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    How China’s HIV Testing Unfairly Targets Gay Men

    Those tackling the epidemic frequently assume that homosexuality, not sexual behavior, puts people at risk.

     According to China’s official stance on its HIV/AIDS epidemic, the prevalence of HIV in the nation is low; however, certain regions and population groups are more heavily affected than others. Since 2005, HIV has mainly been transmitted through sexual contact, followed by needle-sharing when injecting drugs.

    Men who have sex with men (MSM) are among the fastest growing “key populations” in the current fight against HIV in China, especially for younger individuals. While public health authorities are careful to distinguish between “gay men” and “MSM” when talking about the issue, the two terms are often used interchangeably in both the media and everyday life. World AIDS Day has historically been an opportunity for affected groups to set the record straight and talk openly about both the progress they have made and the challenges they still face.

    On Dec. 1, 2004, China’s Ministry of Health published a landmark white paper on homosexuality, believed to be the first official acknowledgement of the existence of homosexuality in Chinese society. The report estimated that there were between 5 and 10 million sexually active gay men in China. The decision to publish such figures on World AIDS Day likely served to emphasize the grim trend of HIV infection within the homosexual community, particularly among gay men.

    The day after the report’s release, state television station CCTV aired a special program titled “Facing Up to Homosexuality Rather Than Ignoring It.” Like the concomitant white paper, the broadcast was believed to be the first-ever discussion of homosexuality aired by China’s most powerful official media outlet. The following year, the CCTV program “News Probe” ran a report titled “In the Name of Life,” which explored the issue of male homosexuality and HIV/AIDS. One participant, a man with the pseudonym Da Wei, made reference to his double identity: “My name is Da Wei. I’m a homosexual, and I’m HIV-positive.”

    To date, health authorities have largely focused on the gay community for HIV intervention efforts. Public fears — especially among heterosexuals — have rendered the topic of HIV taboo. Many people also hold negative views of homosexuality, characterizing gay people as promiscuous or perverse and claiming that their behavior runs counter to human nature. Some even say that contracting HIV is a punishment for unacceptable and immoral sexual behavior. On any TV program devoted to homosexuality, HIV is sure to make an appearance, and vice versa.

    Over time, an apparent equivalence has been drawn between male homosexuality and HIV. After the gay community was identified as a key population in the fight to halt the spread of the virus, an agreement was struck among national and local health and family planning commissions, both national- and local-level Chinese Centers for Disease Control and Prevention (CDCs), and nongovernmental organizations devoted to health care for the gay community itself (colloquially known as “comrade groups” after a Chinese slang term for a gay person).

    Comrade groups have worked hard to tackle the spread of HIV among the gay community and challenge the notion that being gay or MSM equates to having HIV or AIDS. They have consistently fought against attempts to categorize gay men as a high-risk group, which they view as an intentional effort to stigmatize the gay community. They argue instead that there are no high-risk groups, only high-risk behaviors. For example, comrade groups maintain that people from all communities have sex without using condoms, and that gay men are not the only ones to engage in sexual behavior that risks spreading HIV.

    In recent years, the Chinese government has put forth greater efforts to both raise awareness of HIV and adopt practical measures to address its spread. On every World AIDS Day from 2007 to 2009, then-President Hu Jintao visited those living with HIV. Recently, Peng Liyuan, wife of current President Xi Jinping, was named a U.N. goodwill ambassador for HIV/AIDS prevention. These efforts aim to eliminate the stigma surrounding the disease, address the systemic discrimination that HIV-positive people face, and give those with the disease an equal place in society. Yet these practical steps, idealized as they are, do not seem to extend to gay men as a whole.

    Over the course of my research in collaboration with CDCs and an anonymous comrade group I have come to see that the stigma linking HIV/AIDS with gay men is both structural and internalized.

    Although homosexuality has been decriminalized on the Chinese mainland, and to a certain extent de-pathologized as well, the official attitude toward homosexuality remains one of “no support, no opposition, no promotion.” Due to a lack of policy-level support and education, the gay community continues to be marginalized, and the public’s understanding of homosexuality remains inaccurate.

    As one sector of society most closely linked to both HIV/AIDS and the MSM community, the public health system is also the one most capable of influencing public discourse on the subject. It therefore wields tremendous power over attitudes toward both HIV and male homosexuality.

    In some academic publications on public health, “homosexuality” is listed as a direct route of HIV transmission. This view is shared by a number of CDC physicians. One doctor I interviewed expressed her view that “as long as you are not a gay man and do not engage in sexual contact with another man, you won’t contract HIV.” National-level CDC institutions categorize gay men as a group in need of regular HIV testing. But ultimately, such selective attention only reinforces the belief that all gay men require intervention and supervision.

    At a recent workshop, one CDC doctor specializing in HIV/AIDS noted that the communities affected by the virus differ from place to place, as do the routes of transmission; in China, the highest infection rates are generally recorded among gay men. But, he continued, this is not a matter of probability; it has to do with who is tested. He went on to describe recent successful testing drives targeting the gay community, which identified a number of HIV-positive individuals. But a similar policy was not rolled out for, say, female sex workers, because they were more difficult to identify and target than gay men.

    The CDC makes use of contacts within the gay community and comrade groups to promote HIV testing. This work involves going into areas frequented by gay men and handing out condoms, providing educational services, and offering free HIV tests. While such efforts seem well-intentioned, to a certain degree, they still reflect the attitude that the entire gay male community is a risk group for HIV, regardless of whether they have indeed engaged in sexual behavior that puts them at risk.

    The paradox is that the very comrade group NGOs that lead efforts to destigmatize homosexuality are in fact contributing to the stigma. As the head of one NGO put it, “The nature of national policy means the majority of our work is concentrated on the gay male community, and not on heterosexuals or other groups.”

    Comrade groups are largely funded by the CDC. As a result, they have been conscripted, albeit indirectly, into a system that discriminates against male homosexuality. “Although they say they’re opposed to stigmatization,” the same NGO head continued, “as far as [NGOs] are concerned … money is naturally the most important thing for any organization, so this problem occurs.”

    The gay community has also internalized a number of its own stigmas. During my fieldwork with CDCs, I realized the vast majority of self-identified members of the MSM community had similar conversations with doctors when they went for testing. Doctors would ask why they were undergoing the procedure, while patients sat in silence for several moments, visibly uncomfortable, before stammering out: “I’m gay.”

    Remember, only those engaged in HIV-related risk behaviors need to be tested for HIV antibodies. If a heterosexual man who engaged in high-risk sexual behavior came in for a test, would he respond to the doctors’ questions by saying “I’m straight”? Of course not. He would say he is getting tested because he engaged in unsafe sex.

    Many gay men, even those who practice safe sex, self-stigmatize without realizing it. “If you are gay, you need to get tested [for HIV],” one respondent told me. Influenced by the prevailing social climate, the gay male community has accepted the notion that they really are, by nature, a high-risk group for contracting the disease. For many, their identities are closely linked to HIV and its avoidance.

    Heterosexual relationships occupy the dominant position in society, and heterosexual people shape much of the public discourse on HIV/AIDS in China. One result of this phenomenon is the misguided view that the reason gay men have a higher risk of contracting HIV is because, in China at least, they are unable to get married and thereby institutionalize a monogamous relationship with a fellow virus-free partner.

    This false logic gives rise to further prejudice. Many assume that all gay men go through many sexual partners in a short span of time, privileging promiscuity over intimacy. In reality, Chinese notions of sex and intimacy are undergoing a more general transformation, and extramarital affairs in heterosexual relationships, one-night stands, and soliciting prostitutes are not uncommon behaviors. During my fieldwork, I saw that the vast majority of men who came to the CDC for testing did so after having heterosexual sex, regardless of their marital status.

    Of course, some gay men in China do engage in casual sexual relationships, and that gives us cause for concern. One HIV-positive gay man told me: “When comrades get together, it tends to be a ‘me and you, you and me, him and him’ kind of thing. [Sex] goes around, and everything is a bit of a muddle.” Yes, he is describing high-risk sexual behavior. No, it does not apply to all gay men; those who engage in such acts are a group within a group.

    Nevertheless, the gay community remains an undue point of concern for public health experts, as well as the recipient of calls to get tested regularly. Gay people are constantly told that while their sexuality is legal, it is shrouded in the supposedly sordid imagery of HIV infection and therefore nothing to be proud of.

    The late, great American writer and activist Susan Sontag once wrote: “Every feared epidemic disease, but especially those associated with sexual license, generates a preoccupying distinction between the disease’s putative carriers and those defined … as ‘the general population.’” HIV is no different. In China, too, many still judge HIV-positive people far too harshly — believing that they brought the disease upon themselves as just punishment for perversity — and shine too bright a light on one group at the expense of the disease’s other, overlooked patients.

    Translator: Kilian O’Donnell; editors: Lu Hua and Matthew Walsh.

    (Header image: Narendra Shrestha/EPA/IC)