to empower Chinese gay and bisexual men living with HIV to thrive amidst compounded adversities. Findings have implications for future intersectional research and intervention practice, especially in fostering resilience within the context of intersectional stigma.

Sustaining Heteronormativity in Marriage: How Chinese Newspapers Frame Heterosexual Marriage Undertaken by Chinese Queer People

Family members often cite broader societal discourses and norms when forcing Chinese queer people to engage in heterosexual marriage (referred to as HMQ; heterosexual marriage undertaken by Chinese queer people). It is unclear what these social norms entail and how the norms are maintained. This paper examines 89 Chinese newspaper articles to uncover the societal discourses driving families to pressure queer people into heterosexual marriage. We identified three framings: (1) Highlighting problems of formality marriage (the marriage between two queer people) and gay's wife marriage (the marriage between a queer man and a heterosexual woman); (2) portraying people involved in formality marriage and gay's wife marriage as suffering from heteronormative pressure to engage in marriage; and (3) presenting formality marriage in a collaboration frame and gay's wife marriage in a deception frame. These framings suggest heteronormativity in marriage is upheld in societal discourses about HMQ and sustained by two hierarchies created in Chinese newspaper articles: one degrading queer marriage practices, which made heterosexual marriage undertaken by queer people inferior to ideal heterosexual marriage; another stratifying queer marriage practices, which made the marriage between a queer man and a heterosexual woman less acceptable than the marriage between two queer people.

Molecular networks reveal complex interactions with MSM in heterosexual women living with HIV-1 who play peripheral roles in Guangzhou, China

BACKGROUND

With the number of newly diagnosed HIV-positive heterosexual women increasing yearly, it is urgent to understand HIV-1 transmission among heterosexual women in Guangzhou, China.

METHODS

HIV-1 pol sequences were obtained from people living with HIV-1 during 2008 to 2017 in Guangzhou, China. A molecular network was constructed using HIV-1 TRAnsmission Cluster Engine with 1.5% genetic distance. Potential linkage and centrality metric were measured with Cytoscape. Transmission pathways between heterosexual women and men who have sex with men (MSM) were determined using Bayesian phylogenetic analysis.

RESULTS

In the network, 1799 (62.6%) MSM, 692 (24.1%) heterosexual men and 141 (4.9%) heterosexual women formed 259 clusters. Molecular clusters including MSM and heterosexuals were more likely to form larger networks (P<0.001). Nearly half of the heterosexual women (45.4%) were linked to heterosexual men and 17.7% to MSM, but only 0.9% of MSM were linked to heterosexual women. Thirty-three (23.4%) heterosexual women linked to at least one MSM node and were in peripheral role. Compared to general heterosexual women, the proportion of heterosexual women linked to MSM infected with CRF55_01B (P<0.001) and CRF07_BC (P<0.001) was higher than that of other subtypes, and the proportion diagnosed between 2012-2017 (P=0.001) was higher than that in 2008-2012. In MCC trees, 63.6% (21/33) of the heterosexual women differentiated from the heterosexual evolutionary branch, while 36.4% (12/33) differentiated from the MSM evolutionary branch.

CONCLUSION

Heterosexual women living with HIV-1 were mainly linked to heterosexual men and were in peripheral positions in the molecular network. The role of heterosexual women in HIV-1 transmission was limited, but the interaction between MSM and heterosexual women were complex. Awareness of the HIV-1 infection status of sexual partners and active HIV-1 detection are needed for women.

Sex life and sexuality among tongqi: doing gender and heterosexuality

The term tongqi refers to cisgender, heterosexual women who unwittingly marry non-straight men. In mainland China, their adverse social position and health have been the subject of concern. This study aims to broaden and diversify perceptions of the lived experiences of tongqi by focusing on sex and sexualities in mixed-orientation marriages. Four themes (lack of sexuality-related exploration before marriage, the unsatisfactory nature of marital sex life, the exercise of sexual agency, and increased self-awakening) were developed from observations of a tongqi online support group and 12 semi-structured interviews with members. Using inductive thematic analysis, findings reveal how heteronormativity oppresses and punishes both tongqi and their non-straight husbands. In most cases, husbands not 'doing heterosexuality' as expected were still found to be 'doing gender' in patriarchal ways, with wives' subordinate status thereby being reinforced, making them more vulnerable. However, despite women's sexual autonomy and agency being constrained by normative forces, some were able to navigate their conjugal relationships by practising sexual autonomy and agency within and outside their marriage.

"I did not know I was gay": sexual identity development and fluidity among married tongzhi in China

This study aimed to analyse the life experiences of married tongzhi (defined here as men who are sexually attracted to men) in mixed-orientation marriages in mainland China. The study used a life course perspective to understand sexual identity development among tongzhi, born in the 1970s or thereabouts, in heterosexual marriage and rural China. The study focused on identifying the experiences of the 13 tongzhi participants. Using thematic analysis, we found sexual identity development was influenced by China's historical and social context and, in particular, internal (e.g. internalised heteronormativity), informational (e.g. Internet), and cultural (e.g. family-oriented) factors. Some tongzhi did not follow an identity development trajectory as "out and proud" since their identities were embedded in the complexity of family life and social pressure, the invisibility of "gay circles", and normative social roles. They chose instead to maintain their heteronormative marriages, while seeking to explore and fulfil their homoerotic desires. Implications are discussed for epistemology, methodology and advocacy.

The association between HIV disclosure, spousal testing and unprotected vaginal intercourse within marriage among HIV positive married MSM in China

Disclosure of HIV status can encourage spouses of people diagnosed with HIV to prioritize HIV prevention. However, few studies have reported the HIV disclosure status of married men who have sex with men (MSM) and their female spouses. The purpose of this study was to describe the prevalence of HIV disclosure, and whether it was associated with spouses' HIV testing uptake and unprotected vaginal intercourse within marriage for MSM living with HIV (HIV + MSM) in China. A cross-sectional study was conducted in three Chinese cities. Of 309 participants, only 31.1% of men had disclosed their HIV status to spouses. About 80% of participants reported that their spouses had been tested for HIV. A small proportion of men (9.1%) had unprotected sex with their spouse after HIV diagnosis. Multivariate analyses indicated HIV disclosure was positively associated with HIV testing uptake of spouses, but there was no significant association between HIV disclosure and unprotected marital sexual behaviors for HIV + MSM. The findings indicated that HIV disclosure to spouses is uncommon among married HIV + MSM in China, and HIV disclosure is associated with increased uptake of HIV testing among spouses of MSM, but it does not decrease the unprotected sexual behaviors in marriage.

Internalized Sexual Minority Stigma is Associated With HIV Testing Behavior Among Chinese Men Who Have Sex With Men: A Cross-Sectional Study

ABSTRACT

Although studies have examined the relationship between HIV-related stigma and HIV testing among men who have sex with men (MSM) in China, there is still a lack of knowledge regarding whether sexual minority stigma and HIV testing are associated. The purpose of this study was to identify the association between sexual minority- and HIV-related stigmas with HIV-testing behavior. A cross-sectional study was conducted in the Hunan Province of China. After controlling for covariates, the multivariate analyses showed that high internalized sexual minority stigma was negatively associated with HIV testing behavior in the previous year. However, anticipated sexual minority- and HIV-related stigmas were not associated with HIV-testing behavior. Findings suggest that internalized sexual minority stigma should be addressed in health care settings to encourage MSM to seek HIV testing services, especially considering the continuing HIV epidemic among MSM in China.

Social support and coping style of Tongqi in China: A cross-sectional study

Tongqi (gays' wives) in China were under tremendous distress and social pressure due to their special identities and were not clearly known. A sample of 179 Chinese Tongqi were recruited through online social media groups in 2017-2018. Their hidden lives, social support, and coping styles were analyzed. The results showed that the majority of Tongqi concealed their identities, had negative responses to cope with their tremendous distress, and did not have sufficient social support. Their social support was mainly from family members. Hidden identities obstructed Tongqi's access to extrafamilial social support that could alleviate their distress. Tongqi need more social support and protection.

Counselling and psychotherapy service use in Chinese sexual minority populations: a nationwide survey

BACKGROUND

This study investigated the prevalence and factors associated with counselling and psychotherapy service use among Chinese sexual minority populations.

METHODS

A nationwide cross-sectional study was performed using snowball sampling method, which led to the inclusion of 18,193 participants. Participants' sociodemographic background, clinical, and psychological data were gathered. Multivariate logistic regression analysis was performed to explore any associated factors.

RESULTS

There were 2007 participants who had used counselling and psychotherapy service out of the total population. Among those who had used psychotherapy services, 80.2% participants perceived discrimination, 1.1% reported that they had been refused treatment by a counsellor and/or psychotherapist, 1.6% had experienced verbal harassment, and 8.4% reported that their counsellor and/or psychotherapist lacked knowledge and experience in treating sexual minorities. In addition, regression analyses indicated that those who were divorced/widowed, had religious beliefs, and those who had experienced discrimination, verbal harassment, and rejection for treatment by health professionals all had an increased likelihood of utilising counselling and psychotherapy service.

CONCLUSIONS

Service providers and policy makers in China should improve the quality and availability of counselling and psychotherapy services to address the mental health needs of sexual minority populations.

Nursing research on intimate partner violence in China: A scoping review

Intimate partner violence (IPV) is a serious public health issue, and nurses have the potential to screen, navigate to interventions, and provide support, but responses to IPV differ greatly in mainland China, Hong Kong, Macao, and Taiwan. We conducted a scoping review to examine the nursing literature on IPV in the above four regions in China. We conducted a comprehensive search of 11 Chinese and English databases from database inception to January 31, 2020, for eligible papers including empirical studies, reviews, reports, and expert opinion articles. We hand searched references lists and other studies published by the first and corresponding authors of included articles. Two reviewers independently screened articles and extracted data, and three reviewers cross-checked the extracted results. We also conducted quality appraisal for applicable empirical studies. A total of 58 Chinese-language and 63 English-language articles were included, 58 from Taiwan, 44 from Hong Kong, 13 from mainland China, and six from institutions outside China, but none from Macao. The quantitative and qualitative studies described the prevalence and complex nature of IPV, comparable to non-nursing and international studies. Nurse-led advocacy and Qigong (traditional Chinese mind-body health practice) interventions showed promise for improving mental health in women in Hong Kong. There was a low level of knowledge and preparedness to respond to IPV among Chinese nurses, especially in mainland China. Mixed methods studies in Hong Kong and Taiwan as complex designs were generally well-conducted. Nursing case reports from Taiwan uniquely supplemented the evidence base. In Hong Kong and Taiwan, varying designs were used to study various facets of IPV, targeting victims, nurses and other key stakeholders. In mainland China and Macao, IPV research was limited in quantity, quality, and diversity. As more research in the area of IPV is needed, factors influencing nursing research on IPV also merit investigation, while taking into consideration socio-economic-political-cultural factors.

Mapping out a spectrum of the Chinese public's discrimination toward the LGBT community: results from a national survey

Background

China has the world’s largest lesbian, gay, bisexual, and transgender (LGBT) population. This study assessed the discrimination experienced by LGBT individuals in China in a comprehensive way, covering discrimination perpetrated by family, media, medical services, religious communities, schools, social services, and in the workplace.

Methods

The current study involved a national survey of 31 provinces and autonomous regions. Discrimination was measured both in terms of heterosexual participants’ attitudes towards LGBT individuals, and LGBT participants’ self-perceived discrimination. Pearson correlation analysis was performed to examine the difference between heterosexual participants’ attitudes towards LGBT individuals and LGBT participants’ self-perceived discrimination. Linear regression was used to investigate the association between gross domestic product per capita and discrimination.

Results

Among 29,125 participants, 2066 (7.1%) identified as lesbian, 9491 (32.6%) as gay, 3441 (11.8%) as bisexual, 3195 (11.0%) as transgender, and 10,932 (37.5%) as heterosexual. Heterosexual people were generally friendly towards the LGBT community with a mean score of 21.9 (SD = 2.7, total scale score = 100) and the grand averaged score of self-perceived discrimination by LGBT participants was 49.9 (SD = 2.5). Self-perceived discrimination from family and social services is particularly severe. We created a series of provincial level choropleth maps showing heterosexual participants’ acceptance towards the LGBT community, and self-perceived discrimination reported by members of the LGBT community. We found that a higher level of economic development in provinces was associated with a decrease in discrimination, and we identified that every 100 thousand RMB increase in per capita GDP lead to a 6.4% decrease in discriminatory events perpetrated by heterosexuals.

Conclusions

Chinese LGBT groups consistently experience discrimination in various aspects of their daily lives. The prevalence of this discrimination is associated with the economic development of the province in which it occurs. In order to reduce discrimination, it is important for future studies to discover the underlying reasons for discrimination against LGBT individuals in China.