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      Charting a Moral Life: The Influence of Stigma and Filial Duties on Marital Decisions among Chinese Men who Have Sex with Men

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          Stigma constitutes a critical challenge to the rising rates of HIV among Chinese men who have sex with men (MSM). It reduces willingness to disclose one’s sexual orientation and can lead to concurrent sexual partnerships. Disclosure decisions are also affected by cultural norms that place pressures on sons to marry. In this manuscript, we characterize how stigma and cultural factors influenced Chinese MSM’s decisions around disclosure and marriage. We seek to show that MSM’s actions were motivated by moral considerations, even when those choices posed HIV transmission risks.


          We conducted qualitative interviews with 30 MSM in Beijing, China. Interviews were audio-recorded, transcribed, and translated into English for analysis. Transcripts were coded using a procedure that allowed for themes to emerge organically.


          Participants struggled with feelings of shame and believed that others possessed stigmatizing attitudes about homosexuality. They had experienced relatively little discrimination because they infrequently disclosed their MSM status. In response to marital pressures, participant had to reconcile same-sex attractions with filial expectations. Their choices included: not being involved with women; putting on the appearance of a heterosexual relationship by marrying a lesbian; or fulfilling family expectations by marrying a heterosexual woman. Regardless of the decision, many rooted the justifications for their choices in the considerations they had given to others’ needs.


          The growing epidemic among MSM in China requires action from the public health community. As programs are scaled up to serve these men, it is critical to remember that MSM, who often fear social sanction if they were to reveal their sexual orientation, continue to face the same pressures from culturally normative social duties as heterosexual men. Interventions must find ways to help men navigate a balance between their own needs and the responsibilities they feel toward their parents and others.

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          Most cited references 13

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          HIV-related stigma: adapting a theoretical framework for use in India.

          Stigma complicates the treatment of HIV worldwide. We examined whether a multi-component framework, initially consisting of enacted, felt normative, and internalized forms of individual stigma experiences, could be used to understand HIV-related stigma in Southern India. In Study 1, qualitative interviews with a convenience sample of 16 people living with HIV revealed instances of all three types of stigma. Experiences of discrimination (enacted stigma) were reported relatively infrequently. Rather, perceptions of high levels of stigma (felt normative stigma) motivated people to avoid disclosing their HIV status. These perceptions often were shaped by stories of discrimination against other HIV-infected individuals, which we adapted as an additional component of our framework (vicarious stigma). Participants also varied in their acceptance of HIV stigma as legitimate (internalized stigma). In Study 2, newly developed measures of the stigma components were administered in a survey to 229 people living with HIV. Findings suggested that enacted and vicarious stigma influenced felt normative stigma; that enacted, felt normative, and internalized stigma were associated with higher levels of depression; and that the associations of depression with felt normative and internalized forms of stigma were mediated by the use of coping strategies designed to avoid disclosure of one's HIV serostatus.
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            Experiences of social discrimination among men who have sex with men in Shanghai, China.

            In China, men who have sex with men (MSM) are at increasingly high risk for HIV. However, prevention efforts targeting this population may be hindered because of the stigma associated with homosexuality in traditional Chinese culture. We conducted qualitative interviews with 30 MSM in Shanghai to better understand the types and sources of stigma and discrimination and how MSM respond to them. The stigma associated with homosexuality can be traced back to four culturally based factors: social status and relationships, the value of family, perceptions of immorality and abnormality, and gender stereotypes of masculinity. In particular, the centrality of the family and the importance of maintaining key relationships caused stress and anxiety, contributing to more frequent encounters with felt stigma. In response, MSM often evaded the scrutiny of family members through various tactics, even prompting some to leave their rural homes. Implications of these findings on HIV/AIDS prevention are discussed.
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              Evolution of men who have sex with men community and experienced stigma among men who have sex with men in Chengdu, China.

              To understand the stigma and discrimination experienced by men who have sex with men (MSM) in Chengdu, and to evaluate their impact on effective HIV prevention. Focus group discussions and individual in-depth interviews were conducted from June to September 2006. Stigma and social pressure for MSM were reported to mainly arise from their families to get married and have children to protect family reputation and lineage. Few participants reported experiencing stigma and discrimination from friends, colleagues, or general society. Nevertheless, fear of being ostracized because of their sexual orientation was frequently expressed, and was a major barrier for participating in HIV/AIDS prevention programs. Fear of stigma and discrimination related to HIV infection from inside the MSM community was also identified as a major reason for MSM reluctance to seek HIV testing and treatment. Stigma and discrimination related to homosexual activities and HIV/sexually transmitted disease infection have been major barriers for MSM seeking health services. HIV/AIDS programs must be sensitive to issues of stigma both from outside and inside the MSM community.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                9 August 2013
                : 8
                : 8
                [1 ]Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
                [2 ]Institute of Social Development and Public Policy, Beijing Normal University, Beijing, People’s Republic of China
                The University of New South Wales, Australia
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: WTS PM KC. Performed the experiments: WTS PM. Analyzed the data: WTS PM KC. Wrote the paper: WTS PM KC.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 9
                This research was funded by a grant from the United States National Institute of Mental Health (R01MH085581). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Clinical Research Design
                Qualitative Studies
                Social Epidemiology
                Global Health
                Infectious Diseases
                Sexually Transmitted Diseases
                Mental Health
                Non-Clinical Medicine
                Health Care Policy
                Health Risk Analysis
                Psychological and Psychosocial Issues
                Sexual and Gender Issues
                Medical Sociology
                Socioeconomic Aspects of Health
                Public Health
                Behavioral and Social Aspects of Health
                Preventive Medicine
                Social and Behavioral Sciences
                Social Discrimination
                Social Prejudice
                Sexual and Gender Issues



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