Notes from the field: Challenges, concerns and opportunities in relationship building and health promotion among gay Asian international students in AustraliaHeath Paynter
By Horas T.H. Wong, Sujith Kumar Prankumar, Priyadi Prihaswan, Shih-Chi Kao, Tim Chen, Tim Wark, Megan Baiocchi and Limin Mao on behalf of the Culturally and Linguistically Diverse (CALD) Gay Men’s Action Group
There are roughly 700,000 international students currently studying in Australia, most of whom are in their 20s and come from Asian countries such as China, India, Nepal, Malaysia and Vietnam.1 While it is not known how many of these students identify as gay or are men who have sex with men (MSM) or gender and sexually diverse, research tells us that HIV incidence among newly-arrived Asian-born MSM in the past three years is relatively high, despite the overall decline in newly diagnosed cases of HIV among Australian-born MSM.2,3 While efforts are being made to address this inequality, there is much more that can – and should – be done to close the gap.
Opportunities and challenges faced by gay Asian international students in Australia
For Asian-born students who are gender or sexually diverse, living in Australia presents opportunities and challenges. On the one hand, Australia’s inclusivity towards gender and sexual diversity provides exciting opportunities for these students to explore their gender, sex and sexualities. Though some pockets of tolerance exist in some major cities in Asia such as Bangkok, Ho Chi Min City, Taiwan and Tokyo, there exists considerable sexuality-based social stigma and legal discrimination in many Asian countries, and students from these countries may experience a sense of relief and freedom upon moving to largely gay-tolerant Australia.
On the other hand, many international students may find it challenging to embrace their new-found freedom in a foreign environment. Moving to a new country is never easy, and for many new arrivals even basic daily tasks can be challenging such as topping up a travel card, paying fees, booking a medical appointment, navigating the streets and managing campus or the ‘Australian ways of living’ (to use a cliché here). These challenges are compounded for students with limited English language skills, as language barriers make it more difficult for them to negotiate Australian social systems and norms that can be very different from what they were used to back home.
Another oft-cited challenge comes from navigating power dynamics, which can be unfamiliar to many gay Asian international students who come from countries where they never had to question dominant racial discourses. Students keen on exploring gay communities in Australia may soon find themselves rejected by these communities based on their ethnic or national identities or English language fluency, or experience fetishisation, not only from white Australians but also from other Asian migrants. Additional challenges identified include difficulties with sexual and relationship negotiation and with understanding their sexual rights, and in navigating Australian’s complex healthcare system.4,5,6
While the international education sector and its partners have helped to broaden the provision of sexual health support services and information available to international students and other migrants, particularly in the urban core, accessing these services and information requires a high degree of self-awareness, health literacy and courage. If a student comes from an environment where sexual health is rarely – if ever – discussed and sexual stigma is prevalent, they may not know how and when to seek help, or may be uncomfortable to seek help because of internalised stigma or due to fears of being ‘found out’ and judged by their peer group in Australia and their families back home. Additionally, there is much confusion around what students are entitled to under the mandatory Overseas Student Health Cover (OSHC), with pre-exposure prophylaxis (PrEP) and antiretroviral therapy typically not being covered. Due to a lack of clarity as to what they are entitled to, what is available to them and concerns about lack of affordability in general, students therefore put off testing and treatment.
Added to this is the feeling of alienation are persistent concerns with the high fees, cost of living, expensive on-campus and private student housing, lack of transport concessions, worker exploitation and wage theft, and the threat of violence, along with being seen and portrayed in stereotyped ways.7,8,9,10 In situations of high financial and social stress, exercising sexual safety may not be a priority or may even be considered a luxury, and among students who engage in sex work, social stigma may discourage them from exercising their rights and responsibilities and from accessing resources and services.11,12
Research on Asian MSM international students in Australia
There is much diversity in terms of how ‘Asians’ and men who have sex with men (MSM) identify, which complicate research and outreach efforts. However, despite the risk of homogenising diverse lived realities, these terms remain convenient starting points for engaging with target populations. There is a lack of published research directly focusing on HIV- and STI-related practices and health needs among same-sex attracted international students in Australia. In 2018, the Culturally and Linguistically Diverse (CALD) Gay Men’s Action Group – a Sydney-based interagency of government, nongovernmental organisations and researchers committed to improving sexual health and wellbeing among Asian gay men in Australia – conducted the Gay Asian Men’s Survey to investigate sexual health and behaviour among Asian men in Sydney who have sex with men. Respondents were recruited through the internet, gay bars and sex on premises venues, sexual health services and public events.
The survey recruited 870 men, with about one-fifth (n=160) of them reporting as international students, among whom the mean age was 27. The top five reported birthplaces were Chinese regions (mainland China, Hong Kong and Taiwan), Thailand, Indonesia, Vietnam and the Philippines. Most had just arrived in Australia within the past two years.
The survey found that while the international student respondents did not differ much from the other respondents in terms of condom use, they are 50% less likely to have ever had a HIV test.
Medicare eligibility affects international students’ pattern of health seeking practices. Among those who have ever tested for HIV and STI, international students are more than 60% less likely to have had a test at a private GP compared to other respondents. The most reported testing venues for international students are public sexual health services (e.g., sexual health clinics and ACON’s aTEST service) that do not require a Medicare card. Respondents who were not covered by Medicare, such as international students and other temporary migrants, were less likely to have used PrEP in the previous six months.
Language barriers were commonly reported among international students, with about one in five international student respondents having had negative experiences in Australia in relation to their English proficiency, and with nearly 70% spending a considerable amount of their free time with people of the same ethnic and cultural background. Interestingly, while international student respondents responded as being more likely than other respondents to receive sexual health information from non-English speaking doctors, they were more likely to be tested for HIV/STI at public sexual health clinics and associated community-based testing sites.
Compared to other respondents, international students were more likely to have sought sex partners through mobile dating apps and social media, and less likely through offline environments like sex-on-premises venues. This is probably likely due to their familiarity with digital technologies, unfamiliarity with the Australian gay scene, their discomfort with face-to-face interactions due to sexual rejection, loss of ‘face’ (i.e., fear of public embarrassment or failure to maintain the esteem of others), language difficulties and being ‘out’ in public.
Towards better sexual health promotion among ‘gay’ international students
The international education sector and institutions within it have moral responsibilities towards the health and wellbeing of international students during their stay in Australia. Institutions should communicate to students, in plain language, what the OSHC covers in terms of sexual health and wellness. Also, it is essential that their websites are updated and informative (not just filled with links to other services), with all informational videos closed captioned in plain and respectful language. Campus-based health services should explore the potential role of doctors and nurses who speak languages other than English and should recognise their critical role in linking students to sexual health clinics and peer-based community sites if needed. Other interventions, such as providing transport concessions and more affordable campus-based housing, should be considered in order to help lessen the financial burden and to lessen barriers to physically accessing health services.
While there is a comprehensive body of sexual health information (mainly factsheets, linked below) available, the challenge lies in cultural stigma and the difficulty of finding ways to talk about sex, sexuality and mental health. Therefore, it is important to create spaces where concepts of consent and sexual wellbeing can be discussed in order to increase literacy in sexual health and bodily rights and responsibilities, particularly since many students have not had these conversations back home. These discussions should also include information on healthy relationships and dating in Australia.
To address the issues of Medicare ineligibility and language barriers, ACON has implemented a suite of services that are delivered in Mandarin. Most notably, ACON’s aTEST Chinese clinic (a collaborative project between ACON and Sydney Sexual Health Centre, with support from South Eastern Sydney Local Health District), which launched in December 2018, provides all aspects of the service in Mandarin including registration, peer and nurse consultation, and HIV and STI testing. Clients are also referred to relevant programs and services such as ACON’s peer education workshops and social events in which many gay international students participate. Workshops such as “Start Making Sense” in Mandarin (同志101) for example, encourage Asian gay men to learn about identity, sexuality, coming out, relationships, gay communities and sexual heath through a workshop over four weeks in Mandarin. It also breaks down social isolation and provides an opportunity for participants to meet new friends. Community members can also find comprehensive sexual health information on ACON’s Ending HIV website in simplified Chinese (linked below). This website is also planned to be available in Thai, Spanish and other key languages.
Multi-sector collaborations – involving students, education and training organisations, local health districts, NGOs, health services and OSHC providers – should be explored, with a focus on training peer leaders and educators that come with Australian Higher Education Graduation Statement (AHEGS) recognition, if applicable. The training could be tied with a short internship or casual work opportunity at health or peer support services (e.g. at a campus-based health service, sexual health clinic or international student centre). The key aims of this training programme would be to strengthen the information pipeline within the international student community regarding sexual health and wellness, to ensure that services have direct access to international student communities, to enhance students’ communication abilities, to provide professionalisation opportunities for students and to build social networks.
An example of collaborating with gay international students is the Overseas-born men who have sex with men (MSM) students working group in Sydney involving international students and the Culturally and Linguistically Diverse Gay Men’s Action Group partnering to organise a social event for gay international students in late 2019. This partnership has led to new networks being formed and strengthened, including collaborations on programmes at a campus-based health service and among various CALD LGBTQ+ community groups. It has also supported international students in building friendships, connecting with services, forming communities of support, and providing a way for them to engage with community work and research.
On the policy-level, more needs to be done to increase PrEP and treatment access for overseas-born MSM. Inequalities in access to care leads to inequality of health outcomes, additional stigma on already vulnerable populations, a threat to population-level protection and the possibility of highly mobile international students going home or moving to other cities with undiagnosed HIV (thereby posing risks for onward transmission). All of these are highly detrimental to Australia’s reputation as a safe place in which to study and incur higher public health costs in the long term.
From the frontline service providers and policymakers in the field, here are some of our perspectives of the key issues and future directions:
- Specific item numbers relating to sexual health on OSHC statements should be removed in order to protect students’ privacy and reduce barriers to accessing these services.
- Sexual health information should be made available for gay international students through various dissemination channels, not only relying on established university services or groups. Often, gay international students will not go to the Queer Collective or student advisors (often with no/limited representation from international student groups) for sexual health information due to a fear being outed. Further, inconsistent and inadequate information is provided among education providers. Gay international students who are studying at colleges and language schools further lack support with regard to sexuality and sexual health information from education providers.
- Education providers should be supported to collaborate with community organisations on programs that improve gay international students’ sexual heath literacy, support sexual and mental health and support social activities.
- A systematic approach should be taken to create a sex-positive environment to facilitate and improve communications between stakeholders including government, non-government, education institutions, private organisations and international students. This approach should consider where services and programs can be scaled to address challenges and gaps in accessing information, prevention interventions and healthcare.
- Issues related to inequality in the Australian healthcare system should be studied, and continued investment should be made into supporting research aimed at understanding this population group.
- We need to rethink how we develop health promotion materials and engagement activities for gay international students. Rather than just producing sexual health promotion materials and activities that are direct translations of existing content, we need to work alongside gay international students to develop content that addresses their sexual health support needs through content that is created by them, for them. This ensures that the language and cultural context of their lived experience as migrants is taken into account and represented in a meaningful way.
In conclusion, the goal of ending HIV transmission in Australia is certainly not an intractable one. We have come so far, and with a strong will and commitment to address the inequality of access, we will get there.
HIV, STI and broader sexual health in-language online fact sheets (selected):
http://allgood.org.au/ developed by ASHM;
http://www.healthtranslations.vic.gov.au/ developed by the Centre for Culture, Health and Ethnicity;
https://stipu.nsw.gov.au/resources/patient-resources/ developed by the NSW STI Programs Unit);
https://www.fpnsw.org.au/health-information/individuals/non-english-speaking/fact-sheets-community-languages developed by Family Planning NSW
https://endinghiv.org.au/?lang=zh-hans ACON’s Ending HIV website which provides comprehensive sexual health information in simplified Chinese
ACON’s aTEST service in Mandarin Chinese
1.“End of Year Summary of International Student Data 2018” (Australian Government Department of Education and Training, December 2018), https://internationaleducation.gov.au/research/International-Student-Data/Documents/MONTHLY%20SUMMARIES/2018/International%20student%20data%20December%202018%20detailed%20summary.pdf.
- “NSW HIV Strategy 2016-2020: Data Report, Quarter 1” (NSW Health), accessed May 28, 2019, https://www.health.nsw.gov.au/endinghiv/Publications/q1-2019-nsw-hiv-data-report.pdf.
- Nicholas A. Medland et al., “Incident HIV Infection Has Fallen Rapidly in Men Who Have Sex with Men in Melbourne, Australia (2013–2017) but Not in the Newly-Arrived Asian-Born,” BMC Infectious Diseases 18, no. 1 (August 20, 2018): 410, https://doi.org/10.1186/s12879-018-3325-0.
- Jessica Washington, “Special Report: Universities ‘failing’ International Students on Sexual Violence,” SBS News, May 15, 2018, https://www.sbs.com.au/news/special-report-universities-failing-international-students-on-sexual-violence.
- Leesha McKenny and Jarni Blakkarly, “Sex Education Gap Haunts Australia’s International Students,” SBS News, March 1, 2018, https://www.sbs.com.au/news/sex-education-gap-haunts-australia-s-international-students.
- Daniel Reeders, “Double Trouble? The Health Needs of Culturally Diverse MSM.” (Melbourne: Centre for Culture, Ethnicity and Health, 2010), https://www.ceh.org.au/double-trouble-the-health-needs-of-culturally-diverse-men-who-have-sex-with-men/.
- Laurie Berg and Bassina Farbenblum, “Wage Theft in Australia: Findings of the National Temporary Migrant Work Survey” (Sydney: Migrant Worker Justice Initiative, 2017), https://www.ssrn.com/abstract=3140071.
- Ly Thi Tran, “‘I Am Really Expecting People to Judge Me by My Skills’: Ethnicity and Identity of International Students,” Journal of Vocational Education & Training 69, no. 3 (July 3, 2017): 390–404, https://doi.org/10.1080/13636820.2016.1275033.
- Shanthi Robertson, “Cash Cows, Backdoor Migrants, or Activist Citizens? International Students, Citizenship, and Rights in Australia,” Ethnic and Racial Studies 34, no. 12 (December 1, 2011): 2192–2211, https://doi.org/10.1080/01419870.2011.558590.
- Cash Cows (Australian Broadcasting Corporation, 2019), https://www.abc.net.au/4corners/cash-cows/11084858.
- Lauren Renshaw et al., “Migrant Sex Workers in Australia” (Canberra: Auustralian Institute of Criminology, 2015).
- Kate Iselin, “University Students Are Engaging in Sex Work to Pay for Their Education,” NewsComAu, January 12, 2019, https://www.news.com.au/lifestyle/real-life/true-stories/uni-students-taking-up-sex-work-is-more-common-than-youd-think/news-story/a5fc19fa96d36af5bbc083c10433da52#.59kl1.
Horas TH Wong, Ph.D. is a researcher who has a background in sexual health nursing, public health and anthropology. He is currently working in Sydney Sexual Health Centre and the Albion Centre. He has conducted epidemiological and social HIV and sexual health research among same-sex attracted men and other key populations in Hong Kong and Australia.
Sujith Kumar Prankumar is an international PhD student researching sexuality, ethnicity and belonging at the Centre for Social Research in Health, UNSW Sydney. He has a background in human rights, sexuality, religion and media and worked on LGBTQA+ health and inclusion initiatives in Singapore, the USA and Australia.
Priyadi Prihaswan has over 20 years’ experience in HIV, STIs, and viral hepatitis programs in Australia and Indonesia. He is currently the Health Promotion Team Manager for the HIV and Related Programs Unit, SESLHD. In his current role he is involved in a number of HIV, sexual health and viral hepatitis health promotion programs reaching diverse populations. He holds a Master of Public Health.
Shih-Chi Kao completed a Bachelor’s degree in Communication at Wollongong University, Master and Doctor of Philosophy in International Communication at Macquarie University. He has more than 16 years’ experience in the HIV sector including Multicultural HIV and Hepatitis Service, Centre for Social Research in Health at UNSW, ACON and HIV and Related Programs (HARP) Unit and Health Promotion. He is currently Acting Manager of HARP Unit, Sydney Local Health District and Pozhet, a state-wide HIV service for heterosexuals.
Tim Chen is a Community Health Promotion Officer at ACON. He runs Asian Gay Men’s project which works with gay men from all Asian cultural backgrounds to empower and develop healthy and engaged communities.
Tim Wark is the Manager of Peer Education Programs at ACON. Tim oversees a range of project areas including sexualised drug use, young gay men, all ages peer education and HIV programs.
Megan Baiocchi is the Manager of Community Partnerships and Population Programs at ACON. Megan oversees a range of projects, including Asian Gay Men, Aboriginal Project, Women’s Project and Sex on Premises Venues. In addition to HIV projects, Megan manages ACON’s new work in Cancer Screening and Prevention for LGBTQ communities.
Associate Professor Limin Mao works at the Centre for Social Research in Health, UNSW. She has worked in HIV-related social research for more than a decade promoting better clinical and self-management for people living with chronic infections and co-morbidity and adapting established behavioural surveillance in priority populations to inform prevention, diagnosis, treatment, care and support for people with blood-borne viruses and STIs.