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Developing a comprehensive aids prevention outreach program: a needs assessment survey of MSM of East and Southeast Asian descent who visit bars and/or bath houses in Toronto.

ABSTRACT: A survey was conducted to assess the needs of men who have sex with men (MSM) of East and Southeast Asian descent who visit bars and/or bath houses in Toronto, Canada. The majority (n = 86) of respondents included in the final analysis (n=90) self-identified as gay or bisexual. The survey questionnaire addressed reasons for visiting bath houses and bars, sexual practices, condom use, HIV testing, willingness to interact with outreach workers and information respondents would like to receive from safer sex educators. Study results suggest that two sub-groups of this population should be the primary targets of bar/bath house outreach: (1) MSM of East and Southeast Asian descent under 39 and (2) bisexual men of East and Southeast Asian descent who visit bath houses. The findings also show that HIV-testing, information about HIV, and information about other sexually transmitted infections (STI) needs to be more accessible to these populations. Moreover, Asian MSM need safe and positive social spaces to meet as well as workshops about topics that concern them (e.g. safer sex negotiation). Evidence from this study also challenges the negative stereotypes that are sometimes attached to gay and bisexual Asian men.

Keywords: Gay and bisexual Asian men Sexual behaviour

HIV/AIDS prevention Safer sex practices

Community outreach strategies

INTRODUCTION

This study was undertaken to assess the needs of men who have sex with men (MSM) of East and Southeast Asian descent who visit bars and/or bath houses in Toronto. The East and Southeast Asian population in Canada has grown rapidly in the last 20 years and is now the largest racial minority group in the country comprising 4.9% of the population, or about 1,400,085 individuals based on Statistics Canada (1996) categories of Chinese, Korean, Japanese, Southeast Asian and Filipino. In very large urban centres like Toronto, East and Southeast Asians--a term that will be used interchangeably with Asians in this paper--account for more than 15% of the population (n=360, 930; Ornstein, 2000). Given these numbers, it is of interest that so little is known about the impact of HIV/AIDS in this community. Until recently in Canada, information about racial background among reported AIDS cases has either not been collected or, when collected, has not been released. There are a variety of possible social and political reasons for this reticence, including fear that the data could be misused.

Although many of the Canadian studies that have explored issues about HIV/AIDS among MSM have included some Asian participants (e.g., Craib et al., 2000; Piaseczna et al., 2001; Strathdee et al., 1998), Asian MSM in such studies are frequently grouped with other participants of colour as "person of colour" or "non-Caucasian". In such cases, the generalizability of the findings to Asian MSM in particular is unclear. Other studies have not reported the racial backgrounds of participants (e.g., Myers, Godin, Calzavara, Lambert, & Lockeret, 1993) or the number of Asian participants (e.g., Noel et al., undated). When Asian participants have been identified, the numbers have tended to be low. For example, in a survey of bisexual men in Ontario, 0.7% of the 1,314 participants (n=11) were Asian (Myers et al., 1998). Similarly, in a Toronto study of gay and bisexual men, 2.5% of the 1,295 participants (n=32) self-identified as Asian (Myers, Locker, Orr & Jackson, 1991). The generally small subsamples of Asian MSM in such studies has made it difficult to identify features of this population of MSM that might be pertinent to HIV/AIDS prevention and treatment. Even studies that have included a larger sample of Asian participants (e.g., Strathdee et al., 2000) have not always analyzed the data separately for different racial groups (Maxwell, 1999).

Some researchers have examined issues related specifically to HIV/AIDS among Canadians of East and Southeast Asian descent (e.g., Meston, Trapnell, & Gorzalka, 1996, 1998; Singer et al., 1996), but such studies are rare. It appears that mainstream researchers have been challenged in developing and applying the culturally appropriate strategies needed to recruit Asian participants (Sneed et al., 2001). This may explain, in part, why so few studies have specifically explored HIV risk of Asian MSM in Canada, despite the severe impact of the AIDS epidemic on MSM in general.

TRENDS IN HID/AIDS AMONG ASIAN MSM IN CANADA AND THE U.S.

Consistent with the overall decline in number of new AIDS cases reported in Canada in the 1990s, the number of reported AIDS cases among East and Southeast Asian people has also declined from 54 cases in 1991 to 7 cases in 2000. New reported AIDS cases among Asians accounted for 1.4% (n=209) of the national total from 1991-2000 (Health Canada, 2001). The U.S. appears to have seen a similar recent decline in new reported AIDS cases among adult/ adolescent Asians and Pacific Islanders from 445 cases in 1997 to 388 cases in 1998 and 366 in 1999. This followed an apparently drastic increase between 1992 and 1996 although this pattern may have been, in part, a reflection of both the expanded definition of AIDS cases adopted in 1993 and the increased survival of AIDS patients who were receiving treatment. Overall, new AIDS cases among Asians and Pacific Islanders in the U.S. as of December, 1999, accounted for approximately 0.72% (n=5,347) of the total number of reported AIDS cases (Centers for Disease Control and Prevention, 1997, 1998, 1999), or about one-half the percentage noted above for East and Southeast Asian people in Canada in a comparable period (0.72% versus 1.4%). This difference could have been about threefold if similar groups had been compared (the U.S. category of Asians and Pacific Islanders also includes East Indians, Pakistanis and Sri Lankans). The proportion of reported AIDS cases among East and Southeast Asian people in Canada has also been increasing steadily since 1998--from 1.8% in 1998 to 3.2% in 2000 (Health Canada, 2001).

The findings presented above for both Canada and the U.S. may not provide the full picture of the trends and actual effects of the AIDS epidemic in Asian communities. As Health Canada (2001) notes, AIDS cases may have been under-reported or underestimated because of misclassification of race or ethnicity on the medical records. There is also "a wide variation in the completeness of ethnic status reporting among regions ..." (Health Canada, 2001, p. 54). In the U.S., Sy, Chng, Choi, and Wong (1998) suggest that the decline in AIDS cases among Asians and Pacific Islanders may have resulted from recent medical advances and increases in knowledge of AIDS related health issues both of which would have contributed to delayed onset of AIDS symptoms.

Information regarding gender and the exposure category among reported AIDS cases in the East and Southeast Asian population is not provided in Canada. As of December 1999, in the US, men accounted for 88% of the total reported AIDS cases in the Asian and Pacific Islander population. Seventy-seven percent (n=3,561) of these male cases were MSM and MSM who inject drugs (Centers for Disease Control and Prevention, 1999). As Hou and Basen-Engquist (1997) have noted, Asian people tend to view HIV/AIDS as a Western epidemic, which may lead to the belief that they are not at risk for HIV infection. A recent U.S. report supports this claim in that only 17% of the 241 gay Asian and Pacific Islander men studied believed that they were at risk for HIV infection (Choi, Coates, Catania, Lew, & Chowet, 1995). With respect to knowledge about HIV/AIDS, a Canadian study found that Chinese gay men lacked knowledge about AIDS transmission (Singer et al., 1996) and another study, in Vancouver, reported that a sizeable percentage of the 102 Asian MSM studied did not consider receptive anal sex without condoms (30%) and insertive anal sex without condoms (25%) to be high risk sexual activities (Bhat, Yee, & Koo, 1994). This finding is of interest in the light of a recent study in Toronto which found that both East Asian and Southeast Asian MSM had high numbers of male sexual partners in the previous six months (an average of 27 and 11 respectively) (Toronto Three Cities Project, 2000).

The practice of unprotected anal intercourse is particularly prevalent among Asian MSM. For example, the Vancouver study found that 34% of Asian MSM had unprotected receptive anal sex to ejaculation with their primary sexual partners (Bhat et al., 1994). A U.S. study in the same year also found that 27% of Asian and Pacific Islander MSM reported engaging in unprotected anal sex in the previous six months (Lemp et al., 1994). Other U.S. studies have shown comparable rates of anal sex (27%-31%) in this population in a prior three month period (Choi, Coates, et al., 1995; Choi et al., 1996; Lai, 1999). In fact, Asian and Pacific Islander MSM were found to have the highest rate of unprotected anal sex in the US: 66% for Asian and Pacific Islander MSM compared to 48% for Caucasian MSM, 47% for African American MSM, and 45% for Latino MSM (Chng & Geliga-Vargas, 2000). HIV seropositive rates among Asian and Pacific Islander MSM as high as 27% were reported in some areas such as Orange County and San Francisco (Gellert, Moore, Maxwell, Mai, & Higgins, 1994; Osmond et al., 1994).

U.S. studies have also revealed that Asian and Pacific Islander MSM were more likely than MSM of other races/ethnicities to report that they had never been tested for HIV. For example, 19% of Asian and Pacific islander MSM had never been tested compared to 12% of black MSM, 9% of Latino MSM, and 9% of white MSM (Mayne, Weatherburn, Hickson, & Hartley, 1999). Some studies in Australia, Canada, and the U.S. have recorded even higher percentages of Asian MSM who have never been tested for HIV, ranging from 27% (Boldero, Sanitioso, & Brain, 1999) to 30% (Multicultural HIV/AIDS Education and Support Service, 1996; Shapiro & Vives, 1999), 35% (Bhat et al., 1994) and 38% (San Francisco Department of Public Health cited in Choi, Salazar, Lew, & Coates, 1995). Based on AIDS cases reported in New York City from 1997 through 1998, Asians/Pacific Islanders and Native Americans were also found to have the highest rate of opportunistic infection at the time of diagnosis. For example, 44% were already infected with AIDS-related disease at the time of diagnosis, compared to 28% for African Americans, 24% for Latinos, and 21% for whites (New York City Department of Health, 2000). These findings suggest that many Asians and Pacific Islanders do not seek early HIV testing and treatment and that Asian MSM in North America are at high risk for HIV infection.

PURPOSE OF THE STUDY

Comprehensive broadly based sexuality education is an important strategy in HIV prevention and community outreach has been recognized as an effective approach for providing such education and outreach. Unlike other traditional health education models, community outreach programs are conducted where the target populations are, thus enabling workers to reach the otherwise hard-to-reach populations. The natural setting also creates a sense of safety and familiarity among the community members, which encourages them to observe the outreach activities, get to know the outreach workers, and establish trusting relationships (Rhodes & Holland, 1992). This is a critical component for working with Asian MSM given that this population, in general, tends not to seek health or social services (Lau, Tan, Tran, & Yee, 1999; Nakajima, Chan, & Lee, 1996; Wong & Wilkinson, 1991). While some studies (Kegeles, Hays, & Coates, 1996; Kelly et al., 1992) have shown that certain HIV outreach education approaches, such as peer outreach education, significantly reduce HIV risk-taking behaviours among young gay men, effective approaches that are specific to Asian MSM are unknown.

This study sought to assess the needs of MSM of East and Southeast Asian descent who visit bars and bath houses in Canada's largest urban centre. The goal was to obtain first-hand information from the Asian MSM community that could be used to develop a suitable AIDS prevention outreach program.

METHODS

RECRUITMENT

This study was the first survey ever conducted with this population in Toronto. Respondents were recruited from September 1997 to January 1998 in a gay bath house with a large Asian clientele and in bars at two social events (karaoke night and new year celebration) organized by Gay Asian Toronto (GAT). Recruitment in the bath house was designed to cover various days and times (in total 6 visits). The criteria for participation were that respondents visited bars and/or bath houses and were of East and Southeast Asian descent. To ensure that this was the case, the researchers or one of our trained volunteers approached each potential participant, explained the goals and methodology of the study, and invited him to complete the survey. Although participants received no gift or honorarium that would provide an incentive to do a repeat survey, as an added protection against duplication each man who agreed to participate was asked if he had completed this survey before.

Respondents were informed that the survey was available in Chinese and Vietnamese. It is recognized that sex in many Asian cultures is a taboo subject and prohibited from being discussed publicly or with a stranger. To encourage participation and to ensure confidentiality, information was gathered using a self-administered survey that could be completed in the private space provided at individual tables. Some respondents took the survey to their rooms or to other tables, but all who returned the survey did so on the day they received it. No names were recorded in the survey.

QUESTIONNAIRE

Using insights gained from a survey designed by the Gay Mens' Network in Toronto, the authors developed a four-page, self-administered, 26 item questionnaire that included 16 close-ended questions and 10 open-ended questions (Appendix 1). A focus group of eight Asian community members (including volunteers, board members, and clients) was conducted to ensure that the research questions were relevant to the community and that the language used was culturally appropriate. The survey was translated into Chinese and Vietnamese.

DATA ANALYSIS

One hundred and forty-eight Asian men were approached and invited to participate. A total of 95 men were willing to participate and returned their surveys (64% response rate). The 53 non-respondents either indicated that they were unwilling to complete the survey or did not return it. Five surveys were not used either because they were incomplete or because respondents provided obviously false data (e.g., checking all categories in all questions). The final analysis thus included 90 surveys, of which 48 were from the social events and 42 from the bath house. Most of these surveys were in English (n=65; 72%) with 20 (22%) in Chinese and 5 (6%) in Vietnamese. In addition to the descriptive data analysis, seven chi-square tests were performed to examine the association between: (1) sexual identity and bath-house attendance; (2) sexual identity and anal sex; (3) sexual identity and condom use; (4) sexual identity and HIV testing; (5) bath-house attendance and anal sex; (6) bath-house attendance and condom use; and (7) bath-house attendance and HIV testing. With respect to the Chi-square analysis, it was confirmed that the basic assumption of each test was met and independence was achieved (since each observation was only counted once). The examination of normality and the equality of variance is not necessary for Chi-square tests (Witte & Witte, 2000).

RESULTS

SOCIO--DEMOGRAPHIC CHARACTERISTICS Sexual orientation and age were the only two socio-demographic characteristics included in the survey. Based on the 90 usable surveys, 79% of participants self-identified as gay, 17% as bisexual, 4% as other, and none as heterosexual. Most respondents were under the age of 39 with 58% between age 18-29 and 31% between age 30-39 (Table 1).

Within the sample of 15 bisexual men, a significantly larger proportion was recruited from the bath house (73%) than the social events (27%) ([chi square] = 4.363, df = 1, p<0.05) (Table 2). A higher proportion of younger men, age 18-29, was recruited from the social events than the bath house (69% vs. 45%). An earlier study of gay and bisexual men in Toronto found a similar pattern for the site of recruitment based on sexual orientation and age (Myers et al., 1991).

BATH HOUSE AND BAR ATTENDANCE

Sixty-seven percent (n=60) of the 90 respondents reported that they visited bath houses and among those who did so, 75% self-identified as gay and 22% as bisexual. Hence, 87% of our sample of Asian bisexual men versus 63% of our sample of gay Asian men said they visited bath houses. Although this difference is not statistically significant ([chi square] = 3.058, df = 1, p = 0.080), the tendency makes it worth considering whether bisexual Asian men may be more likely to visit bath houses than gay Asian men.

Eighty-nine percent (n=80) of the 90 respondents said that they visited bars. Eighty percent of these respondents self-identified as gay and 15% as bisexual. This difference was not statistically significant, a reflection of the fact that almost all of the respondents attended bars. Eighty-seven percent of the respondents who visited bath houses and 92% of the respondents who attended bars were under the age of 39. As a point of comparison, it is of interest that the Myers et al. (1991) study of gay and bisexual men found that 29.7% of their respondents visited bath houses; in the present study 67% of gay and bisexual Asian men said they visited bath houses. Bar attendance did not differ in the two studies (90% versus 89%).

REASONS FOR VISITING BATH HOUSES AND BARS

With respect to their reason(s) for visiting bath houses, 65% of the men who answered this question said they went "to meet men for sex" whereas 35% said they went "hoping to meet a new partner", and 32% went "to socialize". These latter categories may reflect a lack of alternative spaces for Asian MSM to "hang out" and meet other men for romantic relationships. With respect to their reasons for visiting bars, only 11% of the men who answered said they went "to meet men for sex", 32% reported "hoping to meet a new partner", while most stated "dancing" (72%) and "socializing" (63%).

WILLINGNESS TO INTERACT WITH OUTREACH WORKERS

When asked if they would feel comfortable being approached in the hallways by an outreach worker, 76% of those respondents who visited bath houses and 70% of the respondents who attended bars said yes. Over half (66%) of the respondents who visited bath houses also indicated they would feel comfortable being approached by outreach workers in the rooms when they were alone. In contrast, only 47% of the respondents who attended bars reported that they would feel comfortable being approached on the dance floor. This may reflect the fact that many Asian people do not feel comfortable talking about sex or HIV in public and especially when they are with groups of friends.

CONDOM USE AMONG STUDY PARTICIPANTS

Among all respondents, 53% said they used condoms "every time" they engaged in sexual activity, 20% "usually" used condoms, 19% did so "once in a while" or "sometimes", and 8% said they never used condoms (Table 3). Gay and bisexual respondents did not differ significantly in this respect. However, the gay Asian men who visited bath houses were significantly more likely to use condoms "every time" than those who did not visit bath houses ([chi square] = 10.645, df = 2, p = 0.005). This finding must be interpreted with caution because one of the expected cell sizes (4.3) is slightly smaller than five, which is the conservative rule of all expected frequencies in Chi-square tests (Witte & Witte, 2000).

Despite the apparently greater tendency for bath house attendees to use condoms every time in comparison to non-attendees (62% versus 29%), 26% and 28% respectively of both groups reported infrequent condom use (sometimes, once in a while or never) (Table 3).

With respect to their use of lubricants with condoms, 59% of respondents reported that they used only water based lubricant, 16% only oil based lubricant, 7% used both and 9% said they did not use any form of lubricant. Among all respondents, 65% said they checked the expiration date on the condom before use and read the condom insert.

HIV TESTING AMONG STUDY PARTICIPANTS

Among all respondents, 69% had previously been tested for HIV and 31% had never been tested. Of those never tested, 67% said they visited bath houses, 26% self-identified as bisexual and 74% as gay. Overall 50% of bisexual and 29% of gay Asian MSM in the sample had never been tested for HIV. However, no statistically significant relationship was found between having been tested and sexual identity (gay and bisexual) or between having been tested and bath-house attendance. When asked if they would have an HIV test in a bath house if it was offered, half of the respondents who visited bath houses and had never tested for HIV replied yes (within this subgroup, 78% would request anonymous testing). Among all respondents who visited bath houses (both those who had and had not been tested), 61% said they would agree to testing in the bath house (83% of this subgroup would request anonymous test). Among those never tested, 36% indicated that they would like outreach educator information on HIV antibody testing.

INFORMATION THAT ASIAN MSM WOULD LIKE TO RECEIVE FROM SAFER SEX EDUCATORS

Respondents made clear distinctions among the kinds of information they would like to get from Asian Community AIDS Service's safer sex educators (Table 4). In relation to information about HIV and other STIs, 77% said yes to information on HIV, 49% on hepatitis, and 31-37% on gonorrhea, genital warts, and syphilis. The most often cited areas for information about sexual activities, included oral sex (sucking and rimming) (49%) and anal sex (45%), less often masturbation (24%), and infrequently for other sexual practices including sex toys, fisting, fingering and vaginal sex (14-18%). Among other types of information that participants would like to receive, safer sex practices (48%) predominated followed by condom use (34%), HIV antibody test (32%), and learning how to discuss safer sex with their partners (30%). Since all of these and other options pertained to some aspect of safer sex, this appears to be a notable area of interest for information.

SEXUAL PRACTICES AMONG THE STUDY POPULATION

Participants were asked to indicate, from a list of 8 sexual activities (or other) all that they engaged in. While responses can be assumed to pertain to the recent past, neither a specific time period nor estimated frequency of the activity within the time period were requested. With respect to the range of sexual activities engaged in (Table 5), only about 18% of the 80 respondents checked either one or two of the 9 possible options; most chose three or more. For example, among the 83% overall who said they engaged in oral sex, 18% gave only, 11% received, and 71% did both. For the 58% who engaged in anal sex, 17% engaged in receptive anal sex only, 35% in insertive anal sex only, and 48% did both. Among the 50% who engaged in rimming, 13% gave only, 52% received only, and 35% did both. In addition, 75% said they engaged in kissing and 65% in caressing (65%).

Statistical analyses showed no significant relationship between sexual identity (gay and bisexual) and likelihood of engaging in anal sex or between bathhouse attendance and likelihood of engaging in anal sex.

WHERE Do ASIAN MSM SAY THEY FIND SEXUAL PARTNERS?

Based on 5 options (plus other) to indicate where they find (or look for) sexual partners, 56% of the respondents stated bath houses. Fewer reported going to places such as public washrooms (9%), parks (8%), adult video stores (5%) and/or theaters (4%). Among "other" options, 13% indicated "friends" or "private parties" and, as alluded to previously, only 16% who answered this question said they went to bars to find sexual partners. We recognize that these findings may be biased by our recruitment method and by the questionnaire. For example, participants who consider it embarrassing or immoral to have sex in public places (washrooms and parks) may not have checked that option, or activities done in the past may have been unchecked if they were perceived to be outside the time period implicit in the study.

DISCUSSION

This study sought to better understand the characteristics, behaviour and needs of East and Southeast Asian MSM who visit bars and bath houses with a view to enhancing provision of HIV prevention outreach and services in this community.

We discuss here the implications of the findings for outreach work in HIV prevention among Asian MSM while keeping in mind the limitations of the study as they pertain to our conclusions and recommendations.

SAMPLING LIMITATIONS

In theory, it would not have been possible to obtain a representative sample in the study because the actual population is unknown (Rothblum, 1994). In practice, the sampling procedure may have reached only certain subgroups among the population of Asian MSM since the respondents were recruited in one bath house and at events organized by one social group. The survey was translated into only two Asian languages, which may have limited its reach to other Asian MSM who have difficulty with English. The fact that 72% of respondents completed the survey in English may also reflect this limitation. In addition, generalizability of the findings may have been affected by the small sample size and by the fact that participants in such studies tend to be those who feel comfortable with their sexual identity (Yi, 1998).

LIMITATIONS OF THE QUESTIONNAIRE

In weighing content against time needed for completion of the survey, too few demographic questions were included (age and sexual orientation) to supplement our knowledge that all respondents were of East and Southeast Asian descent. Although the sample size was small, other information such as educational background and length of residence in Canada might have provided additional insights. Interpretation of the findings may have been affected for questions that did not provide response options such as "none of the above" or "not applicable" or in cases (e.g., the question on HIV-testing) where no time frame was given for the response (although we infer that most respondents were giving current or recent information). The lack of questions about the actual risk taking behaviours among respondents (e.g., frequency of anal intercourse with or without condoms and with or without ejaculation) precluded potentially useful information. In addition, some English terms about sexuality cannot be directly translated into Chinese and Vietnamese. Despite our efforts to make the translations as accurate and culturally sensitive as possible, some social connotations that affect the responses may have been missed.

DATA ANALYSIS AND OTHER LIMITATIONS

The analysis was based only on cross-sectional examinations and thus does not offer any causal explanations about risk taking behaviours among the respondents. Possible differences between respondents who completed the survey in English versus the two Asian languages were not examined nor was it possible to assess how often incomplete or inaccurate responses may have been given because sex is a subject often prohibited from being discussed publicly in many Asian cultures. The foregoing observations reflect some of the challenges of research in this area and will be kept in mind in our discussion of the implications and applications of the findings.

IMPLICATIONS OF THE STUDY

The findings reported here support the view that Asian MSM in general do not feel comfortable talking about sex or illness in public especially when they are with friends (Lau et al., 1999; Lee & Fong, 1990; Wong & Wilkinson, 1991). With respect to potential interactions with outreach workers, respondents reported feeling comfortable being approached in hallways or rooms (bath houses) when they were alone, while less than half indicated the same for the dance floor. Based on these findings and experience of outreach work with Asian MSM in bath houses and bars, we suggest that workers should stand in the hallway, distribute condoms and safer sex materials in a non-conspicuous manner, wait to be approached or approach when the individual is alone and/or seems interested in your work and/or safer sex materials. Ideally a private space should be available should a client want to talk further. The outreach worker should also indicate where he/she can be reached if help is needed.

Although other studies (Choi, Coates, et al., 1995; Choi, Salazar, et al., 1995; Shapiro & Vives, 1999) have indicated that Asian MSM in general have good knowledge about HIV/AIDS and its transmission routes, it is interesting that most of our respondents (77%) requested information about HIV/AIDS and many indicated that they would like to receive materials about safer sex practice (48%) and condom use (34%). This difference may be due to the socioeconomic characteristics of the respondents or simply a reflection of the difference between knowing and wanting (i.e., they may know but nevertheless want information that could serve as a reminder or reinforcement related to HIV risk reduction). Whatever the explanation, this finding points to the need for continuous provision of up-to-date and culturally appropriate information to this population.

In contrast to information about HIV, fewer respondents sought information about other STIs (31% for syphilis to 49% for hepatitis). The trend to increased levels of risk behaviour and STI among MSM in Canada (Suishansian, Nguyen & Archibald, 2000) reinforces a view expressed elsewhere in the literature (Rotello, 1998), that STI infection is not generally a concern to many MSM. The practices reported by Asian MSM in this study appear consistent with this view. Only 62% of the respondents who visited bath houses used condoms every time they engaged in a sexual activity, which suggests that many of the Asian MSM who visit bath houses could easily be exposed to STI. The Toronto Three Cities Project (2000) found that only 50% of East Asian MSM and 56% of Southeast Asian MSM are vaccinated for Hepatitis B. A report in the U.S. showed that the rate of hepatitis B infection among Asian MSM (35% infected) was almost four times the that of other races studied (Seage et al., 1997). The Centers for Disease Control and Prevention (2000) also showed that Asians and Pacific Islanders had the highest rate of increase of gonorrhea from 1997 to 1998. Given that STIs facilitate HIV transmission and increase the possibility of HIV infection (D'Adesky, 1999; Wasserheit, 1992), it is important for outreach programs for Asian MSM to provide information about transmission and prevention of STI as part of their overall HIV prevention strategies.

The present findings also support the need to develop culturally appropriate workshops about safer sex negotiation with partners. Approximately one-third of the respondents requested this service. The literature shows that, due to the issue of trust, many young Asian MSM in relationships do not know how to negotiate safer sex practice with their partners (Choi et al., 1999). Furthermore, Asian MSM appear to have difficulty convincing their casual partners to practice safer sex (Pullen, 1992; Kang cited in Yip, 1996, p. 12). Clearly there is a strong need for such workshops.

Surprisingly, many respondents visited bath houses to socialize (32%) and/or in hope of meeting a new partner (35%). This observation is consistent with our view, and that of others, that there is a lack of alternative social spaces existing for Asian MSM to "hang out" and meet people (Poon & Ho, in press; Ridge, Hee, & Minichiello, 1999; for a recent community needs assessment see Myers et al., 2001). Frequenting bath houses may increase the possibility of multiple sexual partners and thus increase risk of HIV and STI infections among Asian MSM. Providing safe and positive spaces may thus be an important element in HIV prevention strategies for Asian MSM. As Hunter and Schaecher (1994) argue, these spaces can provide a sense of belonging and social support, two factors that can increase the self-efficacy needed to make the necessary behavioural choices to reduce HIV risk (see Cranston, 1992; Grossman, 1997). Based on our experiences, events such as karaoke or movie nights tend to attract more Asian MSM participants than do traditional safer sex workshops. Activities should be interactive and fun and they should focus on experiential learning rather than information giving. The location of these activities should be carefully selected. Non-gay specific places such as local community centers and karaoke lounges can ensure anonymity and thus increase participation.

The findings reported here also suggest that two subgroups of Asian MSM should be the primary targets of bar/bath-house outreach. The first subgroup is Asian MSM under 39 years old. They comprised the majority of respondents who visited bath houses (87%) and bars (92%). People in this age group are more sexually active and may thus increase their risk of HIV and STI infection. As noted above, the lack of alternative social space to "hang out" may result in many Asian MSM more often frequenting bars and bath houses for social contact, which in turn may increase the probability of multiple sexual partners. The second subgroup for focused attention is bisexual Asian men who visit bath houses. These men comprised the majority (87%) of bisexual respondents. It is reasonable to assume that these Asian men have multiple sexual partners, but yet, only half of them had ever been tested for HIV and many (64%) did engage in anal sex. Although most (71%) of the bisexual respondents reported using a condom every time when engaging in a sexual activity, approximately half stated that they used only oil-based lubricant. Bisexual Asian MSM would thus appear to be at high risk for HIV and STD infection; however, further research is required in order to provide more understanding of this population.

Consistent with other studies, approximately one-third of the respondents had never been tested for HIV. Of those who had never been tested, over one third sought materials about the HIV antibody test and half would have an HIV test if it was offered in a bath house. This clearly suggests that HIV testing and associated information about it should be made more accessible to Asian MSM. Wong and Wilkinson (1991) point out that successful HIV testing and promotional materials must be culturally and linguistically appropriate. Our experience suggests that because of the moral codes about shame and family honour, many Asian MSM may see HIV testing as a public indication of one's moral failure. Education on HIV testing should thus focus not only on the technical aspect, but on Asian cultural values, health beliefs, help-seeking patterns, and the benefit of early HIV testing.

Interestingly, this study found that condom use was significantly associated, not with sexual identity, but with bath-house attendance, which suggests that many of those who visit bath houses are aware of their risk of HIV infection. However, 18% of the respondents who visited bath houses and also engaged in anal sex reported using only oil based lubricant. Accordingly, they are highly at risk for HIV infection. This finding suggests that some Asian MSM may not fully understand the risk of using oil based lubricant in anal sex, which points to the need of providing such information as well as free high-quality water-based lubricant for this population.

Finally, the findings of this study challenge what we perceive to be the generally negative perception of gay Asian men that may be fostered by their portrayal as submissive and "bottom" (Fung, 1996; Sanitioso, 1999; Sin, 1994). Asian MSM may well feel objectified and dehumanized by the stereotype associated with such labels (i.e., being characterized as "submissive" and "bottom"). This negative perception could lower self-esteem and lead to self-hatred and negative internalization. It has been argued that these factors associated with negative self-image are often barriers to safer sex practice (Choi et al., 1995; Diaz, 1998; Sanitioso, 1999). Indeed, the findings reported here questioned the stereotype itself in that most Asian MSM engaged in a variety of sexual activities.

This study has documented the need for culturally appropriate HIV/AIDS educational outreach and services for Asian MSM in general and for specific subgroups in particular. Future inquiry should focus on the risk of HIV infection in two such subgroups: (1) Asian MSM who have never been tested for HIV; and (2) bisexual Asian men who visit bath houses.

Appendix 1 Questionnaire for HIV/AIDS Outreach Study of East and Southeast Asian Men who have Sex with Men. *
1) What do you identify yourself as:
-- a homosexual
-- a heterosexual
-- a bisexual
-- other
-- none of the above

2) My age is between:
-- 18-29
-- 30-39
-- 40-49
-- over 50

3) Do you visit bath houses? -- Yes -- No (please go to question
 5)
If yes, please check all that apply
-- to socialize
-- to work out
-- to meet men for sex
-- in hopes of meeting a new partner
-- other

4) Would you feel comfortable if you were approached by our safer sex
educators at bath houses?
in the hallways -- Yes -- No
in your room when you are alone -- Yes -- No

5) Do you visit bars? -- Yes -- No (please go to question
 7)
If yes, please check all that apply
-- to socialize
-- to dance
-- to meet men for sex
-- in hopes of meeting a new partner
-- other

6) Would you feel comfortable if you were approached by our safer sex
educators at bath houses?
in the hallways -- Yes -- No
on the dancing floor -- Yes -- No

7) What kind of information would you like to get from our safer sex
educators? (check all that apply) Information about HIV & sexually
transmitted diseases
-- HIV -- Hepatitis A, B & C -- Herpes
-- Gonorrhea -- Genital warts -- Syphilis
-- Parasites
Information about sexual activities
-- Anal sex -- Masturbation -- Fingering
-- Vaginal sex -- Sex toys -- Fisting
-- Oral sex (sucking & rimming)
Other types of information
-- Safer sex practice -- Condom use -- HIV antibody
 test
-- Safer sex negotiation -- Access to services -- Safe needle
 use
-- To learn how to discuss
safer sex with your partner

8) Have you ever had an HIV test? --Yes -- No

9) Would you choose to be tested if HIV testing became available at
bath houses? -- Yes -- No (please go to question 10)
if yes, would you want your test to be anonymous? -- Yes -- No

10) What kind of sexual activities do you engage in? (check all that
apply)
-- Insertive anal (fucking) -- Giving oral sex
 (sucking)
-- Receptive anal (getting fucked) -- Receiving oral sex
 (getting sucked)
-- Rimming (licking asshole) -- Kissing
-- Being rimmed (getting asshole licked) -- Caressing
-- Other

11) Where do you find your sexual partners? (check all that apply)
-- Bath houses -- Parks -- Public washrooms
-- Theaters -- Adult video stores -- Other

12) How often do you use a condom when you engage in a sexual
activity?
Every time -- Usually -- Once in a while
Sometimes -- Never (please go to question 14)

13) Do you check the expiration date of condoms before using them?
-- Yes -- No

14) What kind of lubricant do you use when engaging in sexual
activities?
-- Water base only -- Oil base only -- Both water and oil
 base
No use of any lubricant -- Other

15) Have you ever received condoms given by our agency and/or other
HIV/AIDS organizations? -- Yes -- No

16) Do you read the message on the condom insert from these
organizations? -- Yes -- No


* The survey is reconstructed; only questions that are included in the analysis are listed here.
Table 1 Socio-Demographic Characteristics of the Study
Population

 Social Event Bath House Total
 (n=48) (n=42) (n=90)

Sexual self

identification
Homosexual 40 (84%) 31 (74%) 71 (79%)
Bisexual 4 (8%) 11 (26%) 15 (17%)
Heterosexual 0 0 0
Others 2 (4%) 0 2 (2%)
None of the above 2 (4%) 0 2 (2%)

Age group
18-29 31 (69%) 17 (45%) 48 (58%)
30-39 11 (24%) 15 (39%) 26 (31%)
40-49 3 (7%) 5 (13%) 8 (10%)
Over 50 0 1 (3%) 1 (1%)
Table 2 Sexual Self Identification and Bar and
Bath-House Recruitment

 Social Event Bath House Total

Sexual self
identification

Homosexual 40 (91%) 31 (74%) 71 (83%)
Bisexual 4 (9%) 11 (26%) 15 (17%)

It is confirmed that all expected frequencies in this test are
over five. Significantly more of the bisexual sample was
recruited in bath houses versus bars. ([chi square] 4.363, df = 1, p <
0.05)
Table 3 Bath-House Attendance and Condom Use

 Bath-House Attendance
 Yes No Total

Condom use

Every time 33 (62%) 6 (29%) 39 (53%)
Usually 6 (11%) 9 (43%) 15 (20%)
Sometimes, once in 14 (26%) 6 (28%) 20 (27%)
 a while, and never

Respondents who visited bath houses were significantly
more likely than those who did not to report condom use
every time they had sex ([chi square] = 10.645, df = 2, p = 0.005).
Table 4 Information Sought by the Study Population

Information about HIV & Respondents
Sexually Transmitted Diseases

HIV 55 (77%)
Hepatitis A, B & C 35 (49%)
Herpes 26 (37%)
Gonorrhea 23 (32%)
Genital warts 23 (32%)
Syphilis 22 (31%)
Parasites 21 (30%)

Information about sexual activities
Oral sex (sucking & rimming) 35 (49%)
Anal sex 32 (45%)
Masturbation 17 (24%)
Fingering 13 (18%)
Vaginal sex 11 (15%)
Sex toys 10 (14%)
Fisting 10 (14%)

Other types of information
Safer sex practice 34 (48%)
Condom use 24 (34%)
HIV antibody test 23 (32%)
To learn how to discuss 21 (30%)
 safer sex with your partner
Safer sex negotiation 18 (25%)
Access to services 16 (23%)
Safe needle use 8 (11%)

Respondents were asked to check all that apply.
Table 5 Sexual Practice Among the Study Population

Sexual activities % Responding * (N)

Any anal sex 46 (58%)
 Receptive only (getting fucked) 8 (10%)
 Insertive only (fucking) 16 (20%)
Any oral sex 66 (83%)
 Receiving only (getting sucked) 7 (9%)
 Giving only (sucking) 12 (15%)
Any rimming 40 (50%)
 Rimming only (licking asshole) 5 (6%)
 Being rimmed only (getting asshole licked) 21 (26%)
Kissing 60 (75%)
Caressing 52 (65%)
Other 8 (10%)

* %(N) reflects total number and % responding to category.
Respondents were asked to check all that apply. Total sample
for this question = 80 participants.


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Correspondence concerning this paper should be addressed to Maurice Pooh, Asian Community AIDS Services, 33 Isabella St., Suite 107, Toronto, Ontario, Canada M4Y 2P7. E-mail: gaap@acas.org.

Maurice Kwong-Lai Poon Peter Trung-Thu Ho Josephine Pui-Hing Wong Asian Community AIDS Services Toronto, Ontario
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Title Annotation:men who have sex with men
Author:Poon, Maurice Kwong-Lai; Ho, Peter Trung-Thu; Wong, Josephine Pui-Hing
Publication:The Canadian Journal of Human Sexuality
Article Type:Statistical Data Included
Geographic Code:1CANA
Date:Mar 22, 2001
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