According to public figures, currently 95 percent of HIV transmission in China is through sexual transmission. “In China, the level of knowledge about sexual and reproductive health among young people is still very low, and only 14 percent have sufficient knowledge about HIV and AIDS," the United Nations Population Fund (UNFPA) Representative Office in China wrote in a series of policy briefings in 2013. Sexuality education is inextricably linked to the prevention of HIV. An expert who has worked tirelessly to spread the word about sexuality education and HIV prevention in both China and the United States explained to Wainao the current progress and existing problems in China. In order to avoid affecting his current work, he requested that his real name not be used. The interview was conducted in both Chinese and English and translated by Wainao. In order to facilitate readers' understanding, some adjustments were made on word order. Will they use condoms if they have them? Sexuality education is not just about teaching condom use. Q： What is the relationship between sexuality education and HIV prevention? A: Actually, if you click on Baidu now, you will find lots of articles about the increase in the infection rate among young people. Many experts are concerned about this. I think that there is a value judgment made by some people who pay attention to this issue—college students between the ages of 18 and 26 are pure and worthy of being saved, not the same as homosexuals who are not worthy of being saved. Their infection must be because they were deceived by bad individuals, which is very regrettable. Now many at universities distribute and teach how to use condoms , and some universities distribute free HIV test kits to college students in order to call attention to the issue. There is still a logic error in this, however. Will those who have access to condoms use them? In fact, there is a problem with connecting knowledge and action. Many people know how to use condoms, yet still don’t use them. In that scenario, they don’t dare resolutely say to their partner "No.” For example, their partner might respond, “You wanting me to use a condom means you don’t love me.” In the moment, they may not be thinking clearly, and might give in once and get infected. Therefore, the relationship between sexuality education and HIV prevention is not just a matter of teaching how to use condoms, it should also have a broader scope and be more contextualized. Q: You used to do sexuality education related work in China. What kind of work did you mainly do at that time? A: At that time, I started with a student club while at university. Later, when we cooperated with international foundations, I took this opportunity to work in a youth organization sponsored by an international organization. Our work included conducting training ourselves or doing capacity building, that is to develop or adapt some textbooks and then teach college students or teachers from the school committee. Back then, we received help from various organizations, including the United Nations. They would tell us which ones were the most comprehensive English textbooks in the world and which were supported by tested data. We would Sinicize, translate, and localize some cases. For example, there might be examples from Africa in the textbook, it might be a scene where everyone is doing farm work together, then we would make these scenarios more applicable to the lives of Chinese teenagers and closer to life on a university campus. Q: Where would these adapted textbooks be used? A: At that time, the organization I was in had a network of people in charge in many cities throughout China. They would give the teaching materials to local colleges and universities, and then the organizations would provide small subsidies to those colleges and universities to promote sexuality education. With this funding, they would use these teaching materials—this method was more dependent on international organizations. Now that many international organizations do not do work within China, this method has collapsed. International organizations that are still active in China now tend to do high-level advocacy work instead of supporting grassroots organizations, because international organizations are now more restricted within China. It’s more efficient to cooperate with organizations with a domestic background. Q: The textbooks you mentioned just now are all distributed to colleges and universities. How is sexuality education for children carried out in China? A：I remember that quite some time ago there was a very good children’s sexuality education textbook called “The Footsteps of Growth.(成长的脚步)”* It seems schools and parents objected to it. I think it was too avant-garde and wasn’t used after the trial period. Nevertheless, there is still a culture of “discussing sexual changes,” but parents feel that this type of content shouldn’t be taught to their children too early. The resistance to sexuality education for young children is greater than in colleges and universities. * “The Footsteps of Growth” was the first pilot textbook for elementary school sexuality education curriculum that broke traditional standards. It was tested out in some Beijing elementary schools in 2011. The content was set according to the characteristics of elementary, middle and high schools and their students. The elementary school level included "Where do I come from?”, “Cute boy, cute girl”, and “Will you protect yourself?” The secondary level included “Young beautiful girl”, “Little man”, “Learning skills to communicate with parents." And the third part included “Accept yourself”, “Interacting with classmates”, “Preventing AIDS”, and “Be a healthy little netizen.” I know that Beijing Normal University professor Liu Wenli has been promoting children's sexuality education. She edited that sexuality education textbook, but recently she was bullied online. It was because the parents felt that the textbooks were too provocative. *In 2017, the mother of a second-grade student in a Hangzhou primary school photographed illustrations from Liu Wenli and her team’s book "Cherish Life-Primary School Pupils' Sexual Health Education Reader" and posted them to her personal Weibo. In a picture, "Aunt Li" said to a boy "Xiaojun, you have grown taller again. You take off your pants and let your aunt see if your penis has grown up." Netizens commented on the illustration’s content as too explicit and questioned whether the scientific names of reproductive organs should be introduced to children. After Liu Wenli's team responded, correcting misunderstandings and addressing the importance of reproductive organs in preventing sexual assault, they received support from some netizens. The reader also includes things such as two fathers and two mothers. It was removed from the shelves in January 2019. “Neither supports nor opposes,” the disclaimer has already been expressed. Q：China now often talks about implementing comprehensive sexuality education in 2030. Can you tell us about comprehensive sexuality education and why it is set for 2030? A: This 2030 goal is due to the "Healthy China 2030" planning outline. In 2020, China included sexuality education in the "Law of the P.R.C on Protection of Minors" and the "Healthy China 2030” outline. Now that we have this foundation to implement comprehensive sexuality education, there will be more rules to follow, and there may be less resistance to promotion at the grassroots level. In my understanding, China’s comprehensive sexuality education refers not only to teaching about reproductive organs, but also contraceptives. I think this is mainly because the number of abortions among young people in China is very high and these young people have to consider this, as well as HIV prevention. *According to the UNFPA Representative Office in China, there were 13 million abortions in China in 2015, 62 percent of which for women aged 20-29. Q: What is the difference between China and the United States in terms of sexuality education? A: In terms of basic condom use knowledge and AIDS awareness, I think there is no real difference between Chinese and American teaching methods. However, most sexuality education in the United States recognizes sexual identity and gender, and emphasizes sexuality, sexual orientation, and gender. In other countries’ comprehensive sexuality education, some will discuss how to treat the consumption of pornographic material. For example, anal sex between people of the same sex or the opposite sex is rarely mentioned in sexuality education in China. In the United States, when discussing same-sex relationships, it’s mentioned that anal sex can transmit HIV and other sexually transmitted diseases (STDs). In addition, knowledge related to PrEP (pre-exposure prophylaxis) has become more common in education about HIV in the United States. Of course, states differ. Southern, conservative states are more concerned with abstinence education. Some New York high schools and school clinics have begun trying to promote STD detection, treatment and PrEP promotion among high school students. Some students can get free PrEP from the school clinic. In China’s school system, the content taught in health classes is still based on textbook knowledge. However, some sexuality education institutions use more participatory methods to teach about HIV prevention. For example, the "water-changing experiments" and "wildfire games" mentioned in a China Family Planning Association report are all classic participatory AIDS prevention training activities translated and adapted from foreign textbooks. In addition, some institutions teach how to use condoms through activities, like buying bananas and letting everyone practice putting a condom on a banana. In addition, China has played down the concept of sex and gender. I remember when we were conducting sexuality education training, some teachers would say, "We do not support or oppose homosexuality." In fact, that’s a disclaimer to express their position. Also, the concept of "consent" is not taught much in China. How to express one's desires, to say "no", how to respect another’s desires, and understand the importance of obtaining consent are not taught. In China, the most important things are condom use, abstaining from sex if you can, and avoiding miscarriages. That said, even if it is just promoting condom use, there will still be resistance. Whether it be the schools or parents, people will think “Won’t discussing the use of condoms encourage young people to have sex too early?” They will find this culturally unacceptable, or it will be subject to a moral trial about encouraging certain behaviors by introducing them. Given the above-mentioned concerns, China's current comprehensive sexuality education is actually a comprehensive sexuality education with Chinese characteristics. Q: What kind of chain reaction is caused by conservative sexuality education? A：I want to talk about conservative sexuality education from two aspects: one is the exclusion of diverse groups of people, including homosexuals and gender nonconforming individuals; the other is conservative sexuality, which considers premarital sex wrong and having multiple sexual partners as unclean. First, the exclusion of diverse groups of people has led to a propaganda effort of HIV prevention slogans often based on “threats” and “intimidation.” For example, persuading college students not to engage in homosexuality or touting the devastating effects of HIV infection. Many HIV prevention workers do not have LGBT-competency, that is, the ability to deal in a friendly manner with sexual minorities, and don't even think they need to improve in this area. From the perspective of messaging, AIDS prevention workers don’t really know which channels can actually reach sexual minority audiences, so they follow outdated ideas for outreach, such as putting up posters in public places. This is poor messaging, and may not bring the most useful knowledge to the people who need it most in the most effective way. In addition, many sexual minorities, especially young gay groups, are unwilling to receive HIV prevention services, including regular testing, PEP/PrEP, HIV-related counseling, etc., because they are worried that their behavior will attract criticism from medical staff. This discrimination narrows the living space of many homosexual individuals, especially gay men in small cities, who are often forced to enter into heterosexual marriages. If these gay men were infected with HIV while having relationships with other men without realizing it, they might infect their wives with HIV. Second, the conservative concept of sex seldom mentions "sex positivity" in sexuality education in China, which is having a positive attitude to sex overall. Most sexuality education still emphasizes things like abstinence, condom use, and reduction of the number of sexual partners, rather than discussing topics like consent, sexual agreement, and negotiation skills. Conservative concepts about sexuality will affect the public's attitude towards the LGBTQ+ community. For gay people, the state and society cannot provide them with institutional guarantees (such as same-sex marriage), so it is very difficult to maintain a long-term gay relationship in China. In the face of this kind of realistic pressure, there will be multiple sexual partners, frequent changes in partners, sex appointments, and other behaviors within the LGBTQ+ community. However, in the eyes of the public, these are the "inherent bad habits" of this community, and there are many value judgments made. The public and even medical staff believe that "post-exposure prevention is just a medicine of regret for sexually depraved gay people." If most people think this, it will be difficult to promote post-exposure prevention, such as expanding public messaging, increasing drug delivery locations, and discussing whether drugs can be covered by health insurance. Subheading 3: They worry that pre-exposure prevention will make people "more immoral" Q: The commonality of HIV pre-exposure prevention (PrEP) and post-exposure prevention (PEP) is quite different in China and the United States. How about the acceptance of PrEP and PEP in Chinese society? A: As far as I know, there is currently no research on the degree of public acceptance for PrEP and PEP domestically. The current data on the acceptance of PrEP and PEP are mainly concentrated in two groups. The first are the so-called "key groups" for HIV prevention and treatment, that is, gay men and female sex workers. There are more data collected from gay men, and less data on female sex workers. One particular study is the earliest survey on the acceptance of PrEP in China. Between October 2012 and December 2013, the Centers for Disease Control and Prevention (CDC) and gay community organizations in a certain district of Shanghai recruited 1,033 gay men. About 200 people (19 percent) expressed interest in using pre-exposure prophylaxis, but in the end only 26 people (2.5 percent) actually started using PrEP. I talked about this project with the staff of the community organization who was directly involved in recruitment. They mentioned that there was basically no information about pre-exposure prevention in the community at that time, so many people didn’t understand this method at all. This shows that the generation of demand [targeting marketing to a specific audience] is very important: if you want everyone to accept PrEP, you need to hold many activities and conduct messaging within the community to popularize it. According to statistics from authoritative organizations, more than 60 countries around the world have approved the use of pre-exposure prevention, and the cumulative number of people using PrEP worldwide has exceeded 1.5 million. When I introduced this to people in China, everyone was surprised at the popularity of PrEP abroad. In addition, the promotion of PrEP abroad has had a significant impact controlling the AIDS epidemic. In some large cities in the United Kingdom, Australia, and the United States, the number of new HIV cases has declined since the introduction of PrEP. In cities like San Francisco, there are only about 200 new HIV infections each year (at the peak of the AIDS epidemic in the 1980s and 1990s, there were nearly 100,000 new HIV infections in San Francisco each year), and the number of new infections is already lower than the annual number of deaths due to AIDS. If this trend continues, within a couple decades it is very likely we’ll see "zero new HIV infections.” In recent years, gay men domestically have increasingly accepted pre-exposure prevention, and the willingness to use it is probably around 50-70 percent. For example, a report released in November 2021 on the latest domestic willingness to use pre-exposure prophylaxis shows that 64.6 percent of people are willing to use it if it is free. The other group that data tends to concentrate on are medical and disease control workers involved in HIV treatment. Published research on these workers is limited, but according to my regular contact with them, my sense is that from 2015 to now, their acceptance of pre- and post-exposure prophylaxis is increasing. Of course, their acceptance of post-exposure prophylaxis is higher than that of pre-exposure prophylaxis, mainly because they believe that people who go to the hospital and ask for post-exposure prophylaxis confirm that high-risk behavior has occurred. Therefore, giving them the medication means that the patients can be saved from a possible HIV infection. Some doctors also think that such requests will “teach them a lesson,” so that gay men won’t dare engage in high-risk behaviors in the future. As for whether this kind of logic really exists, I am very skeptical. Although the acceptance of pre-exposure prevention by medical workers has increased in recent years, many people still have reservations. The main reasons are: One, they worry that the promotion of pre-exposure prophylaxis and condom use education in the past few decades conflict with one another; and two, they worry that publicizing pre-exposure prevention will make gay men “more immoral” and have more unprotected sex or find more sexual partners. On the other hand, medical workers and disease control personnel who engage in HIV prevention and control have encountered many people infected with HIV at work, and it is always college students who cause them the most distress. They also know that in recent years, the increases in condom use and HIV tests and prevention has its limitations. They see the effect of pre-exposure prevention in curbing the AIDS epidemic in other countries, yet still retain a lot of moral judgments about the LGBTQ+ community and "sex positivity.” In the future, these two factors will certainly continue to be at play, and I’m looking forward to what will happen. Another point is that in this last year, the China CDC and the Chinese Association of STD and AIDS Prevention and Control have also begun to vigorously promote pre-exposure prevention work, which is also related to the domestic strategy of Gilead, a California-based biotech company and manufacturer of pre-exposure prevention drugs. Promotion from within the disease control and medical system may increase acceptance by doctors more quickly. Even if this does not necessarily change the attitude of medical staff towards homosexuality, it may objectively increase the number of doctors who understand pre-exposure prevention and prescribe drugs as well as the number of hospitals that provide PrEP services. Q：China has been putting out anti-AIDS messaging targeting gay communities for more than ten years. Do you have any observations that you would like to share? A： Gay men often have the problem of a gap between knowledge and action as I mentioned earlier. In fact, many of them are very familiar with preventive methods, but still don't necessarily use condoms. They often tell me, “This person brings me into the circle.” They start out only knowing that they like the same sex, but the LGBTQ+ community has low visibility and they might feel alone. After they discover the community, they realize that they were not alone. They are very grateful to those who brought them into this circle. However, they may be confused and timid. At that time, there’s a power imbalance or inequality. There are those who don’t dare say "no" or cannot refuse their partner’s request to not wear a condom and could contract HIV. Q: Does the issue of power inequality in sexual relationships also exist in heterosexuals? A: Yes, consent in the heterosexual community is also important. Both partners should be used to the process of asking questions, thinking, and deciding whether to agree or disagree, rather than coercion, to the point that each step requires a consent process. Can you kiss, can you penetrate, can you not wear a condom? The answers at each step may be different. Agreeing to kiss does not mean agreeing to have sex. This concept is very important. Q：Is there anything else you would like to add about HIV prevention and sexuality education? A：I believe sexuality education for HIV prevention can also include science education for doctors. For example, some doctors don’t understand that anal sex can be pleasurable. When they are conducting HIV prevention messaging, their advice doesn’t reach the target audience. The doctors’ thought is that "anal sex is dirty and uncomfortable. Don't have anal sex; if you don't have anal sex, your chances of contracting HIV and other diseases will be relatively lower." In fact, whether the individual is a male or a female, anal sex can be pleasurable. I remember that there was a medical seminar in China two or three years ago, which gathered some doctors from the anorectal and STD departments, as well as staff from HIV prevention and LGBTQ+ community organizations. The purpose was to help them understand perianal physiology from a scientific point of view, and understand why anal sex can be pleasurable, so that doctors can understand and respect patients who have anal sex (whether gay or heterosexual) and build trust with said patients and then spread condom use and other HIV prevention methods.