Culture, Health & Sexuality, November–December 2006; 8(6): 487–500
Homosexuality, seropositivity, and family obligations: Perspectives of HIV-infected men who have sex with men
YANQIU RACHEL ZHOU
McMaster University, Ontario, Canada
Abstract The HIV epidemic has had major impact on men who have sex with men in China. Most current studies view male-to-male sex as a behavioural dimension or variable affecting HIV infection, paying little attention to the socio-cultural meanings of homosexuality and their impacts on men's experiences with HIV/AIDS. This oversight has impeded understanding of the health practices of this population. Based on a qualitative study of experiences of Chinese people living with HIV/AIDS, this paper explores the complex processes in which men who have sex with men struggle and negotiate with their sexuality, family obligations, and this disease. To facilitate Chinese men who have sex with men in responding effectively to HIV and AIDS, researchers and practitioners should take into account a wide range of contextual factors including desired gender roles, family obligations, homophobia, and HIV-related stigma that contribute to current constructions of 'homosexuality' in China. Resume En Chine, l'epidemie de sida a eu un impact majeur sur les hommes qui ont des rapports sexuels avec des hommes. Actuellement, la plupart des recherches envisagent les rapports sexuels entre hommes comme une dimension ou une variable comportementale qui a des consequences sur l'epidemie, en pretant peu d'attention aux significations socio-culturelles de l'homosexualite et a leur impact sur les ` experiences des hommes vivant avec le VIH/sida. Cette negligence entrave la comprehension des pratiques de sante dans cette population et l'elaboration d'interventions qui lui soient plus specifiques. En se basant sur une etude qualitative des experiences des Chinois vivant avec le VIH/ sida, cet article explore les processus complexes selon lesquels les hommes qui ont des rapports avec des hommes luttent et negocient avec leur sexualite, leurs obligations familiales et cette maladie. Pour aider les hommes qui ont des rapports avec des hommes a apporter des reponses efficaces au VIH/ ` sida, les chercheurs et les praticiens devraient prendre en consideration un large eventail de facteurs contextuels comprenant les roles de genre desires, les obligations familiales, l'homophobie et le stigma du au VIH, qui contribuent aux constructions actuelles de l'homosexualite en Chine. Resumen La epidemia del sida ha tenido un fuerte impacto en los hombres que tienen relaciones homosexuales en China. En la mayora de estudios actuales se consideran las relaciones homosexuales como una dimension de conducta o variable que afecta a la infeccion del VIH. Se presta poca atencion a los significados socioculturales de la homosexualidad y al impacto que tiene en las experiencias de los hombres afectados con el VIH/sida. Esta negligencia ha impedido conocer las practicas sanitarias en esta poblacion y la posibilidad de desarrollar intervenciones mas sensibles. A partir de un estudio
Correspondence: Yanqiu Rachel Zhou, School of Social Work, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4M4, Canada. Email: firstname.lastname@example.org ISSN 1369-1058 print/ISSN 1464-5351 online # 2006 Taylor & Francis DOI: 10.1080/13691050600847455
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cualitativo sobre las experiencias de chinos afectados con el VIH/sida, en este artculo se exploran los complejos procesos en que los hombres con relaciones heterosexuales negocian y luchan por su sexualidad, las obligaciones familiares y la enfermedad. Para ofrecer una respuesta eficaz al VIH y el sida a esta poblacion con relaciones homosexuales, los investigadores y profesionales de la salud deberan tener en cuenta toda una serie de factores contextuales, por ejemplo los roles sexuales deseados, las obligaciones familiares, la homofobia y el estigma relacionado con el VIH que contribuyen a crear el concepto actual de la 'homosexualidad' en China.
Keywords: HIV/AIDS, homosexuality, socio-cultural meanings, China
Introduction As of the end of 2005, the estimated number of people living with HIV/AIDS in China was 650,000, 7.3% of whom were, in terms of transmission modes, men who have sex with men (Ministry of Health et al. 2006). However, the majority of men who have sex with men have not yet accessed various institutional HIV- and AIDS-related services, including the HIV test (Choi et al. 2006). Among the 89,067 cases of HIV infection officially reported by September 2004, for instance, the proportion of reported transmission through male-tomale sex was only 0.2% (State AIDS Council Working Committee Office and UN Theme Group on HIV/AIDS in China 2004). Recent epidemiological studies (e.g., Zhang 2000, Zhang and Ma 2002, Choi et al. 2004) suggest that Chinese men who have sex with men may be a bridge group that could channel HIV to heterosexual women or the 'general population', given that many men who have sex with men are married and that the rate of condom-use in China is low. In their study with 482 men who have sex with men in Beijing, Choi et al. (2004) found that 64% of participants had had sex with women in their lifetime, and that 30% had had sex with women in the past 6 months. Despite its low visibility in contemporary Chinese society, homosexuality (tongxinglian) is nothing new in China. Literary and historical references can be traced back to the Shang Dynasty (1600–1046 BC) and throughout Chinese history (Liu 1999, Shi 2003). Historically, Chinese society has often turned a blind eye to male homosexuality as long as it did not interfere with men's fulfilment of their traditional gender roles in getting married and having children (Liu 1999, Li 2002, Wang 2004). A similar attitude can be found in the current Chinese policy toward homosexuality, which is jokingly depicted as the 'Four No's': no enquiry (bu wen), no mentioning (bu ti), no talking (bu shuo), and no response (bu li) (Chinese Central Television 2004). The Oscar winning film, Brokeback Mountain, a gay cowboy romance, was recently banned from cinemas in mainland China due to its representation of homosexuality. As this response shows, official silence about homosexuality does not mean social acceptance. While homosexual activities are not illegal, homosexuality is still constructed as 'abnormal', 'deviant', 'promiscuous' and 'immoral' in dominant public discourses in China (Li 2002, Settle 2005). Not until 2001, for instance, was homosexuality removed from China's official list of mental health disorders (UNTG 2002). The stigma associated with homosexuality has forced many men to hide their sexual preference so as to avoid embarrassing themselves and their families. As a result, they may have to struggle between their homosexual desires, their duties to continue family lines, and homophobia in the larger society. Getting married and having a family is still a primary 'choice' for many men (especially older ones) with homosexual preferences (Zhang 2000, Zhang and Ma 2002, Qian et al. 2005). This dilemma may in part explain the long-term invisibility and low-profile status of men who have sex with men in China: drawing the attention of society may
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not only incur criticism of their life style, but also jeopardize their current relationships with families. Recent studies have found that the fear of others learning about their homosexuality is one of the main barriers for Chinese men who have sex with men in accessing the HIV test, in spite of their awareness of their possible exposure to HIV (Choi et al. 2006). Against the background of HIV/AIDS and the international gay rights movements, homosexuals (especially male homosexuals) in China have become more visible in recent years. Across the country, for instance, tongzhi (an euphemistic term for people with samesex preference) websites and hotlines have mushroomed, tongzhi newsletters and journals have been published, and there is increasing communication between Chinese men who have sex with men and their international counterparts. Nevertheless, it is accepted that Chinese men who have sex with men have not yet developed a community with solidarity and a clear identity (Yanhai 1997, Zhang 2000). Moreover, recent studies suggest that many Chinese men who have sex with men perceive that they are at a low risk of HIV infection, and do not know how to prevent it (Choi et al. 2002, 2004, 2006). HIV- and AIDS-related research in China is heavily influenced by the Western traditional biomedical model, and pays disproportionate attention to HIV prevention through traditional forms of disease control (e.g., Gil et al. 1996, Xiaoming et al. 2000, Yap et al. 2001, Qu et al. 2002). As a result, the few empirical studies on Chinese men who have sex with men to date have focused on risk perceptions, reasons for their engagement in unsafe sex, and barriers faced in accessing HIV prevention services (e.g., Choi et al. 2002, 2004, 2006). Despite their pioneering significance in understanding Chinese men who have sex with men's sexual practices in the context of HIV, these studies have rarely considered local constructions of homosexuality and their impacts on men's responses to this epidemic. Reducing homosexuality to sexual practices or behavioural variables neglects the specific socio-cultural conditions on which the meanings of homosexuality are constructed and men who have sex with men's capacity to respond to HIV and AIDS is structured. It is unclear how various contextual elements (e.g., desired gender roles, heterosexual marriage, normative family obligations, homophobia, and HIV-related stigma) in China have influenced men who have sex with men's sexual identifications and sexual practices, or how men who have sex with men's dual or multiple roles (e.g., as individuals with homosexual preference, as members of a traditional family, and/or as men infected with HIV) have shaped their intentions and their ability to deal with this disease, either prior to or after their HIV infection. Behaviour-centred models for understanding sexuality/homosexuality in different sociocultural settings has been challenged by many researchers (especially researchers from nonWestern contexts). Viewing the monolithic and rigid discourses of homosexuality as problematic, these researchers suggest that homosexuality cannot be simply explained by the Western biomedical approach to sexuality that places more emphasis on sexual practices than on the meanings attached to them in specific socio-cultural contexts (e.g., Asthana and Oostvogels 2001, Boellstoff 2005, Williams et al. 2004, Blanc 2005). In Confucian cultures (including Chinese culture), an individual's response to homosexual preference (e.g., sexual identification, practices and disclosure) is largely structured by his/her culturally appropriate social roles (e.g., duties to parents or the family) (Kong 2002, Kimel and Yi 2004). Similarly, the sexual identities of men who have sex with men in India are primarily defined by gender (e.g., cultural norms of 'masculinity' and 'femininity') and power structures (e.g., the legitimacy of the family institution and of heterosexual marriage) rather than their sexual behaviours (Asthana and Oostvogels 2001). In their study on African-American and Latino men who have sex with men, Williams et al.
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(2004) found that these men perceived having a wife and children as significant for maintaining their masculinity despite their same-sex preference. Studies such as these in various non-Western contexts have also revealed other nonsexual dimensions (e.g., class, age, race/ethnicity, religion, poverty, immigration, colonization, and geographic location) that constitute the social meanings of homosexuality. As is, moreover, not the case in Euro-American contexts, same-sex practices in these contexts do not necessarily result in the development of a common sexual identity (e.g., self-identifying as 'homosexual' or 'gay') and/or a community with collective solidarity (e.g., 'gay community') (Asthana and Oostvogels 2001, Williams et al. 2004, Blanc 2005, Boellstorff 2005). The emergence of HIV/AIDS has further complicated the constructions of homosexuality in different socio-cultural contexts. In Vietnam, for instance, homophobia and stigmas associated with homosexuality have been accentuated by the AIDS epidemic (Blanc 2005). In Jamaica, the multiple stigmas associated with homosexuality and HIV/AIDS have inhibited HIV-infected individuals from accessing health care services and revealing their serostatus to their sexual partners (White and Carr 2005). Concealment of homosexual identity is also found to have adverse impacts on the physical and mental health of seropositive gay men (Ullrich et al. 2003). Given the increase in HIV-infected cases among Chinese men who have sex with men, it is important to understand the relationships between local meanings of homosexuality, Chinese men who have sex with men's multiple social roles, and their health beliefs and practices, in the context of HIV/AIDS.
Method The core purpose of the larger study from which the data reported here were drawn, was to understand Chinese people's experiences of living with HIV/AIDS. To this end, a phenomenological approach (e.g., Moustakas 1994, Van Manen 1997, Creswell 1998, Merleau-Ponty 2002a, b) was adopted. This sought to describe, understand and investigate the meanings associated with living with HIV. Viewing individuals' experiences and perceptions as positional and intentional allows an examination of such experiences in a way that is not constrained by researcher preconceptions. In the larger study, data were collected through semi-structured face-to-face in-depth interviews with 10 frontline AIDS professionals and with 21 adults living with HIV/AIDS, eleven of whom were men who have sex with men. Participants were recruited through snowball sampling using multiple social and health networks (e.g., hospitals and AIDS NGOs) in a metropolitan city in north China. Participants were asked to select a convenient location for the interviews. Public places, such as cafes or tea houses, were often chosen. Some interviews were conducted in a separate room of the tea house at the request of the participants. Before each interview, written, informed consent was obtained from the participant. Prior to signing the consent form, participants were asked to read an information sheet describing the purpose of the study. Participants were encouraged to seek clarification and ask questions regarding the study or the research process before signing the consent form. Interviews were either audio-taped, or, where this was not possible, detailed notes were taken. Participants were interviewed in Mandarin, of which the researcher is a native speaker, and each interview lasted approximately three hours. To protect participants' identities, pseudonyms are assigned. At the end of each interview, basic demographic information was collected by using a standardized background questionnaire.
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The interview guide included several general prompts to ensure that the interview maintained a focus, and that major themes of interest were explored. After introducing each participant to the goals of the research project (e.g., main purposes and study focus), the researcher suggested the participant organize her/his storyline according to her/his rationale (rather than the researcher's) so as to facilitate a participant-led discussion, though most participants still preferred sharing their experiences according to researcher's interview questions. Specifically, the researcher asked respondents questions about their experiences of living with HIV/AIDS, their understanding of such experiences, their selfperceptions, and the strategies they used to facilitate living with HIV/AIDS. Depending on the interview context, the specific phrasing of interview questions varied slightly across participants. Of the 11 men who had sex with men, four were still married, three were divorced, two currently lived with same-sex partners, and two were single and had never married. Six of them had children. Their ages ranged from 23 to 46 and educational levels were divided among university (2/11), college (2/11), senior high school (5/21), and junior high school (2/11) graduates. Audio-taped interviews were transcribed verbatim in Chinese. The researcher read through the texts of all transcripts and fieldnotes and then assigned tentative category labels (e.g., 'family relationship' and 'self-perception') to the unique or discrete statements of participants. The statements with similar category labels were later grouped into clusters using N-Vivo, and careful attention was paid to the diversity of perspectives that were presented by participants. Based on the data analysis, the researcher was able to develop both a textual description of the experiences (i.e., the 'what' of the experiences) and structural description of the experiences (i.e., the 'how' of the experiences), and prepared a comprehensive textual-structural synthesis (e.g., the findings presented below) of the phenomenon (Moustakas, 1994). To avoid the loss of nuances within participants' original narratives, transcribed data were not translated into English until the stage of report writing.
Findings Ambiguity of sexual identification and 'justifications' Of the 11 men who had sex with men, six self-identified as 'pure gay man' (chuntong), one man self-identified as 'bisexual' (shuangxinglian), three men were vague about their sexual identity, and one man did not wish to discuss it. Definitions of chuntong and shuangxinglian varied among participants, however. For instance, some men self-identified as a chuntong because their only relationship with a woman (i.e., their wife) had been forced on them by social and family pressures, while others viewed chuntong as those who engaged exclusively in same-sex practices. Among the seven men who had sex with both men and women, only one man self-identified as a shuangxinglian. Importantly, this same term was rejected by a couple of participants, who thought the concept was merely a strategy to minimize the stigma associated with homosexuality, inasmuch as shuangxinglian might mean that the man in question preferred women to men. Despite discrepancies in their sexual identification, most men agreed upon the usage of another term, tongzhi, which refers to people who engage in same-sex practices despite their other characteristics (e.g., marital status and sexual identification). This term is also used in the discussion in this paper.
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Participants' family constraints, specifically, current marital status, appeared to be an important inhibitor for them in explicitly addressing their sexual preference. Strategically, they often adopted a vague tone in discussing it, as elaborated on by Guoqiang, a married man in his late-40s:
People my age didn't have the chance to choose their [sexual] orientation. A man like myself must live life as other people do. In that kind of traditional environment, if he happened to meet a girl who accepted him, then he would get married and live the life of 'normal people' … If the marriage failed, he might become single. Or, he might divorce later. It's hard to say. In my case, I feel my family is very good, but this doesn't mean … doesn't mean I couldn't accept that thing [i.e., having sex with men] … If I wasn't married, it is hard to say what my [sexual] orientation would be, right? What I am saying is, since I chose the life I am living, I have to take the responsibility for it.
In interview, a couple of participants identified their divorced status as essential in enabling them to talk openly about their homosexuality with the researcher: 'If I still had family, I would not say a word'. In this sense, the ambiguity of their sexual identification not only reflects their internal conflicts between homosexual preference and family responsibilities, but also conveys their intention to avoid bringing homosexuality-related stigma upon themselves and their families. As well, some men displayed ambivalence when voluntarily explaining why they were tongzhi. Some attributed their engaging in same-sex practices to having a 'bad wife', an 'unsuccessful marriage', and/or earlier experiences of domestic violence. Guo, for instance, viewed his same-sex relationship as an alternative that enabled him to cope with his unhappy marriage in which his wife had lost her 'womanhood' (e.g., 'she treated me badly', 'she didn't take care of our child, her father and housework', and 'she was not like a woman any longer') after she achieved much success in her career. Similarly, Jian claimed that he would not have become a tongzhi if he had married a girl he really liked rather than his (ex)wife. Pin felt that he was 'pushed' into the tongzhi scene by the violent relationship of his parents, since he needed to seek love and safety elsewhere. Such ambiguity of justification also intersected with men's negative feelings about themselves, such as a sense of isolation, frustration, inferiority, abnormality, shame, and low self-esteem. For instance, Guoqiang felt he had been wronged throughout his life because of his sexuality: 'From my childhood to the present, I brought little happiness to my family. I feel I never do any good to those I love the most. My whole life is a pain'. Recognition of homosexual preference Most older men had not heard the term 'homosexuality' when they were teens, and some had been uncertain about their same-sex preference until they were married. Only after his son was born, for instance, did Dong encounter the tongzhi scene and thus, for the first time in his life, found there were 'so many people just like me'. For married tongzhi like Dong, accepting 'who I am' had been a fierce struggle between their sexual desire and family duties (e.g., as a husband and as a father) from the time they recognized their sexual preference. Yet, none of these married tongzhi disclosed their sexual preference to their wives or family members before their HIV infection, primarily because of the possible consequences of such a disclosure and their unwaivable family obligations. As a result, they had to live a double life, going between their families and the tongzhi scene, and had tried to negotiate their roles as the head of a household and as a tongzhi. However, the difficulties in fulfilling the dual roles also brought about various adverse impacts (e.g., guilt,
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conflict, shame and depression) on their mental health, as displayed in the following two quotes:
I felt much conflict and pain. I couldn't sleep at night. I lied to my wife. I felt I was committing a crime against her and my son every time I went out on the tongzhi scene. You know, things would not be like this if I could have known I was a tongzhi earlier. (Interview with Dong) We felt tired [of living a double life] … At home, we have to be a good son for our parents, a good husband for our wives, and a good father for our children. But when we are on the tongzhi scene, we have to be a good tongzhi. (Interview with Guo)
Younger tongzhi appeared to have recognized their homosexual preference earlier than their older peers because their generation had better access to information about homosexuality, either through the mass media (e.g., Western movies) or the Internet. They also reported fewer barriers to confronting their sexuality given that they were not married yet. Ge, a man in his early-20s, for instance, recognized that he liked men when he was in high school and had never considered forcing himself to have sex with women (through marriage). In comparison to the older tongzhi, younger ones reported less shame in their narratives, and a few of them even stressed their pride in being who they were. Identifying himself as a 'gay' ('gay' is his own word), for instance, Qin spoke loudly in the interview: 'I don't think I am inferior to anyone! I don't think I have less integrity than others!' Despite their better acceptance of their homosexual preference, however, these younger men, as their older peers did, also confronted challenges in 'coming out' in their families and in the larger society. Although Qin was critical of the internalized homophobia among Chinese tongzhi, he was definitely unwilling to disclose his sexual preference to his family. In fact, upon his recognition of same-sex preference, he soon left his home in South China so as to avoid disappointing his family. By living in this northern city, Qin felt he could somewhat escape his family's pressure to get married, but he still could not escape his own guilt for being unable to continue his family line (chuanzong jiedai), which is one of the criteria of 'filial piety' (xiao), one of the most important Confucian doctrines. Such guilt was shared by all unmarried tongzhi, and also had shaped their understanding of and ways of dealing with their sexuality. Pin, for instance, had designed a plan for 'getting married—having children—getting divorced' as a compromise between his samesex preference and his family duties. He would have got married had he not been diagnosed HIV positive during premarital medical check-ups. For this reason, Pin perceived himself as 'less fortunate' than some of his 'bisexual' peers, who 'could finally live a normal life of getting married and having children' in spite of their same-sex preference. To save his parents' face in their social networks, Ge, the only son of his family, was also prepared to participate in a fake marriage with a lesbian, who would, presumably, have the same need to cover up. Being the only tongzhi in this study who voluntarily disclosed his sexual orientation to his parents, Ge described that confrontation as 'the most difficult thing' he had ever experienced, even more difficult than finding out about his HIV serostatus later. Although his parents eventually accepted his sexual preference, he clearly felt that 'my parents' internal happiness was gone, and their hopes for me had disappeared'. Responses to AIDS risk before HIV infection Most tongzhi in this study were not aware of their HIV infection until they had received an HIV antibody test, usually in the context of a blood donation or prior to surgery. Ignorance of HIV-related risks had resulted in their delaying their first HIV test and in engaging with
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health care. A couple of participants didn't even realize they had experienced opportunistic infections associated with AIDS until they had received their diagnosis. Although a 'causal relationship' between homosexuality and HIV infection has been highlighted by the dominant AIDS discourses in China, tongzhi in this study reported that they had 'never heard about this disease', or, 'knew little about HIV or AIDS' before their HIV diagnosis. Qin was the only tongzhi who reported a clear awareness in this study, but he was still shocked by the result of his HIV test result because he had found it difficult to believe that he could really be infected with it. As well, few tongzhi were certain about 'when' or 'from whom' they received the infection. Lack of safe-sex knowledge and the practice of unprotected sex were commonly reported. For instance, Pin had never used a condom since joining the tongzhi scene seven years before, as he knew little about safe-sex until his HIV diagnosis. Other barriers to condom use were also identified by the participants, such as misconceptions about the condom (i.e., viewing it as a birth-control instrument) and its use (e.g., men who insist on using one are suspected to have STDs/HIV), the desire for intimacy (e.g., unprotected sex is assumed to produce a 'more exciting orgasm'), and affordability of condoms and supplementary products (e.g., lubrication). As well, condoms were rarely used by tongzhi couples in a stable relationship because unprotected sex was seen as a symbol of their trust of and love toward their partners. For instance, Qin had suspected that he had been infected with HIV by his cohabitant lover, the man with whom he had considered it 'unnecessary' to use any protection at all. Prejudice toward homosexuality in the larger society encourages the subculture of the tongzhi scene, in which unprotected casual sex with multiple partners is common. To decrease the risk of being revealed or even blackmailed, married tongzhi often avoid developing serious relationships with other men. The dilemma of living a double life also inhibited them from knowing more about their sexual partners before engaging in unprotected sex. New phenomena fuelled by the development of internet access and cell phones, such as '419 (for one night)' and 'money boys' (i.e., male sex workers, who are not necessarily gay), have somewhat increased the flux on the tongzhi scene, which, in turn, has strengthened social discrimination toward members of this group. Describing the relationship between tongzhi's high-risk behaviours and homophobia in the larger society as a 'vicious circle', for instance, Ge commented:
Society only allows us to live in sewers, like mice or maggots. Staying in the darkness, things certainly became uglier and uglier … It is the way the public thinks of tongzhi that has produced so many people with HIV/AIDS in this group … If this group could live in the sun and be accepted by the public, the situation will be different.
'Coming out' after HIV diagnosis Due to the widespread fear of HIV/AIDS in China, tongzhi in this study tended to keep their seropositivity 'secret' from other men, even those who had had sex with them. Most tongzhi participants made the conscious decision of non-disclosure because they were 'very sure' that they would be shunned, rejected, or abandoned by other men if their HIV seropositive status was disclosed. For fear of being suspected of being seropositive, for instance, Pin rarely insisted that his casual sex partners use a condom, even though he did enquire of them about their willingness to do so. Qin, too, felt conflict about maintaining this secret from his current lover: non-disclosure might delay his lover in accessing with health care, while disclosure might create consequences (e.g., breaking-up of the
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relationship and risk of being disclosed to others by his lover) beyond his control and expectations. Similar concerns also prevented HIV-infected tongzhi from alerting their previous sexual partners about their possible exposure to HIV. Four years after his diagnosis, for instance, Han had still not plucked up the courage to reveal his serostatus to his earlier sexual partners, with whom he had never used a condom. Similarly, when Jun visited an HIVrelated health service one day, he bumped into an old sexual partner who had disappeared years before, and he found out that this man had lived with HIV for many of those years. Though most tongzhi in this study carefully hid their secret from each other, Ge and Guo tried to share it with their tongzhi friends. However, Ge later regretted this action, because his friend had been overwhelmed by the news and was unable to refrain from disclosing it to other men. Guo's disclosure to two of his best friends also turned out in a discouraging way: one friend left and never contacted him again; the other seemed undisturbed but had much less contact with him subsequently. 'After that, I didn't dare tell anyone that I have HIV'. He said: 'I gradually alienated myself from my friends. I changed my cell phone number so that they couldn't contact me any longer'. In addition to their difficulties in 'coming out' to other tongzhi, participants found it hard to seek help from the larger society due to homophobia. The multiple stigmas associated with homosexuality and HIV strengthened the barriers against their coming out among people living with HIV, and accessing various institutional AIDS-related services. Perceiving his HIV infection as his 'own fault', for instance, Guoqiang had been reluctant to seek support from others, including fellow people living with HIV and family members. He explained:
Though we all are people with HIV/AIDS, I feel I am inferior … Even though we all are people with HIV/AIDS, people infected through blood transfusion are better than me, even those infected through drug use are better than me, and those infected through heterosexual behaviours are better than me. It's so hard for people infected through homosexual behaviours to come out!
Negotiating between sexual desire, seropositivity and family obligations Having had experiences of living with this disease, many tongzhi in this study attempted to make sense of their HIV infection. Some saw it as 'bad luck' (e.g., 'Why am I the one that got infected?'), while others interpreted it as a 'punishment' for being a tongzhi or for having multiple sexual partners. Assuming that he 'must have done something wrong in his preexistence', for instance, Guoqiang felt that he had been completely silenced by his HIV infection: 'I am such a good person, but I did such a bad thing [i.e., having sex with men]. I have nothing to say'. To some degree, the emergence of HIV on the tongzhi scene has challenged these men's gradual acceptance of and comfort with their sexual preference. Widespread HIV- and AIDS-phobia, intersecting with homophobia, also shaped these men's understanding and/or re-understanding of their sexuality and their seropositive bodies. The stigmas associated with homosexuality in the Chinese context have been compounded with the stigmas associated with AIDS, as conveyed by the following quote:
I didn't want to have sex any more after I was diagnosed … I felt I was dirty! Disgusting! Perhaps other people would not say 'disgusting', but I do. I came out in 1993, and began to learn that there is a big world [i.e. the tongzhi scene] out there. It was only 7 years later that I got this disease [diagnosed]. Don't you think I am dirty?! (Interview with Pin)
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HIV infection also 'pushed' some tongzhi to disclose their sexual preference to their families, who later played a role in disciplining or policing these men's sexual desires. Withdrawal from sexual practices was reported by those tongzhi who felt 'guilty' about their HIV infection and its consequences for their families. Since his diagnosis nine years before, for instance, Dong had never visited the tongzhi scene again, partly because of pressure from his mother's repeated reminders: 'Ensure that you will be a decent man! Don't go to that kind of place again!' Being appreciative of their wives' continuing support, similarly, Yu and Han had decided to retreat from same-sex practices so as to maintain their marriages and keep their families intact. Viewing their current marriages as 'superficial' (i.e., as excluding sex), however, presented neither Yu nor Han with any difficulty in justifying their 'sacrifice': 'All this is for my child, for my family'; or, 'Being parents means we have the responsibility to carry on this family … to contribute to our child's future'. Such family-orientated sacrifice also applied to these participants' wives, who tended to stay in the marriage and assume the role of primary caregiver for their seropositive husbands. Despite the HIV- and AIDS-phobia pervasive in the tongzhi scene, mutual support among tongzhi couples was also reported. Specifically, help and support were often available among tongzhi with relatively stable relationships when either or both were infected with HIV. When his partner had been diagnosed with AIDS 10 years before, for instance, Dong decided to stay with him. The situation was miserable back then: AIDSphobia in society was more serious because of ignorance; his partner's belongings at the working unit were burned by frightened colleagues; and HIV antiretroviral therapy was not yet available in China. When his partner had passed away four years later, Dong recalled: 'He said to me, I feel very fortunate to have met you'. The power of mutual support also presented in the experiences of Jun and Pin, who had been a couple for 10 years by the time of interview. Despite various difficulties in their everyday lives, Pin felt satisfied with his relationship with Jun: for instance, when they couldn't afford medication for both of them, Jun saved his medication for Pin, whose symptoms appeared worse; and Pin, whose health got better because of the medication, did all household chores. The availability and unavailability of social support during their postdiagnosis lives also motivated these tongzhi to reflect on their earlier pursuit of relationships. Denouncing the 'good-looks-centred' and 'money-orientated' subcultures in the circuits of younger tongzhi, Ge said that getting this disease had helped him to rethink the meaning of 'true love'. For instance, he now saw it as 'responsible love' or 'safe sex', the latter of which he had previously viewed as an obstacle to 'love'. Qin also highlighted the reciprocal nature of 'true love', which is the love that can endure despite challenging situations, and that he, unfortunately, had neglected in his earlier life. Discussion Findings from this study suggest that homosexuality in China is not a single-dimensional concept defined solely by an individual's sexual behaviours, but a multi-dimensional concept defined by a variety of socio-cultural dimensions. Tongzhi's experiences in this study illustrate the importance of family obligations for these men in identifying their sexuality and making decisions about their sexual practices. Under the pressure of continuing the family line, for instance, these participants (especially older and married ones) tended to compromise their sexual desire to meet the expectations of their families. As a result, they had struggled with going back and forth between their role as a tongzhi and
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their other more important roles as a father, a son, and/or a husband. To avoid bringing shame on themselves and their families, men had to be very careful in facing up to their same-sex preference and coming out in the larger society. Ambiguity of sexual identification (e.g., reluctance in identifying themselves as 'gay') in this study should be understood in terms of men's exercising autonomy as a strategy to protect themselves and their families from stigma and discrimination related to homosexuality, rather than as resistance to Western homosexuality-related identity politics, as Jones (1999) argued. Despite family constraints on their sexual practices and identification, however, this study also found that family is a significant resource of support for tongzhi infected with HIV. The acceptance of their families has helped them a great deal in alleviating challenges during the process of living with this disease. In the context of HIV and AIDS, therefore, issues of homosexuality in China concern not only those tongzhi that struggle with the conflict between their sexual desire and their family obligations, but also their families (e.g., their wives, children, and parents) who are profoundly affected by both homophobia and HIV- and AIDS-related stigma. Cultural meanings of homosexuality in China not only play an important role in structuring tongzhi's response to HIV and AIDS prior to their HIV infection but also compounded their understanding of their sexuality after the HIV infection. Pervasive homophobia and men's need to protect their 'secret' (i.e., same-sex preference) have forced Chinese tongzhi to stay underground, which, in turn, has made this group hard to reach in the context of HIV/AIDS. This may explain men's ignorance of the disease and lack of awareness concerning protection against HIV. Moreover, these same pressures increase their chance of engaging in unprotected sex with multiple partners given that knowing their sexual partner better may also mean increased likelihood of having their identities as well as their double life revealed, and thus, bring damage to the 'honour' (mingsheng) of themselves and/or their families. HIV has reinforced the internalized homophobia of some tongzhi, while social prejudice toward homosexuality had inhibited them in coming out to seek help either from the broader community of people living with HIV or from the larger society. Among the 'invisible' people living with HIV in China, HIV-infected tongzhi are even more invisible. Intersecting with homophobia, HIV- and AIDS-phobia has constrained the capacity of Chinese tongzhi, both as individuals and as a social group, in responding to the epidemic. The fear of HIV and AIDS that permeates the tongzhi scene has forced the HIV seropositive tongzhi into an even darker closet in which they become more isolated and marginalized due to the lack of support from peers. Fear of discrimination also inhibited HIV-infected tongzhi from disclosing their serostatus on the scene, which has exposed their peers to greater risk of HIV infection. In other words, the present tongzhi scene in China is not yet a supportive environment for its members infected with or affected by HIV/AIDS, a fact that has delayed and will continue to delay this group in collectively fighting this epidemic. Although new phenomena, such as the emergence of media activism (e.g., tongzhi newsletters and websites) and cyber-communities among younger and well-off men, this group has still to develop a more coherent and inclusive community that can be supportive for all tongzhi regardless of serostatus and socio-economic status. A future tongzhi community with solidarity will be beneficial not only for constructing the alliance between HIV-positive and HIV-negative tongzhi during the HIV crisis but also for pursuing social justice in the long-term. To some degree, the emergence of HIV and AIDS presents an unprecedented opportunity for Chinese tongzhi to gradually come out in their
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families, in communities of people living with HIV, on the tongzhi scene, and in the larger society, and to claim their rights to health and sexuality, just as their Western counterparts did in the 1980s (Watney 1994, Silversiders 2003). Criticizing the government's long-term neglect of tongzhi as a social group, for instance, some participants began to advocate that the Chinese government should take a lead in tackling the taboo around homosexuality in the society. This, according to them, would make it easier for tongzhi to discuss HIV and AIDS openly, since many of them still know little about this disease, or do not take it seriously despite their knowledge. In conclusion, in understanding the impacts of HIV and AIDS on Chinese men who have sex with men, meanings of homosexuality should be examined in the context of family norms, desired gender roles, homophobia, HIV- and AIDS-related stigma, and other sociocultural factors in China. At a social level, homophobia in the larger society has decreased the capacity of this group to respond effectively to the epidemic. At a community level, HIV- and AIDS-related phobia on the tongzhi scene has prevented members of this group from openly confronting this disease and offering support to those tongzhi already affected by it. At an individual level, it is significant that HIV-infected/affected tongzhi have tried their best to locate resources to enable them to survive in spite of various barriers within family, community, and the larger society. Dealing with these issues will require a collective initiative that can bridge and incorporate the awareness, commitment, knowledge and resources of individuals, families, communities and society at large. Such effort and understanding will inform the development of more responsive and sensitive HIV- and AIDS-related programmes and interventions for a population whose voices are so far still little heard. Acknowledgements The author is grateful to the people living with HIV who participated in this study. Work was carried out with the aid of a grant from the International Development Research Centre (http://www.idrc.ca), Ottawa, Canada. Appreciation also goes to the Royal Bank of Canada for a Graduate Fellowship in Applied Social Work Research from the University of Toronto, and to the anonymous reviewers of this paper and to those who helped generously throughout this research project. An earlier draft of this paper was presented at the 4th International Conference on Urban Health, Toronto, Canada, 26–28 October 2005. References
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