HIV Australia | Vol. 9 No. 2 | July 2011

Daniel Reeders explores the link between discrimination, exclusion and sexual risk-taking, and asks how we can respond to the needs of culturally diverse men who have sex with men

Late one night, a young man messaged me on a chat site. I was tired and ready for bed; we had chatted before, and his complaint was familiar. ‘I can’t meet white guys, they don’t want Asians.’ He was afraid to post a face picture, and essentially hoped to find someone who would enter a long-term relationship with him, sight unseen. I suggested lightly, ‘why not post up a shirtless picture? You don’t have to show your face.’

Nearly a year passed before I noticed he’d taken my advice. We chatted and he told me he’d been meeting anonymous guys for bareback sex, and that he’d become HIV-positive. His was an exceptional case; I don’t hold it out as the norm. Indeed, I only tell it because, after two years of looking, I still haven’t found an HIV-positive international student willing to talk ‘on the record’, and I think it’s important to represent their experience, even if only second-hand.

The encounter brought two things home to me. One is how powerful intense loneliness can be. Had I owed him more in the way of friendship, or a better answer to his complaint? It also showed me what’s at stake when international students return home with HIV. Even in developed Asian nations, there are less than ten antiretroviral medications available – mostly older ones that are no longer under patent, some no longer even prescribed here.

Double Trouble

In 2009, the Multicultural Health and Support Service (MHSS) convened the ‘Double Trouble’ consultation forum looking at the health needs of culturally and linguistically diverse (CALD) men who have sex with men (MSM).¹ We wanted to find out ‘what do we know, and how do we know it’ as a sector. On the day there was a strong attendance by interstate participants, which added considerable depth and breadth to the consultation and our findings.

At the consultation, following expert presentations, we held small group discussions about key topics – sexual practices and spaces; identity, discrimination and vulnerability; negotiations of identity, family and community; and navigating the health system – which we recorded, transcribed and thematically analysed. In our facilitation and analysis we assigned categories of ‘known’, ‘assumed’, and ‘unknown’ to allow for ‘fuzziness’ and uncertainty in the accounts we elicited.

Rather than summarise all our findings, this article gives a broad overview of the relationship we found between discrimination/exclusion and HIV risk, before suggesting ways we can respond as a sector to the unmet health needs of CALD MSM.

The ‘double trouble’ of the report title refers to the way homophobia (or heterosexism) in ethnic communities, and ethnic prejudice (and ethnocentrism) in gay community services and spaces can separate CALD MSM from sources of information, support and social connection.

What the research tells us

There has been a lot of research trying to show that discrimination ‘causes’ HIV infection risk-taking via ‘low self-esteem’.²,³ In groundbreaking Australian studies in 1999, 2002 and 2003, Asian MSM actually reported lower risk behaviour compared to Anglo-Australians and the Sydney periodic surveys⁴,⁵5,⁶, (testing rates and unprotected sex in relationships were exceptions⁷). Yet surveillance in Victoria showed HIV diagnoses among South East Asian (SEA) MSM increased sharply from six to sixteen in the years 2006–2008.⁸

The rapid growth of Victoria’s international student population has no doubt contributed – but we can’t say to what extent, because our notification form doesn’t ask for visa status. In the separate project analysing Victorian international student needs, focus groups and literature search found the students receive little or no sex education in their countries of origin, and most education providers in Australia don’t cover sexual health during student orientation sessions.

Social connectedness

But international students are only one piece of the puzzle. Research on Asian MSM in Western countries suggests that social connectedness strongly predicts variance in risk-taking between individuals.

Talking to close friends and family about anything predicts lower risktaking; the effect is not limited to conversations about HIV risk.⁹ Men who respond actively and socially to experiences of discrimination report less risk-taking than men who internalised and blamed themselves for their exclusion.¹⁰ In our analysis we alsosuggest risk-taking can occur during ‘time in crisis’, a time of anomie and quiet desperation arising when CALD MSM come to feel the gay community cannot replace what they gave up by coming out.

At the forum, many participants were keen to explore the inherent ‘identity conflict’ they perceived in someone who has overlapping ethnic and sexual identities. In fact, research shows that CALD MSM only choose between identities when compelled by external social pressures, such as prejudice or a lack of culturally competent service provision.¹¹

When looking at prejudice, it’s essential to look at both sides of the equation – including people who practice exclusion, the personal needs it serves, and the cultural process that sustains it.¹² Double Trouble calls for ‘twin’ campaigns (including social media, social marketing and community development) to challenge sexual racism in gay community spaces and promote acceptance of same-sex-attraction in ethnic families and communities.

Strengthen peer education

It also calls for strengthened peer education approaches, like Asian Tea Room (ACON) and Gay Asian Proud (VAC/GMHC), and resource development by and for CALD MSM to raise awareness of tacit, staged approaches to integrate same sex attraction into family life – ‘coming home’ instead of ‘coming out’¹³ – as well as negotiating cross-cultural differences in meanings and expectations around sex and relationships.

These strategies are simple to recommend, but there are significant hidden complexities in their implementation. A recent campaign by ACON and the City of Sydney asked ‘Would you wear it?’, with imagery featuring racial epithets (e.g. ‘Arabs are all the same’) printed on t-shirts.¹⁴ The campaign invited people who experience racism to ‘report incidents’ online or by phone, using a questionnaire adapted from one used to report street violence to the Gay and Lesbian Anti-Violence Project.¹⁵

There is no question that racism has a violent history and racist violence occurs every day. Prejudices evolve along with the cultures in which they circulate, and our response strategies need to keep up.¹⁶ ‘Modern racism’ is subtle and covert, consisting of everyday racial ‘microaggressions’ that are designed to fly beneath the radar.¹⁷,¹⁸ It has an insidious, undermining effect on recipients – unable to tell if it was ‘really’ racism, they are left forever questioning their reactions.

Modern racism frequently comes with an alibi. That staple of gay dating profiles, ‘No Asians’, is now frequently accompanied by ‘(not racist, just preference)’. Enraged by this glib statement, one might feel tempted togive chase, but it’s a circular debate that goes nowhere – and that’s the point.

As we found, unfortunately, the HIV sector has immobilising questions of its own. As one clinical worker put it at the forum: ‘anecdotally, there’s no doubt there are barriers to CALD MSM accessing services – but how do you get evidence that it is due to internalised racism?’¹⁹

This question appeared linked in our analysis with limiting assumptions about evidence – that only published quantitative research counts; that risk and vulnerability can be ‘read off ’ from numbers; and that numeric evidence is the only acceptable basis for action.

In combination these assumptions can produce inertia – a reluctance to initiate change – and a continual questioning of the rationale behind program work for CALD MSM.

The rationale for working with these men is as much about human rights and social inclusion as HIV-related risk. Our report – Double Trouble – shows how discrimination/exclusion and lack of culturally responsive health promotion contribute to distress and risk-taking. It also acknowledges the strength, resilience, assets and protective factors of CALD MSM, and their diversity as a community.

It also calls for ‘social public health’ methods of enquiry.²⁰ Multicultural sexual health promotion works with newly-arrived communities which are small in size and fragmentary in their distribution and social connectedness.

This challenges us to develop skills in community-based research and rapid assessment and community development approaches to health promotion and social change. In closing, I want to return to the young man whose story opens this article. He won permanent residence in Australia, and connected with a community of people who share his sexual interests. His story is a disaster for HIV prevention but for him, life goes on. It’s a lesson against looking too closely at HIV and neglecting its context of friendships, relationships, and social connectedness.

References

1 MHSS led a project partnership including People Living With HIV/AIDS (PLWHA) Victoria, Victorian AIDS Council/Gay Men’s Health Centre (VAC/GMHC), Alfred HIV CALD Service, Melbourne Sexual Health Centre, and the Australian Research Centre in Sex, Health and Society (ARCSHS). MHSS is a program of the Centre for Culture, Ethnicity and Health at North Richmond Community Health Centre.

2 Green, A. (2008). Health and Sexual Status in an Urban Gay Enclave: An Application of the Stress Process Model. Journal of Health and Social Behavior, 49, 436–451.

3 Han, C-S. (2008). A Qualitative Exploration of the Relationship Between Racism and Unsafe Sex Among Asian Pacific Islander Gay Men. Archives of Sexual Behavior, 37(5), 827–837. doi:10.1007/s10508-007-9308-7

4 Prestage, G., Van de Ven, P., Wong, K., Mahat, M., and McMahon, T. (2000). Asian gay men in Sydney: December 1999–January 2000. National Centre in HIV Social Research, Sydney,

5 Mao, L., Van de Ven, P., Prestage, G., Wang, J., Hua, M., Prihaswan, P., and Ku, A. (2003). Asian Gay Community Periodic Survey (2002). National Centre in HIV Social Research, Sydney.

6 Mao, L., Van de Ven, P., and McCormick, J. (2004). Individualism-collectivism, self-efficacy, and other factors associated with risk taking among gay Asian and Caucasian men. AIDS Education & Prevention, 16(1), 55–67.

7 For discussion, see case study in: Reeders, D. (2010). Double Trouble? The Health Needs of Culturally Diverse MSM. Centre for Culture, Ethnicity and Health, Melbourne.

8 Carol el-Hayek, presentation to the consultation forum, ibid, 13.

9 Yoshikawa, H., Wilson, P., Chae, D. H., Cheng, J-F. (2004). Do Family and Friendship Networks Protect Against the Influence of Discrimination on Mental Health and HIV Risk Among Asian and Pacific Islander Gay Men? AIDS Education and Prevention, 16(1), 84–100. doi:10.1521/aeap.16.1.84.27719

10 Wilson, P., and Yoshikawa, H. (2004). Experiences of and responses to social discrimination among Asian and Pacific Islander gay men: their relationship to HIV risk. AIDS Education and Prevention: Official Publication of the International Society for AIDS Education, 16(1), 68–83.

11 Operario, D., Han, Chong-suk, Choi, K-H. (2008). Dual identity among gay Asian Pacific Islander men. Culture, Health & Sexuality: An International Journal for Research, Intervention and Care, 10(5), 447. doi:10.1080/13691050701861454

12 Young-Bruehl, E. (1996). The Anatomy of Prejudices. Harvard University Press, Boston.

13 Chou, W-S. (2000). Tongzhi: Politics of Same-Sex Eroticism in Chinese Societies. Haworth Press, New York.

14 ACON. (2010). Would You Wear It? Available at: http://www.acon.org.au/about-acon/campaigns/would-you-wear-it (accessed 05 July 2011).

15 Solomon Wong, personal communication, 2008.

16 Young-Bruehl, E., op. cit.

17 Sue, D., Capodilupo, C., Torino, G., Bucceri, J., Holder, A., Nadal, K., and Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286. doi:10.1037/0003-066X.62.4.271

18 Sue, D., Bucceri, J., Lin, A., Nadal, K., and Torino, G. (2009). Racial microaggressions and the Asian American experience. Asian American Journal of Psychology, S(1), 88–101. doi:10.1037/1948-1985.S.1.88

19 Reeders, D., op. cit., 10.

20 Kippax, S., and Race, K. (2003). Sustaining safe practice: twenty years on. Social Science & Medicine, 51(1), 1–12.doi:10.1016/S0277-9536(02)00303-9 

Daniel Reeders is Senior Project Worker, Multicultural Health and Support Service at the Centre for Culture, Ethnicity and Health.

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