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Rapid socioeconomic transformation in Vietnam in last 15 years has been followed by more liberation of sexual expression and representation of sexual identity among young people. There has been an increase in the visibility of homosexual men in major cities of Vietnam who were largely an unknown population until the emergence of the HIV epidemic. Men who have sex with men (MSM) are now considered as one of the target groups in many HIV prevention programs. This qualitative study examines local identities, relationships, and sexual practices among young MSM aged 15–24 in the cities of Hanoi and Ho Chi Minh City. Our analyses were based on 26 in-depth interviews and 10 focus group discussions with young MSM recruited through public place intercepts and cruising areas. Data document the linguistic classification, sexual relationships and behaviors, identity and process of homosexual identification, and the potential linkage between sexual identity and sexual behaviors of MSM in Vietnam. Data also highlight the stages of homosexual community development in urban Vietnam and important differences between Vietnam and the West in the representation of homosexual identity, relationships, and practices. In light of the findings, we suggest that the continuing development and elaboration of a homosexual community in Hanoi and Ho Chi Minh City offers significant opportunities for targeted HIV/AIDS prevention activities in the Vietnamese MSM population.
As in many other cultures, homosexuality is not considered a normal or acceptable practice in Vietnam. Although homosexuality has never been explicitly illegal in Vietnam, men who engage in homosexual practices are regarded as a “deviant” group, subject to social stigma and discrimination. As a result, they often attempt to keep their sexual identities and desires secret. Rapid socioeconomic transformation in last 15 years has led to greater freedom of sexual expression among young people, and advances in communication technologies have enabled homosexuals in Vietnam to interact with and learn about their counterparts in other countries. There are now a growing number of men who openly assert homosexual identities in major cities such as Hanoi and Ho Chi Minh City, and their increasing visibility has garnered greater public attention (Blanc, 2005; Colby, Cao, & Dousntouse, 2004).
Men who have sex with men (MSM) constitute an important risk group for HIV in Vietnam. Studies have found HIV prevalence ranging from 5% to 33% among various urban MSM groups (Colby, 2003; Nguyen, Nguyen, Le, & Detels, 2008; UNAIDS, 2007). These studies also found that Vietnamese MSM engage in risky sexual behaviors, including unprotected anal sex, having multiple sexual partners, and/or improper use of lubricants and condoms (Colby, 2003; Colby, Minh, & Toan, 2008; Nguyen et al., 2008; Vu & Girault, 2005).
The emergence of HIV/AIDS spurred interest among public health officials and social scientists about male homosexuality. Western models of homosexuality have been applied to frame MSM research in the HIV/AIDS discourse in developing countries' contexts (Asthana & Oostvogels, 2001). At the same time, the label MSM was introduced in Vietnam in early 1990s in response to HIV/AIDS by public health officials, but neither this foreign label nor its Vietnamese translation (nam quan he tình dục vói nam) are commonly used by men who engage in homosexual activities. Research of male sexuality in Vietnam documented that MSM are often called as ồng cô (womenlike man) or bóng (shadow) (Khuat, 1998, Vu et al., 2008). Đồng cô originally referred to a man who is the sorcerer, wearing women's clothes in ritual ceremonies. This term was later expanded to imply transgenders and gay men. Bóng refers to males who exhibit feminine characteristics or behaviors.
Like other countries in the region, there are several subgroups of MSM in Vietnam: self-identified gay, bisexual, transgender, or heterosexual (UNICEF, 2006; Vu & Girault, 2005). The mechanisms underlying these sexual orientations and representations vary in even more detailed forms. Generally, in Vietnam MSM are classified based on appearances, mannerisms and perceived levels of masculinity or femininity. Bóng kín (hidden MSM) refers to masculine looking and dressing MSM who are closeted in everyday life, and bóng lộ (open MSM) refers to men who wear female clothes and present themselves as women. This classification underlies sophisticated interactions and networking within these subgroups of MSM. Networking and interactions through the Internet are increasing rapidly and have become an important mean of communication especially among young MSM in Vietnam (Colby, Ton, & Truong, 2007; Khuat, 2005). A survey of 600 MSM in Ho Chi Minh City revealed that 79% identified themselves as bóng kín, 13% as bóng lộ, and 9% as others who have sex with both men and women (Nguyen et al., 2008).
Homosexual practices, relationships, and identities vary in different cultural settings, which are important to HIV transmission and prevention. Although the term MSM is often used interchangeably with that of gay men, for this study MSM included males who identified as either homosexual or heterosexual. MSM who identify themselves as members of a gay community are more likely to approach HIV prevention activities that are designed for gay men. However, social stigma attached to homosexual activity may prevent some men from disclosing their sexual orientation, leading them to deny their own risk and to avoid or ignore HIV prevention programs (Doll & Beeker, 1996). Research also indicates that MSM constitute a differentiated group in terms of identities and behavior represented by their varied sexual drives, practices, partnerships and other affective experiences (Asthana & Oostvogels, 2001; Foxman et al., 1998). Sexual identity and the meanings attached to sexual practices, are, like other areas of human life, profoundly influenced by culture and social structure. They are also built on life histories such as significant life events, contexts, and relationships (Herdt, 1989; Stoller, 1985). Social contexts in which sexual acts take place also have an important impact on the types and nature of sexual practices. For example, discrimination against homosexuals often causes sex to be performed unexpectedly and quickly in the dark with significant stress and fear of being discovered by an outsider. This sexual context could increase the possibility and extent of lack of condom use and physical trauma and therefore increase the likelihood of HIV transmission (Asthana & Oostvogels, 2001).
To provide further insight into male homosexuality in a developing country's contexts, this paper presents findings from a qualitative study conducted in Hanoi and Ho Chi Minh City, Vietnam with young men (aged 15–24) who said they had sexual intercourse with other men. Our study explores emergent identities and categories, relationships and perceptions of gender roles, and sexual practices among this population group. We then discuss the implications of these sexual arrangements and identities for HIV prevention.
The findings presented in this article were part of a larger study to gather information from young men for an HIV prevention program in Hanoi and Ho Chi Minh City, Vietnam. These cities were chosen because they have the largest MSM communities. Ho Chi Minh City is the largest city and commercial center in Vietnam with a population of 6 million; the MSM population is estimated to be about 40,000 (Nguyen et al., 2008). There are a number of establishments that cater to MSM such as coffee houses, bars, restaurants, massage parlors, saunas, and health clubs. Also, there are open cruising areas described as chợ tính (love markets) in certain parks and streets where young people can find potential partners (homosexual and heterosexual). Hanoi is the capital of Vietnam with a population of 3.5 million. Similar to Ho Chi Minh City, there are well-known places for MSM to gather such as bars, parks, and streets, but they are fewer in number. In both cities, there are peer-education clubs for MSM sponsored by HFV prevention programs.
This study used qualitative methods, collecting data through in-depth interviews and focus groups. Data collectors consisted of two investigators who were public health professionals and two sociologists. Data collection was carried out in December 2007 in Ho Chi Minh City and January, 2008 in Hanoi. Data collectors approached potential participants with assistance of the peer-education clubs in the two cities. Using the snowball technique, 26 young men were recruited for in-depth interviews and 66 young men for 10 focus group discussions. Six of the in-depth interviews and five of the focus group discussions were conducted with MSM who lived and worked on the streets, often called street based. Each focus group discussion was attended by six to eight young people of the same age group (15–18 [younger youths] or 19–24 years old [older youths]) and recruited from the same setting (street-based or nonstreet-based youth). We divided participants by these two age groups because most young people in Vietnam initiate sex at the age of 19 (Ministry of Health, UNICEF, and World Health Organization, 2005). Also, we wanted a sample of street-based youth because they are known to be at greater risk for HIV.
In-depth interviews were semistructured, focusing on three categories: (a) identities, (b) relationships and perceptions of gender roles, and (c) sexual practices and condom use. Questions asked elicit information on young men's experiences, knowledge, beliefs concerning sexual identities, sexual practices as well as their social interactions and personal relationships within and beyond the MSM community. Key questions included: “How do you call yourself?”; How do you perceive your gender role in your relationships with other bóng?; and What sexual practices did you experience first time and then?” Responses were open-ended, allowing for probing to clarify responses. Focus group discussions explored ways to ensure that the program activities reach and serve young MSM, and take into account the local sociopolitical context. Interviews and focus group discussions were conducted in places where the youth felt comfortable to talk about personal issues (e.g., cafés, karaoke rooms). Participants' consent was obtained before each interview, and each participant was paid 50,000 VND (US$ 3) for their time and transportation costs. This study was approved by the appropriate Vietnamese review committee.
All interviews and discussions were tape recorded and then transcribed. Transcripts and field notes were analyzed using N.ViVo, Version 2.0. These texts were analyzed using a grounded theory approach (Ryan & Bernard, 2000) to identify emergent themes, concepts, and categories through repeated readings of the texts. One of the coauthors (T.T) conducted coding for main themes and issues and developed patterns and models within the narrative data for initial interpretations and explanations. Salient themes were determined by consensus among three Vietnamese investigators (A.N, H.P, and T.T) who then produced the narrative findings in English. Researchers also compared accounts between the two cities, different ages, and subgroups of young men. Quotes supporting key research findings were excerpted from the transcripts and translated into English when the analysis was completed.
The sample comprised 92 young men in the two cities (Table 1). The median age of participants was 17 years. All were single. Seventy percent of participants self-identified as bóng kín and 15% were bóng lộ; 3% were transgender (male to female) women, and 10% identified themselves as trai xin ('real man') but having sex with other men in certain situations (e.g., to earn money). All focus group discussion respondents were bóng kín or trai xin except two focus group discussions in Hanoi attended by a mix of bóng kín, bóng lộ, and other young men.
The terms used to classify homosexual men or other MSM were often expressed using local slang (Table 2). Each term was often attached to a specific subgroup. Rooted in the social and cultural denial of homosexuality in Vietnam, most of the terms were derogatory, insulting, or abusive. The most commonly used terms were bóng, pê é or bê ê, ông tính, and gay. Among these terms, participants preferred to use ông tính because it was considered less pejorative.
Participants reported the most common way to classify youth who self-identify as homosexual was based on their physical appearances and mannerisms. They used bóng kín to refer to men who looked masculine and hid their homosexual activities; they also believed that many bóng kín were married and had children. Bóng lộ was used to describe men who presented themselves as women, and did not attempt to hide their homosexuality. In some cases, it was easy to mistake a bóng lộ for a woman. While bóng lộ cross-dress, they will occasionally have insertive sex with other men on occasion and thus cannot be considered transsexual. Bóng lộ are distinguished from transsexuals by their acceptance of their male biological sex, their lack of a desire to have gender-reassignment surgery, and their self-identification as homosexual. For this study, we use the term bóng kín and bóng lộ for youths who used these categories for self-identification, trai xin to refer to youth who identified themselves as heterosexual, and hai hệ to refer to young men who reported enjoying sex with both men and women.
Participants said that they can easily identify their bóng kín and bóng lộ peers, regardless of whether they dress as women, saying, “people of our world can easily recognize them as bóng based on their delicate gestures or manners” (focus group, older youth, Hanoi). Participants described the subtle emotional connections between men called từ ánh mắt ến irái tim (from eye to heart). They also believed that they could identify bóng by their soft voice or gentle handling of things: “The way they pick up a cup is so gentle. A normal man does not do it like that.”
Another variation was bóng nừa mùa (shadow at mid-season) who altered his presentation according to changing social contexts. For example, someone who is bóng kín during the day time can become bóng lộ at night when they socialize with other bóng. One can also be bóng lộ at home if his relatives are aware of his homosexual status and return to bóng kín in other settings (i.e., at work) where he needs to keep his sexual orientation secret.
Participants noted other situations and behaviors of some MSM. Bóng mén or bóng bao tử implies teenaged (12–15 years old) boys who look and act like girls. Bóng kịnh refers to MSM with big muscles and a very masculine appearance: “They are men who have a neat physical appearance. They often do weight-lifting so they look very strong. It is hard to recognize them as homosexual men” (focus group, older youths. Ho Chi Minh City). The study participants also used phò, ca ve, phẽo, and đĩ đực to describe those men who sell sex to men. They were often street-based youth, unemployed youth, or college students.
The term supersim was used to label men who like having sex with both men and women. They could be married men or single youth who wanted to “have a different experience.” A group of street-based youth in Ho Chi Minh City who sell sex to men described their experiences with supersim clients.
They like private places because they are afraid of being revealed to their family about their real sexual orientation. They are afraid of being laughed at or discriminated against. Many people are married and have children but still search for a strange taste (sex with men). They hide their sexual preference from their family, (focus group, younger youths, Ho Chi Minh City)
However, according to these respondents, it was difficult to distinguish supersim clients who are married from bóng kín who have been pressured to get married but do not enjoy sex with women.
Participants described same-sex relationships as tình trai (man love) or tình đơn phương (single-sided love). They also noted that sexual relationships between young men could be committed, casual, or commercial. Committed relationships were said to encompass both love and sex, and the couple established “husband” and “wife” roles based on their notions of masculinity and femininity. The “husband” was often strong and forceful, deciding when, where, and how to have sex. The “wife” cared for the husband, performed domestic tasks, and decorated their home. Sometimes, similar roles were established in commercial encounters. However, in these “husband- wife” scenarios, couples did not always follow traditional inserter and receiver roles during sexual intercourse. Most participants reported being versatile, alternating between inserter and receiver roles depending on settings or partner; some described how they would also shift roles during one sexual session. For example, bóng lộ said that they usually preferred receiving anal sex but could also give anal sex if their partner desired. Similarly, a bóng kín in Ho Chi Minh City noted, “I go with a guy. If I want, I play the wife role and he is my husband. When I go with another, if he is more feminine than I am, he will be the wife and I will be the husband.” Another bóng kín described how he attempted to arrange husband-wife roles in casual encounters: “Tonight you are my husband, okay? Or you are on top of me, okay? Or, I am on top of you, okay?”
Sexual relationships among men were guided by their notions of gender. Bóng kín usually established sexual relationships among themselves. Rarely would a bóng kín enter into a relationship with a bóng lộ because bóng kín feared public disclosure of their sexuality. In contrast, most bóng lộ believed that sexual contact among them should be avoided because they are of the same gender. Bóng lộ expressed a strong desire for relationships with trai xin. In one case, a postoperative male-to-female transsexual described how she experienced sexual pleasure not through physical sensation of her vagina, but because her vagina was functioning as that of a “real” woman. Bóng lộ who acted like women to attract trai xịn reported taping their penises backward between the thighs, and performing sex in the dark to avoid being exposed. In those situations, the bóng lộ guided his partner's penis between his two thighs to simulate penetrative intercourse. Many bóng lộ described how they hoped to find a trai xịn partner because such a relationship would reinforce their feminine identity. Most participants realized, however, that such committed relationships were unlikely given the current social conditions.
Commercial sexual relations were common, with approximately two thirds of participants, particularly street-based youth, involved in selling sex. College students and young, unemployed men also sold sex. Reasons for selling sex were to earn money and/or to satisfy sexual desire. The typical price for sex varied between 100,000 and 300,000 VND (US$6 – US$ 18). For many, however, it was difficult to draw the line between sex performed for pleasure and sex performed for money. Some said that they often do not charge clients who are attractive: “If they liked me, they paid. If I liked them, I paid” (19-year-old bóng kín, Ho Chi Minh City).
Young, poor migrants from rural areas became involved in commercial sex for survival. They often began this vocation after meeting a man who offered them money, meal, or a drink in exchange for sex. Others started by working in entertainment venues (e.g., hotel, bar, massage parlor), selling sex when asked by a male patron.
I think people need to sympathize for our life. We are young rural boys coming to the city to earn a living. We have to do massage for men, then they want us, asking for sex and paying more. Under these circumstances, it is hard for us to resist. (19-year-old trai xin, Hanoi)
Some reported receiving extended financial support from older men who wanted to establish long-term relationships. Most street-based youth and many other young men also exchanged sex for nonmonetary gifts. For example, older partners offered food, shelter, and other goods that these young men needed:
Many rich gay men can give me whatever I need if I agree to be their lover and satisfy them. For example, if I don't have a bike, they buy a bike for me. If I ask for a cell phone, they offer me a cell phone, and if I need money, they give me money, (focus group, street-based youth, Ho Chi Minh City)
Participants mentioned three ways in which they met clients: through direct contact, through a mối (intermediary), and through the Internet. Street-based youth who sell sex said that they solicited sexual partners primarily through direct contact. They waited for men to approach them on the streets, in particular parks, and areas outside establishments (bar, coffee, club) where gay men frequented; they also approached the men in these locales: “If we see someone standing or sitting alone, we approach and ask, `Do you want to go with me.' Or do you want to sleep with me?'” (focus group, Hanoi). If the man agreed, they then arranged to go to a secluded place, to a hotel, or to the home of the client to have sex. In Hanoi, street-based youth often solicited clients in a particular territory over which they claimed exclusive rights; men from outside the group could be attacked if they approached men these designated areas. In Ho Chi Minh City, there was no defined territory; participants said that anyone could look for potential clients in any public space. Young men there reported a greater number of clients than in Hanoi.
Nonstreet-based youth often solicited clients in entertainment establishments such as tea shops around lakes or parks, or in bars since they had money to pay for drinks or services while looking for clients. Participants also described some unusual places where they had met other men for sex. In Ho Chi Minh City, the family of a deceased person may invite a group of local bóng lộ to the funeral to cry and sing, performing a traditional feminine role in these last rites. Bóng lộ who have undergone genital and breast reconstruction surgery are preferred; many bóng lộ pretend that they have had the requisite surgeries. This phenomenon is similar to that of hijra in India who also perform at birth, wedding and funeral services (Nanda, 1990). Bóng lộ in our study said that sometimes they met clients at these funerals. They said that men would approach them, and then they would go together to find a dark and secluded place near the funeral to have sex: “In general, we often go to a place where they are doing construction because it is a large area, or nearby in a park that has big drainage pipes” (20-year-old bóng lộ. Ho Chi Minh Cityj.
Some youth described meeting clients through a mối (intermediary). The mối are either MSM themselves or have close connections with MSM. Mối usually introduced young men their clients, and received payment from both. Study participants said that sometimes they shared earnings with the mối: “One time when I went with a foreigner, he gave me US$100.1 gave US$50 to the guy who introduced me to that foreigner.” However, in some instances where there was a close relationship between the young man and mối, then there was no expectation of payment.
Some youth mentioned finding sex partners on the Internet. They used Yahoo! Messenger and chat rooms to meet people and arrange appointments. Some street-based and transgender youth said that they sometimes pretended to be women online to search for male clients. After chatting online, they would make an appointment and have sex if both agreed. Participants said that about half of the men would agree to have sex once they found out that the solicitor was not a woman.
Using the Internet, the young men in the study occasionally met wealthy clients who they called gái sang (luxurious girls). According to participants, these clients only bought sex from those who they considered handsome or good looking, such as models or students. They first look at the youth's photos before making an appointment to meet at hotels, private houses, or bars. If they don't like the looks of the youth at the face-to-face meeting, they pay him and send him away without having sex.
For commercial encounters, the price was often negotiated either online before a meeting or very quickly at the meeting and then sex happened. For noncommercial encounters, they would not rush into sex. Older youths attending a focus group discussion in Hanoi explained the differences.
The shortest time to make an acquaintance was five minutes. [But] it can take a few days. If bóng like to form a longer-term relationship, they often go slowly. If bóng just want to be like a one-night stand, they often go straight to sex.
Participants said that the majority of commercial interactions were onetime encounters. However, some became regular clients, and a few turned into long-term relationships after the first sexual contact. In these cases, the partners supported the youth's living expenses such as housing, food, telephone charges, among others.
Young men distinguished between tây (Western) clients and ta (us--Vietnamese). They contacted foreigners primarily through mối or the Internet. Youth considered meeting tây as lucky (hên) since foreigners usually pay at least US$50 for one sexual encounter, much higher than the typical price a Vietnamese client could offer ($US6–$US18). One 22 year-old trai xin in Hanoi who used to exchange sex for money recalled:
There was a big difference between ta and tây. Vietnamese clients often paid 100,000 VND ($US6) for one sexual encounter and if they paid 200,000 VND ($US12), they were considered generous. But foreigners often paid at least 800,000 VND ($US50). One time a foreigner paid me $US300.
Commercial relationships with foreigners could also extend beyond a single sexual encounter. One 21-year-old in Hanoi revealed that he met a Canadian man who took him on vacation and then paid his tuition and fees for a yearlong English class.
Participants reported a variety of sexual practices, ranging from nonpenetrative sexual acts (e.g., touching, kissing, caressing) to penetration (i.e., oral or anal sex). Most participants said that they have multiple and concurrent sexual partners, and that they frequently change sexual partners. Furthermore, sexual contact outside a committed relationship with casual partners was common. One bóng lộ recounted that he had had 50–60 partners in the past year. Group sex was also mentioned by a few participants.
Participants considered their first sexual experience as one of the most significant events in their lives. On average, these young men began having sex at the age of 15 or 16 years (range: 12–18). These initial, exploratory encounters usually involved kissing, caressing, touching, and masturbation or oral sex; anal intercourse would come later. They described how they learned about anal sex from peers, movies, or other partners, and they often assumed the receptive role in their first anal intercourse with a more experienced partner. Although they reported pain or irritation, most of them enjoyed anal sex. However, a few reported intense pain or even bleeding and thus decided not to continue this practice. One 24-year-old bóng lộ in Hanoi said:
The first time was very painful like you lost your virginity. Three days later, it was itching.… This made me want to have it inserted one more time. I looked for that guy and asked him to do it again. Some of my friends did it in a different way. They bought something and inserted it in the rectum to make it larger before inserting his penis.
Several participants recounted that their first sexual experience happened after being coerced by an older man. One young trai xin described his first time in this way:
As I told you, I am not gay. The first time I had sex happened like this: I went for coffee with him, then we drank wine and beer. After having some beer and wine, my mind did not work well. He took me to his home and showed me pornographic movies to turn me on. He made me really want it [sex]. I felt scared a little bit but I was drunk at that time, I did not do anything to resist him. I was lying down and let him do it.
Young men distinguished anal sex from other sexual acts. They described oral sex as thổi kèn (trumpet playing), bú chim or bú cu (penis sucking), and khẩu dâm (oral sex). Nonpenetrative sexual acts such as lying together, touching, kissing, caressing, and mutual masturbation were labeled làm tình (making love). Làm tình was believed to arouse sexual partners without inserting the penis into the anus. Many participants described oral sex as the most enjoyable sexual act aside from anal sex. They said that the man performing oral sex would swallow the ejaculate if he really liked his partner.
Participants considered anal sex to be separate from làm tình. They listed various terms for anal sex: đi ben, đâm gô, chơi lỗ đít (anal play), cắm vào phích, and thông nòng (clean the gun barrel). Most participants stated that anal sex was performed less frequently than oral sex, usually restricted to a long-term or committed partner. Participants explained that experience of the pain caused by anal sex prevented them from doing it regularly:
I don't like to have anal sex because it is painful. It [the penis] is very big and it causes lots of pain when inserted into the anus. I could not bear it. However, many people have anal sex. It hurts but they get used to it. Another thing I know is that if we have anal sex many times, it makes the anus elastic and you gain a feeling. Nevertheless, after a while it will give you hemorrhoids (focus group, younger youths, Ho Chi Minh City)
However, one 20-year-old bóngkín in Ho Chi Minh City described how he avoided anal sex with his long-term partner. The couple expressed their intimacy solely through touching, kissing, and caressing (làm tình.) They believed that having anal intercourse might eventually cause the dissolution of their relationship.
In our world, we love each other and respect each other so that we only touch or caress each other, not having sexual intercourse because we are afraid sex will ruin our romantic relationship. If we want to satisfy our sexual needs through anal sex, we look for it from outside.
Some street-based youth who sell sex described unusual sexual practices performed by their clients. For example, some clients asked to be beaten so they could achieve orgasm. One 19-year-old trai xin in Ho Chi Minh City described how he was beaten while having sex with a Viột kiốu (overseas Vietnamese).
I was so scared when having sex with him. He squeezed and pinched me so that I was in pain. After that I told him, “My Cod, you were so wild.” I only told him that. But the next time he did the same to me. I did not like him so I seldom went out with him, only when he entreated me.
When it came to using condoms, participants described the trade-offs between risks and pleasures. Despite high awareness of the protective effects of condoms, most participants reported inconsistent use of condoms.
We don't use condoms because we don't have any sexual feelings when wearing a condom. We know if our rectum is scratched, so we can easily get a disease if other's penis touches pr slides on our scratches. However, if we use condoms, we lose our feelings. Each sexual practice has its own limitations (20-year-old bóngkín, Hanoi).
Condoms were rarely used during the initial encounter involving anal sex because many young men “did not want to use condoms for the first sex, did not knowing about condom use, and did not have condoms in their hands” (focus group, Hanoi). Furthermore, the first anal intercourse sometimes happened in a coercive manner (often with an older partner) when young men were neither prepared to have sex nor experienced with using a condom.
Participants listed several other circumstances in which condoms were not used. First, the negotiation of condom use was often hampered by feelings of trust in committed relationships. A request for condom use by either partner might be seen by the other as signifying mistrust or infidelity, thus jeopardizing their relationship. For this reason, many used condoms in their casual or commercial encounters, but never with their long-term or committed partners.
When I had sex with my girlfriend, I simply thought that I had loved her for so long that I did not need to use condoms. Using a condom meant that I doubted her love for me. Now, I think, even though they [sex partners] may be upset, we still need to use condoms to prevent diseases (19-year-old haih໙, Ho Chi Minh City).
Young men also evaluated their sexual risk based on their partner's appearance. Many noted that they do not use condoms when having sex with someone who is dànghoàng (decent). One bóngkín in Ho Chi Minh City described his sexual partner as dànghoàng because “he often stays at home all day, rarely going out.” Participants also said that they did not use condoms with they love (yêu) or like (thìch). Also, they said they might not use condoms with a handsome man described as hàngngon (delicious goods).
Sometimes, even though we have condoms with us, we may not use them because we are so excited, unable to control ourselves when we meet the “target,” we would take it easy and ignore using condoms (focus group, older youths, Hanoi).
Not having a condom on hand was another reason for sex performed in the absence of condom use. Young men said that they could obtain condoms through pharmacies, HIV prevention agencies, or health facilities, but these were not readily available when they had impromptu sex in parks or on the streets. “When having casual sex in a public place such as in the park, we don't use condoms if we don't have it in our hands” (22-year-old bóngkín. Ho Chi Minh City).
Finally, in commercial sex, financial power affects youths' decision-making abilities. Living under constant pressure to earn money for survival, street-based youths tended to acquiesce to clients, particularly foreign clients who offered a high price for unprotected sex. Others believed that they should not try to negotiate condom use as a way to show hospitality to foreign clients.
This is one of the first studies that examines the identities and categories, relationships, and detailed sexual practices of young men engaged in homosexual activities in Vietnam. We interviewed over 90 young men who identified themselves and their peers using various terms according to their homosexual, bisexual, or heterosexual preferences. There are terms for effeminate or transvestite men, but also labels that indicate the degree to which men are closeted and can “pass” as straight. There are also terms that suggest interest in both sexes or mixing of sexual partners by gender, as well as colloquialisms that are unique to a particular city. These terms illustrate the diversity of the gay subculture in urban Vietnam. However, some of the more derogatory terms also demonstrate the need for some to continue hiding their sexual identities and desires from public view.
When it comes to relationships, there is considerable differentiation within the MSM population in large urban areas in Vietnam. Bóng kín appeared to be more versatile with regard to sexual positioning, and bóng lộ generally sought heterosexualized encounters in which they identified as themselves as women. As Blanc previously noted (2005), in Asia there is a tradition for homosexual men to adopt opposite sex role characteristics, even to the point of transvestism. Such adoption of opposite gender sex role characteristics owes much to the degree of societal gender differentiation and stigmatization of homosexuality, rather than being inherent in a homosexual identity (Ross 1983). Commercial sex encounters appeared to be well organized in terms of cruising areas, with some young men staking out exclusive territories. Payment was sometimes based attractiveness, with some participants indicating that payment was expected only for unattractive partners, and willing to pay themselves for a very attractive partner. These data suggest the existence of a currency of attractiveness rather than a straightforward commercial transaction. Participants also outlined a clear distinction made between “making love” (làm tình) and anal sex, which is restricted to those partners with whom there is a high level of intimacy or with clients in commercial encounters.
Our data indicate that homosexually identified men, particularly bóng lộ, are forming nascent communities. The emergence of visible bars and clubs, as well as recognized cruising areas resemble early stages of homosexual community development in the United States in the late 1960s (Ross, Fernández-Esquer, & Seibt, 1995; Warren, 1974). The development of the MSM community in Vietnam appears to be informed by globalization in which Vietnamese youths are engaged in a process of “cultural extension,” adopting Western sexual values, practices, and identities through the media and the Internet (Ngo, Ross, & Ratliff, 2008). The emergence of gay identity and recognition of gay bars and clubs indicate that Vietnamese young MSM have been influenced by the gay subculture from Western or other Asian countries.
Although the term MSM has been used in HIV/AIDS discourse since 1990 to replace homosexual or gay, recent social critiques argue that the use of this term “obscures social dimensions of sexuality; undermines the self-labeling of gay, and bisexual people; and does not sufficiently describe variations in sexual behavior” (Young & Meyer, 2005, p. 1144). Consistent with other studies in Vietnam (Nguyen et al., 2008, Vu & Girault, 2005), our study shows that Vietnamese MSM (including homosexual or gay men) have developed a complex and nuanced terminology to represent themselves, and they resist labels that do not apply to their views of self. Thus, we use the term MSM to facilitate academic communication about a particular risk behavior but recognize that it has no meaning among the young men in our study.
The absence of a singular, unified MSM community, the varying degrees of disclosure, and the disparities in their sexual relationships and practices are challenges for HIV prevention. Of particular importance in our study are those youths who describe themselves as heterosexual (trai xin) but have sex with other men. Similarly, there are many bóng kín who have wives, and hai hệ also have sex with men and women. Given these shifts in sexual preferences and/or partners of both genders, they may act as bridges for transmission of HIV to other networks. Additionally, bóng lộ and transsexual women preferred to be the receiver in anal intercourse. This sexual activity puts them at a higher risk for contracting HIV. However, unlike bóng kín and trai xin who often attempt to disguise their sexual orientation, this group of MSM are more open to the public and thus more easily targeted in HIV prevention programs.
In terms of condoms, participants described a constant trade-off between risks and pleasures, and provided reasons for condom use and nonuse that generally paralleled those reported by homosexual men in other countries (Ross, 1988, 1990; Suarez & Miller, 2001). Condom use was associated with partners outside a primary relationship. Lack of condom use was associated with intimacy and trust in a partnership, passion and sex in the heat of the moment, with attractive partners, impaired judgment owing to alcohol, and public sex.
Sexual and gender identity, sexual networks, and types of relationships are closely related to different levels of HIV risk, and thus have important implications for HIV prevention. Communication and services, including condom distribution, for young MSM need to be tailored to effectively address their specific needs, using the appropriate language to reach different groups of MSM (e.g., bóng lộ, bóng kín). The use of the Internet to find partners offers an opportunity to develop Internet-based interventions to reach a larger number of MSM in Vietnam. Given that not all young MSM enjoy anal intercourse, promotion of nonpenetrative sexual practices could be an effective HIV prevention strategy, in addition to the promotion of condom use. Furthermore, interventions should focus on younger MSM who are prone to coercive or unprepared sex, helping them avoid risky situations in which unsafe sexual practices are likely to occur. Finally, changing youth MSM's misperceptions that partners' appearance is indicative of low HIV risk should be included in prevention efforts.
This study had several limitations. The sample was nonrandom, and recruitment through the snowball technique of reaching friends of contacts, and through public place intercepts and cruising areas may have biased toward those who were more sexually active. Also, the sample included only young men, and thus may not reflect the sexual identities, relationships, and practices of older men. Finally, the data were collected in the two largest metropolitan areas of Vietnam and are unlikely to be representative of smaller cities or rural areas.
These data document both the existence and continuing organization of homo-sexuallyidentified men and MSM in the largest urban centers in Vietnam. Mapping of slang terms for MSM indicates a degree of differentiation and specialization with regard to gender roles and sexual activities, exhibiting similarities with other Asian and Western countries. The emergence of diverse communities of bóng lộ, bóng kín, hai hê, and trai xin in Hanoi and Ho Chi Minh City provide an important challenge for targeted HIV/AIDS prevention activities in a groups identifies as constituting a significant gap in HIV prevention efforts in Vietnam.
Funds for the study came from an assessment, “Gathering Input From Youth MSM and Other Young Men” in Hanoi and Ho Chi Minh City, as part of Project NAM, a PEPFAR/USAID through Pact/Vietnam supported project managed by Save the Children USA that works to prevent HIV among young men in Vietnam. This project was partially supported by Award number D43TW007669 from the Fogarty International Center, U.S. National Institutes of Health, to the University of Texas School of Public Health.
The authors would like to thank Dr. Scott McGill of Save the Children USA, Myanmar, for his valuable input in development of data collection tools and suggestions to improve the article.