Gender identity differences in the experiences of family stressors and violence among transgender and non-binary individuals in China.

Emerging research has demonstrated that transgender and non-binary (TNB) individuals face an elevated risk of experiencing family rejection and violence. However, there remains a significant knowledge gap regarding how TNB individuals manage stressors and their gender identity within the family context, particularly in regions where TNB individuals are highly stigmatized and where legal protections against family violence are lacking. The present study represents one of the first pioneering efforts to provide large-scale quantitative data examining the experiences of family stressors, the management of gender identity and expression, and family violence among TNB individuals in China. A national sample of 1063 TNB individuals in China was involved in the study. They completed questionnaires about their experiences of family stressors and violence. The results indicated that 76.0% of TNB individuals reported having encountered at least one form of violence perpetrated by their family members. Transfeminine individuals were more likely to report experiencing emotional and physical abuse, whereas transmasculine individuals were more likely to be subjected to gender identity and/or expression change efforts. Family stressors, including family non-acceptance and the pressure to marry and reproduce, were positively associated with non-disclosure of gender identity, the suppression of gender expression, and family violence. The findings underscore the substantial burden of family violence borne by TNB individuals in China, which warrants immediate legal, institutional, and social responses. Trans-inclusive family violence prevention and intervention are urgently needed, with a focus on Chinese cultural factors and gender identity differences in violence screening and risk assessment.

Effects of identity disclosure on school victimization and long-term educational outcomes among lesbian, gay, bisexual, transgender, and intersex students in China.

This study examined identity disclosure among lesbian, gay, bisexual, transgender, and intersex (LGBTI) students in China and investigated the effects of coming out on school victimization as well as current academic performance and long-term educational outcomes. The study drew on a national sample of 9260 Chinese LGBTI students (age range = 12-42 years) and 9668 LGBTI individuals who were not in education (age range = 14-85 years). The results showed that LGBTI students were more likely to come out to their fellow students (61.4%) than to their teachers (42.4%). Approximately 40.2% of LGBTI students reported having encountered victimization in school, and they also were more likely to report school dropout and lower levels of educational attainment than those who did not experience school victimization. Transgender and gender nonconforming students and intersex students were particularly vulnerable to the experiences and adverse effects of school victimization. In addition, the findings indicated that although students who came out in school were more likely to experience school victimization, identity disclosure was related to better long-term educational outcomes. This study is one of the first to document the identity disclosure, victimization experiences, and school outcomes of LGBTI students in China. The results show that identity concealment may bring short-term benefits by protecting LGBTI students from school victimization but may be harmful to them in the longer run. To foster a supportive climate and a safe school environment, it is important to enact sexual and gender diversity education, inclusive school policies, and teacher training programs at different levels of schooling.

A qualitative study of older people living with HIV Hong Kong: Resilience through downward comparison amidst limited social support.

Research on older people living with HIV (OPHIV) highlights social support as an important dimension of their resilience and coping resources. This study asks: in face of high perceived risk of HIV status disclosure, how do OPHIV cope when they have little social support from family and friends? METHODS: This study broadens the study of OPHIV beyond North America and Europe and presents a case study of Hong Kong. In collaboration with the longest-running non-governmental organization working on HIV/AIDS issues in Hong Kong, 21 interviews with OPHIV were conducted. RESULTS: It was found that a vast majority of them did not disclose their HIV status and many lacked social support from family and friends. The OPHIV in Hong Kong turned instead to coping through downward comparison, drawing on a comparison between their current lives with: (1) how they themselves experienced HIV in their earlier life; (2) how HIV was socially treated in the past; (3) how HIV was medically treated in the past; (4) growing up under harsh economic circumstances when industrialization and rapid economic development took place in Hong Kong; (5) Eastern religions, spiritual support and the associated philosophy of 'letting go' and acceptance. CONCLUSIONS: This study has found that in face of high perceived risk of HIV status disclosure, where OPHIV have little social support from family and friends, they used the psychological mechanism of downward comparison to maintain positivity. The findings also contextualize the lives of OPHIV against the historical development of Hong Kong.

Association between co-residence and loneliness during COVID-19 among sexual minority people in Hong Kong.

BACKGROUND: Research has identified that loneliness during COVID-19 is associated with co-residence status, and individuals living alone were more likely to report loneliness. However, it may not apply to sexual minority people as those living with their family may experience different sexual orientation-related stressors. AIMS: This study aims to (1) understand the pattern of living arrangement and loneliness among sexual minority people during COVID-19, (2) examine parental acceptance, family conflict and loneliness among sexual minority people with different living arrangements and (3) investigate the association between parental acceptance and loneliness among sexual minority people with different living arrangements during COVID-19. METHOD: An online survey with 1,457 Hong Kong sexual minority people was conducted. RESULTS: Sexual minority people living with their partner(s) were less likely to report loneliness. Concurrently, those living with their parent(s) showed a similar level of loneliness as those who lived alone. Living with parent(s) during COVID-19 does not necessarily alleviate feelings of loneliness among them, which we argue may be due to parental unacceptance of their sexual orientation. Nearly half of the respondents stated that their parent(s) were unaccepting of their sexual orientation and 41.8% of them indicated an increase in family conflict during COVID-19. For those living with their parent(s), parental unacceptance is related to more family conflict during COVID-19, which in turn is associated with higher levels of loneliness. CONCLUSIONS: Not living with unaccepting parents may reduce family conflict and feelings of loneliness, but this has not been the case for many respondents from a city with high population density and cost of living. Social and mental health service providers need to come up with timely and appropriate interventions to address the unique needs faced by sexual minority people during and after the COVID-19 pandemic.

Sex Conservatism, Internalized Homonegativity, PrEP Stigma, and Intention to Use PrEP: A Study of Chinese-Speaking Gay and Bisexual Male Youth in Hong Kong.

Pre-exposure prophylaxis (PrEP) stigma has been found to be a major barrier to PrEP acceptability and uptake. Research has found that different ethnic/cultural groups display varying levels of PrEP stigma. This article studies sex conservatism and internalized homonegativity as two sexuality- and culture-related aspects that influence PrEP stigma and intention to use PrEP. An online survey of 279 young gay and bisexual men in Hong Kong found that internalized homonegativity was positively associated with PrEP stigma. Respondents who were more conservative about sex showed lower intention to use PrEP, whereas those who had higher income and more positive attitudes about PrEP were more likely to express intention to use PrEP. This study provides novel empirical evidence for understanding PrEP stigma and uptake from a sexuality and cultural perspective. The influence of sexuality- and culture-related factors on PrEP stigma and uptake warrants greater attention, especially in the Asia-Pacific region.

Heterogeneity in the Desire to Undergo Various Gender-Affirming Medical Interventions Among Transgender People in Hong Kong: Findings from a Community-Driven Survey and Implications for the Legal Gender Recognition Debate.

Previous estimates suggest that there are at least nine million transgender people in Asia-Pacific; however, in most countries, legal gender recognition has not been made possible or there are otherwise stringent eligibility criteria. The obligation of having undergone gender-affirming medical interventions as a basis for such recognition is being hotly debated. However, there has been little empirical evidence on the desire to undergo various gender-affirming medical interventions among transgender people. This study fills the research gap by studying Hong Kong, where a transgender person must produce medical evidence for "complete" sex reassignment surgery in order to change the sex entry on their identity card. A community-driven survey of 234 transgender people found that only 13.0% of the participants who were assigned male at birth could fit such a requirement. Strikingly, because none of the participants assigned female at birth had undergone construction of a penis or some form of a penis, all of them would be excluded from legal gender recognition. Financial reasons and reservations about surgical risks and/or techniques were the most commonly cited reasons for not undertaking the medical interventions. The findings suggest that an overwhelming majority of transgender people in Hong Kong are excluded from legal gender recognition, which fundamentally affects their civil, political, economic, social, and cultural rights. More generally, this study shows heterogeneity among transgender people in the desire for different gender-affirming medical interventions, and thus argues that the legal gender recognition debate needs to consider their concerns and self-determination.

Experiences of COVID-19 among Chinese-speaking lesbian, gay and bisexual people in Hong Kong: an inductive thematic analysis of survey response data.

As social inequalities during the COVID-19 pandemic have been recognised, emerging research showed that lesbian, gay and bisexual (LGB) people may be additionally affected during the pandemic. This paper adds to the understanding of the experiences of LGB people during the pandemic with a focus on Hong Kong, where issues of space significantly influence LGB people's lives in this city with high population density. As part of a larger community study of LGB lives in Hong Kong, COVID-19-related impact on 434 Chinese-speaking LGB people was explored. Data collection was conducted from 20 May to 30 June 2020. Inductive thematic analysis of the open-text response survey data found that the LGB participants described both negative and positive impacts brought by COVID-19. Such impacts could be dimensionalised into those related to personal space and privacy, romantic and sexual space, and community space. It was also found that the experiences of COVID-19 among LGB people in Hong Kong were intersectional, along the lines of living arrangement and relationship status. Such findings make unique contributions to the emerging literature. First, there needs to be a more nuanced understanding of sexual minority individuals' experiences during COVID-19 across cultural contexts. Second, COVID-19 was described as having brought positive impact in addition to its widely known negative impact.

The Influence of Concerns About a Child's Sexual Orientation on Mental Health Among Parents of Lesbian, Gay, and Bisexual Children in Hong Kong.

Sexual minority stress affects not only lesbian, gay, and bisexual (LGB) individuals, but also their families. Due to the pervasiveness of stigma and discrimination, parents of LGB children often express concerns about the public perception of their child's sexual orientation and its possible impact on children, parents, and families. The concerns are particularly pertinent to parents in Chinese families, where there is a strong bond between parents and children. The present study seeks to understand the different dimensions of concerns among Chinese parents of LGB children and examine how these concerns affect their mental health. A total of 146 parents of LGB children in Hong Kong were recruited to participate in a survey regarding attitudes and concerns about their child's sexual orientation. The results revealed three areas of concern, which reflect parental worries about how a child's LGB identity may negatively impact the child, parent, and family. Parents who viewed homosexuality and bisexuality as innate and accepted their child's sexual orientation were likely to show fewer concerns. The results of structural equation modeling indicated that parental acceptance was negatively related to depression and anxiety symptoms through lower levels of child-oriented and family-oriented concerns. As accepting a child's sexual orientation is the key to reducing parental concerns and mental health problems, family-focused psychoeducation is needed to provide parents with accurate information about sexual orientation and foster supportive attitudes toward their LGB child. Clinicians and human service providers should also address child-oriented and family-oriented concerns among parents of LGB adolescents who are more inclined to be concerned about their child's sexual orientation.

Ageing non-heterosexual migrants: Towards global sexual citizenship.

This paper focuses on ageing non-heterosexual migrants, an understudied group, in order to contribute to two emerging strands of research literature in ageing studies: ageing migrants and non-heterosexual ageing. This paper draws on the narrative of a 60-year-old partnered gay man, Oliver, who is originally from the UK and had lived in Hong Kong for more than 20 years at the time of the interview. Oliver's experiences as an ageing non-heterosexual migrant embody both privilege and vulnerability. For him, white privilege acts as a shield against homophobia and ageism. However, although he feels cultural and social belonging to Hong Kong, his same-sex relationship is not legally recognised in Hong Kong. This produces anxiety about future care and end-of-life concerns for him and his Asian partner, as he decides between staying in Hong Kong and returning home to the UK for greater legal recognition of his same-sex relationship. Such findings highlight diversity among ageing migrants, and coexistence of privilege and vulnerability in the lives of non-heterosexuals who age outside of their country of origin. This paper also contributes to the literature on non-heterosexual ageing by adding an understudied diasporic perspective, and on sexual migration by highlighting the life course perspective to show that sexual minority migrants' experience is stratified by age. This paper argues that global sexual citizenship is an increasingly relevant theoretical concept in an era of unequal sexual rights development around the world. Social policies have largely overlooked the later life concerns of ageing non-heterosexual migrants, where a lack of legal recognition of their same-sex relationship has them left without policy protection.

Disruption of HIV Service Provision and Response in Hong Kong During COVID-19: Issues of Privacy and Space.

The impact of the COVID-19 pandemic on sexual and reproductive health and rights is a significant public health issue. HIV/AIDS related services have been severely disrupted during the pandemic in different aspects. This paper highlights how privacy concerns affected HIV service provision during COVID-19 in Hong Kong, by sharing the experience of AIDS Concern Hong Kong. Based on our experience of working with our local MSM clients, temporary closure of center-based testing, venue-based testing in gay saunas, and mobile testing, meant that MSM could not easily go to a safe space to get anonymous and gay-friendly testing. To mitigate this, AIDS Concern Hong Kong put effort into promoting and making self-testing available during periods of testing center closure. We also made sure that people can choose to have test kits delivered to an anonymous pick-up station.

An exploratory study of factors associated with difficulties in accessing HIV services during the COVID-19 pandemic among Chinese gay and bisexual men in Hong Kong.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in the disruption of provision of human immunodeficiency virus (HIV) services. This study examined the factors associated with difficulties in accessing HIV services during the COVID-19 pandemic. METHODS: An online survey of 236 Chinese-speaking gay and bisexual men in Hong Kong conducted in 2020. RESULTS: Among those who expressed a need to access HIV services during the COVID-19 pandemic, 22.9%, 33.9% and 43.2% indicated moderate-to-high, mild and no difficulties in accessing these services, respectively. Difficulties in accessing HIV services were positively related to concerns about potential COVID-19 infection, experience of actual impact on health because of COVID-19, disruption in work/studies, and reduced connection to the LGBT+ community during the pandemic. It was also found that difficulties in accessing HIV services were positively associated with frequency of having sex with casual partners, but were not significantly associated with frequency of having sex with regular partners. CONCLUSIONS: This study provides novel empirical evidence for understanding difficulties in accessing HIV services during the COVID-19 pandemic. It found that disruption in work/studies and frequency of having sex with casual partners were associated with difficulties in accessing HIV services.

To Have or Not to Have Sex? COVID-19 and Sexual Activity Among Chinese-Speaking Gay and Bisexual Men in Hong Kong.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak has fundamentally changed daily routine, including sexual activity. However, most research on sexual activity during the COVID-19 pandemic focused on heterosexual individuals. The only study so far on men who have sex with men was conducted in the United States. AIM: Our study expands the understanding of sexual activity during the COVID-19 pandemic by studying gay and bisexual men in Hong Kong. Although sexual desire and sexual activity continue to be important aspects of one's life during the COVID-19 pandemic, there are COVID-19-related barriers to having sex. This study therefore examined the association between sexual desire, COVID-19-related barriers, and whether to engage in sexual activity or not during the COVID-19 pandemic. METHODS: 857 cisgender sexual minority people in Hong Kong participated in an online survey study, and for this article, only male participants were included in the analysis, yielding an analytical sample of 376 gay and bisexual men. OUTCOMES: Participants were asked to assess their sexual desire (ie, sexual drive and sexual motivation), COVID-19-related barriers (ie, perceived difficulties to have sex with another person during the pandemic and perceived risk of COVID-19 infection), and sexual activity during the COVID-19 pandemic. RESULTS: It was found that while sexual desire remained prevalent among the gay and bisexual men, COVID-19-related barriers were also commonly observed. Sexual drive and sexual motivation were positively associated with sexual activity. Perceived difficulties to have sex with another person during the pandemic and perceived risk of COVID-19 infection were negatively predictive of engaging in sexual activity, after controlling for general sexual desire. CLINICAL IMPLICATIONS: Understanding the ambivalence and driving and inhibiting factors for having sex during the COVID-19 pandemic can provide a new framework for understanding people's sexual activity during an unprecedented scale of the pandemic. It is likely that abstinence would not work as the respondents expressed strong sexual desire and that the pandemic is going to last for a long time. Governments, policy makers, and sexual scientists need to work together to come up with practicable, feasible, and easy-to-follow guidelines for having sex during the pandemic. STRENGTH & LIMITATIONS: This is one of the first studies to examine the impact of COVID-19 on sexual activity among gay and bisexual men. The results should be interpreted with caution because of the use of cross-sectional design and nonprobability sampling. CONCLUSION: Sexual desire and COVID-19-related barriers serve as driving and inhibiting factors in explaining whether or not people have sex during the COVID-19 pandemic. Suen YT, Chan RCH, Wong EMY. To Have or Not to Have Sex? COVID-19 and Sexual Activity Among Chinese-Speaking Gay and Bisexual Men in Hong Kong. J Sex Med 2021;18:29-34.

Effects of general and sexual minority-specific COVID-19-related stressors on the mental health of lesbian, gay, and bisexual people in Hong Kong.

The impact of COVID-19 on mental health has begun to be widely recognized, but there is an absence of studies on how the mental health of lesbian, gay, and bisexual (LGB) people have been affected by the COVID-19 pandemic. A total of 857 LGB people in Hong Kong participated in a community-based survey study. Over one-fourth of them met the criteria for probable clinical depression (31.5%) and generalized anxiety disorder (27.9%). Besides general stressors, we identified sexual minority-specific stressors during the pandemic. 4.2% of the participants indicated that they had frequently experienced family conflict related to sexual orientation. One-third responded that they had largely reduced connection to the lesbian, gay, bisexual, and transgender plus (LGBT+) community (34.7%). The results showed that sexual minority-specific COVID-19-related stressors explained significant variance in depressive and anxiety symptoms, above and beyond the contribution of general COVID-19-related stressors. Since LGB people are particularly vulnerable to poor mental health during the COVID-19 pandemic, LGB people-targeting organizations need to understand more about family, space, and privacy concerns in order to provide better support, and LGB safe spaces and shelters may be needed as a policy response.

Relationship Between Religion and Non-Heterosexuality: A Study of Lesbian, Gay and Bisexual People of Diverse Religions in China.

An established scholarly literature, largely generated from North America and Europe, highlighted intolerance experienced by lesbian, gay and bisexual (LGB) people in some mainstream religious traditions such as Christianity and Islam. However, very little research has examined the lived experiences of LGB people who identify as followers of other religions in other parts of the world. The study examined the self-reported experiences of 2,681 LGB people of diverse religions in China, where any data on the group has been extremely rare because homosexuality and religion are both topics officially sanctioned. It was found that a larger proportion of LGB people of traditional Chinese religions assessed their religious doctrines to be more LGB-accepting and reported that their religious workers and fellow believers were more LGB-welcoming, as compared with their Christian and Muslim counterparts. LGB people of traditional Chinese religions were also less likely to experience negative treatment in the religious community than Christians. However, the majority of the Chinese LGB people surveyed did not disclose their sexual orientation to members of their religious community, and this did not differ significantly across religions. The study contributes to the research literature by diversifying the understanding of the relationship between religion and non-heterosexuality.

A nationwide cross-sectional study of 15,611 lesbian, gay and bisexual people in China: disclosure of sexual orientation and experiences of negative treatment in health care.

BACKGROUND: Lesbian, gay and bisexual (LGB) people often face individual- and system-level barriers in health care. However, LGB people's experiences of health care in non-European and non-American settings have been scarcely studied. In China, while it has been estimated that there are at least 70 million gender and sexual minorities, there has been no larger-scale study on LGB people's experiences of health care beyond a focus on gay men and HIV. This study is the first larger-scale quantitative study to investigate LGB people's experiences of health care in China, where non-heterosexuality is officially silenced and the needs of non-heterosexual people are largely ignored by service providers. METHODS: An online survey was designed in joint partnership by academic, community groups and the United Nations Development Programme. Targeted and snowball sampling was adopted for participant recruitment. Such unique cross-sectoral partnership made this research possible in the authoritarian state of China where data collection on LGB people is extremely rare. For the analysis in this paper, a sample of 15,611 Chinese LGB people were included. Frequency and descriptive statistics were conducted to describe the LGB respondents' demographic characteristics and their experiences in health care settings. Chi-square tests were conducted to test how experiences vary across LGB people with different demographic characteristics. RESULTS: More than three quarters of the respondents said they would be willing to disclose to their medical care providers their sexual orientation if asked. However, only 5.7% of the respondents said that medical care providers ever asked them about their sexual orientation. About 8.0% of the LGB people surveyed reported having experienced negative treatment in medical care settings. Six percent (5.7%) of the Chinese LGB people said in accessing mental health care services, they were recommended, coaxed into, or provided conversion therapy for sexual orientation, gender identity or gender expression. CONCLUSIONS: There is a strong need to enhance LGB cultural competence among health care providers. Policymakers in China should also formulate laws, policies, regulations, clearly articulated codes of conduct, and transparent procedures and practices to ensure non-discrimination of LGB people in the health care system, with a particular focus on banning conversion therapy.

Mental Health of Transgender People in Hong Kong: A Community-Driven, Large-Scale Quantitative Study Documenting Demographics and Correlates of Quality of Life and Suicidality.

A community-driven survey of 106 transgender people (the first such survey in Hong Kong) showed that: (1) more than half the sample (50.9%) had a university degree or higher qualification; (2) despite this, 43.4% had a monthly income below HK$6,000 (about USD$775); (3) 66% reported "fair" or "poor" quality of life; (4) 67% of the sample (87.1% of respondents aged 15-24 years) had contemplated suicide; and (5) 20.8% of the sample (35.5% of respondents aged 15-24 years) had attempted suicide. It was found that (1) those who were single, had a lower monthly income, and identified as transgender women reported lower quality of life; and (2) those who were younger and on a lower income expressed higher suicidality. The findings suggest that service providers and policy makers urgently need to address the mental health needs of transgender people, particular younger transgender people.

Older Single Gay Men's Body Talk: Resisting and Rigidifying the Aging Discourse in the Gay Community.

Previous research saw older gay men as subject to structural marginalization of ageism but yet possessing agency to interpret aging in diverse ways. I move beyond this duality, drawing on the theory of defensive othering to understand how older gay men live with the aging discourse in the gay community. Informed by grounded theory, I analyzed interviews with 25 self-identified single gay men aged 50 or above in England inductively. It emerged that many older gay men found it difficult to escape the discourse that marginalizes the aging body. Even when they argued they were the exception and "looked good," they were discursively producing a two-tier system: they themselves as the "good older gay men," as opposed to the other "bad older gay men," who "had given up." Such a defensive othering tactic seemingly allowed them to resist age norms from applying to them personally, but unintentionally reinforced an ageist discourse.