Association between stigma towards HIV and MSM and intimate partner violence among newly HIV-diagnosed Chinese men who have sex with men

Intimate partner violence (IPV) generally can occur between current or former spouses, common-law spouses, and nonmarital dating partners, whether of the same opposite sex [1]. Studies of IPV commonly consider physical, sexual, and/or psychological violence in the context of intimate partnership [2]. Men who have sex with men (MSM) in America are more likely to experience IPV during their lifetime than heterosexual men [3, 4]. Globally, prevalence rates among MSM range from 32 to 78% for experiencing any form of IPV [5, 6], 12 to 45% for physical IPV [7, 8], 5 to 33% for sexual IPV [8, 9], and 28 to 64% for emotional/psychological IPV [10, 11]. IPV has been associated with higher levels of potentially risky sexual behaviors, such as condomless sex [5, 12, 13], group sex [14], commercial and casual sex, as well as increased risks for substance abuse [15] and sexually transmitted infection [16].

The experience of IPV may be common among MSM who are HIV-positive in America [9, 12, 17]. HIV-status and related HIV stigma may play an important role in IPV within intimate partnerships among MSM. HIV-related stigma can be defined as the procession of prejudice, discounting, discrediting, and discrimination toward people living with HIV and the individuals, groups, and communities they are connected with [18‐20]. HIV stigma can further involve labeling, segregating, stereotyping or discriminating towards people living with HIV via social, economic, or political means [21]. Experiencing HIV-related stigma is not uncommon for MSM living with HIV/AIDS [22, 23], and may play a role in IPV. Among pregnant women living with HIV in South Africa, for example, greater HIV-related stigma was associated with greater combined physical and psychological IPV [24], and women living with HIV reporting high HIV-related stigma reported more frequent physical IPV, social isolation and helplessness [25]. Despite the large number of MSM in China, little is known about the IPV experience among those living with HIV.

In China, stigma concerning HIV can be coupled with stigma concerning same-sex sexual identity. Stigma towards same-sex sexual identity is common in China [26, 27]. Same-sex partnerships challenge the traditional Chinese emphasis on heterosexual child bearing for continuity of family “lines” [28]. Moreover, a person with higher stigma consciousness may be more likely to perceive discrimination towards one’s self [29]. Gay men who in violent relationships may be more likely to keep the intimate partner abuse experience in silence and stay in the violent relationship when stigma consciousness is high [30] .

HIV- and MSM-related stigma [27, 31] are well documented as common for Chinese MSM living with HIV, yet there is sparse literature on IPV and its relationship with stigma in this vulnerable population [16]. We evaluated the prevalence of lifetime IPV and its relationship with HIV- and MSM-related stigma among newly diagnosed HIV-infected MSM in Beijing, China.

In this study, we found that there was a significant association between any IPV experience and stigma among newly HIV-diagnosed Chinese MSM. Higher levels of both HIV- and MSM-related stigma indicated significantly increased odds of reporting any form of IPV after adjusted for potential confounders. Higher level of HIV-related stigma may play a role in social isolation and helplessness among victims of IPV [25]. Sexual minority MSM who are acutely aware of stigma (high stigma consciousness) may fear discrimination and negative treatment from others in the community, limiting accessing resources or seeking outside help [30]. Previous studies have identified the relationship between IPV and internalized homophobia, homophobic discrimination among MSM [38, 39], European American lesbian and bisexual women [40], gay and lesbian [30], and gay, bisexual, transgender, and queer people [41]. The association between stigma and IPV also can be elucidated since stigma consciousness is positively correlated with depression [42, 43], which is strongly associated with IPV [5, 44‐47]. Individuals who experience IPV may report internalized stigma as the most common source of stigma. Anticipated stigma may occur when they expect to be negatively judged or devalued if they disclose IPV experiences to others [48]. It remains unclear whether IPV precedes or follows stigma or if the two co-occur, creating environments that perpetuate a cycle of isolation and abuse. Further mixed methods research could provide critical information about the patterning of these experiences with MSM living with HIV.

The observed prevalence of any IPV (23.7%) in our study is in accordance with the rates among Chinese MSM in other studies (24–29%) [14, 16], but is higher than general males (7.6%) [49]. The prevalence of physical IPV experience in our study participants is higher than that among MSM in a Shanghai study (16.6% vs. 6.6%), whereas the rates of psychological IPV (7.4% vs. 8.2%) and sexual IPV (5.2% vs. 5.5%) were nearly the same [16]. The primary limitation of this study is the nature of cross-sectional surveys, which precludes assessing the temporal relationship between stigma and IPV. The association between HIV- and MSM-related stigma and IPV experience is likely bidirectional: maybe MSM with HIV- and MSM-related stigma are more likely to experience IPV, and it is also possible that IPV experience makes MSM more concerned about stigma. Either way, further research – preferably longitudinal in nature - is needed to better characterize these phenomena. Second, our study was conducted among newly HIV-diagnosed MSM in one city, and the study conclusion may have limited generalizability among MSM in other parts of China. Data from multi-center large sample study may provide more generalizable evidence. Third, we investigated the IPV experience through a simple item questionnaire and did not investigate IPV perpetration. More comprehensive and refined future studies with multiple items measurement are needed. Furthermore, only 50% of the participants responded to all of the 10 enacted stigma items [43], and enacted stigma was not included in any HIV-related stigma in our study.

Despite the limitations, this study has strengths. Of importance, we found a correlation between HIV- and MSM-related stigma and IPV among newly HIV-diagnosed MSM, who have been largely ignored. We also measured the prevalence of physical, psychological, sexual, and any IPV. The findings on specific types of IPV may be helpful for guiding the development of intervention programs. This study fills in the knowledge gap in this population.

There is no government program in China to prevent IPV among MSM and other HIV high risk groups. Our study suggested that IPV is common and it is positively associated with HIV- and MSM-stigma, HIV prevention intervention programs among MSM should provide information about warning signs for, or consequences of, intimate partner and sexual violence; these programs may also incorporate strategies to teach healthy relationship skills, promote social norms that protect against violence, and create protective environments. Professional counseling on reduction of stigma and prevention of IPV and supports from family and community should be available for those in need.

Our study found a relationship between HIV- and MSM-related stigma and IPV among newly HIV-diagnosed Chinese MSM. Further studies are needed to elucidate the reasons for and patterning of this relationship. The high prevalence of IPV and stigma in this population suggests that interventions should be taken to reduce stigma and prevent this risky behavior among MSM.