Experiences of COVID-19 among Chinese-speaking lesbian, gay and bisexual people in Hong Kong: an inductive thematic analysis of survey response data.

As social inequalities during the COVID-19 pandemic have been recognised, emerging research showed that lesbian, gay and bisexual (LGB) people may be additionally affected during the pandemic. This paper adds to the understanding of the experiences of LGB people during the pandemic with a focus on Hong Kong, where issues of space significantly influence LGB people's lives in this city with high population density. As part of a larger community study of LGB lives in Hong Kong, COVID-19-related impact on 434 Chinese-speaking LGB people was explored. Data collection was conducted from 20 May to 30 June 2020. Inductive thematic analysis of the open-text response survey data found that the LGB participants described both negative and positive impacts brought by COVID-19. Such impacts could be dimensionalised into those related to personal space and privacy, romantic and sexual space, and community space. It was also found that the experiences of COVID-19 among LGB people in Hong Kong were intersectional, along the lines of living arrangement and relationship status. Such findings make unique contributions to the emerging literature. First, there needs to be a more nuanced understanding of sexual minority individuals' experiences during COVID-19 across cultural contexts. Second, COVID-19 was described as having brought positive impact in addition to its widely known negative impact.

Background

As discussions about the health, political, economic and social impact of the COVID-19 pandemic develop, social inequalities during the pandemic have been recognised,[1-6] highlighting how the pandemic can exacerbate health disadvantages faced by socially marginalised groups such as older people, people on lower income, ethnic minorities, people living with disabilities and refugees, among others.

The United Nations Human Rights Office[7] and regional and local non-governmental organisations have raised the importance of understanding the impact of the pandemic on sexual and gender minority individuals.[8-11] An emerging research literature has also begun to document the unique experiences of lesbian, gay, bisexual and transgender (LGBT) people during the pandemic. For example, one of the earliest studies was an online survey with 1,051 US men who have sex with men (MSM),[12] which found that the pandemic had had an adverse impact on their general well-being, social interactions, money, food, drug use and alcohol consumption. Half of the participants had fewer sex partners and most had no change in condom access or use. Some of them reported challenges in accessing HIV testing, prevention and treatment services. Compared to older MSM, those who were aged 15–24 were more likely to report economic and service impact. Some exploratory studies on the needs of LGBT youth during the pandemic have also been conducted in the US.[13,14] A rapidly growing literature has documented the impact of the pandemic on different aspects of LGBT people’s lives, including their mental health,[15-18] health behaviours[19-21] experiences of stigma and discrimination,[22,23] difficulties of accessing health services,[24-26] and economic hardship,[27] as well as their agency and resilience in dealing with the pandemic.[28-31] It has been found that, in general, LGBT people faced a disproportionate impact during the pandemic, compared with their heterosexual and cisgender counterparts.[18,32-35] Recent research has argued that the impact of different social positions, such as gender, race, ethnicity, socioeconomic status, and sexual and gender identity, on the experiences of the pandemic works intersectionally.[31,36-39] Thus, an intersectionality framework is needed to understand the unique and disproportionate consequences of the pandemic on sexual and gender minority individuals, as well as the diverse experiences within the LGBT community.[28,31]

Studies on the consequences of the pandemic on LGBT people have mainly been conducted in North America and Europe,[12-14,20,38] while there is emerging research on the topic beyond the Global North. Examples of such research include studies on gay and bisexual men, or MSM in China and India,[28,40] people living with HIV (PLHIV) in China and Indonesia,[41,42] sexual minorities in Chile, India and Taiwan[15,43,44] and hijra, transgender and gender non-binary people in Bangladesh, India and Peru.[45-49] While the effect of the pandemic hit globally, its impact on sexual and gender minority individuals varies across societies and cultures, and interlocks with the pre-existing social conditions, social stigma and marginalisation experienced by this disadvantaged group in different societies.[16,28] For example, hijra in Bangladesh faced additional economic hardship and difficulties to get access to health services because of the exacerbated transphobia in their societies during the pandemic.[48] A study on people living with AIDS in China (PLHIV) in China highlighted the significant challenges related to the unwanted exposure of one’s HIV status and sexual identity to their family members because of the new protocols of mailing antiretroviral drugs to PLHIV’s household amid the suspension of HIV clinics during the pandemic.[42] In view of this, more studies are needed to understand the complexity of the impact of the pandemic on sexual and gender minority individuals beyond the Global North.

The aim of this paper is to add to this emerging literature on the experiences of sexual minority individuals during COVID-19 beyond the Global North. In particular, this paper adds to the understanding of the experiences of LGB people with a focus on Hong Kong, where issues of space significantly influence LGB people’s lives in this densely populated city. Hong Kong is characterised by its high-density built environment and population, with only 24% of its area being built-up land, of which only 7% is for residential purposes for its seven million plus residents.[50] Emerging research has pointed out that issues of space affect LGB people’s experiences of COVID-19 in Hong Kong. A study in Hong Kong has identified that one-third of the LGB respondents indicated that they had a largely reduced connection with the LGBT+ community during the pandemic.[51] It is plausible that the enforcement of social distancing guidelines prevented sexual minority individuals from socialising in LGBT+ spaces (such as bars and saunas). It was also found that in a city where co-residence with family was highly prevalent (92.3% of the respondents were living with family members/partners/friends), family conflict related to sexual orientation significantly contributed to the variance explained in depressive and anxiety symptoms, beyond the contribution of general COVID-19-related stressors. Family conflict also moderated the association between actual health problems and depressive symptoms, such that the negative effect of actual health problems on depressive symptoms was stronger among those who were frequently exposed to family conflict related to sexual orientation.[51] An HIV service provider in Hong Kong also highlighted that privacy concerns affected its service provision during COVID-19 in Hong Kong. During this period of time, temporary closure of centre-based testing, venue-based testing in gay saunas, and mobile testing meant that MSM could not easily go to a safe space to get anonymous and gay-friendly testing. To mitigate this, the HIV service provider had to put effort into promoting and making self-testing available during periods of testing centre closure and to make sure that people could choose to have test kits delivered to an anonymous pick-up station.[52] Given such uniqueness, a case study of Hong Kong will contribute to the understanding of diverse experiences of the pandemic among LGB people.

Methods

This study focuses on the inductive analysis of open-text data that were provided as part of a larger survey of LGB lives in Hong Kong. One particular non-compulsory question asked the respondents to share in a textbox the impact of being an LGB person on their experience of the COVID-19 pandemic.

Participants and procedures

Participant recruitment for the survey was conducted through LGB community organisations, online postings and social media from 20 May to 30 June 2020. Inclusion criteria were (1) being 16 years old or above, (2) being cisgender, (3) identifying as gay, lesbian, bisexual, or otherwise non-heterosexual, (4) living in Hong Kong and (5) being able to understand Chinese. Eligible participants were invited to participate in the study hosted by Qualtrics. Participants were asked to read the background of the survey and provide written informed consent before participating in the study. The study received approval from the Human Research Ethics Committee of the Education University of Hong Kong (Research ethics number: 2018-2019-0111) on 13 March 2019.

Measures and analyses

Among 1084 LGB people who participated in the larger survey, 434 respondents shared their experience of the COVID-19 pandemic. Table 1 describes their demographic backgrounds. The responses varied in length from a few sentences to a few paragraphs. Inductive thematic analysis was adopted to code the responses, and the technique of constant comparison[53] to seek out differences and similarities between the participants’ views. The first and second authors coded the data independently using the software NVivo and compared their coding.

Table 1.

Demographic characteristics of the participants (N = 434)

	n (%)
Gender
Male	185 (42.6%)
Female	249 (57.4%)
Age
16–25	244 (56.2%)
26–35	139 (32.0%)
36 or above	51 (11.8%)
Education level
Secondary education or below	79 (18.2%)
Post-secondary education	45 (10.4%)
Bachelor’s degree and above	310 (71.4%)
Employment status1
In employment	218 (50.2%)
Student	186 (42.9%)
Not in employment	30 (6.9%)
Monthly income
Below HK$5,000	188 (43.3%)
HK$5,001 – HK$19,999	127 (29.3%)
HK$20,000 or above	119 (27.4%)

Respondents could only choose one option for their employment status.

Results

Inductive thematic analysis of the data found that the LGB participants described that COVID-19 had brought both negative and positive impacts. As seen in Table 2, such impact could be further dimensionalised into those related to personal space and privacy, romantic and sexual space, and community space. It was also found that their experiences of COVID-19 were intersectional, along the lines of living arrangement and relationship status.

Table 2.

Thematic analysis of the impact of the COVID-19 pandemic on LGB people’s experiences in Hong Kong

Impact	Different dimensions	Examples
Negative	Personal space and privacy	• “During the pandemic, I feel lonelier than before. As an LGBT person, it is difficult to form my own family for emotional support, thus I feel very helpless. In general, I feel quite pessimistic about my own future.” • “I avoid having social contact with other people and avoid going to the gym.” • “Going out to exercise was very difficult. Physical exercise is important for me because I am very conscious about my health and my body.” • “I spend more time at home, which is a crowded environment with not much personal space. I have to avoid lesbian, gay, bisexual and transgender plus (LGBT+)-related topic at home with my family” • “I feel a lack of privacy because I need to spend more time with my family members.” • “I am forced to stay at home. And I have more conflict with my family members because of that. It is especially the case when LGBT topic comes up during the conversation.” • “I am forced to live with my family members. I need to hide one part of myself and avoid talking with them.” • “I am forced to live with my homophobic parents. I feel stuck and don’t have a way out.” • “I officially came out to my father during the outbreak because my partner visited my home very frequently. My father cannot accept my sexuality.” • “I see that personal details about where confirmed cases live and their closed contacts will be openly reported by the media. I worry that I will be “outed” indirectly if I get infected and become a confirmed case.”
	Romantic and sexual space	• “People on gay applications are more reluctant to meet in person and have sex. They worry about being infected with COVID-19 because of close bodily contact when having sex.” • “I have no place to meet my partner and have sex with him.” • “We couldn’t use hotel rooms for sex during the pandemic because of the fact that a lot of the hotels were used for quarantine purposes.” • “I am hesitant to meet people on gay apps, because I don’t know how sexually active they are. I think there are higher chances for people who have many sexual partners to get COVID-19.” • “My family members are always at home. I don’t have personal space to spend intimate time with my boyfriend. And we need to wear face masks in public. It is very inconvenient for me to kiss my boyfriend when wearing a face mask.” • “There are no “legitimate reasons” for me to go out and meet my partner. It is so difficult to hide my relationship from my family members. I feel very depressed about it.” • “I have a long-distance relationship. I haven’t met my partner since the start of the pandemic. I hope the pandemic can end soon, so I can see him again.” • “Our parents do not know we are in a relationship. We face huge difficulties to find spaces for dating and having sex. We can only go to hotels. But we worry that we might catch COVID in hotels, so the time we spend with each other has reduced significantly.”
	Community space	• “All these spaces are closed. I suddenly feel that the spaces that allow LGBT people to be ourselves freely are gone overnight.” • “I have less connection with the LGBT+ community and their activities.” • “Pride month has been cancelled due to COVID-19, reducing LGBTQ+ visibility.” • “I feel uncomfortable when I saw some news or articles mentioned COVID-19 along with AIDS. I feel like it could create stigmatisation for the members of LGBTQ+, perhaps.” • “I found it very difficult to access HIV testing.”
Positive	Personal space and privacy	• “Ironically, social distancing policies during COVID-19 made me aware of the fact that I may not necessarily need to stick with/ rely on an LGBT+ society to maintain a high quality of life.” • “Life is fragile and you live only once. Be true, be authentic, be proud and be you.” • “Wearing a face mask in a way “disguises” my identity and somehow makes me feel safer as an LGBT person.”
	Romantic and sexual space	• “Staying home with my partner during this period actually brought us a lot of time for intimacy and communication.” • “Work-from-home gives me more time to spend with my partner.”
	Community space	• “I have more time to read more online articles and understand more about the LGBT+ community.” • “Online connection with the community is strengthened during the pandemic.” • “I am more active in engaging in online LGBT+ chatroom and meeting more friends online.”

Negative impact of COVID-19

Personal space and privacy

Many of the respondents described feeling negative emotions because of COVID-19 and the associated social distancing practices. The respondents who were living with their family members and those who were living alone described the negative emotions differently.

For respondents who were living with their family members, many expressed that social distancing measures and staying at home most of the time meant that they spent more time with their family and there were more sexual orientation-related conflicts with their family. This is especially the case as Hong Kong is one of the most densely populated cities in the world with a high property price and small average size for a flat.[54] As one respondent put it, “I spend more time at home, which is a crowded environment with not much personal space. I have to avoid lesbian, gay, bisexual and transgender plus (LGBT+)-related topic at home with my family”. Some respondents mentioned that they were forced to spend time with their homophobic parents and felt no way out. A few others said they felt a lack of privacy.

Comparatively, some respondents who were living on their own felt that there was “too much” personal space. Although they did not experience negative relations with family members, many reported feelings of lacking social support, isolation and anxiety.

In addition, a few respondents had privacy concerns over the possibility that they and their partners were infected with COVID-19. Similar to many other countries in Asia, the Hong Kong government adopted contact-tracing practices for all confirmed cases. The information of any confirmed case’s close contacts was disclosed. This posed a disproportionate impact on sexual minority individuals who may not have disclosed their sexual orientation and their connection with the LGBT+ community openly. One respondent said, “I see that personal details about where confirmed cases live and their closed contacts will be openly reported by the media. I worry that I will be ‘outed’ indirectly if I get infected and become a confirmed case”.

In addition, in Hong Kong, since there is no anti-discrimination ordinance on the ground of sexual orientation, and same-sex partners are not legally recognised, one respondent said,

“I have not come out of the closet to my family and my fiancé’s family. I am worried that if I get infected with COVID-19 and placed under quarantine, I may not even be able to see my fiancé even if I am critically ill or die. Therefore, I am especially careful with my personal hygiene”.

Romantic and sexual space

Some respondents highlighted that their romantic and sex life had been adversely affected because of COVID-19. This affected both respondents who were single and those who were in a relationship in different ways.

Respondents who were not in a relationship reported difficulties in finding romantic and sexual partner(s). They felt fewer social gatherings meant it had become more difficult for them to find a romantic or sex partner. They also found people they met online through different applications became more reluctant to meet in person. They and their potential sex partners expressed worry about being infected with COVID-19 because of close bodily contact when having sex.

Respondents who were in a relationship reported difficulties in expressing intimacy with their romantic and sexual partner(s). They found it difficult to find an excuse to meet up with their partner, especially for those who hadn’t disclosed their sexual orientation to their family, as their family asked why they insisted on leaving the flat. Some said it had become more difficult to find space to have sex, because their family members were staying at home most of the time, and they had not disclosed their sexual orientation to their family. They mentioned that in Hong Kong where there is a lack of personal space, they used to rent hotels for sex, but as many hotels had been used for quarantine purposes, they did not feel safe to go. Also, because of travel bans worldwide, they found it difficult to travel overseas with their partner, which was something that they had frequently been doing before the pandemic in order to spend intimate time together without fear of facing prejudice and unfriendly attitudes in Hong Kong. For those who were in a long-distance relationship, travel bans in both Hong Kong and overseas countries meant they could not see their partner.

Community space

Many respondents felt less socially connected with the LGBT+ community. Their responses could be further categorised into decreased connection with LGBT+ friends, LGBT+ organisations (NGO activities) and LGBT+ spaces (e.g. bars, saunas) as many of these were closed. As one respondent put it, “All these spaces are closed. I suddenly feel that the spaces that allow LGBT people to be ourselves freely are gone overnight”. Some were also worried about the implications of LGBT+ advocacy activities, such as Pride Parade and Pink Dot, two large-scale LGBT+ advocacy events in Hong Kong, being moved online in 2020. They worried there would be less LGBT+ visibility, media presence and acceptance in society. Some respondents noticed there had been an increase in anti-LGBT hate speech online during the pandemic, worrying that the general public might perceive sexual minority individuals as promiscuous and thus having a higher chance of getting infected with COVID-19. Some worried that as society became more unstable, discrimination against social minorities including LGB people might increase and the well-being of sexual minority individuals might be at stake.

Respondents reported difficulties in accessing services and resources during the pandemic because of being a sexual minority individual. Many of the well-established non-governmental organisations in Hong Kong that are more resourceful and can provide urgent support during the pandemic, including distributing free personal hygiene products, have a religious background. They found it difficult to get access to such services and resources because these organisations had expressed LGBT-unfriendly attitudes in the past.

A few respondents said they found it very difficult to access HIV testing services during the pandemic, as most of the HIV testing services were suspended. One respondent who was living with HIV expressed difficulty in accessing medical treatment, and another with accessing mental health services during the pandemic.

There were fewer respondents who talked about the positive impact of COVID-19 but these were nonetheless noteworthy.

Positive impact of COVID-19

A few respondents said that spending more time on their own meant that they had a chance to have more internal dialogue. One respondent said that he was unexpectedly made aware that he could be self-sufficient: “Ironically, social distancing policies during COVID-19 made me aware of the fact that I may not necessarily need to stick with or rely on an LGBT+ society to maintain a high quality of life”. Another respondent said that COVID-19 made him aware of life uncertainties and that he should live authentically: “Life is fragile and you live only once. Be true, be authentic, be proud and be you”.

Some respondents said that wearing a face mask meant that LGBT+ people in society may become less prone to discrimination, as gender expression is less visible to others, given that gender non-conformity is a source of discrimination. One respondent said “Wearing a face mask in a way ‘disguises’ my identity and somehow makes me feel safer as an LGBT person”.

Some respondents said that working from home and living together with their partner meant they could spend more time with and get to know each other more. One respondent said: “Staying home with my partner during this period actually brought us a lot of time for intimacy and communication”.

Some respondents said that having more time on hand meant that they could better understand the LGBT+ community. They said online connection with the community strengthened as they had spent more time talking with other members of the community through different online applications or websites about LGBT+-related news and information.

Discussion

This paper adds to the emerging research literature on social inequalities during the pandemic, by furthering the understanding of the experiences of sexual minority individuals during the pandemic. It contributes to understanding the experiences of LGB people during the pandemic by studying the experiences of Chinese-speaking LGB people in Hong Kong where issues of space significantly influence LGB people’s lives in this densely populated city. By analysing the qualitative survey responses from the participants, this paper has illustrated that the impact of COVID-19 on LGB people is multifaceted.

In particular, the findings highlighted three dimensions of the experiences of COVID-19 among LGB people in Hong Kong: personal space and privacy, romantic and sexual space, and community space.

Concerns over personal space and privacy were reflected in the respondents’ responses. A large number of respondents were concerned about privacy during the pandemic that echoed the situation in South Korea, where an outbreak of COVID-19 cases in the Itaewon area – which contains a congregation of gay bars and clubs – sparked a surge in homophobia.[55] The South Korean government’s contact-tracing policy meant that anyone who visited the establishments in the neighbourhood was investigated, sparking fears that this could lead to people’s sexuality being exposed.[56,57] This sheds light on privacy issues associated with the contact-tracing approaches adopted by the authorities which may disproportionately impact sexual minority individuals.

Romantic and sexual space was another dimension of the impact of the pandemic on LGB people’s lives in Hong Kong. It is important for researchers to continue paying attention to how COVID-19 affects LGB people’s sexual lives.

Many respondents reported feeling a lack of connection with the LGBT+ community. Connection with the LGBT+ community has been shown as an important resilience resource for sexual minority individuals,[58,59] as it can provide them with access to affirming social networks and support, which is associated with less psychological distress[60] and better well-being.[59] The long-term impact of perceived lack of connection with the LGBT+ community needs to be further studied.

It was also found that the experiences of COVID-19 among LGB people in Hong Kong were intersectional, along the lines of living arrangement and relationship status. For respondents who were living with their family members, many expressed that social distancing measures and staying at home most of the time meant that they spent more time with their family and there were more sexual orientation-related conflicts with their family.

Comparatively, some respondents who were living on their own felt that there was “too much” personal space. Although they did not experience negative relations with family members, many reported feelings of lacking social support, isolation and anxiety. Respondents who were not in a relationship reported difficulties in finding romantic and sexual partner(s), whereas respondents who were in a relationship reported difficulties of expressing intimacy with their romantic and sexual partner(s). It was interesting that there was no clear gender difference observed in the respondents’ sharing of their experiences of COVID-19. However, given that the method of data collection allowed only an exploration of the respondents’ experiences, further studies need to study LGB people’s experiences during COVID-19 with greater nuances.

Such findings make unique contributions to the emerging literature. First, the authorities should have a more nuanced understanding of sexual minority individuals’ experiences during COVID-19 across cultural contexts when developing and implementing strategies and policies, such as contact tracing and lockdowns. Second, COVID-19 was described to have brought a positive impact in addition to its widely known negative impact. This demonstrates that despite being a socially marginalised group, the LGB people in the study displayed their agency to interpret a difficult situation in a positive way. The resilience they displayed[61] should not be underestimated. It is possible that as LGB people are accustomed to facing microaggression and discrimination in society, they are especially equipped with crisis competence[62,63] to face up to difficult times.

Although this paper has focused on the experiences of LGB people in the pandemic, it is also possible that similar experiences may be shared by other socially marginalised groups. It is also plausible that these groups also faced “spatial” issues as they had to live in unsupportive or hostile home environments while shelters were closed due to the pandemic. The experiences of other socially marginalised groups during the pandemic are also intersectional. All these require further attention from academics as well as policy makers as it is now clear that the pandemic will have a lasting impact on different communities across the world.

There are limitations of this paper that should be acknowledged. The sampling method may be subject to selection bias where those who were connected to the community were more likely to respond to the survey. LGB people with lower education were underrepresented in the current sample. In addition, the findings are drawn from one open-text response question in a larger survey that was completed by less than half of respondents to the survey. The data provides some timely insights but the findings are only emergent themes that need to be further explored in further research.

Conclusion

Inductive thematic analysis of the data found that LGB respondents in Hong Kong described that COVID-19 had brought both negative and positive impact. Such impact could be dimensionalised into those related to personal space and privacy, romantic and sexual space, and community space. It was also found that their experiences of COVID-19 were intersectional, along the lines of living arrangement and relationship status.

Ethics approval

The study received approval from the Human Research Ethics Committee of the Education University of Hong Kong (Research ethics number: 2018-2019-0111).