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China is home to the world's largest lesbian, gay, bisexual, and transgender (LGBT) population. Until a decade ago, LGBT people were an invisible and hidden population in Chinese society. Although legal persecution was repealed in 1997, discrimination against LGBT people still exists.1Burki T Health and rights challenges for China's LGBT community.Lancet. 2017; 389: 1286Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar Chinese culture esteems filial responsibility for raising offspring and continuing one's family line; not doing so is considered by many a social transgression. China's one-child policy (banned in 2015) created strong pressure on LGBT individuals, as lone children, to continue their family line. Pressure to marry resulted in groups of Tongqi (wives of gay men) and Tongfu (husbands of lesbians). While not directly prohibiting LGBT-related programmes, the State Administration of Press, Publication, Radio, Film and Television of China censors them as unsuitable for the general population. Such discrimination against LGBT people has wider implications for all of society. For example, social stigmatisation of LGBT minorities, together with insufficient sexual health education, can be barriers to preventing sexually transmitted diseases, including HIV.2Zheng SF The growing threat of China's HIV epidemic.Lancet Public Health. 2018; 3: e311Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar From a mental health perspective, in 2000, the Chinese Classification of Mental Disorders 3 (CCMD-3) removed homosexuality and bisexuality from the mental disorders categories.3Chen Y-F Chinese classification of mental disorders (CCMD-3): towards integration in international classification.Psychopathology. 2002; 35: 171-175Crossref PubMed Scopus (136) Google Scholar However, a considerable number of mental health professionals in China still consider homosexuality a disorder that should be treatable by sexual orientation conversion efforts (SOCE). At present, SOCE is provided by hospitals across China, including several leading medical centres in major Chinese cities.4Bhandari B conversion therapy still promoted in china, investigation finds.https://www.sixthtone.com/news/1003870/conversion-therapy-still-promoted-in-china%2C-investigation-findsDate: April 19, 2019Date accessed: July 18, 2019Google Scholar In CCMD-3, transgender presentations were, and still are, categorised as mental disorders.3Chen Y-F Chinese classification of mental disorders (CCMD-3): towards integration in international classification.Psychopathology. 2002; 35: 171-175Crossref PubMed Scopus (136) Google Scholar Now that the 11th revision of the International Classification of Diseases (ICD-11) has removed gender incongruence from its mental disorders section,5WHO. International statistical classification of diseases and related health problems (ICD-11). 2018.Google Scholar it is uncertain whether CCDMD-3 will follow. Such reclassification could be important to reduce stigma.6Drescher J Cohen-Kettenis PT Reed GM Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale.Lancet Psychiatry. 2016; 3: 297-304Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar It is currently extremely difficult for transgender people to access hormone treatment or gender-affirming surgery and there is limited availability of transgender health care.7Zhu X Gao Y Gillespie A et al.Health care and mental wellbeing in the transgender and gender-diverse Chinese population.Lancet Diabetes Endocrinol. 2019; 7: 339-341Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar In addition, contrary to growing international standards,8World Professional Association for Transgender HealthStandards of care for the health of transsexual, transgender, and gender nonconforming people. World Professional Association for Transgender Health, East Dundee, IL2011Google Scholar in China transgender people require at least a year of some form of psychotherapy before obtaining approval for gender-affirming surgery. In this cultural context, our recent survey led by the UN Development Programme and Beijing LGBT Center is informative. To our knowledge it was the first national cross-sectional survey assessing public discrimination against and acceptance of the LGBT community. It included 10 932 respondents from 31 Chinese provinces. The results of that survey showed that 11·1% of heterosexual participants reported being unable to accept LGBT family members, and for other social relationships, the rejection rate ranged from 2·1% to 4·1%. The rejection rate reached a higher level when heterosexual participants were asked about the acceptance of their own children being bisexual (25·1%), homosexual (17·5%), or transgender (66·8%). Furthermore, more than 10% of heterosexual participants rejected the idea of being close (in terms of relationships) to LGBT people and did not believe bisexual (6·0%), homosexual (8·2%), or transgender (21·9%) people should be allowed to raise children. On a positive note, there are many organisations in China now campaigning for LGBT rights, making efforts to increase social visibility of the LGBT community and reduce discrimination. For example, since 2018, a group of Chinese artists launched a protest campaign drawing attention to the use of SOCE.9Edward D Trucks tour China to tackle LGBTQ stigma as dozens of clinics offer electro-shock therapy to ‘cure homosexuality’.https://www.itv.com/news/2019-02-01/gay-conversion-therapy-china-lgbtq/Date: Feb 1, 2019Date accessed: July 18, 2019Google Scholar In addition to granting same-sex marriage and child adoption, other policy issues need to be addressed. Employment protection banning discrimination based on sexual orientation or gender identity is needed. Educational institutions need to take responsibility for preventing bullying, improving sex education, and removing anti-LGBT content from textbooks. Workers at hospitals and private clinics need to be educated about the harms of SOCE. Chinese clinicians should adhere to international diagnostic classifications rather than CCMD-3. The Chinese Government needs to implement domestic violence protections for LGBT children who are subjected to violence by family members. Finally, training on diversity and inclusion in China should be widely promoted among different professional occupations, such as school teachers, police officers, and health-care professionals. We declare no competing interests.
Wang et al. (Sun,) studied this question.