Culture, Health & Sexuality, NovemberDecember 2006; 8(6): 487500

Homosexuality, seropositivity, and family obligations:

Perspectives of HIV-infected men who have sex with men
in China

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 mens
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, lepidemie 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 lepidemie, en
pretant peu dattention aux significations socio-culturelles de lhomosexualite 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 lelaboration dinterventions 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, lhomophobie et le stigma
du au VIH, qui contribuent aux constructions actuelles de lhomosexualite 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: zhoura@mcmaster.ca
ISSN 1369-1058 print/ISSN 1464-5351 online # 2006 Taylor & Francis
DOI: 10.1080/13691050600847455
488 Y. R. Zhou

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-to-
male 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 (16001046 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 mens 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 Nos: 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 Chinas
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
 Homosexuality, seropositivity, and family obligations 489

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 same-
sex 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 mens sexual practices in the context of HIV, these studies have rarely considered
local constructions of homosexuality and their impacts on mens 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 mens 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 mens sexual identifications and sexual practices, or how men who have sex with
mens 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 socio-
cultural settings has been challenged by many researchers (especially researchers from non-
Western 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 individuals 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.
490 Y. R. Zhou

(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 non-
sexual dimensions (e.g., class, age, race/ethnicity, religion, poverty, immigration,
colonization, and geographic location) that constitute the social meanings of homosexu-
ality. 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 homosexu-
ality 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 mens 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 peoples 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.
 Homosexuality, seropositivity, and family obligations 491

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 researchers) so as to facilitate a participant-led discussion,
though most participants still preferred sharing their experiences according to researchers
interview questions. Specifically, the researcher asked respondents questions about their
experiences of living with HIV/AIDS, their understanding of such experiences, their self-
perceptions, 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.
492 Y. R. Zhou

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 didnt 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. Its hard to say. In my case, I feel my
family is very good, but this doesnt mean doesnt mean I couldnt accept that thing [i.e., having
sex with men] If I wasnt 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 didnt 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 mens 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,
 Homosexuality, seropositivity, and family obligations 493

conflict, shame and depression) on their mental health, as displayed in the following two
quotes:

I felt much conflict and pain. I couldnt 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 dont think I am
inferior to anyone! I dont 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 familys 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 marriedhaving childrengetting divorced as a compromise between his same-
sex 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
494 Y. R. Zhou

health care. A couple of participants didnt 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 tongzhis 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
 Homosexuality, seropositivity, and family obligations 495

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 HIV-
related 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. Guos 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 didnt 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 couldnt 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. Its 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 pre-
existence, 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 mens gradual acceptance of and comfort with their sexual preference.
Widespread HIV- and AIDS-phobia, intersecting with homophobia, also shaped these
mens 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 didnt 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]. Dont you think I am dirty?! (Interview with Pin)
496 Y. R. Zhou

HIV infection also pushed some tongzhi to disclose their sexual preference to their
families, who later played a role in disciplining or policing these mens 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 mothers repeated reminders: Ensure that you will be a decent man! Dont 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 childs 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: AIDS-
phobia in society was more serious because of ignorance; his partners 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
couldnt 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 post-
diagnosis 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 individuals sexual behaviours, but a multi-dimensional
concept defined by a variety of socio-cultural dimensions. Tongzhis 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
 Homosexuality, seropositivity, and family obligations 497

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 mens 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 tongzhis 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 mens 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 mens 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
498 Y. R. Zhou

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 governments 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 socio-
cultural 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, 2628 October 2005.

References
Asthana, S. and Oostvogels, R. (2001) The Social Construction of Male Homosexuality in India: Implications for
HIV Transmission and Prevention. Social Science & Medicine, 52, 707721.
Blanc, M. (2005) Social Construction of Male Homosexualities in Vietnam: Some Key to Understanding
Discrimination and Implications for HIV Prevention. International Social Science Journal, 57, 186, 661673.
Boellstorff, T. (2005) Between Religious and Desire: Being Muslim and Gay in Indonesia. American Anthropologist,
107, 575585.
Chinese Central Television (CCTV) (2004) Homosexuality: Its better to face it than to avoid it (tongxinglian: huibi
buru zhengshi). CCTV, 2 December 2004.
Choi, K., Diehl, E., Yaqi, G., Qu, S. and Mandel, J. (2002) High HIV Risk but Inadequate Prevention Services for
Men in China Who Have Sex with Men: An Ethnographic Study. AIDS and Behavior, 6, 255266.
Choi, K., Gibson, D., Han, L. and Guo, Y. (2004) High Level of Unprotected Sex with Men and Women among
Men who have sex with Men: A Potential Bridge of HIV Transmission in Beijing, China. AIDS Education and
Prevention, 16, 1930.
Choi, K., Lui, H., Yaqi, G., Han, L. and Mandel, J. (2006) Lack of HIV Testing and Awareness of HIV Infection
among Men Who Have Sex with Men, Beijing, China. AIDS Education and Prevention, 18, 3345.
 Homosexuality, seropositivity, and family obligations 499

Creswell, J. W. (1998) Qualitative Inquiry and Research Design: Choosing among Five Traditions (London: Sage
Publications).
Gil, V. E., Wang, M. S., Anderson, A. F., Lin, G. M. and Wu, Z. (1996) Prostitutes, Prostitution and STD/HIV
Transmission in Mainland China. Social Science & Medicine, 42, 141152.
Jones, R. H. (1999) Mediated Action and Sexual Risk: Searching for Culture in Discourses of Homosexuality and
AIDS Prevention in China. Culture, Health and Sexuality, 1, 161180.
Kimel, D. C. and Yi, H. (2004) Characteristics of Gay, Lesbian, and Bisexual Asian, Asian Americans, and
Immigrants from Asia to the USA. Journal of Homosexuality, 46, 143172.
Kong, T. S. K. (2002) The Seduction of the Golden boy: The Body of Hong Kong Gay Men. Body and Society, 8,
2948.
Li, X. H. (2002) Subculture of homosexuality (tongxinglian ya wenhua) (Beijing: China Youyi Publishing House).
Liu, D. L. (1999) Sexuality and Chinese culture (xing yu zhongguo wenhua) (Beijing: Peoples Publishing House).
Merleau-Ponty, M. (2002a) The primacy of perception and its philosophical consequences. In D. Moran and T.
Mooney (eds) The phenomenology reader (London: Routledge), pp. 436460.
Merleau-Ponty, M. (2002b) The body as object and mechanistic physiology. In D. Moran and T. Mooney (eds)
The phenomenology reader (London: Routledge), pp. 427435.
Ministry of Health (MOH), Joint United Programme on HIV/AIDS (UNAIDS), and World Health Organization
(WHO) (2006) 2005 update on HIV/AIDS epidemic and response in China (Beijing, China: MOH).
Moustakas, C. (1994) Phenomenological research methods (Thousand Oaks, CA: Sage Publications).
Qian, Z. H., Vermund, S. H. and Wang, N. (2005) Risk of HIV/AIDS in China: Subpopulations of Special
Importance. Sexual Transmission Information, 81, 442447.
Qu, S., Liu, W., Choi, K., Li, R., Jiang, D., Zhou, Y., Tian, F., Chu, P. L., Shi, H., Zheng, X. and Mandel, J.
(2002) The Potential for Rapid Sexual Transmission of HIV in China: Sexually Transmitted Diseases and
Condom Failure Highly Prevalent among Female Sex Worker. AIDS and Behavior, 6, 267275.
Settle, E. (2005) Yes, Gay Men are at Risk in China. International Herald Tribune, 21 January 2005, accessed 12
May 2005, available at http://www.iht.com/bin/print_ipub.php?file5/articles/2005/01/20/opinion/
edsettle.html
Shi, F. (2003) Chinese history of sexuality (zhong guo xingwenhua shi), second edition (Haerbin: Heilongjiang
Publishing House).
Silversiders, A. (2003) AIDS activist: Michael Lynch and the politics of community (Toronto: Between the Lines).
State Council AIDS Working Committee Office (SCAWCO) and UN Theme Group on HIV/AIDS in China
(UNTG) (2004) A#joint assessment of HIV/AIDS prevention, treatment and care in China (2004), accessed 12
December 2005, available at http://www.casy.org/engdocs/JAREng04.pdf
Ullrich, P. M., Lutgendorf, S. K. and Stapleton, J. T. (2003) Concealment of Homosexual Identity, Social
Support and CD4 Cell Count among HIV-Seropositive Gay Men. Journal of Pscyhosomatic Research, 54,
205212.
UN Theme Group on HIV/AIDS in China (UNTG) (2002) HIV/AIDS: Chinas titanic peril: 2001 update on the
AIDS situation and needs assessment report (Beijing, China).
Van Manen, M. (1997) Researching lived experiences, second edition (London, ON: The Althouse Press).
Wang, Z. (2004) On the translation of the word gender in Chinese and its context (guanyu gender de fanyi jiqi
beihou). In H. Lin (ed.) Chinese Feminism (zhongguo nuxing zhuyi) (Guilin: Guangxi Normal University
Publishing House), pp. 160165.
Watney, S. (1994) Practice of Freedom: Selected Writings on HIV/AIDS (Durham, NC: Duke University).
White, R. and Carr, R. (2005) Homosexuality and HIV/AIDS Stigma in Jamaica. Culture, Health and Sexuality, 7,
347359.
Williams, J. K., Wyatt, G. E., Resell, J., Peterson, J. and Asuan-OBrien, A. (2004) Psychosocial Issues among
Gay- and Non-Gay-Identifying HIV-Seropositive African American and Latino MSM. Cultural Diversity and
Ethnic Minority Psychology, 3, 268286.
Xiaoming, S., Yong, W., Choi, K., Lurie, P. and Mandel, J. (2000) Integrating HIV Prevention Education into
Existing Family Planning Services: Results of a Controlled Trial of a Community-Level Intervention for
Young Adults in Rural China. AIDS and Behavior, 4, 103110.
Yanhai, W. (1997) The Human Right Situation of Homosexual in the 1990s in China (jiushi niandai zhongguo
tongxinglian renquan zhuangkuang). Chinese Society for Study of Sexual Minorities, accessed 02 June 2005,
available at http://www.csssm.org/07gb.htm#07jiushi
Yap, L., Wu, Z., Liu, W., Ming, Z. and Liang, S. (2001) A Rapid Assessment and Its Implications for a Needle
Social Marketing Intervention among Injecting Drug Users in China. International Journal of Drug Policy, 13,
5768.
500 Y. R. Zhou
Zhang, K. L. and Ma, S. J. (2002) Epidemiology of HIV in China: Intravenous Drug Users, Sex workers, and
Large Mobile Populations are High Risk Groups. British Medical Journal, 324, 803804.
Zhang, M. J. (2000) An Analysis on the Situation of 714 Chinese Gay Men (714 min zhongguo nantongxinglianzhe
de qingkuan fenxi). Aizhi Action Project, accessed 02 June 2005, available at http://www.aizhi.org/jkwz/
chinagay.txt