China has experienced a sharp increase in HIV infection among MSM in recent years. Although behavioral intervention is considered as an effective means of reducing HIV infection among MSM [7
], an interventional strategy shown to be effective in one setting, place, or time may not necessarily work in another [8
]. Strategies should be tailored for risk-different sub-groups of MSM based on their biomedical, behavioral, social, and psychological characteristics [9
]. In this study, we attempted to characterize social and psychological differences between MSM with and without high-risk behaviors (i.e. having sex with male strangers, participating in group gay sex, and involvement in commercial homosexual activities) in China.
The analysis of the subjects' general demographic data showed that the high-risk MSM and the control MSM were similar in sexual orientation, level of education and types of profession, but significantly differed in marital status and income (Table ). The percentage of married MSM was significantly higher in the high-risk behavior group than in the control group, in agreement with the findings from a study involving 6,661MSM in India where married MSM were more likely to have unprotected anal sex [11
]. At present, there still exist strong cultural stigmas, prejudice and discrimination against homosexuality in China and many other Asian countries; MSM are subject to great pressures from the family and society. As a result, MSM either try to hide their sexual orientation or choose to marry a woman to shield their high-risk homosexual behaviors. This may explain why more subjects were married in the high-risk behavior group than in the control group. Similar to marital status, there was a significant difference in the monthly income between MSM with and without high-risk behaviors, indicating that relatively higher income may make high-risk behaviors, like commercial sex, more economically possible. No significant difference in condom use was observed between the two groups of MSM in this study (Table ), in disagreement with a previous observation that lower income was related with unprotected sex behavior [12
The respondents in the high-risk behavior group had more irregular sexual partners and utilized more diversified modes of gay sexual intercourse (e.g. oral-anal and finger-anal sex) than those in the control group (Table ). This may be related to the fact that MSM in the high-risk behavior group had more liberal and permissive attitude towards sex. Nevertheless, the exact reason behind this needs to be further elucidated. It is well known that an exchange of blood is one of the risk factors for HIV transmission. The analysis in this study showed a relatively high proportion of MSM members in the high-risk behavior group who experienced bleeding during homosexual sex (Table ). This might be related to the large number of sexual partners and unusual sexual behaviors (e.g. masochistic or sadistic sex). Bleeding-associated sexual activities may substantially increase the risk of HIV infection and AIDS transmission, but further studies are warranted to assess the degree to which bleeding-associated gay sex may increase the chance of HIV infection in Chinese MSM.
To date, little is known regarding the mental and psychological characteristics of MSM in China. In this study, we demonstrated that approximately half of the Chinese MSM studied had experienced different forms and degrees of embarrassment, stigma or discrimination after disclosure of their homosexual orientation and that 44% to 60% of the respondents felt that their life was painfully affected by their sexual orientation, regardless of high-risk sexual behaviors or not (Table ). This study also indicated that almost 70% and 80% of the surveyed MSM respectively expressed a willingness to attend gay clubs if legally protected and were supportive of gay marriage legislation in China (Table ). It has been reported that MSM are more likely to have intentions of suicide, as compared with the general population [13
] and that among MSM, suicidal intentions are even stronger among those with high-risk behaviors [14
]. In this study, we found that 29.8% of MSM with high-risk behaviors had considered suicide. Although this number was significantly lower in MSM without high-risk behaviors, the rate was still high at 17.3% (Table ). In China, suicidal thoughts are most likely to result from psychological pressure and failure of being accepted by mainstream society. Although future legal recognition and cultural acceptance of homosexuality may substantially reduce suicide intentions and attempts in MSM in China, these cannot happen overnight. At present, a greater access to psychological counseling services is practical and feasible.
The relationship between the mentality and individual high-risk sex behaviors in MSM has not been well studied [15
]. Although a study on Black and Latino MSM has suggested that impulsive decision-making, sensation-seeking, anxiety and depression and internalized homophobia may all contribute uniquely to the behavior of unprotected anal sex [16
], more has to be learned about the specific factors that lead to high-risk sexual behaviors in MSM in China in order to minimize the development of these high-risk behaviors and to implement more appropriate and effective behavioral and therapeutic interventions. Physical or sexual abuse in childhood has been identified as a contributing factor in adverse psychological states as well as high-risk sexual behaviors in adulthood [17
]. Multivariate regression analyses in this study showed that the most important factor attributable to the development of high-risk sexual behaviors in Chinese MSM was sexual abuse from an adult male before the age of 16, followed by heavy alcohol consumption, income level, and the assumption that the use of condoms can completely (100%) prevent HIV infection (Table ). Our findings are consistent with previous studies which indicated that sexual abuse in childhood [20
] (which is more common in countries lacking legal protection of homosexuality [21
]), traumatic injury-associated alcohol abuse [22
], and alcohol addiction [23
] were identified as risk factors for high-risk sexual behaviors. It is therefore highly logical and advisable to minimize the risk of high-risk homosexual behaviors in MSM by implementing a zero tolerance approach to all forms of childhood sexual abuse and publicly discouraging excessive alcohol consumption as previously proposed [24
]. Additionally, it is imperative to implement public education campaigns to correct the misunderstanding that the use of condoms can completely protect against HIV/AIDS.
The data analyzed in this study were from a national survey where the respondents were recruited by a snowball sampling approach. Given some limitations (e.g. more subjects recruited into the sample by some upper layer subjects who happen to have more acquaintances of MSM) intrinsically associated with this sampling approach, some unavoidable sampling bias may exist in the study.