Background
Gender minorities refer to those whose gender identity is not same as their birth-assigned sex (transgender) and those whose gender identity is not defined by the binary categories of women/men (gender non-conforming) [
1,
2]. In recent studies around the world, there has been a call for further analysis of HIV interventions that target different gender identities among men who have sex with men (MSM) [
3‐
5]. Previous research has shown that transgender and gender non-conforming MSM account for over 23% of the MSM population in Peru [
6]. Jobson et al. found that 9% of individuals identified as gender minorities within the MSM population in a city of South Africa [
7].
Individual MSM who identify as a gender minority report a higher likelihood of HIV risks in comparison with cisgender MSM [
8,
9]. For example, compared to the cisgender MSM population, transgender MSM are at a higher risks of new HIV infections due to sociodemographic characteristics, having higher rates of substance use, and due to the higher engagement in sex work [
10]. In a systematic review of MSM in low and middle income countries, transgender MSM had a higher prevalence of HIV and self-reported that they were more likely to engage in receptive anal intercourse without use of a condom [
9,
11]. A recent survey in Shanghai also documented that transgender and gender non-conforming MSM bore a higher HIV burden, with the prevalence of HIV-infection reaching as high as 12.4% [
12].
In addition, a previous study conducted in China has suggested that transgender and gender non-conforming populations self-report a higher incident of being bullied, higher experiences of neglect and abuse, and more depressive symptoms [
13]. And the studies on transgender conducted in USA have found that psychosocial factors can increase the risk of HIV infection [
14,
15]. Also, psychosocial factors including depression and stigma have been reported to increase the likelihood of HIV affecting in South African MSM [
16]. Therefore, psychosocial characteristics of gender minorities can’t be ignored.
To date, the associated sub-groups within the MSM population, transgender and gender non-conforming, are not considered separate sub-groups within the MSM population in China [
12]. Previous studies typically treat the MSM population as homogenous group and corresponding intervention measures have been generalized to target the MSM population as a whole [
17], providing limited information on the impact of new HIV infections and transmission among MSM gender minorities [
12,
18,
19]. In order to be effective in reducing HIV infections, growing evidence has suggested that it is important to create targeted intervention based on specific gender identity [
7,
12].
Therefore, the present study aims to explore the relationship between gender identity, psychosocial factors, and HIV-related sexual behaviors to provide tailored interventions that can be more effective in reducing HIV infections in Chinese sexual minorities. First, this study estimated the prevalence of transgender and gender non-conforming individuals within the MSM population. Second, the study assessed the HIV-related sexual behaviors and psychosocial characteristics of each subgroup of gender minority MSM, in order to provide new evidence for targeted interventions among the different MSM gender minority populations.
Results
A total of 800 participants were invited into this survey, and 749 participants completed the questionnaire, indicating a response rate of 93.6% (Wuhan city, 93.8%; Changshai City, 91.5%; Nanchang City, 94.7%). Participants who did not have not sex with men in the past 6 months (n = 23), and who were not MSM (n = 11) were excluded. That left data for 715 MSM eligible for analysis. Of the eligible individuals, 502, 106, and 107 participants were recruited from Wuhan, Nanchang, and Changsha, respectively.
As shown in Table
1, the majority of participants were cisgender MSM (91.2%), transgender and gender non-conforming MSM accounted for 8.8% (95% CI: 6.7–10.9%) of the total MSM population. In all samples, 396(55.4%) MSM were between 16 to 25 years of age and 535(74.8%) had completed college or higher education. 604 (84.5%) of the participants were unmarried and 111(15.5%) were married or divorced. 663(92.7%) individuals were employed and 362(50.6%) described that their disposable income exceeded 3000 RMB monthly. 656(91.7%) reported that they were homosexual or bisexual, whereas 59(8.3%) reported as heterosexual or unsure.
Table 1
Socio-demographic characteristics by gender identity, n (%)
Total | | 652(91.2) | 37(5.2) | 26(3.6) | | |
Age group (in years) a | | | | | – | 0.95 |
16–25 | 396(55.4) | 360(55.2) | 22(59.5) | 14(53.8) | | |
26–35 | 211(29.5) | 193(29.6) | 10(27.0) | 8(30.8) | | |
36–45 | 69(9.7) | 64(9.8) | 2(5.4) | 3(11.5) | | |
45–59 | 39(5.5) | 35(5.4) | 3(8.1) | 1(3.8) | | |
Ethnicity a | | | | | – | 0.29 |
Han group | 677(94.7) | 618(94.8) | 36(97.3) | 23(88.5) | | |
Others | 38(5.3) | 34(5.2) | 1(2.7) | 3(11.5) | | |
Educational level | | | | | 6.54 | 0.04 |
High school or lower | 180(25.2) | 156(23.9) | 13(35.1) | 11(42.3) | | |
College or higher | 535(74.8) | 496(76.1) | 24(64.9) | 15(57.7) | | |
Marital status | | | | | 0.66 | 0.73 |
Unmarried | 604(84.5) | 553(84.8) | 30(81.0) | 21(80.8) | | |
Married/divorced | 111(15.5) | 99(15.2) | 7(18.9) | 5(19.2) | | |
Employment status a | | | | | – | 0.62 |
Employed | 663(92.7) | 605(92.8) | 35(94.6) | 23(88.5) | | |
Unemployed | 52(7.3) | 47(7.2) | 2(5.4) | 3(11.5) | | |
Monthly income (RMB) | | | | | 10.18 | 0.12 |
< 1000 | 91(12.7) | 80(12.3) | 6(16.2) | 5(19.2) | | |
1000–3000 | 262(36.6) | 242(37.1) | 10(27.0) | 10(38.5) | | |
3001–6000 | 229(32.0) | 215(33.0) | 8(21.6) | 6(23.1) | | |
> 6000 | 133(18.6) | 115(17.6) | 13(35.1) | 5(19.2) | | |
Sexual orientation | | | | | 67.80 | < 0.001 |
Homosexual | 520(72.7) | 495(75.9) | 11(29.7) | 14(53.8) | | |
Bisexual | 136(19.0) | 116(17.8) | 11(29.7) | 9(34.6) | | |
Unsure/heterosexual | 59(8.3) | 41(6.3) | 15(40.5) | 3(11.5) | | |
After adjusting for age, monthly income, and sexual orientation, gender identity was not associated with psychosocial characteristics, except for identity concealment (see Table
2). Specifically, cisgender MSM reported significantly higher scores of identity concealment than transgender (mean difference = − 3.19, 95%CI = -5.74, − 0.64,
P = 0.01), while the differences among gender non-conforming MSM and the other two groups were not significant. It indicted that the cisgender MSM population were more likely to report high levels of identity concealment than transgender MSM.
Table 2
Psychosocial characteristics by gender identity, Mean ± SD (min-max)
Depression | 17.66 ± 10.50(0,58) | 17.52 ± 10.46(0,58) | 19.54 ± 11.27(2,48) | 18.58 ± 10.43(2,44) | 0.42 | 0.65 |
Perceived social support | 60.42 ± 12.55(12,84) | 60.57 ± 12.38(12,84) | 60.46 ± 14.89(25,84) | 56.46 ± 13.03(25,74) | 1.14 | 0.32 |
Resilience | 36.70 ± 8.48(10,50) | 36.75 ± 8.51(10,50) | 36.14 ± 8.45(10,50) | 36.38 ± 8.11(17,50) | 0.08 | 0.92 |
Identity concealment b | 17.05 ± 6.63(6,30) | 17.19 ± 6.61(6,30) | 16.68 ± 6.15(6,30) | 14.00 ± 7.07(6,29) | 3.33 | 0.04 |
The characteristics of HIV-related behaviors were described in Table
3 and binary logistic regression and the multinominal logistic regression models showed good fit (see Table
4). Compared to cisgender MSM, transgender MSM were more likely to have a one-night stand/occasional partners (AOR = 3.49, 95% CI =1.02–11.98), and to have sex after drug use in the past 6 months (AOR = 2.57, 95% CI =1.05–6.29). No significant differences in HIV-related sexual risky behaviors were observed between gender non-conforming and cisgender MSM.
Table 3
HIV-related behaviors by gender identity, n (%)
Multiple sexual partners | | | | | 0.69 | 0.71 |
Yes | 381(53.3) | 306(46.9) | 15(40.5) | 13(50.0) | | |
No | 334(46.7) | 346(53.1) | 22(59.5) | 13(50.0) | | |
Male partner types a | | | | | – | 0.08 |
All were one -night stand/occasional partner | 79(12.6) | 68(11.9) | 5(15.2) | 6(28.6) | | |
All were regular partners/acquaintances | 335(53.5) | 313(54.7) | 16(48.5) | 6(28.6) | | |
Both regular partners/acquaintances and one-night stand/occasional partners | 212(33.9) | 191(33.4) | 12(36.4) | 9(42.9) | | |
Sex after drugs | | | | | 6.32 | 0.04 |
Yes | 100(14.0) | 87(13.3) | 5(13.5) | 8(30.8) | | |
No | 615(86.0) | 565(86.7) | 32(86.5) | 18(69.2) | | |
Sex after drinking | | | | | 0.85 | 0.65 |
Yes | 281(39.3) | 258(39.6) | 12(32.4) | 11(42.3) | | |
No | 434(60.7) | 394(60.4) | 30(81.0) | 21(80.8) | | |
Commercial sexual behavior a | | | | | – | 0.049 |
Yes | 12(1.9) | 9(1.6) | 1(3.0) | 2(9.5) | | |
No | 614(98.1) | 563(98.4) | 32(97.0) | 19(90.5) | | |
Inconsistent condom use | | | | | 1.81 | 0.41 |
Yes | 286(49.2) | 257(48.4) | 18(60.0) | 11(55.0) | | |
No | 295(50.8) | 274(51.6) | 12(40.0) | 9(45.0) | | |
Table 4
The relationship between gender identity and HIV-related sexual behaviors
Multiple sexual partners (yes) | −0.13 | 0.73 | 0.88 | 0.43–1.80 | 0.12 | 0.77 | 1.13 | 0.51–2.52 |
Male partner type |
All were regular partners/acquaintances | ref | ref |
All were one-night stand/occasional partners | 0.16 | 0.78 | 1.17 | 0.38–3.64 | 1.25 | 0.047 | 3.49 | 1.02–11.98 |
Both regular partners/acquaintances and one-night stand/occasional partners | 0.12 | 0.78 | 1.12 | 0.49–2.56 | 0.73 | 0.18 | 2.08 | 0.71–6.09 |
Sex after drugs (yes) | −0.17 | 0.75 | 0.84 | 0.30–2.39 | 0.94 | 0.04 | 2.57 | 1.05–6.29 |
Sex after drinking (yes) | −0.49 | 0.20 | 0.61 | 0.29–1.30 | −0.04 | 0.93 | 0.96 | 0.43–2.18 |
Commercial sexual behavior (yes) | 0.55 | 0.65 | 1.73 | 0.17–18.00 | 1.71 | 0.06 | 5.51 | 0.91–33.39 |
Inconsistent condom use (yes) | 0.58 | 0.16 | 1.79 | 0.79–4.08 | 0.08 | 0.86 | 1.09 | 0.43–2.78 |
Discussion
To the best of our knowledge, this is the first study to explore gender identity differences in psychosocial characteristics and HIV-related sexual behaviors among the MSM subgroup populations in China. In the current study, compared to cisgender MSM, those in the transgender subgroup were more likely to engage in a one-night stand/occasional partners, have sex after drug use, and reported a lower likelihood of identity concealment. Consistent with Jobson’s research, gender identity played an important role in HIV transmission among the MSM population [
7]. Hence, the findings from this study suggest that effective HIV interventions within the MSM population should be separated by the different gender identities.
The study showed that the proportion of transgender and gender non-conforming accounted for 8.8% of the total MSM population. A study conducted in Peru reported that 23% of sample were identified as gender minorities among the MSM population [
6], while another study found that 7.2% of the MSM population identified as transgender women [
32]. This existing discrepancy could be attributed to various assessment tools of gender identify, different cultural norms, or study settings. Though our sample is limited to the recruitment from the central part of China, this study helps to establish the initial epidemic profile of risk factors for transgender and gender non-conforming MSM in China.
Non-significant associations between depression, resilience, perceived social support, and gender identity in the MSM population was consistent with Sandfort’s research [
37]. The cisgender MSM population were more likely to report high levels of identity concealment than transgender MSM. The lower scores of identity concealment among transgender identifying MSM could mean that transgender MSM have to tolerate more discrimination when compared with the cisgender MSM population [
38], which may increase the frequency of condomless anal sex [
39] or other HIV-related risk behaviors (e.g. male partner type) [
40] and in turn increase their risks of HIV infection. Thus, future research should further explore the relationship between gender identity and psychosocial characteristics within the MSM sub-populations, using additional measures such as discrimination.
Some studies conducted in community population showed that transgender individuals were more likely to have a one-night stand/occasional partners and sex after drug use, when compared to the cisgender MSM population [
12,
41]. A study in Brazil reported that transgender individuals engaged in more HIV-related sexual behaviors than MSM individuals, including having a higher number of sexual partners, being more likely to engage in sex [
42]. Similarly, our study conducted among the MSM population found that compared with cisgender MSM, transgender MSM were more likely to have sex after drug use and have a one-night stand/occasional partners. This is possibly because that transgender MSM have a dual minority identity being both transgender and MSM [
43] and due to this dual identity, they perceive stigma when seeking support from service, while the cisgender MSM population do not. The dual minority identity of transgender MSM, as stated, are shown to have a higher level of discrimination and engage in more risky sexual behaviors [
7]. Consequently, these results suggested that we should focus on gender minority sub-groups, as transgender MSM have different risks than the larger groups of cisgender MSM. Considering the high likelihood of one-night stand/occasional partners and sex after drug use among transgender MSM, it is crucial to increasing the awareness of HIV infection risk about above behaviors for this sub-group population, in turn reducing the frequency of HIV-related sexual behaviors. In addition, government should strengthen drug administration in order to reducing the behavior of sex after drug use.
For gender non-conforming MSM, they may or may not consider themselves to be transgender [
44,
45], so they face unique life experiences and may have different psychosocial health outcomes [
45]. Halley’s research [
45] also showed gender non-conforming MSM populations were more likely to have poor mental health and distress in comparison with transgender individuals. However, in this study, gender non-conforming MSM were not found to have significant differences in psychosocial characteristics and HIV-related sexual behaviors in comparison with the cisgender MSM. This is possibly due to small sample size in the study. Therefore, future research needs to increase sample size for further focusing on the population.
Several limitations should be noted in this current study. First, participants were recruited in three Chinese central cities by convenient sampling, and the sample size of transgender MSM and gender non-conforming MSM was small, which impacted the generalizability of the findings. Second, psychosocial outcomes were measured by four self-reported scales, not considering other variables like anxiety, self-esteem, self-efficacy, and copying styles. Also, other HIV-related behaviors (PrEP/PEP, substance use) weren’t included in the study, and detail information about types of drug or drinking during sex, frequency, duration of use wasn’t obtained. It is necessary that additional psychosocial and behavioral outcomes are incorporated in further research exploring the relationship between gender identity, psychosocial charactristics, and HIV-related risk behaviors. Third, there was a potential for social desirability bias in the psychosocial characteristic assessment. Fourth, the study ignored the differences within the transgender community, further research is needed to understand the difference between transgender women and transgender men in China. Despite these limitations, this study highlights the prevalence of transgender and gender non-conforming MSM in China, and found gender identity differences in psychosocial characteristics and HIV-related sexual behaviors. There is a need for further studies focusing on the association between gender minorities, psychosocial characteristics and HIV related risk behaviors with larger sample and considering more factors.
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