The Holistic Health Status of Chinese Homosexual and Bisexual Adults: A Scoping Review

Background: Same-sex marriage is currently not legalized in China, despite the considerably large number of homosexual and bisexual Chinese populations. At the same time, their holistic health status remains unclear. This is the first scoping review conducted to comprehensively examine all the available literature and map existing evidence on the holistic health of homosexual and bisexual Chinese. Methods: This scoping review used the framework of Arksey and O'Malley and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-ScR). A comprehensive search strategy was carried out across 20 English (EN) and Chinese (both traditional and simplified) electronic databases from January 1, 2001, to May 31, 2020. Two reviewers conducted the reference screening and study selection independently and consulted a third senior reviewer whenever a consensus must be achieved. Data extraction was conducted using a structured data form based on the Cochrane template, after which a narrative synthesis of the findings was performed. Results: A total of 2,879 references were included in the final analysis, with 2,478 research articles, 167 reviews, and 234 theses. Regarding the study populations, the vast majority of studies centered on men only (96.46%), especially men who have sex with men (MSM). Only 1.32% of the studies targeted female sexual minorities. The geographical distribution of all research sites was uneven, with most of them being conducted in mainland China (95.96%), followed by Hong Kong (2.05%), Taiwan (2.02%), and Macau (0.06%). Regarding the specific study focus in terms of the health domain, around half of the studies (45.93%) focused on sexual health only, and an additional quarter of the studies (24.15%) investigated both sexual health and social well-being. Meanwhile, the studies focusing on mental health only accounted for approximately 15% of the total. Conclusions: This scoping review revealed that previous research focused more on male than female sexual minorities, on disease-centered surveys than person-centered interventions, and investigations on negative health conditions than positive health promotion. Therefore, investigations centered on the female sexual minorities and corresponding person-centered interventions are highly needed. Review Registration: The protocol of this review has been registered within Open Science Framework (https://osf.io/82r7z) on April 27, 2020.


Background
Homosexuality have long existed worldwide, and currently there are many western countries having de ned legality for same-sex marriage. However, in contemporary China, the government recognizes neither legal same-sex marriage nor civil unions. Compared to western homosexuals who either remain cohabit or enter legal same-sex marriages when available [1], most Chinese gay people can only choose to either stay single or develop hidden relationships in the 'closet', and even fewer bisexual Chinese choose to disclose their sexual orientation [2], thereby leading to inevitable health concerns.
Speci cally, homosexual people in the Chinese speci c context face many signi cant di culties that have yet to be addressed, the most common of which is the long-standing social discrimination or stigma based on sexual orientation and its impacts on their health as well as quality of life [3]. Besides, public attitudes toward homosexuality in China were still not optimistic though homosexual female (lesbian) were more accepted than male (gay) [4,5]. While both lesbians and gays in China reported they felt stressed and helpless in the face of expectations from society and parents [6,7], and both Chinese gay and bisexual men reported having suffered internalized homophobia [8,9], which was found to be positively correlated with loneliness and negatively correlated with lower self-evaluation [8]. All these indicated that many homosexual Chinese were suffering poor mental health, which could lead to self-loathing then probably negatively affects their self-identity [10].
Referring to the literature and studies conducted nationally and globally, there have been some widely used expressions describing these population groups regardless of their sexual or gender identity, such as MSM (Men/Males who have Sex with Men/Males) and WSW (Women who have Sex with Women). It is worth noting that, although MSM/WSW were coined as behavioral categories, this population may not only involve in homosexual behaviors, but bisexual behaviors as well. For instance, 39.5% MSM acknowledged being MSMW (men who have sex with both men and women) according to a national study targeting 2996 MSM participants [11]. Besides, the sexual orientations among MSM population could be various though the majorities were self-identi ed as homosexual, there were still more than a quarter self-identi ed as bisexual; and vice versa, MSM who acknowledging bisexual behaviors claimed their sexual orientation as homosexual [12], indicating the necessary to scrupulously categorize study samples.
Correspondingly, researchers not only focus on the health of gays and lesbians from the perspective of sexual orientation, the health of MSM or WSW from the perspective of sexual behavior also deserves attention. Similar to the experience of homosexuals, MSM in China reported to have a higher level of homophobia compared with those from outside China [13]. Besides, a population-based survey of 47,231 MSM in 61 cities of China [14] reported that, the overall prevalence of HIV (human immunode ciency virus) was 4.9% and for syphilis was 11.8%. Although there are very few studies on Chinese WSW compared to MSM, existing studies investigating 224 Beijing WSW have shown that they also suffered either STI or reproductive tract infections (RTI), and 15.8% of them were infected with gonorrhea [15]; besides, many of them had ever engaged in different high-risk sexual behaviors, and about half reported bleeding during or after sex [16], all indicating concerning health status among this relatively hidden but considerable large population.
Currently in China, there is no census data on either the homosexual or bisexual population, while with the widely use of the Internet and increasing social tolerance, the sexual minority groups are no longer that hidden as before, and their social and health needs should be perceived then be addressed. To date, there has been a certain amount of research relating homosexual and bisexual Chinese, especially on the MSM population. While the existing studies mainly centered on STI/HIV-related prevalence or prevention attempts [17][18][19][20][21][22][23][24][25][26], or rights and legalization of same-sex marriage in the elds of sociology, anthropology, law and psychology [27][28][29]. Besides, studies targeting on female sexual minorities were much fewer than studies on men [28], which should draw more academia attention.
According to the WHO [30], health is not only the absence of disease, but also complete physical, mental and social well-being. However, in addition to a large number of STI/HIV-centered studies showing sexual unhealthy [31] and mental unhealthy [32] among gay and bisexual Chinese, other aspects of the health and well-being have not been fully studied yet. In sum, the current health-related research targeting Chinese homosexual and bisexual adults seems to be unbalanced and irregular [4], making it di cult to conclude the holistic health of this population, thereby even more di cult to provide people-centered care for their needs.
So far, there is no systematically reviewed evidence available or underway review on the holistic health of homosexual and bisexual people under Chinese context, and current evidence can hardly be summarized due to various types of studies and less precisely de ned subjects and research variables, making it di cult to conduct systematic reviews. Nevertheless, scoping review is a type of systematic reviews and has been widely used to map the known information about a topic based on available information, then to identify potential gaps in the literature and to assess the state of knowledge about the speci c topic [33][34][35][36]. In 2018, the Preferred Reporting Items for Systematic Reviews (PRISMA) Statement was extended to Scoping Reviews (PRISMA-ScR) [37], which was developed from the work of Arksey and O'Malley [33] and enhanced by Levac, et al, [34] then it has been further updated and recommended by the JBI [38]. Therefore, this review will be conducted as a systematic scoping review following the PRISMA-ScR checklist, aiming to comprehensively examine the literature and explore the breadth of the current knowledge relating to the holistic health of homosexual and bisexual Chinese, and identify potential knowledge gaps then inform future in-depth research on improving their health.

Methods
This scoping review has used PRISMA extension for Scoping Reviews (PRISMA-ScR) Checklist [37] as framework, the updated version recommended by JBI [36]. The current protocol is drafted referring to the Preferred Reporting Items for Systematic Reviews and Metaanalysis Protocols (PRISMA-P) [39,40], and the corresponding PRISMA-P checklist is attached as an additional le (see Additional le 1). This protocol has been registered within Open Science Framework (https://osf.io/82r7z) on April 27, 2020.
Speci cally, the proposed stages for this scoping review are: 1) Identify the research questions; 2) Identify relevant studies; 3) Study selection; 4) Data extraction and charting; 5) Collating, summarizing and reporting the results.

Stage 1: Identify the review questions
The "PCC" mnemonic, representing Population-Concept-Context, is recommended by JBI [38] as a guide to construct clear research questions for a scoping review. Correspondingly, 'Population' in this review refers to all homosexual and bisexual adult in China, including both male/female homosexuality and bisexuality of both genders. Meanwhile, referring to some widely used expressions such as MSM and WSW, as a behavioral category which represented in populations of 'homosexually active' men, MSM could incorporate not only gay and bisexual men, but also straight-identi ed MSM or others [41], which should also be applicable to WSW group.
'Concept' in this review refers to the holistic health, a broad conceptualization of health de ned by WHO [30], encompassing varied dimensions of health including the complete physical, mental and social well-being, and this review will target all these health-related aspects. After reviewing health relevant de nitions [42][43][44][45][46], both mental health and sexual health conditions are multifarious which should include negative and positive aspects. Speci cally, mental health conditions will cover all aspects as follows, self-identity, selfesteem, perceived stigma/ prejudice/ discrimination, happiness, loneliness, resilience, mental disorders, distress, anxiety, and depression, etc. Sexual health will involve sexual identity, sexual pleasure/ satisfaction, self-harm behavior and suicidal behavior, risky sexual behavior (drug/alcohol use), unintended pregnancy, sexual violence, etc. In addition, social well-being will consist of quality of life, social network, relationship and support related variables.
'Context' in this review refers to the locations of study settings or the sources of study participations, corresponding to China Geography or Chinese respectively. To be speci c, this review would include studies conducted in all regions of China incorporating North-, Northeast-, East-, Central-, South-, Southwest-and Northwest China [47,48]. Chinese in this review refers to all Chinese from same ethnic while might experience different political system or cultural norms, including people from mainland cities, Hong Kong, Macau and Taiwan.
Thus, following the overarching review question: 'What is the holistic health status of Chinese homosexual and bisexual adults?', some detailed review questions will be formulated and further re ned as review continues, including: 1. What health-related variables or behaviors have been investigated about homosexual and bisexual Chinese?
2. What types of research have been conducted and which disciplines were most involved in carrying out studies in this population?
3. What are the differences among sample populations with different characteristics? Sexual orientation differences between homosexual and bisexual.
Gender differences between male and female minorities.
Cultural or social norm differences among mainland China and Hong Kong, Macau as well as Taiwan.
Geographical differences among seven major regions in China.  [49]. The eligibility criteria for this proposed scoping review using PCC framework is shown in Table 1.

Information sources
The goal of search in this review is to ensure comprehensiveness and accuracy. For a comprehensive literature search, all relevant databases related to health care, psychology, nursing and social science will be searched from 2001 to 2020, including both English and Chinese electronic databases. Speci cally, the English databases incorporating published studies and thesis/dissertations to be searched include: The search strategy for this review is drafted with reference to the Peer Review of Electronic Search Strategies (PRESS) Evidence-Based Checklist [50]. Handsearching will also be used as a supplementary by identifying those key authors in this eld (via citation report) and scanning their personal les (if applicable) to follow their publications. On this basis, other unpublished documents or grey literature will not be included in this review due to limited resources. Each search via the abovementioned databases would be documented in Additional le 2 with all electronic search results and terms used to retrieve studies.
A preliminary search was conducted in PubMed (English) and SinoMed (Chinese) in March and April 2020, aiming to verify the feasibility of conducting this review and identify the diversity of evidence available and determine the search strategy as well. In the pilot search trials (see Additional le 3), all relevant keywords or subject headings appeared in titles and abstracts were searched and summarized in form of Medical Subject Headings (MeSH terms) and corresponding Chinese translation MeSH terms (CMeSH terms), which would be modi ed and adapted for further use in all abovementioned databases. Currently, the nal search strategy has been con rmed and all MeSH and CMeSH terms or other expressions have been summarized in Additional le 4.

Stage 3: Study selection
The study selection process will be conducted by two reviewers independently (CCW and KWYC). Speci cally, the titles and abstracts of all searched studies will be carefully read and evaluated referring to the proposed eligibility criteria, and excluded records will be labeled by the PCC criterion that was not applicable. For studies that are initially considered eligible or potentially eligible by at least one author, the full text of these will be retrieved to further con rm if they could be included in this review. Besides, the reference lists of enrolled review articles would be screened to examine any missing relevant articles and identify more potential studies. Disagreements on study selection will be resolved by discussion and by consulting a third senior researcher if needed.
In accordance with JBI guidelines [37,38], a detailed description of this screening and selection process will be recorded at each stage and shown in an adapted PRISMA ow diagram (see Additional le 5), and studies that are excluded on retrieval of the full text will be recorded with speci c reasons for exclusion in line with PCC framework.
The nal search results will be exported into then be managed by EndNote X9 (good at managing English literature) and NoteExpress (better management of Chinese literature) respectively. Duplicate records will be automatically identi ed by the two software and the remaining duplicate ones would be hand-removed.

Stage 4: Data extraction and charting process
A standardized and comprehensive data extraction form will be used to extract data from all included studies, and the extraction template has been developed based on Cochrane Data Extraction Template [51] after con rming all essential variables and key information to extract.
The data to be extracted will include Reference Characteristics, Study Characteristics, PCC-related information, and recommendations as well as summary of key ndings from the reviewer's perspective (see Table 2).
This template form will be piloted on 3~5 qualitative and quantitative studies eligible for inclusion respectively, then it would be further re ned and updated until all important data can be adequately extracted. Afterwards, the data extraction and charting process will be conducted by two reviewers (CCW and EPHC) independently with regular discussion and will be continuously updated in an iterative manner. Any discrepancies in extraction information will be resolved through discussion with the involvement of the third researcher until consensus reached, and any missing data will be sought by contacting study authors.
Stage 5: Collating, summarizing and reporting the results.
The critical appraisal process is not necessary in a scoping review [34,35], while this proposed review will try to conduct a quality assessment of included sources of evidence and report on their basic study characteristics. It could be expected that this review will include a considerable amount of literature and many domestic studies would be published in local journals, which might not be peer reviewed but are still very important parts of the overview. Thus, it is not feasible to evaluate the quality of each reference, then this review will brie y analyze the sources of the included literature journals, such as journal impact factors and/or whether they are included in China core journals, etc.
All retrieved information from the data extraction form will rstly be documented in Microsoft Excel. It is anticipated that evidence identi ed in this scoping review will be broad and diverse (population characteristics and conceptual variables with outcomes), thus a narrative synthesis of the ndings will be used. Speci cally, the preliminary ndings will be descriptively summarized and presented in a form of table, and characteristics of included literature will cover essential and key items from the data extraction form, including authors and a liations, year of publication, study design, population and sample size, study settings, health domains and corresponding ndings. Then the SPSS 25.0 software will be used to perform some basic calculations about frequencies and percentages of quantitative evidence, and the summary of qualitative evidence regarding author network and descriptions of key health-related variables/ domains would be mapped and presented with the assistant of visualization software which could be available for free download along with technical manuals [52][53][54].

Timeline
This proposed scoping review is planned to be commenced from March 2020 and is projected to conclude in December 2020, details are as shown in Table 3.

Discussion
In order to map a whole picture that contains all the health-related studies on homosexual and bisexual Chinese, scoping review could serve as a most appropriate way since existing evidence is hardly to be synthesized due to various types of studies and less precisely de ned subjects and research variables. Although this review will try to conduct a quality assessment of journals to which the included studies belong, the lack of evaluation of each included reference is still a potential limitation of this study.
Nevertheless, through the results of this scoping review, it is expected to highlight existing health issues among homosexual and bisexual Chinese and identify areas that have not been paid attention to relating to their holistic health; then provide scienti c references for health care systems to design person-centered culturally sensitive services with Chinese characteristics, and also draw policy-makers' attention who could provide appropriate welfare to these groups at all ages and highlight areas for subsequent research. Findings from this review will be disseminated at relevant conferences and published in a scienti c peer-reviewed journal. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated during the current protocol stage. While all data generated or analyzed afterwards will be included in the published systematic scoping review article and will also be made available upon request.

Competing Interests
The authors declare that they have no competing interests.

Funding
This review received no speci c grant from any funding agency in the public, commercial or not-for-pro t sectors. • Studies investigated health-related risk factors or protective factors.
• Studies evaluated health promotion programs among target population.
• Studies did not report any results relating health or well-being.
• Non-human studies, such as genetic experiment or other laboratory research only using biological samples of target population.

Context
• Studies settings located in or study population came from either mainland China or Hong Kong, Macau, Taiwan.
• Study populations were overseas Chinese.

Types of studies
• Original studies used recognized qualitative, quantitative or mixed methods.
• Informal or unscienti c references, such as blogs, book chapters, conference abstracts, research letter, editorial note or commentary.
Limitations • Studies were published between the period of 2001 to 2020.
• Publish language was English or Chinese (either simpli ed or traditional).