- What factors influence East and South East Asian women’s sexual health in Canada and the United States, and what approaches to prevention have been found to be most effective?
Note on population: The literature examining the sexual health concerns of East and South East Asian women used various terms to define the population including “Asian”, “South Asian”, “Asian/Pacific-Islanders”, “East Asian” and “South East Asian”. Furthermore, the study population in some studies did not examine East and South East women exclusively. For the purposes of this review, we define East and South East Asian women as people who identify as female (female sex or transgendered women), who are of East Asian or South East Asian ethnicity (China, Hong Kong, Japan, Macau, Mongolia, North Korea, South Korea, Taiwan (ROC), Brunei, Burma, Cambodia, East Timor, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, and Vietnam), and who are living in Canada, the United States, or a comparable region (e.g., U.K. or Australia). We included studies that exclusively sampled East and South East Asian women or where this population was a substantial proportion of the sample (more than 40% of the sample).
Key take-home messages
- There is very little research that exclusively focuses on the sexual health and prevention of sexually transmitted infections (STIs) and/or HIV prevention for East and South East Asian women. Existing research suggests that although this population may be less likely to be sexually active than the general population (1;2), those that are sexually active engage in sexual and substance use behaviours that may put them at risk of becoming infected with STIs or HIV.(3;4)
- Substance use such as alcohol use, illicit drug use, binge drinking, and substance use preceding sex was reported as increasing the risk of engaging in risk sexual behaviors.(1;3;4)
- Acculturation was associated with STI/HIV risk activities and sexual health engagement. Higher levels of acculturation were reported as increasing the odds of engaging in sexual risk behaviours (3;5); alternatively acculturation was also associated with high self-efficacy in risk reduction and sexual health engagement.(6)
- Studies reporting comparisons to other populations found that East and South East Asian women tended to have lower levels of HIV knowledge and lower rates of sexual health care utilization.(7;8) The findings suggest that factors such as cultural mores and practices, language barriers, financial constraints, and parental attachments were influential to health care utilization of East and South East Asian women.(3;9-11)
- Due to diversity of this population, it is import to develop culturally and linguistically appropriate HIV education programs that address gender, youth culture and ethnocultural practices. (3;4;8) and key providers of these programs (and HIV prevention efforts in general) likely include cultural institutions (e.g., religious organizations and educational institutions) (9;12;13) as well as parents and healthcare providers.(4;7)
- Several studies assessed sexual health and STI/HIV prevention efforts among East and South East Asian women who engaged in sex work and found that educational messages need to address the context of sex work (e.g., economic constraints, immigration status, exposure to violence, substance use, and cultural and linguistic barriers) and include all parties (e.g., customers and massage parlor owners) that impact engagement in HIV preventative behaviors.(10;14-16)
- There was limited research evidence focused on the sexual health and STI/HIV prevention among transgendered women.(16)
The issue and why it’s important
To develop evidenced-informed programs that promote healthy sexuality among East and South East Asian women who are living in Canada, it is important to understand the factors that influence their sexual health and prevention practices for STIs and HIV. Additionally, East and South East Asian communities are ethnically diverse, and those who reside in Canada range from newly immigrated to Canadian-born. Therefore, it is important to understand the multiplicity of the population and the ways in which cultural strengths, social context, and gender constructs within East and South East Asian communities can play a role in promoting sexual health and HIV prevention.
The diversity of the HIV epidemic is reflected in East and South East Asian regions. Though most countries in the region have adult prevalence rates below 1% , the response within each country is shaped by cultural context, access to treatment, and political response to the epidemic.(17;18) For East and South East Asian women residing in Canada, the Canadian response is challenged by the diversity of the population, in addition to contextual factors such as immigration, socioeconomic status, and gender, racial, and ethnocultural constructs that are shaped by both their East and South East Asian ethnicity and Canadian residency.
Recent findings indicate that HIV is increasing amongst East and South East Asian populations residing in Western cultures.(19) Although the literature discussing HIV prevention for this population is increasing, there is very little published research evidence about the sexual health needs and the HIV rates in East and South East Asian female populations.
What we found
In our search, we found a number of articles that reported on the factors that influence sexual health, HIV risk and HIV prevention of East and South East Asian women. However, very few studies sampled this population exclusively.
Two studies exclusively sampled East and South East Asian women: one quantitative study conducted in the United States that examined the factors contributing to perceived HIV susceptibility (19); and an Australian qualitative study exploring the uptake of sexual health care services by Vietnamese Australian women.(11) A subset of studies conducted by Nemoto et al. focused on the sexual health and HIV preventative needs of East and South East Asian women (Vietnamese, Chinese, Korean, Thai) who work in massage parlors in San Francisco.(10;14;15) Although these three sets of studies provide an understanding of the sexual health and HIV prevention needs of East and South East Asian women, additional research that exclusively examines this population is required.
Several of the included articles compared study results amongst East and South East Asian populations based on gender (3;7;8;20). For example, a set of studies conducted by Hahm et al. used a subset of data from a national cohort to examine the sexual health, HIV risk and preventative behaviours of Asian/Pacific Islander youth of which half of the participants identified as female.(3;7;20) Other studies compared study results amongst East and South East Asian populations and other ethnicities.(1;2;4;6;9;13;16;19) One Canadian study examined the reproductive health behaviours of Indian women, Indo-Canadian women, Euro-Canadian women, and Canadian East Asian women (40% of sample).(9)
Many of the studies focused on the sexual, HIV risk and preventative behaviours of Asian youth and/or immigrant students.(1-5;7;20) Only one study focused on the sexual risk behaviours of transgendered womem.(16) We also included one study that explored the role of Asian religious institutions, including Chinese religious organizations in HIV prevention efforts.(12)
Sexual health among East and South East Asian populations
A common stereotype referred to in the peer-reviewed literature was the notion of Asian populations, including East and South East Asian populations as the “model minority” in regards to engaging in sexuality activity, and engaging in activities that increase the risk of STI/HIV infection.(4;6) Two studies reported lower rates of sexual activity and HIV risk behaviours in East and South East Asian populations compared to the general population.(1;2) So et al.’s study, of which 54% of the participants were female, reported that the Asian-American sample had the lowest prevalence of sexual activity among 18-24 year age group compared with other ethnic groups, and the lowest prevalence of unprotected sex over the preceding 30 days.(1) Similarly, Song et al.’s study examining sexual behavioural differences between Australian-born and Asian-born students attending an Australian university (China, Hong Kong, Indonesia, Malaysia, Singapore and Thailand) reported that despite being older, Asian-born students were less likely to have had sex and reported having fewer sex partners.(2)
Other studies reported rates of STIs and HIV risk behaviours that challenge this notion of “model minority”. For example, a study by Lee et al. examining risk behaviours in youth (of which half the sample was female) reported that Asian/Pacific Islander youth, consistently reported lower rates of lifetime sexual intercourse than their cross-ethnic peers; yet those who were sexually active were more likely to engage in sexual risk behaviours such as not using condoms during their last sexual encounter.(4) As well, they reported that compared to their White peers, there was a statistically significant increasing trend among Asian-Pacific Islander youth of engaging in risk behaviours such as substance use.(4) Furthermore, after the seven-year evaluation period, the study found that compared to African-American, Hispanic, and White participants, the levels of lifetime drinking were highest (91.5%) and marijuana use was second highest (68%) among Asian-Pacific Islander youth.(4) In addition, the “model minority” myth does not consider the heterogeneity of Asian populations and how that might shape their sexual health decision making. For example, one study that examined STI rates in Asian/Pacific Islander populations reported that the likelihood of ever having an STD varied across Asian ethnicities.(20)
STIs and HIV risk among East and South East Asian women
Factors highlighted in the literature that may influence the engagement of East and South East Asian women in HIV risk or preventative behaviours include:
- Substance use such as alcohol use (4), binge drinking (3), illicit drug use (4), and substance use preceding sex (1) were reported as being associated with HIV risk behaviours.
- Acculturation (i.e., born in Canada/U.S., long term residency, reading or speaking English at home) was reported as being influential to STI/HIV risk but was also reported as fostering sexual health and HIV prevention. Higher levels of acculturation were reported as significantly increasing the odds of engaging in sex and engaging in HIV sexual risk behaviour.(3;5) However, acculturation was also reported to be significantly associated with higher self-efficacy in HIV risk reduction.(6) Lastly, years in the country or immigration was identified as moderating the relationship between risk behaviours and perceived susceptibility to HIV infection, but the study was unclear about what length of time in the immigrant country adequately reflected acculturation levels.(19)
Findings from the reviewed studies also suggest gender differences with respect to risk for STIs and HIV. One study that examined sexual experiences and predictors of STIs among Asian/Pacific Islander youth reported that female participants were nearly four times more likely than their male counterparts to report having an STI.(20) Another study examining the sexual experiences of Asian/Pacific Islander youth reported that acculturation, parental attachment, school attachment, and binge drinking were significant predictors for women having had a sexual experience but were not statistically significant for men.(20)
Sexual health among East and South East Asian women engaged in sex work
Findings from the literature also reported on sexual health among East and South East Asian women engaged in sex work. Some of the factors noted as influential in HIV preventative behaviours include:
- Economic Pressures and financial needs were reported as deterring women from engaging in preventative beahviours such as not using condoms if there is a financial incentive for doing so. Findings from these studies suggest that for some East and South East Asian women engaged in sex work, the need for money could supersede their perception of HIV and STI risk.(10;14;15)
- Violence: Findings from these studies also suggest that the daily work lives of East and South East Asian women who engage in sex work was associated with a constant risk for physical, verbal, sexual or emotional abuse and violence, particularly from customers.(10;14) In one study, 62% of the participants reported physical assault by a customer, and 45% reported threats of physical harm from a customer.(14)
- Low perceived risk with intimate partners: Findings from these studies noted contrasting views of risk between customers and intimate partners. One study reported a high rate of condom use with clients (51% consistent use for oral sex, 91% consistent use for vaginal sex, 58% consistent use for oral and vaginal sex) but the same study reported less consistent condom use with intimate partners (17% consistent usage).(14)
- Substance Use: One study reported substance use among sex workers as a form of self-medication, such as “numbing themselves” as they engage in the work.(15) In a study of sexual health and transgendered women, substance use was associated with engaging in commercial sex work.(16)
HIV risk among East and South East Asian transgendered women
HIV risk among transgendered women was only reported in one study we reviewed:
- 20% of the sample engaged in unprotected receptive anal intercourse with a male partner (private partner, casual sex partner or commercial sex partners);
- 46% engaged in sex under the influence of drugs;
- Nearly half of the sample reported using non-injecting drugs (49%) and alcohol (45%) in the past 30 days.(16)
More literature reporting the unique and collective needs of transgendered women would better illuminate factors that may influence their sexual health.
Health care utilization for sexual health, STI/HIV testing and treatment
Some studies raised concern around the utilization of health care by East and South East Asian women for sexual health, and STI/HIV testing and treatment. One study that compared health care utilization amongst multiple ethnocultural groups found that Asian/Pacific Islander women reported the lowest proportion of health care utilization for STI/HIVs compared to their cross-ethnic peers.(7) Another study reported that only 30.8% of Southeast Asians sampled reported that they had ever been tested for HIV which was noted as being lower than the general U.S. adult population.(8)
Contextual factors can also shape health care utilization of East and South East Asian women. Emerging themes from a qualitative study exploring the uptake of health services by Vietnamese Australian women suggest that the ethnicity of the general practitioner can impact their utilization of health services. For instance, the study found that participants assumed that a non-Vietnamese health professional would be less likely to hold traditional views of sex held by their parent’s generation that may result in less optimum care.(11) Another study found that language barriers or financial constraints could discourage health care seeking.(10) Lastly, a study by Brotto et al. found that higher levels of mainstream acculturation were associated with more accurate reproductive health knowledge.(9)
Sexual health knowledge among East and South East Asian women
The studies we reviewed reported lower levels of HIV knowledge among East and South East Asian women compared to the general population. One study examining HIV knowledge of first year Australian post-secondary students reported that Asian-born students had consistently lower levels of knowledge that their Australian-born peers.(2) Another study examining HIV testing behaviours amongst South East Asians living in the United States reported low levels of HIV knowledge in the study population, a sample that was otherwise relatively well educated and acculturated.(8) Lastly, a Canadian study examining reproductive health knowledge of Canadian women, including East Asian Canadian women, reported that acculturation had a direct positive effect on reproductive health knowledge, which in turn influenced preventative reproductive health.(9)
For East and South East Asian women, the literature highlighted the importance of culture in accepting prevention messaging (9;13), and developing culturally and linguistically appropriate HIV education programs.(8) Findings for specific populations of East and South East Asian women include:
- Youth – the literature recommended using educational institutions such as high school and universities as forums for HIV prevention activities (2); addressing gender, youth culture and ethnocultural practices in prevention activities (3;4); involving parents in HIV prevention programs and educating parents about sexual health and HIV (4); and involving medical professions who care for these women in HIV preventative education.(7)
- Women engaged in commercial sex work – educational messages need to address the context of sex work for these women including economic constraints, immigration status, exposure to violence, substance use, cultural and linguistic barriers, and address all parties (customers, massage parlor owners) that impact engagement in HIV preventative behaviors.(10;14;15)
- Transgendered women – the evidence is limited but the findings reviewed suggest that sexual health promotion programs should consider the associations between sexual risk behaviour and substance use as well as consider the unique gender, cultural and socioeconomic context of these women and how they may shape sexual health decision making.(16)
A qualitative study also explored the role of Asian religious institutions (including Chinese religious institutions) in HIV prevention and suggested that cultural institutions may play an important role in providing HIV prevention education. The findings suggest that religious institutions could take a stance of “conservative innovation” meaning that when confronted with a new situation such as HIV prevention, they interpret their religious teachings, cultural values, institutional policies and practices and adapt to the current realities of their congregations. The authors of this study recommend understanding the attitudes of religious institutions around HIV prevention and their perception of HIV risk for the communities they serve when engaging them in prevention.(12)
What we did
We conducted two searches of Medline and Embase using a combination of search terms relevant to the question posed:
- (HIV or human immunodeficiency virus or human immune deficiency virus or acquired immunodeficiency syndrome OR Sexually Transmitted Diseases) AND (south east asia* OR southeast asia* or east asia* OR south asia*) AND (women OR woman OR female)
- (Asian American [MeSH] OR [(south east asia* OR southeast asia* or east asia* OR south asia*) AND (Canada* OR United States OR USA] ) AND (HIV OR human immunodeficiency virus OR human immune deficiency virus OR acquired immunodeficiency syndrome OR Sexual Transmitted Diseases)
Factors that may impact local applicability
The existing evidence about sexual health and HIV prevention for East and South East Asian women in Canada and the United States should be reviewed with caution for a number of reasons. First, the heterogeneity of the East and South East Asian women in Canada with respect to ethnicity, age, gender identity, and nativity challenges the applicability of study findings across this population. Second, there are only a small number of studies that exclusively focus on this population. Third, study participants were selected in ways that did not limit selection biases. For example, while some studies provided the option of conducting data collection in the native language of the participants, most were conducted in English which may have biased study results to those with English fluency. Fourth, sexual risk behaviours were not defined consistently across included studies. Lastly, the study designs limit the generalizability of findings beyond the group of East and South East Asian women who participated in each of these studies.
Additionally, the majority of the research that we found involved East and South East Asian women residing in the United States with one study each from Canada and Australia. However, given the similarities of the epidemic in all three regions as well as the similar cultural context identified in the included literature, these findings could potentially be adapted to the Canadian context.
- So DW, Wong FY, DeLeon JM. Sex, HIV risks, and substance use among Asian American college students. AIDS Education and Pre-vention 2005;17(5):457-68.
- Song A, Richters J, Crawford J, Kippax S. HIV and sexual health knowledge and sexual experience among Australian-born and over-seas-born students in Sydney. Journal of Adolescent Health 2005;37(3):243.
- Hahm HC, Lahiff M, Barreto RM. Asian American adolescents’ first sexual intercourse: Gender and acculturation differences. Perspec-tives on Sexual & Reproductive Health 2006;38(1):28-36.
- Lee S-J, Rotheram-Borus MJ. Be-yond the model minority stereo-type: Trends in health risk behav-iors among Asian/Pacific islander high school students. Journal of School Health 2009;79(8):347-54.
- Lin P, Simoni JM, Zemon V. The health belief model, sexual behav-iors, and HIV risk among Taiwanese immigrants. AIDS Education & Prevention 2005;17(5):469-83.
- Takahashi LM, Magalong MG, De-bell P, Fasudhani A. HIV and AIDS in suburban Asian and Pacific Is-lander communities: Factors influ-encing self-efficacy in HIV risk re-duction. AIDS Education & Preven-tion 2006;18(6):529-45.
- Hahm HC, Song IH, Ozonoff A, Sassani JC. HIV testing among sexually experienced Asian and Pacific Islander young women asso-ciation with routine gynecologic care. Womens Health Issues 2009;19(4):279-88.
- Huang ZJ, Wong FY, De Leon JM, Park RJ. Self-reported HIV testing behaviors among a sample of Southeast Asians in an urban set-ting in the United States. AIDS Education and Prevention 2008;20(1):65-77.
- Brotto LA, Chou AY, Singh T, Woo JS. Reproductive health practices among Indian, Indo-Canadian, Canadian East Asian, and Euro-Canadian women: the role of accul-turation. Journal of obstetrics and gynaecology Canada 2008;30(3):229-38.
- Nemoto T, Iwamoto M, Wong S, Mai NL, Operario D. Social factors relat-ed to risk for violence and sexually transmitted infections/HIV among Asian massage parlor workers in San Francisco. AIDS and Behavior 2004;8(4):475-83.
- Rawson H, Liamputtong P. Influ-ence of traditional Vietnamese culture on the utilisation of main-stream health services for sexual health issues by second-generation Vietnamese Australian young wom-en. Sexual Health 2009;6(1):75-81.
- Chin JJ, Mantell J, Weiss L, Bhaga-van M, Luo X. Chinese and south Asian religious institutions and HIV prevention in New York City. AIDS Education and Prevention 2005;17(5):484-502.
- Murray-Johnson L, Witte K, Liu WY, Hubbell AP, Sampson J, Morrison K. Addressing cultural orientations in fear appeals: Promoting AIDS-protective behaviors among Mexi-can immigrant and African Ameri-can adolescents and American and Taiwanese college students. Jour-nal of Health Communication 2001;6(4):335-58.
- Nemoto T, Operario D, Takenaka M, Iwamoto M, Le MN. HIV risk among Asian women working at massage parlors in San Francisco. AIDS Education & Prevention 2003;15(3):245-56.
- Nemoto T, Iwamoto M, Oh HJ, Wong S, Nguyen H. Risk behaviors among Asian women who work at massage parlors in San Francisco: Perspectives from masseuses and owners/managers. AIDS Education & Prevention 2005;17(5):444-56.
- Operario D, Nemoto T. Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women. AIDS Education & Prevention 2005;17(5):430-43.
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- UNAIDS. HIV in Asia and the Pacific: Getting to Zero. Geneva, Switzer-land: Joint United Nations Pro-gramme on HIV/AIDS (UNAIDS); 2011.
- Cooper M, Loue S, Lloyd LS. Per-ceived susceptibility to HIV infec-tion among Asian and Pacific Is-lander women in San Diego. Jour-nal of health care for the poor and underserved 2001;12(2):208-23.
- Hahm HC, Lee J, Ozonoff A, Amo-deo M. Predictors of STDs among Asian and Pacific Islander young adults. Perspectives on Sexual and Reproductive Health 2007;39(4):231-9.
Rapid Response Service. East and South East Asian Women’s Sexual Health. Toronto, ON: Ontario HIV Treatment Network; January, 2012.