Zhang L, Shen L, Wei-Ti C, Sun M, Sun W, et al. (2019) Marriage and Fertility Issues: Ethical Dilemma Faced by Gay with HIV/AIDS in the Context of Chinese Culture. Int Arch Public Health Community Med 3:021.

CASE REPORT | OPEN ACCESS DOI: 10.23937/2643-4512/1710021

Marriage and Fertility Issues: Ethical Dilemma Faced by Gay with HIV/AIDS in the Context of Chinese Culture

Lin Zhang1#, Lei Shen1#, Wei-Ti Chen2, Meiyan Sun1, Wenxiu Sun1, Zheng Zhu3 and Hongzhou Lu1*

1Shanghai Public Health Clinical Center, Fudan University, Shanghai, China

2School of Nursing, University of California, Los Angeles, CA, USA

3School of Nursing, Fudan University, Shanghai, China

#Equal Contribution.


Acquired Immunodeficiency Syndrome (AIDS) is a kind of serious infectious disease caused by Human Immunodeficiency Virus (HIV) [1,2]. In the report of World AIDS Day of 2015, the UNAIDS estimated that there are 3690 million HIV affected people and AIDS patients, including 200 million people newly infected with HIV and 1.2 million AIDS-related death that year. There are 15.8 million people living with HIV were accessing antiretroviral therapy as of June 2015 [3]. According to the latest AIDS report [3]: by the end of November 30, 2015, it estimated HIV-infected people and AIDS patients about 580,400 cases, 180,200 cases of death, survivals infected with HIV 342,600 cases, and 237,700 patients with AIDS. China has entered the peak of AIDS incident and related death, the current HIV epidemic in China presents four characteristics: 1) The whole country maintains a low prevalence level while some areas shows a high prevalence of phenomenon; 2) Sexual transmission has become the main route of transmission instead of mother to child transmission and intravenous drug; 3) The middle age people and young students have become key infected groups of people; 4) The number of infected survivals and patients increased year by year. The men infected with HIV who have sex with men also increase [4]. According to the data from the Joint Programme on AIDS (UNAIDS) of 2014, the infected rate of HIV in MSM from the world's five continents is from 6% to 19% [5]. In the UNAIDS report of 2014, the Chinese infection rate in MSM from 2005 to 2014 has reached 7.7% which has increased 5.5 times. MSM rate accounted for newly diagnosed HIV has increased from 3.4% to 25.8% [6].

In Chinese traditional culture, homosexuality is always being considered as abnormal sex behavior which violates the natural and human evolution regulations. Most people still appose to homosexuality and they think it is a kind of disease called sexual deviation or variation. Even there is mutual love between homosexuals, and they have to maintain sneaky, shady, and secret love. Many homosexuals try to conceal this situation by marrying members of the opposite sex aims at covering for them, continuing family generation and keeping accordance with social traditions. Many homosexuals dislike this form, but they have no choice which led to their marriage in name only. For the homosexuals, heterosexual spouses just became nominal and tools of having children [7].

Gay men suffer dual pressures of HIV infection and not accepted by social, and they have to face social difficulties, personality difficulties, emotional difficulties as well as marriage difficulties. Except for that, they have to deal with dilemma of responsibility and love while married men are despised among homosexuals. Another major problem in the emotional difficulties is the pressure from heterosexual marriage. Since there is no basis of love, the heterosexual marriages of homosexuals are definitely unhappy because they can not cultivate feelings. For gay men themselves, wives and children, these kinds of marriage are tragedies. When there is a possibility of infected with HIV, gay men will be more unworthy to their wives and children, and they are afraid that their families and children will be excluded by society.

Emergence of AIDS is the important reason to get people concerned about the survival situation of homosexuals while the gay men become high risk of HIV infection because the infective rate of gay men is just lower than drug addicts. For the gay men entered heterosexual marriages, they may have sexual relations with opposite sex led the innocent women infected with HIV. Therefore, these "wives of homosexuals" have become a potential threat of the rising spread of AIDS [8].

In the case of Chinese traditional religious background and unique social problem, "gay men" and "wives of homosexuals" have been concerned by medicine, ethics, sociology and the science of law. With the high spread rate of HIV infection through "gay men" [9], Ethical problems and medical problems the presence of HIV infection causes AIDS contrary to "gay" community "wives of homosexuals" phenomenon.

The "gay men" infected with AIDS undertook the important task of "continuing family generation". In the families with single HIV-positive (husbands are HIV infected, wives are uninfected), if wives accept exposure and post exposure treatment, it is possible to have given birth a healthy offspring.

However, when these "gay men" with AIDS consult fertility problems with nurses, although the nurses knew their marriages are not based on love only because of "continuing family generation" or other reasons. In these kinds of marriages, "wives of homosexuals" have no ideas about their husbands' sexual orientation. It is obviously unfair and harmful to these wives. But researchers cannot tell any related information to the "wives of homosexuals" because of secret protection regulation. How to answer their questions and comfort the fertility attitude of wives is another important and ethical issue for researchers.

We will use two cases study to discuss the following two major ethical concerns that are likely to confront researchers conducting HIV prevention intervention research among persons living with HIV and AIDS/MSM?

1. Beneficence. Two general rules are applied which are a) Do not harm and b) Maximize possible benefits and minimize possible harms. In applying these edicts, when is it necessary to break confidentiality and privacy?

2. Justice. Whose views determine the intervention content and design?

The Research Study

After tracking and interviews with the following two cases, we believe that each participant faces different ethical dilemmas including AIDS, gay men, and wives of homosexuals. Under the background of Chinese traditions, everyone feels confused and sad in the principles of harm, respect, advantages, and fairness.

Mr. A and Mr. B

Mr. A is a staff infected with HIV for three years, starting treatment for two years, current CD+ 4 counts of 350 cells/μL. Viral load is undetectable.

Mr. A thinks he divided "sex" and "love" clearly: "Personally, I think I will only create a sense of feeling with homosexual, but relations with my wife for so many years has grown to a sense of family…I can tell the difference between love and sex. I think homosexual acts are physiological needs, for my wife is love…"

Mr. A intended to break up with his wife, but when they know Mr. A has infected with HIV, they are getting closer than before and ultimately married: "After infected with HIV, I began to realize I will try hard to love as long as there is something worth to cherish, and it is the only reason why we didn't break up. For me, my wife is a symbol of truth, kindness and beauty. She is real that I think I will continue my life with her…"

Mr. B is a corporate employee infected HIV for three years and accepted treatment for 3 years, current CD+ 4 counts 40 cells/μL. Viral load is undetectable.

The couple relationship between Mr. B and his wife is better than before: "At the beginning, I was resistant because this combination is not based on love and my feeling is not good…later she didn't left me when I infected with this disease. I began to realize that she is kind and relationship is better than before. She always concerned about me. I was always looking forward her to go for work when I was not ill, but now I am looking forward her to come back early".

The most concerned problem is also fertility issue: "She always wants a child, so do I. We come to see doctors together, but I am still a little afraid and she keeps seeing doctor to avoid infection…"

The biggest concerned problem of Mr. A and Mr. B is how to have a healthy baby without infection AIDS, so they are very concerned about preventive measure about pregnancy and consult about drugs on baby with nurses.

Analysis from the Researchers (Nurses) in Interviews Participants

Speaking from technologies, it is realistic to have a healthy baby from using prevent drug of HIV, but wives don't know about their husbands' sexual orientation in these relationships, and researchers can't release any detail information because of secret principles. It is unfair for wives who will face these questions: 1) Possible risk of infection; 2) Possible to have unhealthy offspring; 3) If they want a divorce after knowing about the true situation of their husbands, kids will become one of the key affects.

The researchers also believe that discussion without "fertility issue" will cause the participants have reflection and self-questioning about birth, marriage, and wife problems. Meanwhile, the researchers are not able to provide better solution and these kinds of marriage will bring more problems, like: 1) Effect on treatment of their husbands; 2) How to inform their children about healthy conditions; 3) Children will bring more effective factors, and husbands how to maintain the balance. These issues also bring guilty and anxiety because they can't prevent and provide correct advice.

From the perspective of social ethics, marriage violates the principle of fairness and respect of ethics. But for AIDS gay people, if the nurses let their wives know their homosexual identity, and it is also contrary to the principles of fairness and respect for ethics.

Researchers think they must strive to remain neutral non-judgmental attitude while introducing prevention and precautions about before and after childbirth under unfair situation.

In particular, the researchers have no idea how to treat this situation and give advice when they realized the positive attitude about pregnancy.

Analysis from Gay Men Infected with HIV

For the gay men infected with HIV, researchers are not sure about whether it is the real idea to have their own generation. Because they have to face a lot of ethical dilemmas and were forced to have heterosexual marriage:

Gay men were forced to have normal marriage under the pressure of families and society, at the same time, they concerned about HIV infection to their wives and felt strong guilty and needs that wish themselves to take responsibilities for wives and families. Maybe they think having a baby can be seen as performance of responsibilities and love to their families.

In an interview, Mr. B was also doubt about whether to have a baby. But after speaking of giving back to his wife, he insisted his thought. Mr. A also have the same performance.

In Chinese traditional society, the men should take task of "continuing family generation" which makes them feel sorry to have no babies. In the eyes of the people around them, their parents will suffer a lot of doubt and pressure because of having no grandchildren. Meanwhile, they are afraid that their homosexual identity will be known by their wives and bring side effect to both families (their own parents' home, wives and wives' parents' home).


Ethical dilemmas

90% of male homosexuals in China choose to get married with opposite sex, while most of their wives do not know about this. Many of them are suffered from criticism, ignorance, unfaithfulness and even family violence because of the special sexual preference from their husbands. But numbers of wives of male homosexuals have no choice but to bear this kind of pain for the sake of the kids' growth, completion of family and the maintenance of reputation [10].

Due to the disability of giving birth to offspring, the living conditions of homosexual people are deviated from traditional Chinese moral concept relating to reproductive sex morality such as "raising sons to support parents in their old age", "carrying on the family line", which makes homosexual people suffer from the reprimands, discrimination and extremely unfair treatment.

And the gay men with HIV are even suffering from multiple stresses and discrimination, from HIV and homosexual people; at the same time they have to bear the duty of continuity of a clan vested by family and society, which makes them overloaded.

Patient role intensification is generated among gay male because of the infection of HIV. They will feel guilty to their wives who do not know their husbands are homosexual for the attention and care, and decide to pay back their wives with love and offspring production. And their wives are very touch about this though they know nothing about male sex preference of their husbands; in this case, conjugal bonds get improved and strive together for bearing healthy offspring.

But, as a researcher, in order to protect the interest of gay male with HIV, when asked about the reproduction, the topic of anything about husbands' sex preference can't be mentioned to their wives, which is from the point of researcher unfair to the wives' marriage. In addition, researcher believes that this kind of marriage status shouldn't be appeared, not to mention the offspring reproduction, these are deviated from researcher's ethics. Researcher is filled with contradiction and deeply feels anxiety and impotence when introducing how to do preventive medication before and after fertilization to gay male with HIV and their wives.


Gay with HIV will conceal their identity to their wives, but when researcher does interview to gay and their wives, this will increase the wives' suspect to husbands' sex preference, generating the possibility of passive notification to the wives of gay.


In China, forced by traditional stresses, most of gay with HIV need to step into marriage status and give birth to children, this kind of marriage and births brings many unavoidable questions for HIV prevention and control.

The analysis on the problems of marriage and births of gay with HIV from the perspective of bioethics has the assignable theoretical and practical significance; and the researcher do not know how to give answers when asked about marriage and births, so the answers are like these:

1) Tell them when wives are not infected by HIV, the probability of giving birth to healthy offspring will be big by prophylactic use of drug;

2) If the gay with HIV do not get married, then ask him to think whether he love this woman who married with him;

3) If he was married, then ask him can he provide a complete family and future to kids or not;

4) Advise the couples to be open-minded about the treatment to pregnant, the most important thing is to live your life well.


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Zhang L, Shen L, Wei-Ti C, Sun M, Sun W, et al. (2019) Marriage and Fertility Issues: Ethical Dilemma Faced by Gay with HIV/AIDS in the Context of Chinese Culture. Int Arch Public Health Community Med 3:021.