Written by Stephen Pan.

Shortly after the United States Supreme Court decision to legalise same-sex marriage in all fifty states, Chinese netizens began renewing calls for similar privileges in the People’s Republic of China, where marriage has only been permitted between persons of the opposite sex. Though legalized same-sex marriage in China appears unlikely in the near future, it is no longer inconceivable, given the gradual shift in policies and public opinion towards sexual minorities, whose most obvious landmarks include the decriminalizsation of male homosexuality in 1997, and the de-listing of homosexuality as a mental disorder in 2001. Eventual legalizsation of same-sex marriage in China could have profound implications for numerous health trends, including the country’s rapidly evolving HIV epidemic.

HIV & men who have sex with men

Since the early 2000s, the primary modes of HIV transmission in China have been shifting from injection drug use and plasma donation, to sexual intercourse. Between 2008 and 2013, the percentage of newly diagnosed HIV cases attributed to sexual intercourse rose from 47% to over 90%. Naturally, sexual intercourse takes on various forms, and each has its own associated risk of HIV transmission: in fact, because cells in the rectum are biologically more susceptible to HIV than cells in the vaginal canal, the probability of HIV acquisition during receptive anal sex is 10 – 21 times higher than during vaginal sex.

This physiological difference partly explains why HIV imposes a disproportionate burden on men who have sex with men (MSM) throughout the world. In China, despite representing less than 5% of the male population, MSM account for 29% of all new HIV infections. Moreover, HIV prevalence among MSM in China is now over 100 times higher than in the overall population (6.3% vs 0.058%).

Research on HIV and same-sex marriage

Some research suggests that legalization of same-sex marriage could mitigate the spread of HIV among MSM. First, official spouse/partner status conferred by marriage may discourage riskier sexual behaviors such as unprotected sex with multiple partners. According to one study in San Francisco from the late 1990s, men in same-sex domestic and spousal partnerships were 50% less likely to have had casual unprotected sex with a third party, when compared to men in committed relationships with men who were not spouses or domestic partners. It remains debatable how official spousal status would affect sexual behaviors among already committed same-sex couples in China, but at a minimum, legal entitlements to spousal inheritance and jointly shared property suggest that same-sex couples who marry would have greater material incentive to preserve their relationship.

Second, legalizing same-sex marriage could indirectly reduce HIV transmission among MSM by weakening stigma against sexual minorities (a.k.a., homonegativity). Experiences of homonegativity can undermine the mental well-being of sexual minorities, and in turn, sap personal motivation to consistently maintain safer sex practices such as condom use, as research has shown in China and elsewhere. MSM who harbor strong homonegative attitudes are also more isolated from sources of information about sexual health and become less likely to access HIV prevention services.

Certainly, the degree to which same-sex marriage legislation is able to influence societal attitudes about sexual minorities is debatable. Legislative protections of same-sex marriage may simply reflect established social acceptance of sexual minorities, rather than actively driving changes in the public’s attitude. In any case, correlations between same-sex marriage and HIV incidence in the US have been striking – cities with legalized same-sex marriage laws experienced about 25% fewer cases of HIV for every 100,000 MSM when compared with cities where same-sex marriage, civil unions, and domestic partnerships were banned.

Wives of men who have sex with men

Despite growing mainstream acceptance of sexual minorities in China, MSM continue to face immense familial and Confucian cultural pressures to establish traditional families and continue their lineage, as do most grown-up children in China. Consequently, millions of MSM in China enter conventional marriages and bear children in order to fulfill their duties as a son, while discreetly continuing to have sex with other men. Given the higher prevalence of HIV among MSM, public health researchers have begun to express concern about the HIV vulnerabilities of tongqi, women married to MSM.

Generally, female sterilization and intrauterine devices (IUD) are favored over condoms as a form of contraception in China (33% female sterilization; 40% IUD; 4% condoms). Thus, it can be difficult for MSM to proactively use male condoms without eliciting spousal suspicions about marital infidelity. One study estimated that only 23.3% of MSM consistently used condoms with their regular female partners. Some experts believe that 80-90% of MSM in China will at some point marry a woman.

Legalizing same-sex marriage may provide sexual minority men with viable alternatives to traditional marriage which still allow them to fulfill their filial duties of procreation. Intuitively, fewer tongqi implies fewer women potentially exposed to HIV by married MSM. The extent to which legalization of same-sex marriage can help reduce HIV infections among tongqi in China, however, will likely be influenced by attitudes towards childhood adoption by same-sex couples.

Religion and sexual behaviours

That being said, same-sex marriage legislation may have more muted effects among Christian and Muslim MSM in China who believe that having sex with men violates their religious moral principles, and remain committed to traditional marriage. The population size of Christian and Muslim MSM in China is unclear, but approximately 5.1% and 1.8% of Chinese citizens identify as Christian and Muslim, respectively. Several sexual minority Christian organizations in China have begun to challenge Christian proscriptions against all forms of sex among men, but this author is unaware of any high-profile sexual minority Muslim groups.

In short, same-sex marriage and the antecedent factors enabling its legalization in China have potential to modestly help reduce the spread of HIV, particularly among MSM and tongqi. The effects of course, will be highly uneven given the diversity of MSM. Lastly, a cursory look at countries with legalized same-sex marriage underscores the limitations of same-sex marriage in the fight against HIV. Same-sex marriage in Canada has been legal since 2005, and yet, 20% of HIV-positive MSM in Canada remain unaware they are infected. Issues such as HIV stigma remain salient and should not be overlooked.

Stephen Pan is a Ph.D. candidate at the School of Population and Public Health, University of British Columbia and Liu Scholar at the Liu Institute for Global Issues. Image Credit: CC by Qiangning Hong/flickr.