Community Report: Asian Gay Internatoinal Students' HIV Needs Assessment

2019/2020 Community Report

A Community-based Needs Assessment An HIV Prevention Needs Assessment of East and Southeast Asian International Students in Toronto

Asian Community AIDS Services (ACAS)

2019/2020 Community Report Executive Summary Thank You Note and Disclaimer About ACAS Abbreviation List of Figures Background Literature Review ACAS ISgbMSM Needs Assessment Methodology Findings Discussion Recommendations References

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EXECUTIVE SUMMARY Asian Community AIDS Services (ACAS) conducted a community-based needs assessment to investigate the HIV prevention needs of East and Southeast Asian international students that identify as gay, bisexual, and/or men who have sex with men (ISgbMSM). The project’s activities include hiring and training ISgbMSM Peer Outreach workers, developing relevant community-based research knowledge and skills amongst the team, developing and executing individual semi-structured interviews and cross-sectional survey to explore ISgbMSM’s unique experiences of migration and settlement, various vulnerabilities for HIV and other STBBIs, overall experiences when accessing healthcare and other HIV/STI prevention resources. 11 East and Southeast Asian ISgbMSM participated in the semi-structured interviews and 100 participated in the survey, with most from Vietnam, China, South Korea, and Japan.

The average age of all participants was 25.1 years old, with 98% identifying as cisgender men and 2% identifying as trans men. The average duration of residency in Canada amongst participants was 3.6 years, ranging from four months to eight years. Most ISgbMSM participants (70.7%) reported having insurance through their school, only 5.4% reported having no insurance at all. Just over half of survey participants (53.3%) reported having a primary healthcare provider here in Canada. However, even though half (50%) of ISgbMSM participants felt like they would be comfortable speaking to a healthcare provider about sexual health, only 20% actually reported having spoken to their doctor about it, with a large majority (92.4%) reported preferring accessing sexual health information online.

Although a large majority of participants reported they were tested for HIV (85.9%), only about half (57%) of these participants reported having done so within the last six months. Amongst survey participants, we saw high self-reports of knowledge with respect to HIV risk factors (84.8%) and protection methods (83.7%). Participants also self-reported high confidence in suggesting the use of protection (76.1%) and reported feeling like they were at low risk for HIV (64.7%). However, fewer participants reported always knowing their sexual partners’ HIV status (22.8%) or reported remembering to use condoms when under the influence of recreational drugs or alcohol (20.7%).

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Through the individual interviews with ISgbMSM participants, various themes arose that shone a light on their migration experiences and potential challenges that may impact their health and well-being. A large majority of participants spoke about their experiences of loneliness and isolation upon arrival into Canada, as well as the specific challenge of integrating into the 2SLGBTQ+ community in Toronto due to different expectations and racism. They also spoke about the lack of accurate and comprehensive sexual health education in their home countries, which was often associated with homophobia arising from rigid gender norms in their countries, the pervasiveness of HIV stigma, and general misinformation about sexual health. Additionally, substance use stigma was also discussed but many participants shared how they have since used different substances upon arrival to Canada due to the openness to share and discuss amongst peers.

Lastly, participants also shared their difficulty navigating their health insurance as well as the healthcare system due to affiliated costs, language barriers, and different approaches to healthcare back in their home countries.

Based on the survey results and the rich stories shared by our participants, we conclude that earlier interventions that aim to support network building, sexual health and harm reduction education, and improving understanding of how to navigate health insurance and Canadian healthcare would greatly benefit Asian ISgbMSM. Additionally, educational resources created must be cognizant of the conservative social norms imposed upon Asian ISgbMSM, as well as the entrenched stigmas relating to HIV and substance use. Asian ISgbMSM would also benefit from community-based programming that simultaneously affirms their cultural, gender, and sexual identities.

Knowledge gained from this study will be used to develop community strategies and interventions that better reach, engage, and support East and Southeast Asian ISgbMSM studying in Toronto. With an improved understanding of social and structural challenges faced by Asian ISgbMSM, we will be able to extend formal partnerships and support to different agencies, community partners, and academic institutions, to create a more robust plan to include and address the specific needs of ISgbMSM, through knowledge translation and dissemination. A digital community forum for both Asian ISgbMSM community members and service providers was held to disseminate the findings in June 2020.

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We would like to thank…

Our participants: A heartfelt thank you to our participants for sharing their stories, time, and energy to provide us with a better understanding of their experiences of migration, settlement, network building, healthcare, sexual health practices, and knowledge.

Our Volunteers: For their commitment to translating documents from English to Korean, graphic designs.

Special thanks to Dr Mandana Vahabi, Ryerson University

Our Project Advisory Committee: Dr. Alan Li Ian Tian Alvin Yao Douglas Yuan The Needs Assessment Team: Kai Ip Wong, Needs Assessment Project Coordinator Bill Liu, Peer Outreach Worker Liem Vu Nguyen, Peer Outreach Worker Sucre Li, Peer Outreach Worker Project Supervisor: Noulmook Sutdhibhasilp, Executive Director of ACAS Our Funder: For providing us with the resources to carry out this needs assessment.

The City of Toronto through the Toronto Urban Health Fund.

Disclaimer: This report is the result of the analysis, conclusions and recommendations carried out by staff members of ACAS. The paper does not purport to represent the views or the official policy of ACAS or of the Funder.

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About ACAS Asian Community AIDS Services (ACAS) is a charitable, non-profit community-based organization located in Toronto, Canada. We provide safer sex education and services to the East and Southeast Asian communities and support services to persons living with HIV/AIDS and members of the LGBTQ+ communities.

OUR HISTORY On World AIDS Day, December 1, 1994, three of the AIDS groups serving the East and Southeast Asian communities in Metro Toronto - Gay Asians Toronto’s Gay Asian AIDS Project, Southeast Asian Service Centre’s Vietnamese AIDS Project, and the Toronto Chinese Health Education Committee’s AIDS Alert Project - joined forces to form a new coalition agency: Asian Community AIDS Services (ACAS). This was a turning point for the agencies and signified communities to work together and build a safer space for the marginalized members of our community. The amalgamation was also our collective response to the HIV/AIDS epidemic at that period of time.

HIV and LGBTQ+ issues continue to be a struggle for many people in our communities. Many still see having HIV or being LGBTQ+ as taboo, fearful, and shameful.

These barriers prevent many community members from accessing information and services needed for their protection and survival and reinforce many forms of discrimination and harassment against immigrants and refugees, queer and trans people, youth, women, substance users, sex trade workers, and people of colour. ACAS continues to organize concerted community efforts in addressing these on-going challenges year after year

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OUR MISSION To provide HIV/AIDS education, prevention and support services to the East and Southeast Asian Canadian communities. Our programs are based on a pro-active and holistic approach to HIV/AIDS and are provided in a collaborative, empowering, and non-discriminatory manner.

OUR OBJECTIVES • To reduce the infection of HIV/AIDS by promoting public awareness on HIV/AIDS prevention and safer sex in Asian communities.

• To provide comprehensive and culturally appropriate support, education, and outreach services to Asians and Asians infected and affected by HIV/AIDS in a non-discriminatory and non-judgmental manner.

• To enhance the well-being of Asians infected and affected by HIV/AIDS by providing direct services, increasing their control over their own health, and by promoting a supportive environment in the larger community • To promote a supportive environment to Asians infected and affected by HIV/AIDS by increasing access to services and by reducing racism, homophobia, and AIDS-phobia • To increase networking and collaboration among the Asian communities and HIV/AIDS services in Canadian society

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Abbreviations 2SLGBTQ+ ACAS AIDS CBNS ESL gbMSM HIV LGBTQ+ ISgbMSM STIs

Two-spirit, lesbian, gay, bisexual, transgender, queer (or sometimes questioning), and others Asian Community AIDS Services Acquired immune deficiency syndrome Community-based needs assessment English as a Second Language Gay, bisexual, and/or men who have sex with men Human immunodeficiency virus Lesbian, gay, bisexual, transgender, queer (or sometimes questioning), and others International students that identify as gay, bisexual, and/or men who have sex with men Sexually transmitted infections

List of Figures: Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7:

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Participants’ Countries of Origin Participants’ Future Plans to Stay in Canada after Studies Participants’ self-reported knowledge, confidence, and awareness of HIV risks HIV-Negative Participants’ Concerns Regarding HIV Self-Reported Use of Recreational Drugs Since Arriving in Canada Types of Recreational Substances Used

by Participants Preferred Methods of Acquiring Information on HIV and Safer Sex

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Background: Canada has a long-standing history of being perceived as a desirable destination for potential students to travel to for their studies, as the country is perceived to be safe and welcoming, and the prestigious education system afforded to its students(1). In 2018, it was estimated that there were over 495,000 international students in Canada, with more than half (over 250,000) being in Ontario alone(2). Canada also has an incredibly diverse population of international students, with representation from over 186 countries(3). East and Southeast Asian countries in particular make up over one-third of all international students residing in Canada, with China alone making up 28% of all international students(3).

The Canadian Bureau of International Education (CBIE), estimated that, in 2017, Toronto hosted approximately 168,730 international students, which was a 23% increase from 2015(3). However, it is worthwhile to note that even greater increases in enrolment have occurred in other cities, including Windsor (54% increase), Kitchener-Waterloo (39% increase), and St. Catherines-Niagara (27% increase)(3).

With the upward trend of international students enrolling and attending Canadian universities or colleges, it is imperative that sexual health and HIV resources are not only available but must also be accessible (e.g. linguistically, culturally sensitive) to these demographics. However, a preliminary review carried out by the Ontario HIV Treatment Network (OHTN) found that resources on these subjects were limited on post-secondary school websites and resources. Additionally, resources about HIV provided by governmental bodies and affiliated agencies focused more on HIV non-disclosure laws and took a criminal punishment tone, contributing to the entrenched stigmas already in many of these communities.

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In Toronto, there is a high incidence and prevalence of HIV among international students who identify as gay, bisexual, or men who have sex with men (ISgbMSM). In the first half of 2018, 15% of people diagnosed with HIV at the Toronto Hassle Free Clinic, were international students; nearly 40% of all positive diagnoses at the clinic during this time were people on student, visitor or work visas, or who did not have immigration status (e.g. short-term ESL students). Young ISgbMSM face many unique barriers when trying to access healthcare and HIV prevention resources, including ineligibility for OHIP and limitations in their school insurance to access laboratory testing costs and medication coverages.

ACAS also reported that amongst the clients accessing our support services for people living with HIV, 22 were either current or former ISgbMSM. From our existing work with East and Southeast Asian international students, it has become clear that there is a lack of culturally competent and accessible sexual health resources for newcomers, especially those that address the intersecting stigmas of homophobia and HIV within the Asian communities. Additionally, ISgbMSM also face issues pertaining to racism, language barriers, social isolation, lack of HIV awareness, and risk factors, all of which contribute to additional challenges faced by this group.

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LITERATURE REVIEW Research exploring Asian/Pacific-Islander men who have sex with men (APIMSM) and their risks relating to HIV emphasizes the importance of taking a more critical and holistic approach to understanding their needs in this regard. In a systematic review looking at factors influencing HIV risk-taking behaviours in APIMSM over a 20 years, it was identified that various factors, including demographic characteristics, personal psychological resources, interpersonal relationships (e.g. family, peers, romantic and sexual), community connection, culture, and structural factors are all associated with HIV risk behaviours(4). This highlights the importance of taking an intersectional approach that looks beyond one’s individual knowledge on HIV and sexual health, but to incorporate analysis of one’s environment, including culture, community, discrimination, immigration, and structural barriers, when undergoing a study that looks at Asian gbMSM needs, experiences, and challenges related to HIV prevention(4).

Building upon this, international students identifying as gay, bisexual, and/or men who have sex with men (ISgbMSM) may likely face additional layers of challenges as it pertains to their experience of migration, which is characterized by a period of accelerated changes to their lives, including social, economic and intimate well-being(5). Most notably, the sudden loss of support networks results in a need to establish new friendships and kinship that are safe, supportive, and reflective of their needs as gbMSM(5).

However, this loss of support networks, compounded with potential experiences of racial discrimination, language barriers, and financial challenges (e.g. employment) has been identified as factors that exacerbate outcomes of poorer mental health, substance use, and HIV infection(6).

As such, the period immediately following migration for this group is has been deemed a formative time that can shape and develop long-lasting social networks, habits, and lifestyles, especially concerning factors such as sexual health practices and substance use(7,8).

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Given the significance of supportive networks, the prioritization of establishing new connections is natural given its direct impact on Asian ISgbMSM health and well-being(5,7,8), and thus the theoretical framework guiding this needs assessment will be rooted in the Network-Individual-Resources Model for HIV prevention. This model examines not only the individual-level knowledge, attitudes, and behaviour as it pertains to HIV prevention and risk, but also places value on the resources within their networks (e.g. friends, peers, sexual and romantic partners, family), and how their resources (e.g. mental and tangible benefits) interact with the individual to impact HIV risk(9). Therefore, this project sought to identify and understand the individual-level characteristics (e.g. knowledge, attitudes, behaviours) pertaining to HIV risk reduction, the networks and their resources accessed by Asian ISgbMSM, and how these characteristics shape HIV risk or resiliency. As highlighted, this model moves beyond individual-level prevention and understanding of HIV risk but incorporates the complex factors associated with ISgbMSM migration, including their interactions with their social environment and also structural challenges that may further impact their health(10).

Despite the growing number of East and Southeast Asian international students and the HIV incidence rates within the ISgbMSM group, there is still limited to no literature on the HIV prevention needs for this group, specifically within the context of Toronto, Canada. As such, an explorative needs assessment project was conducted that aimed to identify and characterize key attributes including demographic information, length of immigration, risk behaviours and characteristics, approaches to navigating racism, homophobia and HIV stigma, the HIV/STI prevention strategies and health services currently being used by the participants and their networks.

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Methodology: Theoretical Framework: The guiding principle of this community-based needs assessment project is intersectionality and community empowerment. To ensure this, community members (i.e. current and former international students who identify as East and Southeast Asian gbMSM) were engaged in the entire process of the project, including planning and development of project objectives, data collection, and analysis of the project. Four members of the community of interest were also recruited and sat on the project’s advisory committee to ensure comprehensive analysis and engagement with affected stakeholders.

To promote community capacity-building and meaningful engagement with our community, the project recruited and trained three Peer Outreach Workers (POW) who are current and past East and Southeast Asian ISgbMSM. Our POWs helped lead the outreach and recruitment for participants for all stages of the project, while also being engaged at all stages of the project planning and execution, including research tool development, data collection (e.g. interviewing participants), data analysis, and dissemination.

POWs also underwent various training sessions, including introductions to community-based needs assessment, developing data collection tools (e.g. survey design and key informant interviews), and data analysis (e.g. qualitative thematic analysis).

Design: A cross-sectional mixed-methods study design was used to explore the HIV prevention needs of East and Southeast Asian international students identifying as gay, bisexual, or as men who have sex with men (ISgbMSM) studying in Toronto. Specifically, this project also sought to explore the broader settlement experiences of East and Southeast Asian ISgbMSM, and how individual, interpersonal and structural barriers contributed to HIV vulnerability among this population, and what are possible solutions to help address these gaps.

Participant Inclusion Criteria: In order to participate, project participants of our project must be: at least 18 years of age; a current or recent (within five years) international student that studied in Toronto; having arrived from an East or Southeast Asian country; self-identify as a gay, bisexual, queer, or man who has sex with men; and must be able to read, understand and converse in any of the languages in which the surveys/interviews were offered in (including English, Vietnamese, Mandarin or Cantonese). These criteria were confirmed through a self-reporting screening questionnaire.

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Data Collection: Two data collection methods: semi-structured interviews and online surveys were used to provide a more comprehensive assessment of the HIV prevention needs of ISgbMSM. All information and data were collected between January 2020 and June 2020. Both the interviews and surveys consisted of four main areas, including: • Sociodemographic data, specifically collecting data on age, gender, country of origin, sexuality, education, sources of income, length of stay in Canada, and marital status.

• Participant’s experiences settling into Toronto and Canada, assessing their experiences of establishing new connections and support networks, maintaining friendships, and concerns in various areas/social determinants of health.

• Sexual health, HIV, and testing, by gathering an array of self-reported measures for HIV knowledge, sexual health practices, dating experiences, substance use, and harm reduction practices.

• Experiences accessing healthcare and sexual health information, which included an array of questions exploring experiences navigating healthcare in Toronto, testing and treatment, preferred sources of accessing sexual health information, and open-ended questions about any challenges or barriers they have faced related to their health and social needs.

Both of the project’s data collection tools (i.e. semi-structured interview questions and a survey questionnaire) were first drafted in English and then translated into Chinese and Vietnamese by the project’s two Peer Outreach Workers, as well as Korean by ACAS volunteers.

Interview questions and surveys were tested to ensure accuracy of translation, clarity, and comprehension amongst peer workers and volunteers. 11 ISgbMSM were interviewed (seven of the interviews were conducted in English and four were conducted in Vietnamese), with each interview ranging from 40 minutes to 85 minutes. Additionally, 100 ISgbMSM participants were recruited for the participation in the surveys (31 respondents completed the English survey, 32 completed the Vietnamese version, 30 completed the Chinese version and seven completed the Korean version). Interview participants were compensated with a $40 honorarium for their time, and survey respondents received a $20 digital gift card for their participation.

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Findings: (i) A little bit about our participants: A total of 111 East and Southeast Asian ISgbMSM participated in our HIV prevention needs assessment project, 11 of which participated in our interviews and 100 participated in the surveys. However, of the 100 survey responses, only 92 responses were used for the analysis and reporting due to the quality of responses.

The average age of all participants was 25.13 years old, ranging from 18 to 38 years of age. Of all of the participants, 98% identified as cisgender men, and 2% of our participants identified as transgender men. Participants also hailed from many diverse east and southeast Asian countries, including Vietnam (36.3%), China (34.3%), South Korea (7.8%), and Japan (5.9%). Other home countries reported include Taiwan (4.9%), Hong Kong (2.0%), Malaysia (2.0%), and others as well.

Figure 1: Participants’ Countries of Origin

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A large majority of our participants are currently students (64.7%, n=66) with diverse arrays and levels of education achieved. When asked about their highest levels of education achieved, over a quarter (26.5%, n=27) of participants reported having completed their high school diplomas, 25.5% (n=26) completed a college-level degree, 11.8% (n=12) of respondents had completed a supplementary diploma or certificate degree, 30.4% (n=31) of our participants completed an undergraduate degree and 5.9% (n=6) of respondents completed their Master’s degree.

Amongst our participants, the average duration of residence in Canada is 3.6 years, with the most recent arrival being 4 months at the time of their participation and the longest residing participant having lived in Canada for 8 years. The majority of our participants are currently on study permits (64.7%, n=66), while others were on work visas (21.6%, n=2), and a small percentage (13.7%) are permanent residents. When asked what their plans are for the future after completing their studies, the large majority planned on staying in Canada after their studies (73.5%, n=75) while 16.7% (n=17) were still undecided.

Staying in Canada 73.5%

Undecided 16.7%

Figure 2: Participants’ Future Plans to Stay in Canada after Studies

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(ii) Employment & Income A large proportion of our participants (59.8%, n=61) reported that they currently work. Of those that do work, more than half (53.3%, n=59) of respondents indicated that their annual income is below $39,999. Of the participants who are currently students, about half (48.1%, n=25) of students do not work and rely solely on the support of their family for the coverage of tuition and living expenses. (iii) Settlement Experiences Feeling connected to others was reported to be a significant concern for more than half (57.6%, n=53) of participants. Even though participants largely reported feeling welcomed by their immediate networks, including school campuses (54.3%, n=50), the greater Asian community (44.7%, n=41) and the 2SLGBTQ+ communities (44.7%, n=41) here in Toronto, a noticeable proportion (29.4%, n=27) distinctly reported not feeling welcomed by the 2SLGBTQ+ community specifically. A more telling finding is that one third (41.3%, n=38) of participants felt like they did not belong, even amongst these communities and those that they knew.

“In the first year, I'm also struggling with my identity. I don't know how do I fit into both communities, but I don't also want to just fit into either one. So like it's kind of like a struggle for myself. […] I just find it weird when I hear like Canadian-Asians or like Asian-Canadians talking about Asian-ness because I would just be like, what do you mean by that? Because I didn't understand what do you mean by Asian-ness because I'm Asian, like I'm not even Canadian so like the Asian-ness you're talking about is something that I already have, like, yeah. So I feel like because I have that struggle … because we are coming from different background or like culture, so like, I kind of like hesitate to make some new friends here.”

- ISgbMSM from Hong Kong, age 22 Concerns amongst ISgbMSM about discrimination based on their sexuality and race were assessed, and while marginal, it was worthwhile to note that more individuals reported greater concern for racism (39.1%, n=36) as opposed to concern for homophobia (31.5%, n=29).

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(iv) Sexual Orientation and Disclosure: When asked about their sexual orientations, 86.9% (n=80) of respondents indicated that they identified as gay, 10.9% (n=10) reported identifying as bisexual, and 2.2% (n=2) reported “not sure”.

When asked about whether participants have disclosed their sexual preferences to people in their lives in Toronto compared to their home countries, responses for having disclosed to “everyone” was higher within the context of Toronto (26.1%, n=24) compared to their home countries (14.1%, n=13). However, over one-third of participants reported that even though they have disclosed to friends or peers, they have not disclosed to their families (34.8% in Toronto and 35.9% in their home countries). When asked what potential barriers existed concerning disclosure of their sexuality, the most common responses were “judgement from family” (67.1%, n=53), “family abandonment” (50.6%, n=40), and judgement from friends (32.9%, n=26).

“Family, I know that they know but they don’t accept it. ‘Cause I’m the only guy in the family, and they really want a guy, you know, yeah […] my dad really wants a guy, you know, passing on the legacy and stuff like that. And when my mom know that she’s having me, just really happy and stuff like that. If I come out to them now, it would be devastating to them.”

- ISgbMSM from Vietnam, age 23

(v) HIV & STI status Amongst our survey participants, while a significant proportion of our participants have received an HIV test before (85.9%), only half of those that have been tested (57%) have done so within the last six months. Amongst those that were aware of their HIV status, 8.5% (n=8) of our survey participants reported being HIV positive, and over one-third of those living with HIV (37.5%, n=3) reported being unaware of their viral load. Amongst participants who responded, 21.62% (n=16) report having tested positive for another STI other than HIV since moving to Canada.

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(vi) HIV and Sexual Health Knowledge: Many of the participants self-reported greater knowledge about HIV risk factors (84.8%, n=78), knowledge of how to use protection (83.7%, n=77), confidence in suggesting protection use (76.1%, n=70), and believed that they are at low-risk for HIV exposure (67.4%, n=62). The findings also demonstrated that a significant proportion of participants don’t always know their sexual partner’s HIV status (22.8%, n=21) or always remember to use condoms if under the influence of drinking or drugs (20.7%, n=19).

Figure 3: Participants’ self-reported knowledge, confidence, and awareness of HIV risks Despite this high self-reported knowledge and confidence of HIV and risk reduction skills, we still saw a high level of concern amongst HIV-negative participants about HIV, with over half of respondents (51.7%, n=31) reporting that it is still a very significant concern to them.

51.7% Still concerned

Figure 4: HIV-Negative Participants’ Concerns Regarding HIV

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(vii) Experiences of Dating and Hooking Up From the survey, the majority (78.3%, n=72) of respondents indicated that they hook up with other men (i.e. specifically meeting with other men solely for the purpose of having sex with them). While the most commonly cited means of meeting men was through online dating apps and webpages (e.g. Grindr, Jack’d, Scruff and Blued) for random hookups (65.2% of respondents, n=58), it is also worthwhile to note that a significant proportion (22.5%, n=20) of our ISgbMSM participants relied on meeting men within their networks (e.g. friend of friends). Approximately one third (33.7%, n=31) of participants reported having had unprotected anal sex since arriving in Canada.

“I feel like whenever you want to, you go on an app, no matter if it's like 3:00am in the morning, there will be people. When you are in China, at 3:00am you probably won't find people because they have a busy schedule? […] I don't know how to analyze this, but the fact is, if you want to look up here any time, you will find someone.”

-- ISgbMSM from China, age 26 While about a third (37.0%, n=34) of participants indicated that they felt like it was easy to find men to hook up with, 39.1% (n=36) of respondents conversely reported that they are having less or much less sex than when they were back in their home countries. Even though 41.3% (n=38) of participants reported that they saw themselves as sexy, nearly half (46.7%, n=43) of participants reported that they felt like their race was not a positive factor when seeking other men to hook up with. (viii) Substance Use A significant number of ISgbMSM participants (31.5%. n=29) reported having used a recreational drug since arriving in Canada, with the most commonly reported substances used included marijuana (78.8%), poppers (45.5%), and methamphetamine (21.2%). Other drugs that participants indicated having used include cocaine, ecstasy, heroin, opioids, and ketamine.

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31.5% Use of Recreational Drugs Since Arriving in Canada

Figure 5: Participants’ Self-Reported Use of Recreational Drugs Since Arriving in Canada

Marijuana 78.8% Poppers 45.5% Methamphetamine 21.2% 0%

20%

40%

60%

80%

Figure 6: Types of Recreational Substances Used by Participants Of those who do use drugs, more than half of indicated occasionally having sex while under the smaller portion (19.8%) reported more regular participants (84.8%) reported not having shared needles, syringes, pipes) since moving to Canada.

the respondents (59.4%) influence of drugs, with a frequency. Most of the drug-use equipment (e.g.

A greater proportion of respondents (79.4%, n=73) reported having consumed alcohol while living in Canada. Of those that do consume alcohol, approximately half (50.7%) of respondents stated that they occasionally have sex under the influence of alcohol, while more than a third (36%) reported never having sex under the influence of alcohol.

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(ix) Healthcare access: While most of our ISgbMSM participants (70.7%, n=65) were on insurance with their school, some (13.0%, n=12) received insurance through their work and others who were permanent residents (11.9%, n=10) were on the Ontario Health Insurance Plan (OHIP). There was also a small number of respondents (5.4%, n=5) that did not have any healthcare insurance coverage at all.

Amongst survey participants, over half (53.3%, n=49) of respondents reported that they had a primary healthcare provider. Of those that reported having a healthcare provider, most of whom (46.8%) indicated that they preferred to a doctor through a walk-in clinic as opposed to having a regular family doctor (30.7%).

Despite half of the respondents reported being comfortable discussing their sexuality and sexual health with their healthcare providers (50%, n=46), when asked where they would get their information on HIV and safer sex practices, less than expected (19.6%, n=18) of respondents indicated that they would get this information from their healthcare providers. The internet is still the most preferred method of accessing information on HIV and safer sex practices (92.4%, n=85).

92.4% Internet

Figure 7: Preferred Methods of Acquiring Information on HIV and Safer Sex. Amongst our participants, almost half (44.6%, n=41) reported having experienced language barriers while accessing healthcare or other social services since moving to Canada. However, even though a language barrier only impacted half of the group, an overwhelming proportion of respondents (80.4%, n=74) stated that it was important to them to receive programs and services that were culturally sensitive to their needs and experiences as East and Southeast Asian gbMSM men.

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Discussion: The results of this explorative needs assessment highlighted some of the unique experiences, challenges, and barriers faced by ISgbMSM upon arrival to Canada, all of which are directly implicated in their health and wellbeing, as well as their needs concerning HIV prevention. More specifically, we noted various recurring themes associated with their migration and settlement experiences, limitations in knowledge of safer sex upon arrival in Canada and substance use, as well as barriers faced when trying to access healthcare and social services in Toronto.

As predicted, the most commonly discussed challenge faced by ISgbMSM was the issue of social isolation upon arrival in Canada. Despite all participants reporting that their overall first impressions of Canada were that people were kind and welcoming across various networks in their lives (e.g. campus, classes, social groups in the community), more than one-third of survey respondents still reported that they do not feel like they belonged, with specific difficulties fitting in with the 2SLGBTQ+ community in Toronto. Along with the stresses associated with their loss of support networks from home, the impacts of isolation on ISgbMSM may have been exacerbated by experiences of racial microaggressions (e.g. stereotyped), mocked for their accents or other language barriers faced, and exclusions from social gatherings(11,12). At the intersections of challenges faced, Asian ISgbMSM are faced with compounding issues when attempting to connect with the mainstream gay community in Toronto, where whiteness is upheld as the standard and racialized men are often harassed, fetishized, or excluded(13–17). One interview participant highlighted: “Like I found it like the queer community here is kind of white […]

Like the example of Ru Paul and stuff - like I watch Ru Paul now just because - not because I like it - just because I can have like some topics that I can catch on the trends. So my friends whenever they have a conversation, so I would be like 'Oh I know what you're talking about' […] So like I feel like I'm getting used to it, like blending into another culture but like, in general, I'm just like yeah, like I'm like an outsider. Like if we talk about LGBTQ like I'm LGBTQ, but I'm not your LGBTQ” -ISgbMSM from Hong Kong, age 22

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The priority of rebuilding one’s support network in a new environment while simultaneously needing to compromise their views of themselves, interests, or comfort in order to fit in may also be a common stressor faced by Asian ISgbMSM(18). Further mental health distress may arise due to the conflicting experience and the overall impression that “it’s more diverse and inclusive in Western culture” (ISgbMSM from China, 24 years old). As reported by almost half of our participants, racism also negatively impacts the development of sexual networks in the form of sexual racism, where Asian men are purposefully rejected on the basis of their race(13,19). These culminating experiences may contribute to feelings of loneliness, powerlessness, and a loss of control, poor mental health, poor self-esteem while simultaneously increasing HIV risk amongst Asian ISgbMSM(7,13,18–21). However, participants discussed how they managed their feelings of isolation, including joining extracurricular groups at school, volunteering with ethno-racial community agencies, and building networks of other Asian community members, which aligns with a common coping strategy among Asian newcomers to reaffirm their ethnic and cultural heritage, while simultaneously resisting social and environmental forces of racism(11,22). One recurring trend shared among some of the ISgbMSM participants is the value of establishing online friendships on social media pages and dating apps.

“But I think in most cases I don't like - it's not like I am not able to [make friends], it's more like I'm not willing to. Like sometimes I want to kind of take care of any kind of adversities just myself before I necessarily need help. And anyways, I don't know if it's weird, but just for me, sometimes I make online friends that are like I would never meet them or like we would we have never met. But I share some of the emotions of life with them just because I do not, you know - When you're sharing with somebody that you know that you will not have any kind of involvement in each other's life, so then you kind of like speak freely. That's also how I dealt with my emotions and stuff. Yeah, but not necessarily the friends that I'm close with.”

- ISgbMSM from China, age 24 This phenomenon of seeking refuge in online spaces and confiding in digital friendships is not surprising, nor is it a novel phenomenon, especially amongst the 2SLGBTQ+ community. The preference for utilizing online platforms among Asian ISgbMSM may be associated with the anonymity and discretion associated with these tools, which offers them opportunities and safety to undergo self-exploration without fear of social repercussions among peers and family(23–25).

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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.

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“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 efforts for Asian ISgbMSM may be most effective 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:

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“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 effects 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 different 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 different drugs, however, due to stigma and criminalization of drug use, many have never tried before in their home countries.

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“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 efforts 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

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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, different 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 difficulty 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.

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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 different 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 affirm 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; • Offer culturally safe and linguistically appropriate safer sex and HIV prevention information relevant to East and Southeast Asian ISgbMSM, and ensure accessibility by offering various mediums of information especially digital online resources (e.g. reading materials and/or videos in various East/Southeast Asian languages) • Offer 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 efforts 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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Asian Community AIDS Services (ACAS) 260 Spadina Ave, Suite 410 Toronto Ontario, M5T 2E4, Canada E-mail: info@acas.org Phone: (416) 963-4300 Fax: (416) 963-4371 Toll-free numbers: 1-877-630-2227 CHARITABLE NUMBER 889432431 RR001