Queer People of Color - American Medical Student Association



Queer People of Color

Instructions to Facilitator:

This module is designed to provide your group with a springboard for discussing current issues in healthcare that affect Queer People of Color (QPOC). AMSA’s hope is that this discussion will also create a more understanding environment within your medical school for students who have yet to reconcile their sexual identities with their identities as people of color and who therefore have yet to “come out” as LGBT or continue to struggle with the racism and homophobia that make this combination of identities challenging to negotiate. Furthermore, we would like all students to gain insight on the unique cultural background of queer people of color in order to facilitate professional and quality patient care. (Note: It is important to maintain focus on the type of environment your school is providing for such students without singling out any particular students who may or may not identify as QPOC.)

The following outline is meant to serve as a guide for your use in structuring an open discussion about issues important to QPOC in terms of healthcare disparity. Use it to dispel myths, highlight current research, and provide a safe place for “stupid questions.” As facilitator, you do not need to identify as an LGBT student, nor do you need to be an expert on LGBT healthcare. AMSA has provided you with a number of great resources and discussion points to assist you because we want everyone at your school, not just the LGBT medical students, to be comfortable discussing these important and timely issues. Let the sincere curiosity and the motivation of the participants play a role in guiding your discussion, but be sure to maintain focus on the goals of this particular module.

In order to maximize this module, please read the discussion points ahead of time. Additionally, you may find it helpful to read some of the suggested articles on the topics you are less familiar with before the discussion group. Please use this copy as your guide and distribute the “Discussion Handout”, a handout listing only the discussion items and cases, to the participants.

When to use this module:

This module is designed to facilitate discussion and would work best in a small group format. However, it may be adapted as necessary for a large group workshop or lecture style format. We encourage you to use this module during lunchtime or whenever your academic schedule allows. The timing of its use is up to you, but the following are some suggestions:

▪ At the beginning of the year to highlight serious disparities in healthcare

▪ During a minority health awareness week sponsored by another medical student group

▪ Any point in your curriculum where you think issues important to LGBT ethnic minorities should be highlighted

Specific calendar dates you might consider include the following:

▪ Latino Heritage Month (September)

▪ LGBT History Month (October)

▪ American Indian Heritage Month (November)

▪ Black History Month (February)

▪ LGBT Health Awareness Week (April)

▪ Asian Pacific American Heritage Month (May)

▪ South Asian Heritage Month (May) [Canada]

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MODULE OUTLINE

I. Introductions

II. Discussion Items

III. Cases

IV. Take Action

V. Resources

VI. References

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I. INTRODUCTION

Just as members of the LGBT community add to the overall diversity of our global society, diversity among those who consider themselves to be LGBT is an important contribution to the richness that comprises the LGBT community itself.

While we often use the label “LGBT” (or “LGBTQI” or some other similar letter combination) to describe a large body of individuals with diverse sexual orientations and identities, it is important to recognize that no lesbian, gay, bisexual, transgender, queer, or intersex individual is necessarily like any other. (See the “Alphabet Soup” presentation for an excellent introduction to just how varied LGBT self-identities can be.)

The Inclusion Campaign Modules therefore seek to provide you with an opportunity to start a conversation among your classmates about the great diversity within the LGBT community—in regard to your patients as well as your peers.

The first of these discussion modules focuses on Queer People of Color (QPOC), individuals who self-identify as LGBT and also as members of an ethnic, cultural, or racial minority. QPOC face many of the same disparities in healthcare as their counterparts not of color, but their dual minority status creates a second layer of disparity that often contributes to or even compounds the first. (Note: While AMSA uses the label QPOC in a general sense to apply to the population at large, it is important to realize that not all LGBT individuals who may appear visually to be “of color” necessarily will identify as such. For example, a “black lesbian” you know may consider herself to be simply queer, and additionally may not consider being black, African-American, or otherwise a part of her self-identity.)

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II. DISCUSSION ITEMS

Item #1: Latino masculinity and HIV transmission

Recent information released by the CDC indicates that young Latino men who have sex with men (MSM) are becoming infected with HIV at a much higher rate than are their non-Hispanic white counterparts.

✓ What are some reasons why young Latino men who have sex with men might be affected by HIV transmission disproportionately when compared to young white men? Consider prevention education, access to prevention methods, and gender and cultural issues.

▪ Approximately half of the HIV/AIDS cases among non-Hispanic black and Hispanic males reported by 33 states using name-based HIV surveillance during 2001-2005 were among men who have sex with men (MSM). (Centers for Disease Control and Prevention (CDC) 2006)

▪ Individuals from ethnic minority communities in particular do not choose to identify with gay culture for a variety of reasons, ranging from subcultural tolerance of bisexuality to internalized homophobia or the perception that gay identity is conflated with being white. (Makadon, Mayer et al. 2006)

▪ Many young gay Latino males do not identify themselves as gay because of family stigma. CDC research indicates that one of out of every six Latino men who have AIDS contracted the disease by having sex with other men, but still consider themselves to be heterosexual. Studies show that fear of being shunned by family and friends prevents many HIV+ Latino men to avoid seeking medical care and community services and leads many of these men, who progress to AIDS, to die alone. (ASPIRA National Office 2002)

▪ Machismo is a concept unique to Latin cultures that refers to “an exaggerated or exhilarating sense of power or strength in all activities including sexual intercourse.” This concept leads many young Latino men to take unnecessary risks with their lives, including having unprotected sex. Using condoms during sex with other men, when the idea that sexual activities are sexual at all is often denied, could be seen as a sign of weakness. Latino men can engage in unprotected sex as a way to display their masculinity. (ASPIRA National Office 2002)

▪ Gay Latino men who have experienced racism or homophobia are likely to participate in risky sexual behavior and contract HIV. Many gay Latino men feel excluded from the mainstream gay community on the basis of racist or classist values, socioeconomic or educational status, or language ability. This exclusion particularly applies to recent immigrants and certainly includes men who would otherwise welcome the opportunity to affiliate with a supportive mainstream community. (ASPIRA National Office 2002)

✓ What actions can you take now as a medical student and in the future as a provider to reduce these barriers to HIV prevention among young Latino MSM? Consider bilingual educational materials for patients, culturally sensitive office décor, and medical Spanish courses to improve your own communication skills.

✓ Is the notion of machismo truly unique to Latino men? Could ideals of masculinity serve as a barrier to safer sex practices in other cultures as well?

Item #2: Black and Latina women’s health

Annual health maintenance, or well woman, exams are an excellent way to screen women on a regular basis for medical conditions responsible for a great deal of morbidity and mortality worldwide. However, evidence indicates that black and Latina women are at much higher risk than women of European descent for many preventable health problems.

✓ What factors might explain the disparity between women of European descent and women who are black or Latina? What conditions could be prevented by more effective screening?

▪ Black and Latina lesbian and bisexual women were much more likely to be overweight (61% and 54% respectively) than heterosexual Black women and Latinas (42% and 39% respectively) in an L.A.-based study. Several studies indicate that women who are overweight or obese are less likely to be screened for breast and cervical cancer in primary care settings. (Charles and Conron 2002)

▪ One study of black and Latina women found that lesbian and bisexual women were more likely to use tobacco and to drink heavily than heterosexual women. (Charles and Conron 2002)

▪ In the year 2000, a disproportionate number of victims of reported hate crimes in Boston were Black or Latino. (Charles and Conron 2002) Domestic violence screening is an important part of the annual well woman exam.

▪ Latina and black lesbian and bisexual women in socioeconomically depressed communities are about twice as likely to be without health insurance as their heterosexual female neighbors. (Charles and Conron 2002)

▪ In 1990, a household headed by a black lesbian was twice as likely to earn less than $10,000 per year as a household headed by a white lesbian. (Charles and Conron 2002)

▪ Within the healthcare setting, LGBT people of color are very likely to be underserved by agencies focused on heterosexual communities of color and white LGBT populations. (Charles and Conron 2002)

▪ According to the 2003 Spirit Study by the Mautner Project, almost 20% of African-American women partnering with women delay seeking care because they fear homophobia by providers. (The Mautner Project 2004)

✓ How do race/ethnicity and sexual orientation combine to create poorer health outcomes for lesbian and bisexual women of color? Consider conditions that affect ethnic minorities that also affect sexual minorities.

✓ How should healthcare agencies take action to improve health outcomes? What can you do as a student now and as a provider in the future to contribute to better health outcomes?

Item #3: Substance abuse and suicidality among LGBT Asian-Americans

Studies in recent years have demonstrated a trend among LGBT Asian-Americans for substance use and abuse out of proportion to that of other ethnic groups. (Choi, Operario et al. 2005) Additionally, suicidality among Asian-Americans within the LGBT community has also remained higher than non-Asian ethnic groups. (Leong, Leach et al. 2007)

✓ What underlying factors likely contribute to LGBT Asian substance use and/or suicide? How might these outcomes be related? Consider mental health as well as social/environmental factors.

✓ What role might culture play in contributing to these findings? How might U.S.-born individuals differ from Asian immigrants?

▪ Very little research exists in regard to suicidality in Asian-American populations, but a recent review notes that for Asian lesbians “outness” was inversely related to psychological distress, including suicidality. (Leong, Leach et al. 2007)

▪ Other small studies have found that being an LGBT Asian-American adolescent was associated with increased suicide attempts in Guam and that “coming out” to family and the community may bring shame to the family, accounting for many Asian Americans to hide their sexual identity. Emotional distress is linked to suicide in both cases. (Leong, Leach et al. 2007)

▪ Though the prevalence of HIV among Asian and Pacific Islander (A&PI) gay men remains to be clearly documented, research has shown that these men engage in relatively high rates of HIV risk behavior. A&PI gay men who responded to discrimination with self-attribution, rather than in a situational context, showed greater HIV risk behaviors. In other words, men who blamed themselves and/or their Asian heritage were more likely to engage in risky sex. (Wilson and Yoshikawa 2004)

▪ Asian MSM report high rates of depressive symptoms as well as HIV risk behavior, with Asian MSM who have experienced racial discrimination reporting significantly higher rates in both cases. Men who report discussing instances of discrimination with family or another support network have lower instances of HIV risk behavior than men who do not access a support network. (Yoshikawa, Wilson et al. 2004)

▪ Results from a sample of 60 young Asian men who self-identified as “having sex with other men” indicated they were generally knowledgeable about methods of transmission and prevention. However, significant percentages held culturally biased views of AIDS, such as believing race of partner or one’s own gender role in the sexual encounter determined level of risk. (Shapiro and Vives 1999)

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III. CASES

Case #1: Akta

Akta is a young graduate student at your university who you have spoken to a few times at campus events and in passing at the medical school. She is pursuing a Ph.D. in molecular biology and always seems quite stressed about her current research. You know that her parents are first-generation immigrants to the U.S. from India and that they have very high expectations for Akta, both professionally and personally.

During a shadowing experience with the Emergency Department, you see Akta speaking with the triage nurse. She is visibly upset and looks up from her lap, which is filled with moistened tissues, to notice you across the room. Once the triage nurse has completed her initial exam, you approach Akta to assure her that she has no reason to be uncomfortable because of your presence. She bursts into tears and tells you that the reason she came to the E.D. was because she had nowhere else to go.

Over dinner that evening she fought with her parents after telling them she no longer wished to see the young man with whom they had set her up in hopes of arranging a future marriage. In her anger, she divulged that she recently had become involved romantically with another student at the university, a female with whom she had much in common. Her father became enraged, struck her forcefully, and told her there was no place in her culture for such ideas. He then banned her from the house and refused to discuss the matter further.

✓ How would you counsel Akta initially regarding her current situation?

✓ What kind of an effect might her father’s actions have on her mental health?

✓ In what ways can Akta work to ensure her own happiness and success in school despite emotional distractions?

✓ How do you think she reconciled her cultural background with her feelings of attraction toward another woman? Is her father correct in saying that there is “no place in her culture for such ideas”?

Further Reading:

▪ Khan S. Culture, sexualities, and identities: men who have sex with men in India. J Homosex. 2001;40:99-115.

▪ Kole SK. Globalizing queer? AIDS, homophobia and the politics of sexual identity in India. Global Health. 2007 Jul 11;3(1):8

Case #2: Mr. Johnson

Your preceptor has asked you to do an H&P on Mr. Johnson, a 49yo black male patient who has been coming to his practice for years for annual health maintenance exams. Because black men are at 50% higher risk for prostate cancer than white men, your preceptor explains, you are also to perform a screening digital rectal exam (DRE) due to Mr. Johnson being over age 45.

Mr. Johnson turns out to be quite pleasant and overall in good health. He has given up smoking in the past year at his wife’s request, and his only complaint is the recent development of a case of hemorrhoids that “just won’t go away with Preparation H.” On exam, Mr. Johnson is well appearing with no significant findings. DRE is negative for an enlarged prostate, but visually you note that Mr. Johnson’s “hemorrhoids” look suspiciously like condyloma acuminata (anal warts).

You excuse yourself to report your H&P findings to your preceptor, wondering if your sexual history-taking should have been more thorough. Could Mr. Johnson be on the “down low” and acquired HPV from a male sexual partner?

✓ How would you begin a conversation with Mr. Johnson about his possible HPV infection?

✓ What are some ways that you might have taken a more detailed sexual history, considering that a married man may not necessarily be heterosexually monogamous?

✓ How does the popular media portray the “down low” phenomenon, a term coined to describe (predominantly) black MSM who maintain heterosexual relationships publicly? Is media portrayal consistent with published reports that only about 20% of black MSM are on the “down low” (Wolitski, Jones et al. 2006)? Are black men the only men who have different relationships in public and in private? How might the lens of race affect societies perception of these men, and the media portrayal of them?

Further Reading:

▪ Miller M, et al. Sexual diversity among black men who have sex with men in an inner city community. J Urban Health. 2005;82(1 suppl 1):i26-i34.

▪ Millett GA, et al. Greater risk for HIV infection of black men who have sex with men: a critical literature review. Am J Public Health. 2006;96:1007-1019.

▪ Pathela P, et al. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York City men. Ann Intern Med. 2006 Sep 19;145(6):416-25. Erratum in: Ann Intern Med. 2006 Dec 19;145(12):936.

▪ Wolitski RJ, et al. Self-identification as “down low” among men who have sex with men (MSM) from 12 US cities. AIDS Behav. 2006 Sep;10(5):519-29.

Case #3: Trini

While volunteering at your medical school’s mobile homeless clinic, you meet Trini, a recent immigrant from the Philippines. Her English is quite limited, but you are able to ascertain from her interview that she misses living in the Philippines because she has not had great success in finding work, housing, or a social network since immigrating to the U.S. As a transgender woman, who was born a man, she was very popular in her home country where gender fluidity was not so stigmatized; she even won pageants for transgender women and hosted many parades and festivals in and around Manila.

Her life has been quite different in the U.S., however, and she confides that she has turned to prostitution to provide for herself. She has met many other transgender sex workers, particularly of Asian background, but she does not identify with them. She tells you that she really has nothing else in common with them. When you ask about safe sex practices, she assures you that she always has condoms handy in case the men want to use them.

A few weeks pass and Trini misses a follow-up appointment at the clinic. Despite follow-up rates being extremely low due to the transient nature of the patient base, you were hopeful that you would be able to meet with Trini again, particularly since you were concerned that a “fall down a few stairs” she described at her last visit had somehow left her with a black eye.

✓ What factors put Trini at particular risk for being a victim of violence? How does race/ethnicity contribute to this risk? Consider her transgender status (male-to-female), homelessness, Asian background, and her activities as a sex worker.

✓ If Trini returns to mobile clinic, how might you counsel her on reducing her risk for being a victim of violence? How might her Filipino background be used as an advantage? How might this differ in a rural versus an urban area?

Further Reading:

▪ Edwards JW, Fisher DG, Reynolds GL. Male-to-female transgender and transsexual clients of HIV service programs in Los Angeles County, California. Am J Public Health. 2007 Jun;97(6):1030-3.

▪ Holland, A. (2006). A Girl Like Me: The Gwen Araujo Story. USA, Lifetime Movie Network. (FILM)

▪ Laurent E. Sexuality and human rights: an Asian perspective. J Homosex. 2005;48(3-4):163-225.

▪ National Coalition of Anti-Violence Programs. Lesbian, Gay, Bisexual and Transgender Domestic Violence in 2001. 2002.

Case #4: Eagle

During your pediatrics clerkship at a local community hospital, an exhausting afternoon in high-risk teen clinic finally is winding down when you pick up your last chart for the day. Eagle is a 16yo male of Apache descent. Until last year, he received medical services while living on the Mescalero Reservation in southeastern New Mexico. However, last year his mother left his father, an abusive alcoholic with post-traumatic stress disorder from serving in the Gulf War, and relocated with her four children to a low-income housing community near the hospital. Extensive notes in the chart detail a cycle of abuse that did not leave Eagle unscarred, both physically and emotionally.

Eagle greets you with an annoyed grunt when you enter the exam room and is quick to tell you that he is “fine, all fine.” When you ask how life has been for him since leaving the reservation, he is somewhat hesitant to respond but concedes that he is enjoying time “away from his father.” Just recently, Eagle explains, he has come to realize that he is two-spirited, an idea he suppressed while within the abusive confines of his former home life. He tells you that he no longer uses illicit drugs to help him cope with confusing identity issues and that he has made some open-minded friends at his new school.

His mother agrees that some progress has been made in terms of Eagle’s past drug usage, although she is not entirely convinced he is drug-free, but she worries deeply about disconnecting the family from their cultural heritage. She hopes that Eagle’s new friends and newfound comfort with being two-spirited does not detach him even further from the traditions by which he was raised.

✓ What suggestions might you make to Eagle’s mother to support her son? In what ways might her efforts also encourage him to hold on to his Apache culture?

✓ Given Eagle’s multiple minority status, how do you think he will cope with being “different” on two levels as he continues to grow into adulthood? What support mechanisms will he need to avoid substance abuse?

✓ How might Native American ideas of spirituality, which in many ways embrace two-spiritness, contrast to the beliefs held by LGBT members of other cultures? What disadvantages might this create for two-spirit Native Americans in relating to the mainstream LGBT community?

Further Reading:

▪ Balsam KF, et al. Culture, trauma, and wellness: a comparison of heterosexual and lesbian, gay, bisexual, and two-spirit native americans. Cultur Divers Ethnic Minor Psychol. 2004 Aug;10(3):287-301.

▪ Barney DD. Health risk-factors for gay American Indian and Alaska Native adolescent males. J Homosex. 2003;46(1-2):137-57.

▪ Garrett, MT, Barret, B. Two Spirit: Counseling Native American Gay, Lesbian, and Bisexual People. J Multicult Couns Devel. 2003 Apr;31(2):131-42.

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IV. TAKE ACTION

Now that you have put a great deal of thought into issues faced by QPOC, take action toward making a difference in the lives of your patients and your peers. Visit AMSA on the web at lgbt/qpoc.cfm to find out how you can contribute.

Top of Form

1. Join the QPOC Facebook Group

This Facebook group is distinct from the AMSA LGBT and serves QPOC med students nationally to both discuss QPOC issues and to create a QPOC community within LGBTPM. Join by logging into facebook and searching for “Inclusion Campaign” after clicking on the “Groups” link at the top. Once you’ve found the “AMSA – Inclusion Campaign” group, request to join the group.

2. Co-sponsor events between LGBTPM and SNMA, APAMSA, LMSA, AAPI.

3. Help establish LGBT advocacy groups within SNMA, APAMSA, LMSA, AAPI.

4. Participate in national QPOC projects and attend AMSA’s annual National Convention

Bottom of Form

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V. RESOURCES

Asian Health

▪ Asian & Pacific Islander Coalition on HIV/AIDS (APICHA). apicha/main.html

▪ Asian & Pacific Islander Institute on Domestic Violence. apidvinstitute/GenderViolence/lgbt.htm

▪ Asian & Pacific Islander Wellness Center. home.html

▪ Queer Asian Women’s Shelter.

Black/African-American Health

▪ Affinity. a/index.php

▪ Gay Men of African Descent (GMAD).

▪ People of Color in Crisis.

▪ S.H.E. Circle.

▪ Soul Food, Gay Men’s Health Crisis, programs/soul_food.html

Latino Health

▪ Gay and Lesbian Latino AIDS Education Initiative (GALAEI). galaei/

▪ Hispanic AIDS Forum. eng/index.php

▪ Latino Commission on AIDS.

▪ Proyecto P.A.P.I, Gay Men’s Health Crisis. programs/papi.html

Native American Health

▪ Indigenous Peoples Task Force.

▪ National Native American AIDS Prevention Center (NNAAPC).

▪ Red Circle Project, AIDS Project Los Angeles (APLA). native_american/RCP/

QPOC

▪ Community United Against Violence (CUAV). index.php

▪ National Minority AIDS Council (NMAC). home/

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VI. REFERENCES

ASPIRA National Office (2002). Barriers Latino Gay Men Confront. ASPIRA Policy Brief.

Centers for Disease Control and Prevention (CDC) (2006). “Rapid HIV testing among racial/ethnic minority men at gay pride events--nine U.S. cities, 2004-2006.” MMWR Morb Mortal Wkly Rep 56(24): 602-4.

In the United States, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) disproportionately affect men from racial/ethnic minority groups. Approximately half of the HIV/AIDS cases among non-Hispanic black and Hispanic males reported by 33 states using name-based HIV surveillance during 2001-2005 were among men who have sex with men (MSM). Each year, approximately 100 gay pride events are held in cities across the United States to celebrate diversity, demonstrate solidarity of the gay community, and heighten awareness of topics of importance to the gay community. These events are attended by several hundred to several hundred thousand MSM. Certain gay pride events are focused on celebrating solidarity in the minority gay community and are attended primarily by MSM from racial/ethnic minority groups. These events offer an opportunity for community-based organizations (CBOs) and health departments to provide HIV-prevention education and outreach. In 2004, CBOs and health departments, with technical assistance from CDC, began conducting rapid behavioral assessments at gay pride events and at minority gay pride events. This report describes the results of assessments and rapid HIV testing conducted at 11 events in nine U.S. cities during 2004-2006; most of these events were attended primarily by MSM from racial/ethnic minority groups. A total of 543 attendees who participated in the assessments reported at the time of the event that they had not had HIV infection diagnosed previously. Of these, 133 (24%) were tested for HIV during the event, and eight (6%) of those tested during the event had a positive rapid test result. All eight were subsequently confirmed to be HIV positive by Western blot testing. Testing at gay pride events provides an opportunity to identify new HIV infections among MSM outside of health-care settings, particularly those from racial/ethnic minority groups.

Charles, V. and K. Conron (2002). Double Jeopardy: How Racism and Homophobia Impact the Health of Black and Latino Lesbian, Gay, Bisexual, and Transgender (LGBT) Communities. LGBT Health.

Choi, K.-H., D. Operario, et al. (2005). “Substance Use, Substance Choice, and Unprotected Anal Intercourse among Young Asian American and Pacific Islander Men Who Have Sex with Men.” AIDS Educ Prev 17(5): 418-29.

Substance use has been shown to be an important factor associated with having unprotected anal intercourse (UAI) among Asian and Pacific Islander (API) men who have sex with men (MSM). However, little is known about which substances are used in conjunction with sexual activity and whether having UAI varies by substance choice in this population. From January 2000 to September 2001, we sampled API MSM aged 18-29 years from 30 gay-identified venues in San Francisco, California, and interviewed 496 API men face-to-face using a standardized questionnaire. Overall, 47% of the sample reported UAI in the past 6 months. During the same time period, 32% and 34% reported being “high” or “buzzed” on alcohol and drugs during sex, respectively. The most common drugs used in conjunction with sex were methylenedioxymethamphetamine (“ecstasy”; 19%), followed by marijuana (14%), inhalant nitrites (“poppers”; 11%), and crystal methamphetamine (“crystal”; 10%). In a multivariate model, we observed associations between UAI and being high or buzzed on ecstasy (odds ratio [OR] = 2.62; 95% confidence interval [CI] = 1.37, 5.02) and poppers during sex (OR = 3.29; 95% CI = 1.50, 7.25). However, being high or buzzed on alcohol, marijuana, gamma-hydroxybutyrate (GHB), and crystal methamphetamine during sex had no association with UAI. One third of sampled young API MSM used drugs or alcohol during sex. The co-occurrence of ecstasy and popper use and unprotected sex underscores the need to develop HIV prevention programs focusing on particular drugs.

Leong, F. T., M. M. Leach, et al. (2007). “Suicide among Asian Americans: what do we know? What do we need to know?” Death Stud 31(5): 417-34.

The current review begins with an acknowledgment of the diversity within the Asian American population as well as the scarcity of information on suicide among this particular racial/ethnic minority group. In analyzing what is known and what still needs to be learned about suicide among Asian Americans, the current article provides a critical review of significant factors such as age, gender, religious and spirituality issues, acculturation, social support, familial dynamics, social integration as well as gay/lesbian/bisexual orientations. In examining these factors, recommendations related to interventions and the existing research gaps are also discussed.

Makadon, H. J., K. H. Mayer, et al. (2006). “Optimizing Primary Care for Men Who Have Sex With Men.” JAMA 296(19): 2362-2365.

Shapiro, J. and G. Vives (1999). “Demographic and attitudinal variables related to high-risk behaviors in Asian males who have sex with other men.” AIDS Patient Care STDS 13(11): 667-75.

Although AIDS is spreading rapidly in minority communities, little is known about attitudes, knowledge, and behavior related to AIDS and HIV in the Asian community. The purpose of this study was to examine these variables in a sample of gay Asian males, as well as to investigate the relationship between knowledge, sources of information, culturally influenced attitudes and high-risk behaviors in this population. Results from a sample of 60 young Asian men who self-identified as “having sex with other men” indicated they were generally knowledgeable about methods of transmission and prevention, and appeared linked to a large information network that included informal sources such as peers and formal sources. However, significant percentages held culturally biased views of AIDS, such as believing race of partner or one's own gender role in the sexual encounter determined level of risk; and one third of the sample did not use condoms regularly. Having been tested for HIV was associated with holding less traditional cultural beliefs and a higher sexual activity level. Open communication about safer sexual practices was associated with monogamous as opposed to multiple relationships and with decreased tendency to engage in alcohol-related unprotected sex. Variance in overall risk was predicted by demographic variables such as education, age, and level of sexual activity, rather than by the attitudinal factors measured. Limitations of this exploratory study include a time-limited subject recruitment period and consequent small sample size, a homogeneous sample weighted toward young, well-educated, and middle-class respondents, and the exclusion of non-English speaking individuals. Nevertheless, study findings suggest that educational outreach targeting Asians who have sex with other men needs to address inaccurate cultural beliefs about HIV/AIDS, emphasize consistent condom use, and encourage models of open communication with partners about safer sexual practices.

The Mautner Project (2004). Lesbian Health Risks: Factors Facing a Medically Underserved Population. Washington, DC, The Mautner Project.

Wilson, P. A. and H. Yoshikawa (2004). “Experiences of and responses to social discrimination among Asian and Pacific Islander gay men: their relationship to HIV risk.” AIDS Educ Prev 16(1): 68-83.

As the HIV/AIDS epidemic enters its third decade, rates of infection continue to rise in ethnic minority populations. Though the prevalence of HIV among Asian and Pacific Islander (A&PI) gay men remains to be clearly documented, research has shown that these men engage in relatively high rates of HIV risk behavior. The social discrimination that minority gay men experience may impact their HIV risk behavior and mental health (Diaz & Ayala, 2001). This article examines the experiences of and response to social discrimination among A&PI gay men, and their links to HIV risk behaviors. The study analyzes 166 narrative episodes of discrimination, as well as data on HIV risk obtained from in-depth interviews with 23 A&PI gay men. Results showed that A&PI gay men experience types of discrimination across a variety of contexts. Homophobia and anti-immigrant discrimination were linked to confrontation and social network-based responses whereas discrimination based in stereotypes of passivity / submission were linked with self-attribution. A&PI gay men who used confrontational, social network-based or avoidance response types showed less HIV risk than those who did not. Conversely, A&PI gay men who responded to discrimination with self-attribution showed greater HIV risk behaviors. These findings indicate that experiences of social discrimination and responses to discrimination may impact A&PI gay men's well-being and health.

Wolitski, R. J., K. T. Jones, et al. (2006). “Self-identification as “down low” among men who have sex with men (MSM) from 12 US cities.” AIDS Behav 10(5): 519-29.

Men who have sex with men (MSM) who are on the “down low” (DL) have been the subject of considerable media attention, but few data on this population exist. This exploratory study (N=455) compared MSM who considered themselves to be on the DL with MSM who did not (non-DL MSM). 20% self-identified as DL. Blacks and Hispanics were more likely than Whites to self identify as DL. MSM who did not identify as gay were more likely than gay-identified MSM to describe themselves as DL. DL-identified MSM were less likely to have had seven or more male partners in the prior 30 days, but were more likely to have had a female sex partner and to have had unprotected vaginal sex. DL-identified MSM were less likely to have ever been tested for HIV than were non-DL MSM. Prevention agencies should expand existing programs for MSM to include specific efforts to reach DL MSM.

Yoshikawa, H., P. A. Wilson, et al. (2004). “Do family and friendship networks protect against the influence of discrimination on mental health and HIV risk among Asian and Pacific Islander gay men?” AIDS Educ Prev 16(1): 84-100.

This study examined the influence of experiences of racism, homophobia, and anti-immigrant discrimination on depressive symptoms and HIV risk among a sample of Asian and Pacific Islander (A&PI) gay men (N = 192). In addition, the potential protective influences of conversations about discrimination with gay friends and with family were explored. These men reported high rates of depressive symptoms (45% above the clinical cutoff on the Center for Epidemiological Studies-Depression scale) as well as HIV risk behavior (31% reporting at least one episode of unprotected anal intercourse (UAI) in the last 3 months). Controlling for income, ethnicity, age, and relationship status, experiences of racism were associated with higher levels of depressive symptoms, and experiences of anti-immigrant discrimination were associated with higher rates of secondary-partner UAI. Conversations about discrimination with gay friends and with family were associated with lower levels of primary-partner UAI. The combination of low levels of discussion with family about discrimination with high levels of experienced discrimination (of all three types) was associated with higher rates of UAI. Implications for mental health and HIV prevention interventions for A&PI gay men are discussed.

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