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1 Introduction

As China’s modernization marches forward at an extremely rapid rate, younger generations are facing new economic and social environments and traditional values are increasingly being questioned. In Chap. 14 in this volume, Lieber and colleagues highlight one aspect of this tension in their discussion of sexuality and the redefinition of sexual norms among Chinese youth today. Similarly, the emergence of gay identities and communities in contemporary China clashes with many traditional cultural values and norms. And as a result, men who have sex with men (MSM) experience a variety of subtle as well as blatant rejection and discrimination on the basis of their sexual orientation (see also Chaps. 15, 17, and 18). As many authors in this volume have highlighted, perceived stigma and discrimination can result in deterioration of physical and mental well-being as well as lead to risky health behaviors and delayed medical treatment. For MSM in China, social discrimination may also have deleterious consequences for public health as individuals avoid taking health precautions as a means to avoid discovery, placing themselves, and potentially their heterosexual partners at higher risk for HIV infection (Choi et al. 2008).

As researchers increasingly pay attention to this vulnerable population, our understanding of the social discrimination that MSM in China face is becoming richer, enabling the development of interventions. However, policy efforts may prefer to take a more nuanced approach rather than target the entire MSM community because such attention may spark even greater social marginalization. To that end, this chapter describes our initial attempts to understand the prevalence of social discrimination against MSM in China and identify which individuals are disproportionately affected by it. We also make a critical distinction between perceived stigma and experienced discrimination as implications for risky sexual behaviors and intervention development can differ. For example, MSM perceiving high levels of stigma and experiencing few overt discriminatory acts may be more isolated form social networks (even from other MSM), engage in riskier sexual behaviors, and be more difficult to reach than those who perceive less stigma but experience greater discrimination (see also Chaps. 15, 17, and 18 in this volume). While our empirical analysis is based on a sample of MSM living in Shanghai, China, we believe that some of our observations may become more generalizable to MSM living elsewhere in China as more and more communities of MSM emerge in other urban areas.

2 Theoretical Background

2.1 Social Discrimination

Conceptually, social discrimination is derived from the process of stigmatization that can have both internal psychological and external physical consequences. According to the sociologist, Erving Goffman (1963), stigma is associated with an undesirable attribute that is “deeply discrediting” and results in a “spoiled identity,” radically changing the way individuals view themselves and are viewed as persons. Once a stigmatized individual is set apart from others, his/her life chances and opportunities are lessened because he/she is considered to be inferior and to represent a danger to society, all of which lead to social rejection and social isolation (Goffman 1963; Jones et al. 1984; Link et al. 1989). That individual may experience perceived or felt stigma or shame and fear of discrimination, which can prompt people to attempt to pass as a member of the non-stigmatized group and reduce the likelihood of experienced or enacted stigma or actual episodes of discrimination (Scambler and Hopkins 1986; Scambler 1989; Jacoby 1994; see also Chaps. 1, 2, 8, 9, 11, 12, and 17 in this volume).

Furthermore, because stigma derives from social definitions of acceptable standards, what attributes are considered to be deviant will vary depending on cultural and social contexts (Katz 1981; Liamputtong and Kitisriworapan 2012; see Chaps. 1, 2, 7, and 8). In China, although homosexuality is not expressly illegal, it is not socially accepted and is often equated with rejecting China’s fundamental cultural tradition that expects each person to fulfill certain filial pieties. Sons, in particular, are obligated to get married, have children, and carry on the family name. China’s transition to a market-based economy in recent decades has ushered in a flurry of changes within Chinese society and culture. Exposure to transnational influences along with increased individual liberty has facilitated the emergence of new identities, including gay and lesbian identities. For example, MSM in China have adopted “gay” from Western culture to describe themselves. MSM communities in China first emerged in major urban areas in the mid-1990s (Zhang and Chu 2005) and have since quickly developed in medium-size cities as well with venues, such as bars, cafes, teahouses, and gyms that cater to nonheterosexuals. Gay and lesbian communities have also established a prominent presence on the Internet with over 500 websites dedicated to gay, bisexual, or lesbian topics (Wang and Ross 2002).

Although homosexuality has become more visible in contemporary China, same-­gender sex is still proscribed. Until recently, MSM could be arrested under vague laws against hooliganism (Liu and Choi 2006) and homosexual behavior was considered to be psychiatric condition until 2001 (Chu 2001). In a recent qualitative study of social discrimination against MSM in Shanghai, MSM described fears of being socially ostracized from their families and peers, fears of jeopardizing their social status and the status of their families because of his sexual orientation, and intense pressures to marry and form a family (Liu and Choi 2006). Moreover, misconceptions of homosexuality as a physical or mental defect and popular stereotypes that equate homosexuality with femininity were pervasive. Men experienced discrimination in areas such as employment, health care, education, and housing (Gill 2002) and could be denied some basic human rights (see Chaps. 8 and 15). Some may also encounter harassment from neighbors and police due to physical appearances and experience social rejection from peers and family members (Liu and Choi 2006). Thus, gay men in China can often encounter subtle as well as blatant rejection and discrimination on the basis of their sexual orientation.

2.2 Social Discrimination and Health

Numerous studies have shown that experiences of social discrimination lower one’s physical and mental health and increase the likelihood of engaging in risky behaviors. In a study of 741 gay men in New York City, Meyer (1995) found that individuals who experienced internalized homophobia, stigma, and actual discrimination and violence were twice to three times more likely to suffer from high levels of distress. This “minority stress” may partially explain observed elevated psychiatric morbidity risk among lesbian, gay, and bisexual individuals. Mays and Cochran (2001) revealed that perceptions of discrimination were positively associated with both harmful effects on quality of life and indicators of psychiatric morbidity. In reference to sexual activity, individuals who suffer from social discrimination are also more likely to place themselves in risky situations. In a study of 912 Latino gay men in Miami, Los Angeles, and New York, Diaz and colleagues (2004) found that men who experienced more instances of social discrimination were more psychologically distressed and more likely to participate in risky sexual situations. Similar results were reported for a study of 250 gay Latinos in Virginia (Jarama et al. 2005).

Linkages between social discrimination and health have also been shown among Asian immigrants in the United States and studies conducted in China. In a qualitative study of young Asian and Pacific Islander (API) MSM, Choi and colleagues (1999) found that those who had a negative self-image were more likely to have had risky sexual encounters than those with a positive self-image, who were motivated to engage in HIV-protective behavior (i.e., condom use during anal sex). Among API in New York City, different types of coping mechanisms used in response to experiences of social discrimination were related to HIV risk behaviors (Wilson and Yoshikawa 2004). In China, individuals with sexually transmitted infections (STIs) who have reported feeling stigmatized are not only associated with more sexual risk-taking behaviors but also are less likely to notify spouses (Liu et al. 2002). Perceived discrimination has also been linked to inconsistent use of condoms among a sample of 187 gay men in Hong Kong (Wong and Tang 2004b).

In China, because of the stigma associated with homosexuality, MSM may be willing to forego safe-sex precautions, avoid seeking health services or testing, or be unwilling to accept outreach services, even if free, to avoid the risk of discovery. Consequently, social discrimination may also have adverse implications for public health as well. For example, high rates of risk behaviors and low rates of condom use may help to fuel China’s emerging HIV/AIDS epidemic among MSM. Understanding the dynamics of the disease within this population is only beginning to be understood as the existence of MSM in China has often been denied in the past. Early surveys conducted among MSM communities in various large cities and provincial capitals throughout China have reported HIV prevalence rates ranging from 1.0 to 3.4 % (Choi et al. 2003, 2005; Tao et al. 2004; Wu et al. 2004; Zhu et al. 2005). More recent data show much higher HIV prevalence rates, ranging from 2.9 % in various cities across China to an alarming high of 26.5 % in Chongqing (Feng et al. 2009; Xiao et al. 2010). Surveys have also found that many MSM in China are married and have sex with women, have low rates of condom use, and have limited knowledge of HIV transmission routes (Zhang et al. 2000; Choi et al. 2004; Wu et al. 2004). As a result, MSM may unknowingly spread HIV and other sexually communicable diseases to their partners, both men and women. Indeed, experiences of homophobia have been directly associated with having unprotected anal sex with men within the same sample of Chinese men studied here (Choi et al. 2008).

2.3 Social Discrimination and “Coming Out”

Individuals may experience different types of social discrimination depending on the degree to which they have disclosed their homosexuality to others. Being “out” may target the individual for more overt acts of victimization as evidenced by numerous accounts of violence against gay, lesbian, and transgender individuals (for a review, see Meyer 2003). Empirically, Huebner and colleagues (2004) revealed that men who were more likely to report antigay experiences (harassment, discrimination, and physical violence) in the previous 6 months were also more open to disclosing their status to others. Indeed, prior qualitative work studying MSM in Shanghai suggests that it may be the case that MSM who are “out” to individuals who are not homosexual (e.g., parents, siblings, colleagues) experience more enacted stigma, while those who have not disclosed contend more with perceived stigma (Liu and Choi 2006). In fact, fear of being discriminated against or socially rejected because of one’s homosexuality was often the form in which perceptions of stigma was described for gay men in Shanghai. Experienced discrimination occurred when the individual was suspected to be gay because of his appearance or mannerisms or originated from family members to whom the respondent had already come out to.

3 The Study

3.1 Study Aim

Although social discrimination against MSM in China hinders both individual and public health, little quantitative evidence is available to understand the prevalence of antigay harassment, discrimination, and victimization in China. This study is a first attempt to measure lifetime experiences of social discrimination against MSM in China through a survey conducted with 477 MSM surveyed in Shanghai. This study aims to identify which individuals are disproportionately affected and assess the effect that disclosure of homosexuality may have on individuals’ experiences of social discrimination. We separately measure perceived stigma and experienced discrimination, operationalized as separate ordinal scales, and hypothesize that disclosure of one’s homosexuality differentially affects one’s experiences of each type of discrimination.

3.2 Survey Data Collection

From September 2004 to June 2005, 477 MSM who met three eligibility requirements (age 18 and over, lived in Shanghai, and had ever had sex with a man) were recruited using a snowball sampling method (Liamputtong 2010). Initial seed participants were recruited through outreach activities and fliers posted at MSM venues, such as bars, dance clubs, and restaurants. During screening, eligible participants were given the option of conducting the survey with either a male or female member of the research team at the Shanghai Municipal and five District Centers for Disease Control and Prevention (CDCs). Six male and two female health care workers conducted interviews. Prior to administering the face-to-face questionnaire, participants were asked to read an information sheet describing the study’s purpose and procedures and give verbal informed consent. At the conclusion of the survey, participants were given 50 yuan (about US$6.50) as compensation for their own participation. Participants were also given three coupon cards to refer three more participants to the study and were compensated 10 yuan (about $1.20) more for each additional participant he recruited and subsequently enrolled into the study. The questionnaire took about 30 min to complete on average and was conducted in Mandarin Chinese or the local Shanghainese dialect according to the respondent’s preferences. The institutional review boards of the University of California, San Francisco, and the Shanghai Municipal CDC approved this study.

The instrument was initially drafted in English, translated into Chinese by one member of the research team, and then cross-checked with a second research team member; both researchers are fluent in these languages. To check the accuracy of the translation and the clarity of questions and response choices, the instrument was pilot-tested with 12 individuals comprised of both research team members and MSM recruited from the local community. After several iterations, the translation of the instrument was again checked and confirmed by a third bilingual member of the research team. Also prior to beginning the study, researchers administering the survey instrument participated in a 2-day training event to understand the purpose of the study, familiarize themselves with the instrument and procedures for obtaining verbal informed consent, and practice interview techniques. In particular, interviewers were instructed to read each question verbatim and in exactly the same manner while administering the survey.

In addition to obtaining sociodemographic information, the questionnaire asked participants about their lifetime experiences with social discrimination. Respondents were asked how often (“never,” “once or twice,” “a few times,” or “many times”) they had experienced a particular situation involving social discrimination in their lifetime. Three questions pertained to perceived stigma: (1) How often have you felt that your homosexuality hurt and embarrassed your family? (2) How often have you had to pretend that you are not homosexual in order to be accepted? (3) How often have you heard that homosexuals are not normal? Seven questions pertained to enacted stigma: (4) How often have you been made fun of or called names for being homosexual? (5) How often have you lost a job or career opportunity for being homosexual? (6) How often has your family not accepted you because of your homosexuality? (7) How often have you been hit or beaten up for being homosexual? (8) How often have you lost your friends because of your homosexuality? (9) How often have you been kicked out of school for being homosexual? (10) How often have you lost a place to live for being homosexual?

Results of factor analysis confirms the existence of two dimensions, one measuring perceived stigma (questions 1–3) and one measuring experienced stigma (questions 5–10). Question 4 did not load on the experienced stigma dimension and therefore was excluded.Footnote 1 The resulting scales for felt and enacted stigma are constructed as a sum of the frequencies reported (i.e., never = 0, many times = 4). The aggregation of three questions for perceived stigma results in a scale that ranges from 3 (i.e., never experienced any instance) to 12 (i.e., experience each act many times). Similarly, the range for the experienced stigma scale ranges from a minimum value of 6 to a maximum of 24. These scales represent ordinal measures of lifetime experiences of each type of discrimination. The simple correlation between the perceived stigma and experienced stigma scales is very low (0.03). The development of this scale has since been repeated and published elsewhere (Neilands et al. 2008).

The questionnaire also asked about the degree to which individuals had disclosed their sexual orientation to others. This was measured from a series of questions asking participants to answer “yes,” “no,” or “no such person” to whether certain other people knew that he has sex with other men, including male friends who have sex with men, male friends who have sex with women only, female friends, one’s wife, parents, siblings, coworkers or employers, doctors or other medical professionals, and others.

3.3 Empirical Analysis

Statistical analysis was conducted as follows: To test the difference between the two ordinal scales for felt and enacted stigma for each observation, the Wilcoxon signed-­rank test was employed. Multivariate linear regression was then used to investigate the correlates of social discrimination. The main explanatory variables were chosen based upon a priori hypotheses about which individual characteristics may influence the frequency with which MSM experience each type of stigma. These include age, highest educational attainment, monthly income, marital status, migrant status (measured by whether the respondent possessed a Shanghai residency card), self-­reported sexual orientation, and disclosure of sexual orientation to different groups of individuals (“no” and “no such person” responses were combined and coded as “0”). Because prior qualitative research suggests that experiences of perceived stigma and experienced discrimination may differ by migrant status (Liu and Choi 2006), we test for interaction effects in subsequent specifications.

4 Main Findings

4.1 Sample Characteristics

The summary statistics for our sample of MSM are displayed in Table 16.1. This sample of MSM is generally young; over two-thirds of sample participants were under the age of 30 (68 %, N = 326) with a median age of 26 (range 18–57). Respondents are also generally well educated with 22 % (N = 103) having received a college degree and 39 % (N = 187) completing high school. Over three-fourths of participants are never married (78 %, N = 372), 13 % (N = 62) are married, and 9 % (N = 43) are divorced or separated. Almost three-fourths of participants are employed (N = 350) at the time of the survey and only 22 % (N = 105) are registered residents of Shanghai. Nearly half of the respondents earn between 1,001 and 3,000 yuan (51 %, N = 242), a quarter earn 501–1,000 yuan (24 %, N = 113), and 7 % (N = 35) earn less than 500 yuan. Approximately 57 % (N = 270) of participants self-identify as gay or homosexual, 38 % (N = 181) as bisexual, and 6 % (N = 26) as heterosexual or undecided.

Table 16.1 Sample characteristics (N = 477)
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Responses to disclosure questions are shown in Table 16.2. About 91 % (N = 435) of respondents are out to some other MSM. Fewer respondents are out to heterosexual male and female friends: 27 % (N = 128) and 13 % (N = 64), respectively. In contrast, only 2–8 % of respondents are out to members of their immediate families, such as their wife, parents, or siblings. Some 13 % (N = 64) are out to coworkers, but only 4 % (N = 19) to employers. Nearly 9 % (N = 41) are out to their doctor.

Table 16.2 Disclosure of homosexuality (N = 477)
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4.2 Prevalence of Stigma and Discrimination

Respondents’ lifetime experiences of social discrimination are reported in Table 16.3. As hypothesized from previous qualitative work in Shanghai by Liu and Choi (2006), perceived stigma was more prevalent than instances of experienced discrimination. Almost 97 % (N = 461) of respondents had perceived some stigma at least once in their lifetime, whereas only 23 % had experienced at least one instance of discrimination.

Table 16.3 Lifetime experiences of perceived stigma and overt discrimination based on sexual orientation (N = 477)
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The results of the Wilcoxon signed-rank test indicate that perceived stigma is experienced more frequently than experiences of overt discrimination (adjusted variance = 8,278,185.25, t = 10.60, p < 0.01). Only 11 % (N = 51), 25 % (N = 119), and 41 % (N = 197) of respondents have never heard that homosexuals are not normal, have never had to pretend not to be homosexual in order to be accepted, and have never felt that their homosexuality hurt and embarrassed his family, respectively. In contrast, 83 % (N = 397) have never lost friends, 93 % (N = 442) have never failed to be accepted by their family, 95 % (N = 455) have never lost a job, 96 % (N = 458) have never lost a place to live, 97 % (N = 462) have never been physically beaten, and 99 % (N = 473) have never been kicked out of school because of their homosexuality.

The disparity between the prevalence of perceived stigma and experienced discrimination is not surprising given the nature of stigma. Although individuals may not encounter discriminatory acts on a day-to-day basis, the process of self-­stigmatization associated with perceptions can lead to ongoing internal psychological and emotional struggles with shame, negative feelings about one’s sexual orientation, and fear (Meyer 1995). However, gay men in Shanghai appear to experience less overt discrimination but relatively the same rates of felt stigma in comparison to the discrimination experiences of other gay men around the world. For example, the prevalence of perceived stigma among this sample of MSM is surprisingly similar to that among Latino gay men in the United States by Diaz and colleagues (2001). In their sample of 912 MSM, 91 % had heard that gays are not normal, 64 % had had to pretend to be straight, and 70 % felt that their homosexuality hurt their family. Although much smaller percentages of Latino men similarly encountered actual victimization (18 % experienced violence as a child, 10 % experienced violence as an adult, and 15 % experienced job discrimination), these rates of experienced discrimination are somewhat higher than those observed in this study. These results can also be compared to a study of 1,248 gay men in the southwestern USA (which found that 11 % experienced discrimination and 5 % experienced physical violence in the previous 6 months; Huebner et al. 2004) and a survey of 656 gay men in England (which found that 38 % had been attacked in the past 5 years and 51 % physically bullied at school (King et al. 2003)).

4.3 Predictors of Perceived Stigma

Although MSM in Shanghai may experience less overt discrimination stigma than gay men in Western countries, this lower prevalence is most likely not due to a more socially tolerant environment in China. Rather, gay men in China may be more reluctant to disclose their homosexuality to others due to a more repressive environment. Results of linear regression analysis for perceived stigma are reported in Table 16.4. Note that the reference group consists of individuals aged 18–29 who did not attain at least a high school degree, were never married, were not migrants, earned over 1,000 yuan per month, and self-identified as gay. In column 1, perceptions of stigma are significantly higher for men aged 40+, those who are unemployed, and those who have migrated to Shanghai. Older men may feel greater tension between traditional values and their sexual orientation as they may have contended with these issues for much of their adult lives when homosexuality was even less tolerated in China. Less tolerance of homosexuality in more traditional villages sheltered from social changes in large urban areas may contribute to perceptions of stigma for migrant MSM who are also often unemployed. Because MSM may be pressured into marriage by their families (Liu and Choi 2006), gay men from rural areas may deal with feelings of guilt and shame associated with failing to fulfill the wishes of family members back home. They may also contend with the fear that their families or children could be stigmatized out of association. Consequently, moving to urban areas can be one way of escaping social discrimination in home villages for gay men. The perceived stigma scale is unrelated to education, marital status, or income, indicating that such stigma transcends these demographic differences. Men who self-identify as heterosexual or undecided are marginally significantly (p < 0.10) less likely to perceive greater stigma possibly because they do not identify as gay and thus are not sensitive to the stigma associated with homosexuality.

Table 16.4 Linear regression analysis of perceived stigma correlates
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This sensitivity toward antigay sentiment may also explain why disclosure of one’s sexual orientation is significantly related to experiences of perceived stigma. Being “out” to other MSM significantly reduces perceived stigma, but being out to family members significantly increases it. This suggests that individuals who disclose their homosexuality status to their MSM peers may find social support within this community. On the other hand, family members who are aware of a young man’s homosexuality may be the source of social disapproval. This is supported by previous qualitative research that shows that family members are not often accepting of homosexuality, particularly when he is the only child, and often try to intervene (Liu and Choi 2006). The supportive effect of MSM social networks is further supported by the results for migrant status interactions displayed in column 2. Nearly all of the effect of migrant status on elevated perceptions of stigma is offset when migrants are out to other MSM. No other interactions are significant.

4.4 Predictors of Experienced Discrimination

The results of linear regression analysis for experienced discrimination are reported in Table 16.5. The main effects in column 1 show that younger men experience significantly more discrimination and the effect for married men is marginally significant (p < 0.10) and positive. No other sociodemographic background characteristics are significantly related. As younger men adopt more Westernized identities and behaviors, including recent trends in appearance, fashion, and expressions, generational differences among the population may associate such differences with other practices that are also perceived as deviant, such as homosexuality. Interviews with MSM in Shanghai showed that appearance and dress among younger men invited criticisms, even from casual observers (Liu and Choi 2006). Moreover, association with other similarly adorned people may arouse suspicion. Indeed, regression results show that being out to other MSM significantly increases experiences of discrimination. However, being out to heterosexual friends and coworkers significantly decreases it. We cannot say for sure that disclosure to wider social circles outside of MSM groups can actually reduce discrimination. In fact, disclosure can lead to significant backlash among friends and family members who feel it necessary to intervene. Some of these effects may be due to selection whereby friends and colleagues may choose to disassociate themselves, and only those who remain are those who are accepting and supportive of the individual.

Table 16.5 Linear regression analysis of experienced discrimination correlates
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Hence, disclosure results should be taken cautiously as wholesale disclosure of homosexuality in China may lead to adverse outcomes. Further regressions results in column 2 intimate that the effect of being out to family members for nonmigrant MSM is strongly predictive of experiencing increased discrimination. Since migration and physical separation from family members is one type of coping strategy for MSM who come from the countryside, this result supports the fear that many MSM face of being found out by their parents or family back home (Liu and Choi 2006). Some migrants will tap into MSM networks in Shanghai not only for social reasons but also to find employment. Male prostitutes, or “money boys,” working in Shanghai are often migrants from the countryside who do not necessarily identify themselves as “gay.” Some of these men expressly deny being gay and rationalize their work in terms of the monetary reward, while others are extremely ashamed of what they do and see it as an interim job until more respectable employment is found. In other analysis using this data, homophobia has been directly linked to financial hardship (Choi et al. 2008). It is unclear how much overlap there is between MSM circles and coworkers in our disclosure questions. A large amount of confluence may explain why migrants who are out to coworkers experience significantly less discrimination. On the other hand, migrants may often find work in jobs that are predominately held by other migrants, such as construction labor, where greater empathy may be shown for individuals facing similar migration challenges. Interaction results also show that migrants who are unemployed experience significantly more discrimination. Thus, association with other migrants may also provide some social support. In any event, the difficulty in interpreting this result indicates a need to further refine disclosure questions. Finally, results in column 2 also show that migrants who are separated or divorced experience significantly more discrimination. Separation or divorce from a spouse may signal some other reason for being an unfit husband, which runs counter to traditional marital values and may be closely associated with sexual dysfunction. As Liu and Choi (2006) found, being unmarried at an older age is one aspect associated with the stigma of homosexuality as it defies cultural expectations and may be perceived to be a result of some physical or mental flaw in China. For example, employers may inquire as to why an individual is not married or does have children, which, in turn, may adversely influence hiring decisions.

5 Conclusion

The study on which this chapter is based attempts to quantitatively measure the prevalence of social discrimination against MSM in China through a sample of respondents in Shanghai. Although Shanghai is perceived to be a more socially tolerant city given its international connections and booming economic activity, results show that homosexuality is still highly stigmatized. Few individuals are out to wider social circles, including family members, contributing to higher prevalence of perceived stigma and fewer experiences of overt discrimination. Our data show that being out to other MSM was associated with lower perceived stigma, while being out to one’s family members was associated with higher perceived stigma for all men and greater experienced discrimination for nonmigrants. These results affirm general findings in the literature that close family members can contribute to social discrimination for gay men. On the other hand, socializing and coming out to other MSM may have a protective effect against perceptions of stigma, even though results show that it may increase experiences of overt discrimination.

As homosexual identities and communities continue to emerge throughout China, social discrimination against gays is likely to increase. Interventions to reduce stigma and discrimination in China may want to take two approaches. First, interventions may want to focus on general attitudes toward MSM and awareness among non-MSM groups to dispel misconceptions and misunderstandings of homosexuality as a physical or mental condition. Although the frequency of enacted stigma is lower in China than in other countries, still, one-fourth of the men in this sample encountered violence, rejection, or discrimination in employment, housing, and education due to homophobia at least once in their lifetime. While homosexuality is no longer officially classified as a mental disorder in China, actions by government and law enforcement that interfere with the lawful operation of gay venues and activities continue to fuel general negative attitudes toward homosexuality. Official government tolerance often lags popular sentiment in China and cultural values may change without policy intervention, however slow. More targeted interventions may want to assist MSM who want to come out to family members of friends by empowering with strategies to dispel popular misconceptions. Additional research will be needed to understand what specific approaches may help, but recounts of MSM in Shanghai who have come out to family members indicate that acceptance, or at least tolerance, can be gained eventually.

Other targeted interventions may opt to help MSM cope with stigma and reduce sensitivity to negative feelings by leveraging the protective effects of supportive peer social networks. Certainly, the positive effects of social networks in coping with discrimination have been documented for gay men (Holahan and Moos 1987; Pierce et al. 1996; Wilson and Yoshikawa 2004). Empirical research by Meyer (1995) suggested that gay men are protected from the effects of homophobia through receiving emotional support from other gay men. Furthermore, social networks can mediate the effects of social discrimination and elevated risk behaviors. Studies have shown that gay men are more likely to use condoms when they have already come out (Kelly et al. 1990), have favorable attitudes toward coming out (Anderson and Mavis 1996), and identify with gay communities and social networks that openly endorse community health concerns, preventive messages, and safer sex norms (McKirnan et al. 1995; Waldo et al. 1998). Among gay men in Hong Kong, those who consistently used condoms showed greater self-acceptance and disclosure of their homosexual sexual orientation, were more involved with local gay communities, and endorsed more favorable attitudes toward coming out (Wong and Tang 2004a). However, for these men, disclosure also followed a gradient whereby gay friends were told first, followed by heterosexual friends, siblings, parents, and coworkers (Wong and Tang 2004b). This suggests that interventions that promote MSM activities and interpersonal relationships within the MSM community can help enforce safety norms and provide coping mechanisms.