Background
It is estimated that AIDS killed more than 25 million people worldwide from 1981 to 2006 [
1]. According to the estimation and statistics of the Joint United Nations Programme on HIV/AIDS (UNAIDS), China remains one of the geographic areas with the lowest overall prevalence of HIV/AIDS in the world. However, there has been an alarming increase in the HIV/AIDS epidemic in recent years in the country [
2]. To cope with the increased burden of HIV/AIDS transmission, the Chinese National Center for AIDS/STD Control and Prevention has recommended implementing HIV/AIDS behavioral and therapeutic interventions in China. However, these interventions primarily target drug users and female sex workers through education of HIV-related knowledge and skills, promotion of condom use, increased access to voluntary HIV counseling and testing services, and improved access to treatment for sexually transmitted infections [
3]; currently, insufficient attention is being paid to the most-at-risk populations [
4].
As one of the most significant changes in the HIV epidemic in recent years in China, MSM have become the group most likely to be infected by HIV. According to a recent estimation, 12.2% of the total HIV infection in 2007 in China occurred among MSM, but by 2009 this proportion robustly rose to 32.5% [
5]. To tackle the sharply increased HIV infection rate in this unique subpopulation, "the Chinese government has made addressing HIV prevention among MSM a priority and that is something which UNAIDS welcomes", as stated by Bernhard Schwartlander, UNAIDS Country Coordinator in China [
3]. Given the illegal nature of homosexual conduct as well as the prevalent stigmas and discriminations against homosexuality in the general public and even within the MSM community itself in China, it is a significant challenge to reach members of the MSM. As a result, interventions are difficult to be applied to this unique high-risk subpopulation.
Previous studies have shown that sex with multiple gay partners, group sex, commercial gay sex and sex with male strangers are high-risk behaviors for HIV transmission [
6]. However, the psychological and social characteristics of the Chinese MSM with these high-risk behaviors as well as factors that may contribute to the development of these behaviors are largely unknown. This study was therefore conducted to assess psychological and social characteristics of MSM with high-risk sexual behaviors across mainland China as well as factors that may contribute to the development of these high-risk behaviors. Our ultimate goals are to develop social and psychological characteristics-based strategies to more effectively identify high-risk Chinese MSM for appropriate interventions as well as to minimize the risk factors underlying the development of high-risk sexual behaviors in Chinese MSM.
Methods
Ethical considerations
This study involved MSM, a unique subpopulation of men at high risk of HIV infection. The study protocol, including access and use of the data described below, was critically reviewed and approved by the Institutional Ethics Committee.
Data access
During the 10th Five-Year Plan (2001-2005) of the People's Republic of China, the Chinese Ministry of Science and Ministry of Health jointly launched and supported a National Key Research Project titled "Risk Analysis and Strategic Prevention of HIV Transmission from MSM to the General Population in China". As part of that project, a questionnaire survey was conducted on MSM in hidden bars in 9 large Chinese cities (i.e. Harbin, Shenyang, Xi'an, Zhengzhou, Shanghai, Nanjing, Wuhan, Chongqing, and Chengdu), using a snowball sampling approach by which potential future subjects were recruited by the existing respondents or subjects from their acquaintances. Based on the retrieved data, the respondents included both urban residents (either by birth or due to employment after college graduation) and rural migrant workers living in the surveyed cities. The execution of the survey strictly followed the ethical principles outlined in the Declaration of Helsinki regarding human clinical research. A written consent signed in person in the snowball sampling process was obtained from each of the subjects. The questionnaire consisted of a total of 214 questions, covering 12 aspects of gay life in China. Data from the returned questionnaires, either totally or partially completed, were stored confidentially in the database of the Project. To investigate the psychological, social, and behavioral characteristics among Chinese MSM, we requested for and were granted conditional access to the Project's database.
Data retrieval and subject categorization
In the database, there were a total of 2250 returned questionnaires, of which 714 were retrieved for analyses in this study. The exclusion criteria included: 1) "professional" gay sex workers; and 2) failure or refusal to have completely answered the following 3 core questions: 1) Have you ever hunted for male strangers in gay places and had sex with them as well within the last 6 months? 2) Did you keep a sexual relationship with at least 3 male partners at the same time in any time period of last year? 3) Have you ever engaged in commercial sex with homosexual males? Of the 2250 respondents surveyed, 59 answered "yes" to all 3 core questions and were categorized as MSM of high-risk HIV infection, 655 answered "no" to all 3 core questions and were categorized as control MSM, and those who answered "yes" to one or two of the 3 core questions were excluded.
Statistical analyses
Data were expressed as means ± SD. Differences between groups were analyzed with chi-square test or Mann-Whitney Test. A multiple regression analysis was performed to assess risk factors underlying high-risk behaviors. Differences were considered significant when P < 0.05.
Discussion
China has experienced a sharp increase in HIV infection among MSM in recent years. Although behavioral intervention is considered as an effective means of reducing HIV infection among MSM [
7], an interventional strategy shown to be effective in one setting, place, or time may not necessarily work in another [
8]. Strategies should be tailored for risk-different sub-groups of MSM based on their biomedical, behavioral, social, and psychological characteristics [
9,
10]. In this study, we attempted to characterize social and psychological differences between MSM with and without high-risk behaviors (i.e. having sex with male strangers, participating in group gay sex, and involvement in commercial homosexual activities) in China.
The analysis of the subjects' general demographic data showed that the high-risk MSM and the control MSM were similar in sexual orientation, level of education and types of profession, but significantly differed in marital status and income (Table
1). The percentage of married MSM was significantly higher in the high-risk behavior group than in the control group, in agreement with the findings from a study involving 6,661MSM in India where married MSM were more likely to have unprotected anal sex [
11]. At present, there still exist strong cultural stigmas, prejudice and discrimination against homosexuality in China and many other Asian countries; MSM are subject to great pressures from the family and society. As a result, MSM either try to hide their sexual orientation or choose to marry a woman to shield their high-risk homosexual behaviors. This may explain why more subjects were married in the high-risk behavior group than in the control group. Similar to marital status, there was a significant difference in the monthly income between MSM with and without high-risk behaviors, indicating that relatively higher income may make high-risk behaviors, like commercial sex, more economically possible. No significant difference in condom use was observed between the two groups of MSM in this study (Table
2), in disagreement with a previous observation that lower income was related with unprotected sex behavior [
12].
The respondents in the high-risk behavior group had more irregular sexual partners and utilized more diversified modes of gay sexual intercourse (e.g. oral-anal and finger-anal sex) than those in the control group (Table
3). This may be related to the fact that MSM in the high-risk behavior group had more liberal and permissive attitude towards sex. Nevertheless, the exact reason behind this needs to be further elucidated. It is well known that an exchange of blood is one of the risk factors for HIV transmission. The analysis in this study showed a relatively high proportion of MSM members in the high-risk behavior group who experienced bleeding during homosexual sex (Table
3). This might be related to the large number of sexual partners and unusual sexual behaviors (e.g. masochistic or sadistic sex). Bleeding-associated sexual activities may substantially increase the risk of HIV infection and AIDS transmission, but further studies are warranted to assess the degree to which bleeding-associated gay sex may increase the chance of HIV infection in Chinese MSM.
To date, little is known regarding the mental and psychological characteristics of MSM in China. In this study, we demonstrated that approximately half of the Chinese MSM studied had experienced different forms and degrees of embarrassment, stigma or discrimination after disclosure of their homosexual orientation and that 44% to 60% of the respondents felt that their life was painfully affected by their sexual orientation, regardless of high-risk sexual behaviors or not (Table
4). This study also indicated that almost 70% and 80% of the surveyed MSM respectively expressed a willingness to attend gay clubs if legally protected and were supportive of gay marriage legislation in China (Table
4). It has been reported that MSM are more likely to have intentions of suicide, as compared with the general population [
13] and that among MSM, suicidal intentions are even stronger among those with high-risk behaviors [
14]. In this study, we found that 29.8% of MSM with high-risk behaviors had considered suicide. Although this number was significantly lower in MSM without high-risk behaviors, the rate was still high at 17.3% (Table
4). In China, suicidal thoughts are most likely to result from psychological pressure and failure of being accepted by mainstream society. Although future legal recognition and cultural acceptance of homosexuality may substantially reduce suicide intentions and attempts in MSM in China, these cannot happen overnight. At present, a greater access to psychological counseling services is practical and feasible.
The relationship between the mentality and individual high-risk sex behaviors in MSM has not been well studied [
15]. Although a study on Black and Latino MSM has suggested that impulsive decision-making, sensation-seeking, anxiety and depression and internalized homophobia may all contribute uniquely to the behavior of unprotected anal sex [
16], more has to be learned about the specific factors that lead to high-risk sexual behaviors in MSM in China in order to minimize the development of these high-risk behaviors and to implement more appropriate and effective behavioral and therapeutic interventions. Physical or sexual abuse in childhood has been identified as a contributing factor in adverse psychological states as well as high-risk sexual behaviors in adulthood [
17‐
19]. Multivariate regression analyses in this study showed that the most important factor attributable to the development of high-risk sexual behaviors in Chinese MSM was sexual abuse from an adult male before the age of 16, followed by heavy alcohol consumption, income level, and the assumption that the use of condoms can completely (100%) prevent HIV infection (Table
5). Our findings are consistent with previous studies which indicated that sexual abuse in childhood [
20] (which is more common in countries lacking legal protection of homosexuality [
21]), traumatic injury-associated alcohol abuse [
22], and alcohol addiction [
23] were identified as risk factors for high-risk sexual behaviors. It is therefore highly logical and advisable to minimize the risk of high-risk homosexual behaviors in MSM by implementing a zero tolerance approach to all forms of childhood sexual abuse and publicly discouraging excessive alcohol consumption as previously proposed [
24]. Additionally, it is imperative to implement public education campaigns to correct the misunderstanding that the use of condoms can completely protect against HIV/AIDS.
The data analyzed in this study were from a national survey where the respondents were recruited by a snowball sampling approach. Given some limitations (e.g. more subjects recruited into the sample by some upper layer subjects who happen to have more acquaintances of MSM) intrinsically associated with this sampling approach, some unavoidable sampling bias may exist in the study.
Conclusions
Of the 714 MSM analyzed in the present study, 59 (8.26%) had high-risk homosexual behaviors. A higher in-marriage rate, a higher monthly income, a higher percentage of individuals who had experienced sexual abuse by adult male(s) in childhood, heavier alcohol consumption, a higher percentage of individuals with the mistaken belief of 100% prevention of HIV infection and AIDS transmission by condoms, and a higher percentage of individuals who had committed at least one suicide attempt were observed in the high-risk behavior group, as compared with the control group. In contrast, MSM with and without high-risk homosexual behaviors did not differ significantly in sexual orientation, level of education, types of profession, drug use, condom use and experiences of social stigma and discrimination. Additionally, a vast majority of the individuals in both behavior categories expressed support of legally protected gay clubs as well as gay marriage legislation in China. Taken together, our analyses indicate that MSM with and without high-risk homosexual behaviors have their own unique social and psychological characteristics and that sexual abuse in childhood, alcohol drinking, monthly income and the mistaken assumption of complete protection against HIV infection and AIDS transmission through the use of condoms are major contributing factors for high-risk sexual behaviors in Chinese MSM. All these group-specific social and psychological characteristics as well as contributing factors for high-risk sexual behaviors must be taken into account when developing and implementing behavioral and therapeutic interventions to target MSM, particularly those with high-risk behaviors, in China.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
Guanzhi Chen and Yang Li equally contributed to this work by performing data retrieval and statistical analyses and preparing the initial draft of the manuscript. Beichuan Zhang was the PI of this study and constructed the conceptual framework of the work. Zengzhao Yu participated in the data analyses. Xiufang Li and Lixin Wang offered help for the conception of this paper, and assisted in the completion of writing the paper. Ziming Yu consolidated the intellectual contents of the study, re-constructed and re-wrote the manuscript in a logically clearer and language-wise more proficient manner. All authors have read and approved the final version of the manuscript.