To our best knowledge, this is the first study to explore mental health and HIV-related risky sexual behaviors among the MSM population separated by gender identity sub-groups in China. In the current study, we found that, when compared with cisgender MSM, transgender were more likely to engage in HIV-related risky sexual behaviors and have a lower likelihood of identity concealment, while gender non-conforming MSM were not significantly having engaged in HIV-related risky sexual behaviors and having some psychological characteristics. Consistent with Geoffrey’ research, gender identity factor plays an important role in HIV transmission among the MSM population . Hence, it is essential to note that research on the MSM population should be separated by gender identity sub-groups, which is necessary for targeted interventions to be developed.
The study showed that the prevalence of transgender and gender non-conforming identifying MSM accounted for 8.8% of the total population. A previous study reported that 23% of sample were identified as gender minorities among the MSM population, while yet another study found that 9% of the MSM population were identified as transgender women . This existing discrepancies among different studies could be attributed to various assessment tools of gender identify, different districts, and cultural norms, etc. And though our sample was recruited from the central part of China, it is noteworthy that this study helps us establish the initial understanding of the epidemic profile of risk factors for transgender and gender non-conforming MSM in China.
We found that it was not significant that depression and perceived social support were associated with their gender identity in MSM population, which is consistent with Sandfort’s studies . In terms of identity concealment, the cisgender MSM population was found to be more likely to report it than transgender MSM. The lower likelihood of identity concealment among transgender identifying MSM possibly made them have to tolerate more discrimination when compared with the cisgender MSM population, increasing the frequency of condomless anal sex and could in turn increase the risk of HIV infection. Thus, it is necessary in future research to make further efforts to provide new evidence linking gender identity with mental health and explore the complex relationship within the MSM sub-populations.
Some studies conducted in community population showed that transgender individuals were more likely to have one-night stand/occasional partners, sex after drug use, or engage in commercial sexual behavior when compared to the MSM population [11, 22]. A study surveyed in Brazil reported that transgender individuals engaged in more HIV-related risky sexual behaviors than MSM individuals, including the number of sex partners, commercial sex activities, and so on . Similarly, our study conducted among MSM population found that compared with those cisgender MSM, transgender MSM were more likely to have sex after drug use, have one-night stand/occasional partners, and engage in commercial sexual behaviors. This is possibly because that transgender MSM have a dual minority identity being both transgender and MSM , while cisgender MSM population do not. The dual minority identity of transgender MSM are endowed with higher level of discrimination and risk sexual behaviors. In the study, gender non-conforming MSM were not found to have a significant correlation with HIV-related risky sexual behaviors in comparison with the cisgender MSM. It can be accounted for by the fact that gender non-conforming MSM may or may not self-considered themselves to be transgender. Consequently, these results suggested that we should pay more attention to transgender MSM within the larger groups of MSM.
There are several limitations to this current study. First, this study was a baseline survey of a four-year cohort study conducted in three Chinese central cities, which limited the representative of samples and the integrality of the whole research. Second, mental health outcomes were measured by four self-reported questionnaires, which did not consider other mental health like anxiety, self-esteem etc. It is necessary that additional mental health outcomes are incorporated in further research exploring the relationship between gender identity, mental health, and HIV-related risky sexual behaviors. Third, the study did not look at differences within the transgender community, further research is needed to understand the difference between transgender women and transgender men in China.