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CHNG ET AL.SEXUAL HEALTH AMONG AAPI MSM

A Model for Understanding Sexual Health Among Asian American/Pacific Islander Men Who Have Sex With Men (MSM) in the United States Chwee Lye Chng, Frank Y. Wong, Royce J. Park, Mark C. Edberg, and David S. Lai

The model to understand sexual health among Asian American/Pacific Islander men who have sex with men first locates the dynamic process in the home coun- try, with its prevailing cultural norms including sexual mores, shame or stigma, sexual attitudes, sexual behavior, and drug use/abuse. Second, these cultural norms are modified by the migration/immigration experience. Third, these norms, beliefs, and practices are continually influenced by the process of accul- turation as these men try to adjust to life in the United States. The effects of the first two domains may vary by the degree to which a particular immigrant com- munity remains socially and culturally insulated from the mainstream commu- nity. Conceivably, the effect of home country and migration/immigration would be less significant for those who were either very young at the time of immigra- tion or are born in the United States.

According to the Centers for Disease Control and Prevention (2001), when compared to only men who has sex with men (MSM) in other racial/ethnic groups Asian Ameri- can/Pacific Islander (AAPI) MSM have the second highest proportion of cumulative AIDS cases (72%)—only 2 percentage points lower than White MSM. Proportion- ately, AAPI MSM (53%) ranked second in number of AIDS cases in the year 2000, again after White MSM (62%). More than half of all AAPI MSM with AIDS are born overseas, as reported by epidemiological data (Sy, Chng, Choi, & Wong, 1998; Wong, Crepaz, Campsmith, & Nakmura, 2002), suggesting that the cultural experi- ences of an immigrant may have had an effect on their risk for HIV. This finding is re- inforced by Chng and Geliga (2000) who reported that of the AAPI MSM born overseas the shorter the time these men live in the United States the greater is their like-

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AIDS Education and Prevention, 15, Supplement A, 21–38, 2003 © 2003 The Guilford Press

Chwee Lye Chng is with the Department of Kinesiology, Health Promotion and Recreation of the Univer- sity of Texas, Denton. Frank Y. Wong is with the Center for Health Services Research and Policy and Pre- vention and Community Health Department of the George Washington University School of Public Health and Health Services. Royce J. Park is with the Center for Health Services Research and Policy of the George Washington University School of Public Health and Health Services. Mark C. Edberg is with the Develop- ment Services Group, Inc., Bethesda, MD. David S. Lai is in San Francisco. Preparation of this article was supported in part by two National Institute of Drug Abuse grants (R01DA14512 and R01DA15623) to the second author. All opinions expressed are those of the authors. Address correspondence to Chwee Lye Chng, Ph.D., Department of Kinesiology, Health Promotion and Recreation, University of North Texas, P.O. Box 311337, Denton, TX 76203-1337; e-mail: [email protected]

lihood of engaging in unprotected anal intercourse. Evidently, behaviors placing AAPI MSM at risk of HIV infection are often rooted in scripted sexual-social roles and layered with cultural values (Houston-Hamilton & Day, 1998).

This article addresses the need to understand social roles among AAPI MSM in the United States. Unlike the European American tradition, the social construction of sexuality in many AAPI cultures does not dichotomize heterosexual or homosexual orientations. Thus, AAPI MSM may or may not identify as gay, and may or may not perceive a connection between their sexual behavior and their social role or sexual ori- entation, complicating the process of HIV prevention. The extent to which social roles or perceived sexual orientation are related to stigma, shame, and loss of face among AAPI MSM, and whether these are in turn related to their HIV-related risk attitudes, sexual practices, and drug use/abuse will be explored here.

SOCIAL ROLES AMONG EAST AND SOUTHEAST ASIANS: SEXUALITY

The concept of social scripts or roles refers to shared interpretations and behaviors in a social-cultural context. The social scripts or roles people learn influence how they perceive situations, the meanings they attribute to these situations, and the behaviors in which they engage. As social scripts or roles are conveyed through cultural norms, this framework argues that most behaviors and identities are consequences of social scripts or roles (Chou, 2001; Lai, 1998; Ng & Lau, 1990; Wong, Chng, Ross, & Mayer, 1998a ; Zhang, Li, Li, & Beck, 1999). In a relatively homogenous society, the relationship among social scripts or roles (mostly likely to be “prescribed”), public personae, and private personae are more or less congruent. For example, in Chinese culture (based on the dominant Han tribe), there is a unique term to designate every type of familial relationship (as opposed to such English terms as first cousin and sec- ond cousin). The hierarchical structure defines one’s social script in the relationship. The expectation of how one should act and behave in each type of setting depends on the status of the other party in the interaction. This type of hierarchy permeates all as- pect of “traditional” Chinese culture. One is allowed to marry a first cousin only if the cousin is from the maternal side of the family (e.g., a cousin from a brother of the mother). Any sexual contact and unions among relatives from the paternal side are considered taboo (immoral). In extreme cases, some Chinese do not marry people sharing the same last name due, in part, to the possibility that people from the same village share the same last name, and might be related to each other. These examples il- lustrate the powerful influence of prescribed social or cultural forces (often a number of prescribed scripts work together in tandem) in shaping sexualities and sex scripts.

In other words, “same-sex activities are portrayed in predominately social, rather than sexual terms, with homosexual roles being used in expressions such as . . . hanlu (the dry canal), and . . . tuzi (little rabbit); homosexual relations are described in terms such as . . . qidi and qixiong (adopted brothers), and hanlu yingxiong (stranded heroes) . . . or as specific behaviorial practices such as . . . chui xiao (to play a vertical bamboo flute)” (Chou, 2001, p. 29). Similarly, in Filipino culture, a bakla is a biologi- cal male who assumes the role and behavior of a woman, not unlike the modern Amer- ican Indian concept of “two spirits” (Wong et al., 1998). However, this practice should not be confused with the Western notion of “gayness” (an ascribed concept).

The seminal study conducted by Ford and Beach (1951) on homosexuality sug- gests that same-sex sexual behaviors or relationships are more prevalent than once

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thought, but these behaviors are likely to be highly regulated by social factors or pa- rameters (e.g., religious beliefs). For example, Liu and Chan (1996) argued that Con- fucianism, Taoism, and Buddhism “coexist in a curious mixture in East Asian societies and very much shape the nature of relationships within the family” (p. 140). An important value of the family is the concept of “face.” That is, one must only en- gage in activities and behaviors that will not “shame” the family. Another key value of family is “lineage” or procreation—to pass on the family name according to a patriar- chal lineage. These factors dictate many social exchanges and relationships. One might surmise that homosexual behavior “will be tolerated by the family only to the extent that it does not interfere with the individual’s and the family duties and even- tual marriage. Furthermore, both the individual’s and the family’s face must be intact in the context of the larger community” (Liu & Chan, 1996, p. 141).

Indeed, Carrier, Nguyen, and Su’s (1992) study on sexual behaviors and HIV in- fection among Vietnamese Americans in Orange County, California, gives credence to the premise of “social roles” in defining sexuality in East and Southeast Asians. Car- rier et al. stated that

as some homosexuality involved adolescent males move into adulthood, and become aware of their homosexuality and the societal beliefs that equates it with feminine behav- ior, they restrict their sexual pleasures to the passive role of fellating “masculine” men. They may use their feminine behavior to attract other males interested in homosexual en- counters, and so become sexual targets, but their major focus appears to be on meeting the sexual needs and pleasures of their partners. The sexual preference, then, generally becomes less important than the sexual preferences of their partners (p. 553).

Although there is a rich body of cultural and historical literature and analyses address- ing same-sex and bisexual sexual issues, expressions, and phenomena for some East and Southeast Asians (e.g., see Manalansan, in press; Ruan, 1991), the same cannot be said for the scientific field. Nonetheless, some of these “sexuality-related” issues could be inferred and gleaned from the small set of studies addressing HIV- and drug-related issues in both the APPI MSM and non-MSM communities.

HIV-RELATED RISK ATTITUDES AND PRACTICES AND DRUG USE AMONG AAPI MSM

Nemoto et al. (1998) identified eight published studies that reported the seroprevalence rates, HIV risk behaviors and/or attitudes toward HIV/AIDS among AAPI MSM. Specifically, seven reported HIV seroprevalence rates, which were based on either self-disclosure of HIV or HIV test results among study participants. Four studies also reported findings about the relationships between HIV-related behaviors and factors. In addition, two studies were intervention studies. With the exception of two, all studies were conducted in California—four studies were in San Francisco Bay Area, one in Los Angeles and one in Orange County; the two other studies were con- ducted in Chicago and the greater Boston area. Only four of the eight studies specifi- cally targeted AAPI MSM; the other studies targeted AAPI MSM among other groups.

The sampling methodology of the eight studies ranged from convenience sam- pling (Choi, Coates, Catania, Lew, & Chow, 1995; Choi et al., 1996; Yep, 1992) to participants recruited from a county HIV/STD clinic (Gellert, Moore, Maxwell, Mail, & Higgins, 1994; Matteson, 1997) to targeted sampling (Lemp et al., 1994; Seage et al., 1997) to probability sampling (Osmond et al., 1994). Estimated HIV

SEXUAL HEALTH AMONG AAPI MSM 23

seroprevalence rates ranged from a low of 1.4% (Matteson, 1997) to a high of 28% (Gellert et al., 1994). Except for the studies by Choi et al. (1995a) and Choi et al. (1996), sample sizes of AAPI MSM were very small and studies did not specifically tar- get AAPI MSM. These limitations may likely underestimate or overestimate the HIV seroprevalence rate among AAPI MSM. To provide relative comparisons among be- havioral risk groups, we note that the AIDS Office of the San Francisco Department of Public Health (1997) estimated that HIV seroprevalence rates in the city among AAPI MSM and AAPI MSM who also inject drugs are 38% and 45%, respectively. While recognizing design limitations, we note that these estimates are higher than the eight studies cited earlier.

One of the studies (Choi et al., 1995a) revealed high rates of HIV risk behavior among AAPI men in San Francisco. Ninety-five percent of the men reported multiple sex partners within the past 5 years, 59% reported multiple sex partners in the past 3 months, and 27% had engaged in unprotected sex in the past 3 months. Substance abuse was the strongest predictor of unsafe sex among the AAPI sample, and men who engaged in high-risk behaviors were less likely to believe that they were at risk. Simi- larly, Lai’s (1998b) study reported that among AAPI MSM who had sex in the last 3 months (n = 77), 31% engaged in unprotected anal intercourse. This potential for en- gaging in risk behavior was later confirmed in the study by Chng and Geliga (2000), where they reported that among all ethnic MSM surveyed (N = 302), AAPI MSM (n = 76) reported the highest rate of unprotected anal sex.

Unfortunately, none of the eight studies investigated how sociocultural factors influenced, regulated, or shaped HIV-related risk behaviors and drug use among the targeted AAPI MSM. This lack of attention is symptomatic of the inherent difficulty for most AAPI MSM to discuss openly two major cultural taboos: sex and drugs (Wong, Chng, & Choi, 1998; Wong, Chng, Ross, et al., 1998). Another contributing factor to the lack of a science-based knowledge on these two topics is the portrayal of AAPIs as “model minorities” (Zane, Takeuchi, & Young, 1994) with lower level of sexual activity and less drug use (Zane & Kim, 1994; Zane & Sasao, 1992). Mean- while, the sexual and drug use images of AAPIs being portrayed by the U.S. popular media are limited and tend to promote negative stereotypes (Sanitioso, 1999; Wong, Chng, Ross, et al., 1998b). For example, sexual images fall into four broad stereo- types: asexual (see Choi et al., 1995b), china doll (e.g., the Suzie Wong type), dragon lady (e.g., Yoko Ono), and effeminate men (e.g., submissive house boys; see Choi et al., 1995; Ho & Tsang, 2000). In the words of a 22-year-old Chinese American gay man in San Francisco, Alex, recalled his shock when his White boyfriend dumped him while exclaiming, “I don’t date fortune cookies”:

I was completely shocked that he would reduce my whole existence into the equivalent of a cookie. . . . I think the only reasons he dated me was because he was intrigued by my “exoticness” and when I didn’t fit the stereotypes he expected, he lost interest (as cited in Lee, 2000).

Similarly, although AAPIs are perceived to use drugs less than other racial/ethnic groups, the image of an “opium den” is often associated with AAPIs. No doubt, the lack of information is also due to the fact that major surveys, such as Monitoring the Future, often group AAPIs into the category of “other.” In addition, the sampling methodologies used are often inadequate in addressing the diversity of AAPI com- munities. Research has worked the limited value of using the telephone to reach lim- ited-English or monolingual AAPIs (Nemoto et al., 1998). However, in a study

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examining the HIV-related risks among a multiracial/multiethnic young MSM (n = 125; aged 18-25) in Boston, Landers et al. (1998) found that AAPI MSM (n =25) are more likely to use speed (7%) and ecstasy (11%) as well as nitrite (11%) than other racial/ethnic MSM.

In an attempt to examine the effects of sociocultural and environmental factors on HIV-related risk attitudes and practices among AAPI MSM, Choi et al. (1999) con- ducted semistructured interviews with 40 AAPI MSM (25% Chinese, 33% Filipino, 15% Vietnamese, 20% multicultural, and 7% other Asian ethnicities) as part of a larger 1997-98 study in San Diego and Seattle. The mean age of these men was 22, and 68% were foreign born and had lived in the United States an average of 12 years. Find- ings reveal eight factors for promoting risky behaviors: (a) negative feelings about oneself, (b) being “closeted,” (c) “trusting a partner in a relationship,” (d) wishing to please a partner, (e) having judgment overwhelmed by passion, (f) being high on alco- hol and drugs, (g) sexual attitudes in the gay and Asian communities (i.e., balance of a dual identity), and (h) lack of support of Asian families. One of these factors, sexual attitudes in the gay and Asian communities, speaks to the challenge for APPI gay/bi- sexual men in maintaining a positive dual identity. One respondent noted:

But growing up you are not given a lot of Asian role models so you don’t have anything to go along with. You have to create your own self-esteem. On top of that you are thrust into this White mainstream society. You are a lot more inferior. If everyone wants to be a model and all of them are Whites . . . there is lack of self-esteem. Being gay, sometimes it is very superficial in the sense that many things are based on physicality. Physical beauty, the standard is the model, and all the models are Whites. Then you think you are less than that. (Choi et al., 1999, p.50).

Respondents also cited several factors associated with protective behaviors including (a) having a positive self-image, (b) conservative sexual values, (c) living with one’s parents, (d) sexual attitudes in the gay and Asian communities (i.e., balance of dual identity), (e) values associated with the respondent’s family, (f) overt urging by the family, and (g) wishing to avoid hurting one’s parents. There is variation among re- spondents in dealing with the issue of dual identity. One respondent stated: “In the Asian community they are always watching me. My way to prove them wrong is to be safe. Why give them the chance to talk bad about me?” In sum, the issues of “dual identity” and “family relationship” both have negative and positive effects on sexual risk taking among AAPI gay/bisexual men and MSM.

A MODEL FOR UNDERSTANDING SEXUAL HEALTH AMONG AAPI MSM

Theoretical models in the past designed to explain or predict risk behaviors have sometimes ignored social, relational, and cultural factors involved in behavior and of- ten viewed these forces as independent variables, without recognizing that they might be interactive or reciprocal. Unsafe behaviors are rarely the direct product of merely a deficit of knowledge, motivation, or skill but instead can have layered meanings within a given, complex personal and social-cultural context. Our proposed model is based on the premise that AAPI MSM develop their sense of self in a social-cultural en- vironment marked by triple oppression: racism, homophobia and immigrant status. We propose a conceptual model to understand sexual health among AAPI MSM as outputs of a dynamic cultural process potentially encompassing multiple generations

SEXUAL HEALTH AMONG AAPI MSM 25

and moving through different “impact domains” (Wong & Edberg, 2000, 2001). In this article, sexual health refers to the “integration of the physical, emotional, intellec- tual and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication and love” (World Health Organization, 1975).

As seen in Figure 1, the model first locates the process in the home country (Im- pact Domain 1), with its prevailing cultural norms—including sexual mores, shame or stigma, sexual attitudes, sexual behavior and drug use. Second, these norms, beliefs, and practices will be modified by the migration/immigration experience (Impact Do- main 2), which for some segments (especially Vietnamese and Cambodian refugees) may include severe trauma and the endurance of prolonged hardship. Although many Pacific Islanders are “native” to their lands and not “immigrants” in the traditional sense, when they migrate to the mainland, they experience similar barriers that Asian Americans face, and in that context and to that extent this model will be applicable to them. Third, these norms, beliefs, and practices will be continually influenced by the process of acculturation (Impact Domain 3), as these AAPIs try to adjust to life in the United States. An important subset of the third domain is the “generation” factor. Conceivably, the effect of Domains 1 and 2 will be less significant for those who were either very young at the time of immigration or are born in the United States. The ef- fects of the first two domains (cultural norms of home country and the effects of mi- gration/immigration) on individuals may also vary by the degree to which a particular immigrant community remains socially and culturally insulated (e.g., through lan- guage, social networks, cultural practices, economic participation) vis-à-vis the sur- rounding mainstream community and the larger influences of “American cultural practices and norms” (using this term in a gross sense to include social norms, gender roles, behavior codes, daily practices, values, commonly found in key socializing insti- tutions such as schools and mass media).

IMPACT DOMAIN 1: HOME COUNTRY PATTERN More specifically, in Domain 1, we include home country patterns that are rele-

vant to later (U.S.) lifestyles, such as gender roles, home country sexual mores, sexual risk practices (especially MSM and multiple sex partners), drug use, and cultural con- ceptions of shame and face. Sexuality remains a very private matter in many AAPI countries. Because sexual issues are rarely or openly discussed in homes, schools or community, many young AAPI adults have minimal experience or skills in coping with relationships, sex, and sexuality issues in later life. This lack of experience can lead many to feel socially awkward (Lai, 1998a). Candid discussions about sexual is- sues in public is not easy with AAPI men, especially when non-Asians are also present, as clearly evident in this comment from an AAPI outreach worker:

I found that to be the case when I did my first workshop, which was with the Long Yang club and hardly anyone asked questions, and it’s a mixed group as far as Asians and non-Asians, and it was primarily non-Asians who were asking questions. Ummm, when I did the workshop with GAPIMNY, we actually had them write out the questions on cards, index cards, which allow people to ask more questions, and that seemed to work a lot better (Yoshikawa, Chin, Kim, Hsueh, & Rossman, 1999).

Aoki, Ngin, Mo, and Ja (1989) stated many years ago that little is known in terms of HIV education and prevention in the AAPI community. Moreover, they reasoned that within the Chinese American and Japanese American communities, education for pre- venting AIDS is a daunting task because it brings up four taboo subjects: sex, homo- sexuality, disease, and death. Sex, considered a private matter, is not talked about

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publicly (Aoki et al., 1989; Chan, 1995). Confucianism sanctions sex only as a means to continue the family lineage. Talking about illness is considered bad luck and thought to bring about the illness. Aoki et al. reported that in contemporary Japan many physicians routinely, as standard practice, do not disclose cancer diagnoses to their patients. The subject of death is avoided at all cost in the Chinese and Japanese cultures. For example, the Chinese words for three and four are homophones for birth and death, respectively. Hence, many customs include groupings of three items and avoid groupings of four. The Japanese shares the avoidance of four because the word for four, shi, is also a homophone for death. In general, like the Chinese, the Japanese avoid selling or presenting items in fours.

Likewise, sexuality is rarely discussed between the Issei (first) and Nisei (second) generations in the Japanese community, partly due to a language barrier between the two generations (Nagata, 1989). Moreover, recent data suggest that difficulty in dis- cussing sexuality continues into the Sansei (third) generation. Studies found that Japa- nese Americans express significantly greater sex-related guilt than White Americans. Similarly, the language barrier has been found to impede discussions about sex be- tween first- and second-generation Chinese Americans (Lai, 1998a). Because sex is rarely discussed in Asian families, the Asian young adult often has a late start in learn- ing how to deal with relationships. An AAPI MSM stated:

The communication pattern for API is more indirect. White Americans are direct, and so if we have trouble talking about sex, it’s got to be compounded in the Asian community, where homosexuality just isn’t spoken of, where the family ties are so strong, where car- rying on the family name is so important for guys (Choi, Yep, & Kumekawa, 1998, p. 25).

SEXUAL HEALTH AMONG AAPI MSM 27

FIGURE 1. Impact domains.

Gay AAPI men have a very difficult time in their own communities because of the con- tinual denial of their existence; there is a prevailing belief that homosexuality is a Western phenomenon (Chan, 1995; Dynes & Donaldson, 1992; Nakajima, Chan, & Lee, 1996), an indication of the “decline and evil of Western civilization” (Ruan, 1991, p. 121). The recognition of HIV in the AAPI communities often implies the ac- knowledgment of homosexuality. However, because the family is such a powerful so- cial unit, MSM have to choose between perpetuating the family name through marriage or deriving personal satisfaction through same-sex relationships. The con- flicts between ethnic identity and sexual identity might hinder safer sex behaviors (Chng & Geliga, 2000; Yep, 1993). For example, whereas China has decriminalized homosexuality in 1997, and has removed it from a list of mental illnesses in 2001, the norm in the Chinese gay community is to get married, have children, and pass as het- erosexual at work but frequent gay establishments at night. This growing under- ground community of partly closeted, partly liberated, and sexually active gay males with dual identities presents unique challenges to HIV prevention. However, Chinese doctors are beginning to see the effects of AIDS in this poorly defined high-risk group, whose members are sometimes still unclear about their sexuality and frequently have sexual relations with both men and women (Rosenthal, 2002).

Because AAPI culture traditionally views the family across all time, the rejection of the gay man by his family has a greater impact, because the family includes all mem- bers across time—past, present, and future.

So you’re a White person. You tell your parents that you’re gay, and they reject you. Sure it’s hard, but look at it this way: If you were Asian, not only your parents might reject you but also your grandparents, your great-grandparents, and several thousand other ances- tors. Now that’s a burden (Hippler, 1989, p. 1).

Being gay is strongly stigmatized by most AAPI families and communities, and the re- sulting shame would keep many gay AAPI sons closeted, as illustrated by the com- ments of an AAPI man interviewed by Choi et al. (1998, p. 25): “Asian culture looks down on homosexuality. Even if the families did know that the son is gay, it is not dis- cussed. I know very few gay Asians who are out to their families to the point where they talk about things.” Sin, Myers, Souza, and Gardner (1994) reported that AAPI MSM often struggle to find self-acceptance given the homophobia in their family and the racism in the mainstream gay community. A large number of these men reported that their parents taunted, teased, and joked about homosexuals despite the knowl- edge that their sons were gay. The inability of the family to acknowledge the sexual identity of these closeted men can lead to repression of sexual urges which can become “overwhelmingly strong, and to satisfy sexual urges, people can go out and seek sex . . . in strange places like in bathrooms, parks. If it has to be fast and loose, it could be without protection, because that’s the only thing offered at that moment” (Choi et al., 1998, p. 25).

Because of the shame and stigma of homosexuality in AAPI cultures, and the threat of disclosure in their small community, some AAPI MSM actively avoid inter- acting with other AAPI men. The work of Carrier (2001) and Carrier et al. (1992) has demonstrated that the issue of “face” may be relevant when designing programs for this population. In a description of recruiting strategies among AAPI men engaging in bisexual behavior (Matteson, 1997), several important points emerged. No study sub-

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jects were recruited through network or snowball techniques or through advertise- ments in ethnic newspapers.

Implication for HIV Prevention. Sensitivity to social-sexual norms and histori- cal experiences of AAPI subgroups is important when designing and implementing ef- fective HIV interventions. Unfortunately, cultural norms and values sometimes can be at cross-purposes with HIV prevention: The reticence in talking openly about sexual- ity and other risk behaviors can result in difficulties with interpersonal sexual commu- nication, weaker safer sex negotiations, and greater sexual discomfort (Aoki et al., 1989; Chan, 1995). For example, the cultural need to maintain social harmony and tendency to avoid interpersonal conflict in the highly hierarchical systems, such as among Chinese and Japanese, can endorse silence rather than open dialog about sexu- ality. For some AAPI MSM, sometimes protecting their partners from uncomfortable feelings takes precedence over protection themselves from HIV.

Many AAPI cultures frown on exchanging information with strangers having anything to do with sexuality. HIV/AIDS is associated with sexuality, and there- fore any indications that materials are about HIV/AIDS are usually rejected out- right. In AAPI cultures condoms are still associated with promiscuity and Asians tend not to accept condoms for fear of being perceived as promiscuous, especially when they are with family or friends, or partners. To overcome this resistance, con- dom packaging has been modified to appeal to certain AAPI communities (e.g., red packaging with gold letters to imitate Chinese New Year gift packaging). When safer sex materials are introduced as health materials, AAPI clients are more likely to accept them.

For AAPI MSM, social support within the family system constitutes an important and powerful safe haven from which to cope with poverty, discrimination, and racism that they experience as ethnic minorities in the United States. Sometimes they are forced to choose between either remaining closeted in order to be involved with their homophobic family or living open lives without family support or acceptance (Chng & Geliga, 2000; Lai, 1998a; Wat, 2002; Wong, Chng, Ross, et al., 1998). Sexuality for these men, often married with wives and children, finds expression in anonymous, hidden sexual encounters with other men. Messages tailored for “gay men” will not necessarily resonate with these men. Although research has shown that difficulties in coming out as gay men and a lack of social support are predictors of high-risk behav- iors (Catania, Coates, & Stall, 1991), within the AAPI immigrant world individual be- havior cannot be accurately understood apart from the social cultural structures in which it is rooted. Seen in this light, many of the “irrational” sexual choices made by AAPI MSM immigrants become more understandable.

This avoidance of fellow AAPI men as sexual partners for fear that their behavior would become known among other AAPIs; and concerns about confidentiality if AAPI outreach workers were used suggest that data collection through face-to-face in- terviews by AAPI interviewers may not be effective if the subject matter is perceived as shameful or controversial.

IMPACT DOMAIN 2: MIGRATION EXPERIENCE Migration is likely to involve a loss of the cultural environment of the “home

country” and an attempt at integrating sociocultural constructs and values of the new “host country.” Migration, in essence, is a dynamic, time-dependent process of dis- continuity and transition, whereby an individual moves from a familiar world to an unknown, confusing, distressing, but sometimes rewarding life in a new country.

SEXUAL HEALTH AMONG AAPI MSM 29

Some of these same elements may also be experienced by the host culture receiving the immigrants, but from a position of greater power than do immigrants (Chng & Geliga, 2000; Haour-Knipe & Rector, 1996). It is important to clarify from the outset that being an immigrant in and of itself, is not a “risk factor” for HIV. It is the circum- stance encountered and the activities undertaken during the migration process that are risk factors.

The challenges of providing HIV/AIDS prevention among AAPI immigrants are unique because it involves sexual intimacy. Here, differential familial and social pres- sures for continuity and conformity can create strong tensions not only in the immi- grant community but also in the host society. The problem is further aggravated because in many AAPI immigrant cultures, the issues of intimate relations and sexual behavior are routinely shrouded in secrecy and taboo. Such cultures, which are usu- ally more traditional, have a tendency to avoid public discussions of sexual matters (Sabatier, 1996).

Sociological case examples highlight the migration-immigration experiences of three major AAPI groups (Chinese, Filipino, and Vietnamese) to illustrate how home country cultural norms can be modified by immigration to the United States. Al- though Chinese Americans have been residing in the United States since the 1800s, many were concentrated in ethnic enclaves such as those in San Francisco and New York City. The 1965 Family Reunification Act has significantly increased the Chinese population (from mainland China, Hong Kong, and Taiwan) in this country. The re- laxation of migration policy by the mainland Chinese government in the late 1970s has also contributed to an influx of migration. Thus, people of Chinese descent in the United States are a mixed group, ranging from fifth-generation Chinese Americans to recent immigrants. When it comes to their perspective on the family, Chinese Ameri- cans can best be described as conservative, particularly in terms of their views of the role of women, sexual attitudes, and political philosophy. Although Chinese Ameri- cans are able to adjust to changing conditions in American society, it is also true that they still maintain a strong cultural and ethnic identity.

The process of immigration is difficult for most and often has significant impact on people’s psychological well-being. Chinese and Japanese immigrants face major conflicts and difficulties assimilating into American culture. Of particular importance for immigrants are prejudiced and discriminatory policies enacted by the American government such as the Chinese Exclusion Act of 1882 and the internment of Japa- nese Americans (Takaki, 1989). The imprisonment of the Japanese American citizens during World War II seriously affected the lives of two generations of Japanese Ameri- cans. The effects included a change in family structure, economic loss, psychological stress, feelings of victimization (Nagata, 1989), and subsequent higher levels of assim- ilation (Uba, 1994). Second-generation Japanese Americans who had been interned made greater efforts to raise their children to be thoroughly “American” (Nagata, 1989). This resulted in few third generation Japanese Americans speaking Japanese or adopting its cultural norms. It is not surprising, therefore, that studies have reported that more acculturated Japanese Americans (primarily third-generation individuals) have rates of drug use and other risk behaviors that mirror those of White Americans (Price, Risk, Wong, & Kringle, 2001; 2002).

The Philippines holds a special place in U.S. military history and cultural connec- tions (English is the lingua franca for many Filipinos); many Filipino Americans either have immigrated here dating back to the 1950s or earlier, or were United States born in the United States. In addition, during the 1960s there was a shortage of medical per-

30 CHNG ET AL.

sonnel, which led to a significant number of Filipino medical professionals (doctors and nurses) migrating to the United States. As a higher proportion of Filipinas are in the medical professions, more Filipino men are married to wives with higher levels of education than they have, creating role conflicts. Many Filipino Americans have pur- chased homes in the suburbs, with the result that they are highly integrated into White American neighborhoods. Families who arrived first often served as host families for later arrivals (Almirol, 1982), who all contribute to their mortgage payments. In es- sence, the purchase of a home for many Filipinos is a “family affair,” as they not only share household expenses but also make personal loans to one another. As family ties are extremely close with Filipino Americans, living enmeshed lives can make it diffi- cult for some Filipino gay men to come out of the closet to family members. For the need to maintain boundaries around private versus public behaviors, central to many AAPI cultures, can drive these gay men deeper into the closet. Whether for pleasure, economic reasons, compulsion, or a lack of available women, these men have sex with one another, despite strong cultural taboos against homosexuality. These men often hide their sexual orientation by having clandestine sexual encounters with other men. In these oftentimes hurried circumstances, condoms are unlikely to be used consis- tently. Some men, married to women because of social or family expectations, have been known to have sex with other men “on the side”—they do not view their same-sex behaviors as linked to a sexual identity. As AAPI MSM—whether exclu- sively or only occasionally—are at heightened risk of contracting HIV and transmit- ting it to their partners and offspring, HIV prevention programs targeting AAPI MSM is essential.

Vietnamese are one of latest additions to the “melting pot.” The “first wave” came immediately after the fall of Saigon in 1975. Much of this wave was middle class and urban, with some experience participating in a Western-style market economy, and therefore has assimilated more easily than subsequent arrivals. However, despite their skills and education, many in this initial wave of Vietnamese Americans had to accept positions that were lower in status than those they had held in Vietnam. The Refugee Resettlement Act brought on a second wave of Vietnamese between 1978 and the mid-1980s. This wave included large numbers of poor, rural, and illiterate individ- uals (Wong, Chng, Ross, et al., 1998), who remained trapped in low-paying jobs, iso- lated from the mainstream by language and cultural barriers and from the more affluent Vietnamese community by economic and regional differences. They often have been forced to depend exclusively on their children who most often are the only family members with a working knowledge of English. As such, in the United States these adults had to relinquish their traditional social status and authority, while Eng- lish-speaking youths assume more power in social interactions with the mainstream society. This shift in power can produce negative social effects, such as the prolifera- tion of Vietnamese youth gangs in the community. More important, persons who have been subjected to war, political repression, torture, interpersonal violence, or other traumas may experience residual power imbalances, which may play out in their risk behaviors; these imbalances in power among AAPI need to be made explicit in or- der for prevention interventions to be effective (Houston-Hamilton & Day, 1998). Carrier et al. (1992), in their examination of Vietnamese American MSM, found that social isolation complicates the process of sexual identification, especially for new im- migrants. They tend to be isolated because of language barriers, lack of knowledge re- garding the gay community, or the insularity of their community. This was reported anecdotally also in the gay Chinese community.

SEXUAL HEALTH AMONG AAPI MSM 31

In sum, these differential migration experiences among various AAPI groups may act as stressors that could contribute to risky health-related attitudes and practices (Takeuchi & Young, 1994). For example, in the study conducted by Chng and Geliga (2000) of those MSM in the sample who were born overseas, the majority was AAPI (61%), followed by Latinos (29%). For men born overseas, the longer they have lived in the United States, the less likely they are to engage in unprotected anal intercourse with other men. Marin, Gomez, and Tscann (1993) have suggested that high accultur- ation levels and exposure to mainstream gay community are factors associated with consistent use of condoms among MSM of color. For many immigrants, time spent in the United States is positively correlated to acculturation levels and exposure to main- stream culture. As suggested by these findings, many immigrant AAPI MSM may not have access to HIV prevention messages until they are exposed to the mainstream gay culture.

Implications for HIV Prevention. Forced to work low-paying service industry jobs that rarely provide health insurance, many AAPI MSM immigrants may overlook serious HIV-related illnesses until they reach later stages of the disease—then rushing to the hospital for emergency treatment. Until then many are unaware that they are HIV-positive or have full-blown AIDS. Many illegal immigrants who suspect having HIV avoid testing or seeking medical care, fearing that a positive HIV result will ruin any chance of gaining legal residency. Undocumented HIV-positive immigrants often fear returning to their native countries where potentially lifesaving AIDS medicines are rare and where they are more likely to face discrimination. Instead they choose to go underground and risk deportation. In addition, AAPI MSM immigrants without marketable skills attempting to escape extreme poverty may resort to trading sex for goods, services, and cash. Because of language, cultural, and power disparities, many AAPI MSM, particularly newly arrived immigrants, are unaccustomed to initiating sexual discussions with their partners.

AAPI migrant populations have a great risk for poor health in general and HIV infection in particular (Chng & Geliga, 2000; Wong, Chng, & Choi, 1998). More generally, AAPI migrants have other concerns far more pressing than a seemingly dis- tant threat of AIDS, such as legal, housing and employment problems. Health may not be a first priority, and an effective HIV intervention may have to widen its scope in or- der to be acceptable to this population.

For effective HIV prevention, it is important to involve migrant communities at all stages, starting with needs assessment and planning. Employing AAPI profession- als from the migrant population as HIV educators/case managers and training them to work in the field of HIV/AIDS serve more than one purpose. When trained, they could enhance the delivery of HIV messages from one culture to another. They are also the most appropriate people to serve as cultural mediators in the United States health, welfare, and educational systems. Being knowledgeable of the nuances of their own society, they could inject cultural insights into the development, training, and imple- mentation processes of HIV prevention.

IMPACT DOMAIN 3: U.S. EXPERIENCE There are significant stressors created by the acculturation process to life in the

United States, regardless of migration experience (Takeuchi & Young, 1994). The ac- culturation process may include significant changes in social status, challenges to tra- ditional gender roles, the effects of coping with racism and homophobia.

32 CHNG ET AL.

Using the categorization proposed by Fung (1994), we will illustrate the effects of acculturation to life in the United States on AAPI MSM. Fung (1994) differentiated three distinct groups of AAPI MSM: (a) men who are both AAPI identified and gay identified, (b) men who are gay identified but not AAPI identified, and (c) men who are AAPI identified but not gay identified. Although the categorization of three dis- tinct groups may be a simplistic overgeneralization of a diverse community, it does of- fer a framework to examine how AAPI MSM acculturate to life in the United States. The first group, men who are both AAPI identified and gay identified, is usually the group who is least closeted and most politically involved (Choi et al., 1995b). These individuals are most likely to form and participate in queer AAPI groups such as the Gay Asian Pacific Alliance (GAPA) and Cal-B-Gay (at the University of California, Berkeley).

The second group, men who are gay but not AAPI identified, makes up the largest of these three groups and is most diversified (Fung, 1994). This segment of the com- munity was described by Choi et al. (1995) and Nakajima et al. (1996) as having more affinity toward the gay community than the AAPI community. Nakajima et al. (1996) observed that many do not have AAPI self-awareness and go through an internalized racism stage where they believe they are “White.” This phenomenon is reflected in the dating patterns of AAPI men with specific pejorative terms used among them: where the majority of AAPI men (“potato queens”) are dating exclusively White partners (“rice queens”), who are men exclusively attracted to AAPIs, and where AAPI men dating other AAPI men are referred to as “sticky rice.” Nakajima et al. (1996) attrib- uted this pattern to the internalization of dominant cultural portrayal of AAPI men as un-masculine and undesirable. Perhaps such AAPI men believe that their self-worth is dependent on their assimilation and acceptance by the gay, White mainstream com- munity. Nakajima et al. reported the common stereotype held by some Whites of AAPI MSM as “passive partners and sexually subservient” (p. 572). This stereotype has two implications. First, those AAPI MSM with difficulty asserting themselves are now reinforced by the mainstream society to be passive. Second, AAPI MSM are ex- pected to be the “passive” partner in anal sex—the role that carries the highest risk for HIV infection.

In fact, Fung (1994) reported members of this second group have feelings ranging from indifference to hostility toward other AAPI men. They participate mostly in gay “mainstream” dance clubs and social groups that are not AAPI identified. Many expe- rience cultural ambivalence, having to choose between values of their ethnic commu- nity and the values of the predominantly White gay culture. Many end up choosing gay White values and demonstrate internalized racism by believing they are “White” and associating only with Whites. This observation has been corroborated by the Gay Asian and Pacific Islander Men’s Study, which found that 63% of participants who were in primary relationships were partnered with White men (Choi et al., 1995a). This is consistent with field observations in an ongoing National Institute of Drug Abuse-funded study in New York City (T. Case, personal communication, November 1, 2001). The investigator noted that many Cantonese-speaking Chinese gay men are engaging in “club drug use and/or trade” in Chelsea (a New York City’s gay district) as a way to gain acceptance into the predominately “White, gay, Chelsea boy” circle. The use of “club drugs” by these Cantonese-speaking Chinese gay men may represent a form of acculturation to the “mainstream American culture” in general and/or “gay culture” (being a Chelsea Boy) in particular (cf. Ross, Fernandez-Esquer, & Seibt, 1995). Fung found many members of this second group express low self-esteem espe-

SEXUAL HEALTH AMONG AAPI MSM 33

cially when they are “trying to be ‘one of the boys’ without ever being permitted into the exclusive club of the White beauty standard” (p. 3). This second group is often underrepresented in studies because of low self-esteem and reluctance to assist their own community. In Lai’s study (1998a), participants who identified with both the AAPI and gay community had significantly (p =. 01) higher self-esteem (M = 18.14) than those who did not identify with both communities (M = 16.08). Similar to Chan’s (1989) findings, for those who did not identified with both communities, more partic- ipants identified with being gay (n = 26, 25.2%) than being AAPI (n = 11, 10.7%). This might be the phenomenon of White identification in the AAPI MSM community described by researchers (Choi et al., 1995b; Nakajima et al., 1996; Wat, 2002).

Uba (1994) reported that Chinese Americans and Japanese Americans males are perceived to be less masculine than White males. This might be related to the fact that cultures influenced by Confucianism emphasize scholarship, learning, and other non- physical endeavors (Nakajima et al., 1996). In contrast, the American gay culture places a great emphasis on masculine physical appearance. Hence, AAPI MSM might have lower self-esteem due to the mismatch of social-sexual ideals and stereotypes. Many experience difficulty adjusting to the ideal image of male beauty and negative stereotyping of AAPI MSM in the mainstream gay community (Choi et al., 1998). Be- cause AAPI MSM do not fit the White standard of male beauty (e.g., chiseled, healthy-looking, young White man with blond hair and blue eyes), many have devel- oped a low sense of self-esteem about their physical appearance (Ona, Cadebes, & Choi, 1996; Wat, 2002).

According to Ona et al. (1996), many AAPI MSM indicated that they engaged in unsafe sex as a consequence of low self-esteem. These assaults on their self-esteem take place in a more general atmosphere of discrimination, racism, negative stereotypes, and cultural ambivalence. Discrimination can encourage AAPIs to adopt self-esteem hampering personality traits, becoming self-abased (deferring to others and feeling in- ferior), less assertive, more conforming, less expressive, and less extroverted (Lai, 1998a). Negative stereotypes can keep them from developing positive identities (Wat, 2002).

The third group refers to AAPI men who are not gay identified. This group may also be the most closeted and hardest to reach. They are not activists in the AAPI com- munity but are limited in their ability to live freely in the gay community due to their immigration status, language and cultural barriers. These individuals are most likely to participate, if they participate at all, in social clubs organized by White men who want to meet AAPI men, such as Pacific Friends, Asians and Friends, and the Long Yang Club. This is the group that most accurately reflects the definition and charac- teristics of AAPI MSM, as they seldom perceive themselves as gay.

Implications for HIV Prevention. To reach out to unacculturated AAPI MSM it may be important to reframe the process to include (a) identification of new social net- works and settings in which specific AAPI MSM community members gather; (b) sat- uration of those settings with HIV relevant information; and (c) diffusion of new norms concerning HIV risk and protective behaviors, through a series of presenta- tions.

For example, as reported by Yoshikawa (1999), in New York City, ethnic gro- cery stores and restaurants had been identified by HIV educators as informal social support settings for immigrant Bangladeshi men and cabdrivers, respectively. Many of these men appeared to engage in unprotected sex with men. In both these initiatives, repeated contacts were made with members of these settings (in one case, the owners

34 CHNG ET AL.

of grocery stores, and in the other, Bangladeshi cabdrivers who regularly congregate in a few ethnic restaurants on their breaks). Next, to promote location-wide reduc- tions in HIV risk, peer educators saturated the settings with HIV outreach materials, distributing condoms and brochures to virtually everyone entering the restaurants or grocery stores. In the third step, HIV educators attempted to diffuse new norms about HIV risk and protective behaviors among tightly knit social networks. A series of house parties in Bangladeshi communities have made use of the high levels of cohesion in networks of Bangladeshi individuals to diffuse awareness about HIV/AIDS. In a typical scenario, an initial house party will generate interest among friends of those who attended, and that group is then invited to a subsequent party. Using diffusion of innovation, peer educators have presented multiple workshops in the same apartment building or residential area. Such a method may potentially result in reductions in HIV risk across the given setting (e.g., apartment building or area), through a process of diffusion of new information and norms for risk behavior in existing social networks.

CONCLUSIONS

Three conclusions emerge from this review. First, popular behavioral models in use do not serve the needs of AAPI MSM because these models essentially ignore important cultural practices, beliefs, and attitudes of this population. Second, cultural back- grounds (e.g., social and sexual norms from their home country, migration experi- ences, and acculturation experiences in the United States) can have significant effects on risk behaviors of AAPI MSM, and their responses to HIV prevention messages and interventions. Finally, researchers and practitioners serving AAPI MSM must inte- grate social-cultural factors into research designs and program structures.

Researchers are encouraged to explore issues of xenophobia and stigmatization of immigrants; impact of legislation on access to prevention and mental health ser- vices; impact of policies on HIV testing, status disclosure, names reporting, and con- tact tracing on health seeking behaviors; and perceptions of stigma/shame related to HIV and homosexuality/bisexuality in AAPI subgroups. In the course of their HIV-re- lated research, investigators should also consider including in general assessments items related to current immigrations status of respondents; length of time in the United States; health coverage and access to health care, and whether respondents have been tested for HIV or not (Gilmore & Sommerville, 1994).

SEXUAL HEALTH AMONG AAPI MSM 35

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