Discussion

In addition to navigating their newfound responsibilities of independent living and sense of freedom away from conservative social norms embedded within their home countries, Asian ISgbMSM are also faced with learning how to navigate and explore their own sexuality within the context of a new country. According to our project, participants generally reported that they were more likely to disclose and be open about their sexuality to their peers here in Canada as opposed to peers in their home countries. However, regardless of the geography, participants reported that they were less likely to disclose their sexuality to their families. These findings not only corroborate the idea that Canada is perceived as a more accepting country (compared to their home countries), possibly making it easier to be open about one’s sexuality, but it also highlights the influence of stigmas and gender norms that are imposed upon East and Southeast Asian ISgbMSM (e.g. duty to family), which compounds the often intertwined stigmas related to sexuality and HIV, exacerbating their HIV-related risk(21,26–28) .

“...in Korea it’s much much harder to get information. [...] Fake news or rumours. So when you search for HIV AIDS in a Korean research website the first thing you see would be gay people end up dying with HIV. That sort of thing. [...] it's not even sexual education, like their behaviour. It's kind of funny, some friend, some Korean international student friends here, doesn't like to hold hands with his boyfriend in public. He just say he can't. [...] the friends that are reluctant to hold hands with his partner are very afraid of HIV, but he never went to the clinic before I took him [with] me.”

- ISgbMSM from South Korea, age 23

Many of the younger ISgbMSM participants reported being dependent on their families for financial support. Therefore, the fear of disclosing one’s sexuality could also be compounded by the potential financial repercussions that may arise due to potential family fallout, in addition to the cultural pressures to avoid ‘burdening’ or ‘shaming’ the family(27,28) .

Asian ISgbMSM face many socio-cultural norms and structural factors that may limit their access to comprehensive HIV knowledge and deter them from accessing more information. Our interview participants shared how their own HIV and safer sex knowledge was limited when they first arrived in Toronto.

“So even during the first two years, during the two years when I was in school, I wasn't really aware of sexual health, or any testing. I didn't even know that. A friend brought me to, well not brought me, but he taught me some STI testings and I went there and did some testing. And that was three years after I arrived. [...] [The sexual health in China is] very basic. It's more like not sexual health, it's more like understanding your body. [...] I feel like, for example, when I was here, when I was younger, I didn't know this kind of thing. If you don't know, you don't even look for it, you don't look for anything.”

- ISgbMSM from China, 27

Through accounts like this and others, it becomes evident that conservative social norms embedded within many East and Southeast cultures, which uphold rigid gendered roles of men (e.g. a man must marry a woman so that they can have children to carry on their family name) can reinforce misinformation on sexual health and sexuality by limiting access to comprehensive sexual health information, especially within the context of education and conversations with their peers(29,30). The findings in this need assessment, which found that participants self-reported high HIV knowledge, high awareness of HIV risk factors, high knowledge of risk reduction strategies and confidence in applying those strategies, may seem contradictory to this idea. However, as illustrated in the previous participant’s quote, limitations to sexual health and HIV knowledge may be greatest upon an ISgbMSM’s arrival in Canada but can then improve after a some time after arrival, which corroborates with other findings that suggest sexual health knowledge likely improves over time through accessing educational resources or community programs after arrival(31). This finding may help explain the high self-reported levels of sexual health knowledge among our Asian ISgbMSM participants as the average duration of residence of our participants was 3.6 years, with participants reporting having lived in Canada for up to eight years. This finding may suggest that sexual health outreach and education e orts for Asian ISgbMSM may be most e ective in the earlier years upon arrival in Canada.

In addition to limiting access to relevant and accurate sexual health information, these social norms also shape stigma around HIV. As demonstrated by the fact that despite high levels of sexual health knowledge and confidence in HIV reduction strategies, half of HIV negative respondents in our study still reported very significant concern about HIV. This may highlight the deeply rooted impact of HIV stigma amongst Asian ISgbMSM, which may negate or hinder the knowledge and application of biomedical advances in HIV prevention, including Treatment as Prevention or U=U(32). As one participant shared:

“And also because of like, I know all the science behind STIs. So I'm also like really afraid of STIs, that's why I can't have like random sex with strangers even though I'm on PrEP or like wearing a condom, there's still are like risks. So that's - and it's also because I grew up in a culture where like STIs were are like really stigmatized. […] I know it's not like a big deal, like most STIs actually has a cure. And some STIs can be suppressed, like the viral load can be suppressed, but still - like it's just in my head, it's the stigma.”

- ISgbMSM from China, age 24

The e ects of intersectional stigmas, including HIV, homophobia, and racism, contribute to various barriers when accessing information and healthcare, as well as navigating situations pertaining to HIV risk (e.g. disclosure and negotiation of safer sex practices)(33,34). This may contribute to the further interpretation of our results, which found that despite high levels of self-reported knowledge on HIV and confidence in negotiating the use of protection among participants, we saw limitations in the confidence among Asian ISgbMSM in di erent situations, including almost 20% of participants reporting not being aware of their partners’ HIV status (ie. may not have asked due to fear of discussing HIV) and less confidence reported in their use of protection when under the influence of alcohol or drugs.

There is a common misconception and potentially dangerous assumption that substance use is not an issue among the Asian community(35). Despite there being evidence that there is a significant increase in substance use among Asian communities(36,37) and greater usage of specific substances (e.g. LSD, and other hallucinogens) than other ethno-racial groups, public health and community interventions tend not to prioritize Asian groups when it comes to substance use and harm reduction(35,38). This idea may be perpetuated by the popular ‘Model Minority Myth’, which puts forward an image that through diligence and strong work ethic, Asians are able to achieve greater socioeconomic status, thereby reducing their likelihood of involvement with ‘problematic behaviours’, such as drug use(35). However, the current needs assessment found that approximately one-third of ISgbMSM participants have used recreational drugs since arriving in Canada. Amongst the interview participants, those that spoke of using substances in Canada often referred to how they had already been curious about di erent drugs, however, due to stigma and criminalization of drug use, many have never tried before in their home countries.

“I smoke weed. I try some other stuff, too. Like G - like heroine? Yeah. Like I try it. I feel like I try it because I'm just like 'Oh yeah, now I'm in Canada, everyone is more open-minded. That's why I should try it.' And I'm not like really like addicted to it. Yeah. I only try it like once and that's it. […] That's why when I came here and said, okay, let's try it out, like maybe it could be good. I feel like - I also want to understand the reason why people do it. So that's why yeah”

- ISgbMSM from Hong Kong, age 22

This sentiment described, in conjunction with the survey results, align with previous findings that emphasize that peer pressure alone is unlikely to force someone to use drugs, but friendships and networks formed that are rooted in similar attitudes and beliefs towards people’s use of drugs play a significant role in exploration(39). In this instance, it was the non-judgemental attitude and openness amongst peers to discuss and share that led to a comfortability and sense of safety in exploring new substances in ISgbMSM participants(35). The significant proportion of Asian ISgbMSM that reported using substances since arriving in Canada may be related to the elevated stresses associated with isolation, conflicts associated with cultural dissonance, and experiences of racism, whereby alcohol and drugs could be used as a ‘coping mechanism’ to manage these multiplying and compounding pressures(35,40). As such, our needs assessment findings also suggest that Asian ISgbMSM may benefit from more harm reduction outreach and educational e orts with respect to party-and-play (PnP) culture, as over half of our participants who reported using recreational drugs or alcohol also reported having sex under the influence. One participant recounts:

“Well, the hardest one was meth. At the time I didn't even know it was that serious of a drug, he just offered it to me. And he said, it is just totally OK, it's a mild thing. […] I just wanted to try, just for once. And after sex, I was really shocked. I can't control my body. BUT, fortunately, apparently it was not a serious amount of drug used, so next day I got totally fine. And I just blocked him and I never used afterwards.”

- ISgbMSM from South Korea, age 23

When reviewing healthcare access amongst ISgbMSM, our findings pointed to various levels of barriers that existed at the personal, interpersonal, and structural levels which impacted their ability to and willingness to seek out health care services. The commonly cited reasons for not accessing healthcare included independence and responsibility to care for their own health, di erent cultural understandings of when medical professional intervention is necessary (i.e. only when it’s severe enough), limited English language proficiency, fear of judgement from service providers, financial barriers, and di culty navigating the Canadian healthcare system. These findings corroborate with other studies that explored barriers resulting in delayed access or even avoidance of healthcare services amongst Asian gbMSM(41,42) .

“Also I wasn’t sure what I was getting because I went to the counter and I was like ‘I want to get checked because like this guy told me he had gonorrhoea, I want some treatment.’ And he handed me a few forms. Two hours later, you know, go into some room. I had no idea I was getting because they didn’t really explain it to me that well. Well, maybe they did, but I forgot. And they didn’t give me like a prescription paper or like what I was getting into. So he gave me the pills and he jabbed me and I didn’t know what those were.”

- ISgbMSM from Singapore, age 24

Participants also reported that even though they would feel comfortable speaking with their healthcare provider about their sexual health needs, very few reported actually getting this information from their primary healthcare providers. A significant number of participants reported that they preferred accessing sexual health resources online by themselves. This may once again be the direct result of stigma and fear of judgement for their sexuality by their healthcare providers, for being perceived as deviant, resulting in avoidance to disclose their sexuality to their health care providers(43,44). This then has potential implications with respect to accessing healthcare and treatment for HIV and sexual health should Asian ISgbMSM ever need it. Adequate access and linkage to culturally competent and empathetic service providers are needed to ensure a continuum of prevention and care.

Recommendations:

Based on the findings from this explorative needs assessment project, various recommendations can be made for the programs, services, and agencies serving East and Southeast Asian ISgbMSM, including:

• Engage Asian ISgbMSM earlier upon their arrival to help facilitate network development and reduce feelings of isolation, promote positive lifestyle habits and increase knowledge of relevant HIV and sexual health information/resources; • Utilize di erent forms of outreach that will meet international students where they are comfortable accessing sexual health and substance use information, including online outreach (e.g. dating apps, WeChat, Facebook); • Create safer spaces and opportunity for East and Southeast Asian ISgbMSM that recognize and a rm the unique experiences, cultural influences, and social norms that shape their understanding of gender and sexuality; • Support and integrate peer health promotion and harm reduction initiatives that engage East and Southeast Asian ISgbMSM, promoting the dissemination of accurate, relevant, and comprehensive safer substance use knowledge; • O er culturally safe and linguistically appropriate safer sex and HIV prevention information relevant to East and Southeast Asian ISgbMSM, and ensure accessibility by o ering various mediums of information especially digital online resources (e.g. reading materials and/or videos in various East/Southeast Asian languages) • O er more accessible (e.g. linguistically, financially, physically) and regular programming that specifically helps Asian ISgbMSM to understand and use their health insurance; • Identify relevant community partners to develop a ‘Community Strategy’ specific for urban locations where ISgbMSM live and study.

With a large majority of participants reporting their intentions of staying in Canada after their studies, by ensuring earlier access to more comprehensive and culturally safe health information, improving understanding of how to navigate and access healthcare, and fostering greater resiliency through community and network building, the impact of these dedicated e orts to support these identified needs would improve the health and well-being of not only incoming Asian ISgbMSM, but also future Canadian citizens as well.

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