What factors affect the health and well-being of lesbian, gay and bisexual Asian youth?
Key take-home messages
- Some studies have found a relationship between sexual minority status and substance use among Asian youth and adults. However, other studies have found evidence of resilience among sexual minority youth with no significant differences between ethnicities in terms of mental health.
- Effective interventions highlight the role of story-telling to reduce stigma within the Asian community, and the need to make HIV prevention messaging more accessible to Asian gay and bisexual males.
The issue and why it’s important
Sexual minority Asian youth face unique social pressures. They must come to terms with a sexual identity that deviates from the values and norms of both American culture and their ancestral culture (7), and they have to respond to an Asian culture that strongly values heterosexuality (7). Stigma may affect not only the Asian lesbian, gay and bisexual (“LGB”) youth, but extend to their parents, who may be viewed as having failed at instilling traditional gender roles (7).
LGB Asian youth may feel rejected by their family and their cultural community (7) while, at the same time, confronting LGB communities that consist predominantly of European people (1). The prospect and/or experience of rejection may contribute to poorer psychological health among LGB Asian youth (1). At the same time, the “model minority” myth may lead researchers to assume that Asian people obtain good medical care and do not have health problems or substance use issues (1).
What we found
Substance use and HIV risk behaviours
A 2011 San Francisco Bay Area study surveyed 1,349 Asian and Pacific Islander (API) men at high risk of HIV infection. Of those surveyed, 645 (48%) were men who have sex with men (MSM), 49% of whom were 29 or younger (2). Ninety per cent of the MSM group reported having tested for HIV (2), however, more than a quarter reported inconsistent condom use when engaging in anal sex with casual partners in the past six months (2), and nearly half did not know their casual partners’ HIV status (2).
Among HIV-positive API men who have sex with men, 36% had engaged in unprotected anal sex with steady partners and 59% with casual partners (2). In addition, 38% of HIV-positive API men had had sex with casual male partners under the influence of alcohol and 62% had had sex under the influence of drugs (2). Lifetime drug use rates among the entire sample of API MSM were 90% for marijuana, 60% for hallucinogens, 32% for cocaine, 36% for methamphetamines, 32% for inhalants, 22% for GHB, and 4% for heroin (2).
A 2012 British Columbia study looking exclusively at Asian youth in grades 7 to 12 assessed substance use rates by sexual orientation. Over 30,000 East and Southeast Asian students completed the survey. Among males, 5% identified as mostly heterosexual and 2% identified as gay or bisexual. Among females, 9% identified as mostly heterosexual and 4% as gay or bisexual (1). Over half of gay and bisexual males and lesbian and bisexual females had had a drink in their lifetime, compared to less than half of exclusively heterosexual males and females (1).
Mostly heterosexual and gay/bisexual males were less likely to have used alcohol more than three days per month (1) and less likely to report binge drinking compared to exclusively heterosexual males (1), but they were twice as likely to have ever used marijuana and also twice as likely to report other drug use (1). Mostly heterosexual and lesbian/bisexual females were more likely to have used alcohol more than three days per month, more likely to report binge drinking, and more likely to report marijuana and other drug use compared to heterosexual females (1).
The authors of the San Francisco and British Columbia studies both note that their findings suggest the need for interventions that are sensitive to substance use within the Asian/Pacific Islander populations (1;2). The authors of the British Columbia paper note that there should be culturally competent programs for Asian Canadian sexual minority teens (1).
There may also be differences between Asian ethnicities in terms of substance use. A 2012 study disaggregated the behaviours of 126 Chinese, Filipino and Vietnamese men living in the San Francisco Bay Area. Seventy per cent of participants were men who have sex with men and 29% were between the ages of 18 and 25 (8). The study found that, among men who have sex with men, Chinese men reported only alcohol and marijuana use while Filipino and Vietnamese men reported alcohol, marijuana and methamphetamine use (8). Although the overall use of meth was low among men who have sex with men (6%), the authors stressed the importance of disaggregating data so that information is not just about “Asians” (8).
Ethnic differences have also been found in relation to HIV testing. A New York City study assessed HIV testing rates among a sample of 540 racially diverse men who have sex with men aged 18-29 (9). Twelve per cent of participants were Asian or Pacific Islander. Overall, most men in the sample (85%) had tested for HIV at some point (9). However, testing rates varied by ethnicity. Eighty-one per cent of API men had tested, compared to 91% of black men and 75% of white men (9). API men were also less likely to have tested in the past year (70%), compared to black men (87%) and white men (75%) (9).
Several papers have documented the ways in which LGB Asian youth are coping well with what has been called their “dual minority” status (7). A New York City study that sought to understand the sexual practices of young men who have sex with men assessed 558 individuals between the ages of 13 and 19 (10). Sixty per cent of participants were ethnic minorities. The study found that Asian and Pacific Islanders had the oldest age for sexual onset with male partners of any ethnic group (10). Young Asian and Pacific Islander men also had the lowest rate of HIV infection, with only one API participant self-reporting as HIV-positive (10).
A 2015 national U.S. survey sought to assess differences in trauma exposure, mental health problems and substance use among 967 white, black, Asian and Hispanic lesbian and bisexual women aged 18 – 25. Four per cent of the sample were Asian Americans. The study found no significant differences between the four racial groups studied (3). Young sexual minority women of colour did not report more negative LGB identity attitudes or less LGB community involvement than Whites (3). Asian American women reported lower post-traumatic stress disorder (PTSD) scores than whites, and were also less likely than whites to report childhood sexual assault or forcible rape at any age (3). The authors stressed that the lack of differences between sexual minority women of different races may reflect changing generational and social attitudes towards sexual minorities in the U.S. (3), and that there are clearly sources of resilience at work protecting young sexual minority women from negative health effects (3).
A 2013 study of young sexual minority men in New York City came to a similar conclusion. The study involved 589 men who have sex with men aged 18 or 19 years; 5% of the sample were API men. The authors found no significant differences between races with respect to mental health measures (depression, suicide and PTSD) (4). APIs had the lowest depression and PTSD scores of any ethnic group (4). The biggest association was between socio-economic status and mental health: the effects of socio-economic status seemed to “trump” other minority status categories such as race (4).
A very large study (over 50,000 respondents) of youth in 13 U.S. cities and states assessed differences in experiences of victimization by sexual identity, sexual behaviour, and ethnicity (11). The authors studied three indicators of victimization: skipping school due to feeling unsafe, fighting, and having personal property stolen or damaged at school. Asian American gay, bisexual and unsure youth reported the lowest levels of victimization of any of the four ethnic groups studied (black, white, Hispanic, Asian) (Russell). There were also no significant differences between gay, bisexual and unsure Asian youth and heterosexual Asian youth in terms of victimization (11).
A study conducted between 1999 and 2002 in San Diego and Seattle sought to understand the factors contributing to a positive sense of self among 763 Asian and Pacific Islander gay or bisexual men (aged 15 – 25) (12). Half the sample was U.S. born and half were immigrants. Within the immigrant group, half had migrated after the age of ten. The authors found that men born in the U.S. were twice as likely as those who arrived after the age of 10 to hold a positive self-image about being gay or bisexual; there was no difference between men born in the U.S. and those who arrived before the age of 10 (12). The authors theorized that men who arrived after 10 may have experienced different, more severe forms of homophobia in their country of origin, while those born in the U.S. may not understand the extent of homophobia within API cultures and therefore be more accepting of themselves (12). The authors also found that men who reported greater self-worth about being API were three times more likely to have a positive attitude about being gay or bisexual (12). The authors concluded that positive sexual identity was significantly associated with positive ethnic identity, and that interventions for API men who have sex with men should to address these two issues simultaneously (12).
Intervention and prevention messaging
An intervention targeting Chinese immigrant parents from Hong Kong tried to challenge homophobia and increase support for LGB youth in Toronto. The intervention recruited 12 parents for a 10-session training program. As part of the program, a young male Chinese gay activist and the mother of a lesbian daughter spoke to parents and told their stories (5). Many parents said that hearing first-person stories changed their perception of homosexuality: 70% said they wanted to learn more about sexual orientation and felt more confident talking with their children about sexuality (5). The “graduates” of the program then reached out to other Cantonese-speaking parents in Toronto through radio interviews, education programs and community events (5).
A New York City study of 481 racially diverse young men who have sex with men sought to understand how different ethnic groups were exposed to HIV prevention messaging (6). Twelve per cent of the sample was API; ranging in age from 18 – 25. The study found that 79% of API men reported seeing HIV prevention messaging on the internet, 46% saw it in print and only 19% saw it at a communitybased organization (6). The authors stressed that ethnicity needs to be considered when designing HIV prevention messaging (6). Messages are often found in gay-oriented print publications, but the emergence of a gay identity might be delayed for people in some ethnic groups; print messages are also less likely to be seen if someone is not going to a gay neighbourhood. Young men who have sex with men also won’t receive messaging at clinics, bars, community-based organizations or doctor’s offices if they are not out or are straight-identified (6).
All of the papers cited in this response were from the United States and Canada. However, several papers discussed “Asian and Pacific Islanders” together, while one included API youth and adults but did not disaggregate by age.
What we did
We searched Medline and PsycInfo using a combination of [text terms (gay or men who have sex or homosexual or bisexual or transgender or MSM or lesbian or transsexual or queer or intersex or asexual) or MeSH terms (Bisexuality or Homosexuality or Homosexuality, Female or Homosexuality, Male or Transgendered Persons or Transsexualism)] and [text terms (Asia* or Chin* or Tibet* or Hong Kong or Japan* or Macau or Mongolia* or Korea* or Taiwan* or Burm* or Cambod* or Indonesia* Lao* or Malaysia* or Philippin* or Filipino* or Singapore* or Thai* or Vietnam*) or MeSH terms (Asia or Asia, Southeastern)] and [text terms (youth or adolescent or young) or MeSH terms (Young Adult or Adolescent)]. Searches were limited to articles published since 2010 in English.
- Homma Y, Chen W, Poon CS, Saewyc EM. Substance use and sexual orientation among East and Southeast Asian adolescents in Canada. Journal of Child & Adolescent Substance Abuse 2012;21(1):32-50.
- Nemoto T, Iwamoto M, Kamitani E, Morris A, Sakata M. Targeted expansion project for outreach and treatment for substance abuse and HIV risk behaviors in Asian and Pacific Islander communities. AIDS Education & Prevention 2011;23(2):175-91.
- Balsam KF, Molina Y, Blayney JA, Dillworth T, Zimmerman L, Kaysen D. Racial/ethnic differences in identity and mental health outcomes among young sexual minority women. Cultural Diversity and Ethnic Minority Psychology 2015;21(3):380-90.
- Storholm ED, Siconolfi DE, Halkitis PN, Moeller RW, Eddy JA, Bare MG. Sociodemographic factors contribute to mental health disparities and access to services among young men who have sex with men in New York city. Journal of Gay & Lesbian Mental Health 2013;17(3):294-313.
- Wong JP-H, Poon MK-L. Challenging homophobia and heterosexism through storytelling and critical dialogue among Hong Kong Chinese immigrant parents in Toronto. Culture, Health & Sexuality 2013;15(1):15-28.
- Kingdon MJ, Storholm ED, Halkitis PN, Jones DC, Moeller RW, Siconolfi D, et al. Targeting HIV prevention messaging to a new generation of gay, bisexual, and other young men who have sex with men. Journal of Health Communication 2013;18(3):325-42.
- Lee J, Hahm HC. HIV risk, substance use, and suicidal behaviors among Asian American lesbian and bisexual women. AIDS Education & Prevention 2012;24(6):549-63.
- Toleran DE, Tran PD, Cabangun B, Lam J, Battle RS, Gardiner P. Substance use among Chinese, Filipino, and Vietnamese adult men living in San Jose, Daly City, and San Francisco, and its implications on ATOD prevention services. Journal of Ethnicity in Substance Abuse 2012;11(1):86-99.
- Siconolfi DE, Halkitis PN, Moeller RW, Barton SC, Rodriguez SM. HIV testing in a New York city sample of gay, bisexual, and other young men who have sex with men. Journal of Gay & Lesbian Social Services 2011;23(3):411-27.
- Halkitis PN, Brockwell S, Siconolfi DE, Moeller RW, Sussman RD, Mourgues PJ, et al. Sexual behaviors of adolescent emerging and young adult men who have sex with men ages 13-29 in New York City. Journal of Acquired Immune Deficiency Syndromes 2011;56(3):285-91.
- Russell ST, Everett BG, Rosario M, Birkett M. Indicators of victimization and sexual orientation among adolescents: Analyses from Youth Risk Behavior Surveys. American Journal of Public Health 2014;104(2):255-61.
- Vu L, Choi KH, Do T. Correlates of sexual, ethnic, and dual identity: A study of young Asian and Pacific Islander men who have sex with men. AIDS Education and Prevention 2011;23(5):423-36.
Rapid Response Service.What factors affect the health and wellbeing of lesbian, gay and bisexual Asian youth?. Toronto, ON: Ontario HIV Treatment Network; December, 2015.
Emily White and Jason Globerman