Sexual health status of women who have regular sexual relations with men who have sex with men in mainland China

Li et al. BMC Public Health (2017) 17:168 DOI 10.1186/s12889-017-4096-z RESEARCH ARTICLE Open Access Sexual health status of women who have regular sexual relations with men who have sex with men in mainland China Xiufang Li1*, Beichuan Zhang1, Juan Wang2, Yang Li3, Xianhong Li4, Peiheng Yu5, Minghua Liu6 and Xinqiao Liu1 Abstract Background: Men who have sex with men (MSM) are a high-risk group for sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) infection. In China, the vast majority of MSM feel forced to marry or plan to marry women, according to traditional Chinese culture. Women who have regular sexual relations with MSM, called tongqi in mainland China, live with a high risk of STDs or HIV infection, but these risks are often ignored. Our investigation of this group of the women is a preliminary study that aims to understand the sexual health problems of tongqi and related factors. Methods: This study relied on website mobilization and was funded by tongqi. Participants were limited to women who had sex with MSM to whom they were married (in-GWs), whom they had divorced (ex-GWs), or with whom they were friends (GGFs). The data were collected using questionnaire software. Results: A total 144 valid surveys were returned from 100 in-GWs, 33 ex-GWs, and 11 GGFs. Average respondent age was 32.8 ± 6.4 years (range 22 to 58 years). Among in-GWs and ex-GWs, over 95% learned that their husbands were MSM after marriage. More than half of respondents had had sex before marriage, and one-third of those women had sex partners other than their husbands. In addition, 35.3% of tongqi had STDs symptoms. About 50% participants had had oral sex with sex partners of MSM and 10% had had passive anal sex, with low condom use during both oral (9.7%) and anal sex (23.1%). Most tongqi had misunderstandings about STDs and HIV and less than 30% had undergone HIV screening. Among participants tested, 5.6% were HIV positive. A total 93.5% of respondents believed that laws should be established to protect the sexual rights of women. Conclusions: Women who have regular sexual relations with MSM face adverse sexual health issues and are susceptible to STDs and HIV infection. Measures must be taken to protect the rights and interests of tongqi in mainland China. Keywords: Women, Regular sex partner, Men who have sex with men, Sexual health status, Mainland China Background Women who have regular sexual relations with men who have sex with men (MSM) include three subgroups: 1) women who have sex with MSM to whom they are married; 2) those who had sex with MSM to whom they were married but who they later divorced; and 3) women who have regular sexual relations with MSM but who are unmarried (female friends). These women are called * Correspondence: 1 Department of Sex Health Center, Affiliated Hospital of Qingdao University, 16 Jiangsu Street, Qingdao, Shandong 266003, China Full list of author information is available at the end of the article tongqi in mainland China, and the three subgroups are respectively designated in-GWs, ex-GWs, and GGFs. Today, there is a more open attitude toward homosexuality in western countries, with some passing legislation to legalize homosexual marriage. In contrast to these countries, homosexual marriage is illegal in China as well as in many other developing eastern countries. As a result, the status of heterosexual women who are married to MSM varies among different countries worldwide. In developed countries such as the United States or Switzerland, some MSM have regular sex with women or marry women with a different sexual © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Li et al. BMC Public Health (2017) 17:168 orientation. The political, cultural, and economic backgrounds of such countries permit greater individual freedom of choice and legal protection [1, 2]. Few women have regular sex with MSM, and surveys of these women are focused mainly on qualitative psychology [3–5]. According to a 2002 survey of MSM in the United States, married MSM were more likely to have unsafe sex than unmarried MSM, thus exposing their wives to a higher risk of human immunodeficiency virus (HIV) infection. Future strategies for the prevention of acquired immunodeficiency syndrome (AIDS) among such women should be more targeted [6]. A 2005 statistical analysis of a large sample of MSM in India indicated that 41.8% of MSM were married to women [7]. Data from a 2010 survey of 443 MSM in Tanzania who did not use injection drugs showed that 29.1% of them were married and 11.9% were separated, divorced, or widowed [8]. Another survey of MSM with HIV/AIDS carried out in India showed that women whose sex partners were MSM were at risk for HIV/AIDS [9]. Surveys of MSM with HIV/AIDS in some countries reveal a high percentage are married or have had sex with heterosexual women; however, few surveys have focused on these women [7, 10, 11]. Evidence from recent surveys in China has revealed that the marriage status of MSM to women is significantly different from that in Europe and the United States but is similar to that in many developing countries [12, 13]. A 2011 survey of 318 MSM infected with HIV in China demonstrated that 37.7% of them were married and in some cases, their wives had also been infected with HIV, a situation that should be urgently addressed [14]. The reasons why MSM marry heterosexual women include traditional moral, philosophical, and religious constraints (in which MSM consider a wife and family to act as a “shield” against negative social opinion), a desire for family life and children [6], and unawareness of one’s own sexual identity. It is worth noting that as a very important group closely related to MSM, tongqi receive little attention and support, a phenomenon that is contrary to the requirements of the theory of social construction [15]. Based on this theory, we conducted a survey of tongqi from 2011 to 2012 that aimed to understand their physical and mental health problems, marital status, and influencing factors. Methods Procedure Our survey relied on “Tongqi Homeland”, the first webbased grassroots organization for women who have regular sexual relations with MSM in China, established in 2009. This organization provides services to tongqi Page 2 of 10 such as psychological counseling, support, and legal advice for divorce. The survey was mainly mobilized by Tongqi (...truncated)