“Moving from one environment to another, it doesn’t automatically change everything”. Exploring the transnational experience of Asian-born gay and bisexual men who have sex with men newly arrived in Australia

Asian-born gay, bisexual and other men who have sex with men (gbMSM) who are newly arrived in Australia are at a higher risk of acquiring HIV than Australian-born gbMSM. We used a social constructionist framework to explore HIV knowledge and prevention strategies used by newly-arrived Asian-born gbMSM. Twenty four Asian-born gbMSM, aged 20–34 years, attending Melbourne Sexual Health Centre, who arrived in Australia in the preceding five years, participated in semi-structured, face-to-face interviews. Interviews were recorded, transcribed verbatim and analysed thematically. Participants described hiding their sexual identities in their country of origin, particularly from family members, due to fear of judgement and discrimination resulting from exposure to sexual identity and HIV related stigma in their countries of origin, although some were open to friends. Despite feeling more sexual freedom and acceptance in Australia, many were still not forthcoming with their sexual identity due to internalised feelings of stigma and shame. Exposure to stigma in their country of origin led many to report anxiety around HIV testing in Australia due to a fear of testing positive. Some described experiencing racism and lack of acceptance in the gay community in Australia, particularly on dating apps. Fear of discrimination and judgement about their sexual identity can have a significant impact on Asian-born gbMSM living in Australia, particularly in terms of social connectedness. Additionally, HIV-related stigma can contribute to anxieties around HIV testing. Our data highlights the potential discrimination Asian-born gbMSM face in Australia, which has implications for social connectedness, particularly with regard to LGBTQI communities and HIV testing practices. Future studies should determine effective strategies to reduce sexual identity and HIV-related stigma in newly-arrived Asian-born gbMSM.


Introduction
There has been a decline in new HIV diagnoses since 2016 among gay, bisexual and other men who have sex with men (gbMSM) born in Australia [1,2]. The proportion of HIV diagnoses among Asian-born gbMSM living in Australia have increased significantly, from 9% in 2008 to 23% of all new male-to-male HIV diagnoses in 2017 [2]. By 2017, gbMSM born in Asia were more than four times as likely to be diagnosed with HIV infection than other gbMSM living in Australia (1.6% vs 0.4%, p<0.001) [3].
The overall aim of this study was to explore HIV knowledge and prevention strategies used and preferred among newly-arrived Asian-born gbMSM, the results of which are pending publication in a separate paper. In exploring this, it became evident men experienced a transnational duality of lived experiences as a gbMSM in their country of origin and in Australia, strongly influenced by their exposure to deeply embedded societal and cultural beliefs around same-sex relationships and HIV in their country of origin. Despite feeling greater acceptance and sexual freedom in Australia, the stigma and shame around their sexual identity and HIV in their country of origin, endured and influenced their living experience in Australia, where some also faced other forms of sexual and racial minority discrimination.
The minority stress model explains the effects of minority sexual identity on mental health and posits that marginalised groups experience more social stress than non-marginalised groups [4]. Asian-born gbMSM who are migrants or temporary visa holders (e.g. students or those migrating permanently) in Australia are socially categorized in marginal groups not only due to their sexual identity, but also their ethnicity and migration status; an intersectionality that can contribute to HIV-related stigma, and, in turn, have effects on HIV-related health behaviours [5]. A previous systematic review of migrant minority gbMSM in the USA and Europe found varying HIV risk profiles in migrant gbMSM depending on their ethnicity, country of origin, and current location and highlighted the importance of viewing HIV risk in the context of migration [6]. In order to understand the broader range of inequalities including racism, discrimination and socio-economic status that may be contributing to HIV vulnerability in Asian-born gbMSM living in Australia, it is essential to use an intersectional approach that examines culture, integration into the host community, and health of the individual [7].
It is well documented that HIV-related stigma and shame pose significant barriers for accessing HIV testing [8,9]. HIV-related stigma continues to impede efforts to reduce HIV transmission in Australia as it presents a major barrier for accessing care [10]. Additionally, sexual identity-related stigma contributes to mental distress [11,12] and can lead to concealment of sexual identity [13,14]. Sexual identity concealment, in turn, is associated with worse mental health outcomes [15], a decreased sense of belonging, and social isolation [4,16]. In Australia, Asian-born gbMSM are more likely to have advanced HIV upon diagnosis but to report fewer numbers of male sexual partners compared to Australian-born gbMSM [17]. This may indicate an underlying stigma related to HIV and sexual identity, particularly given the reported prevalence of such stigma in several Asian countries [18][19][20][21][22].
To better understand the underlying beliefs around HIV and, in turn, the possible contributors to HIV vulnerability in newly-arrived Asian-born gbMSM, it is important to examine the complex relationship of social and cultural values attributed to HIV in their countries of origin as well as their experience in sexual and ethnic minority communities within their countries of origin and Australia [23]. There are limited data on the experience of Asian-born gbMSM migrants in Australia [24]. With this population continuing to be at a higher risk of HIV than Australian-born gbMSM [3] it is important to understand the intersectionality of their experience and their experiences of HIV-related stigma.

Materials and methods
This study has been reported in accordance with the Consolidated Criteria for reporting qualitative research (COREQ) guidelines [25].

Ethics statement
Ethical approval was obtained from the Alfred Hospital Ethics Committee, Victoria, Australia (222/19) on the 30 th April 2019.

Theoretical framework
The framework for this study was informed by a social constructionist approach. According to this approach, an individual's perceptions of their reality and meaning they give to phenomena (beliefs, values, experiences) are shaped by the social and cultural norms in which they live [26]. From this viewpoint, each man's experience or 'reality' of living as an Asian-born gbMSM in their country of origin and Australia will differ and what is important is not the accuracy of their accounts but rather the insights they provide into their realities or lived experience. The way an illness or condition is viewed or responded to in a culture or society can greatly impact or influence the lived experience or perceived reality of individuals, especially if the illness is stigmatised [27]. Given the considerable negative stigma still surrounding both same-sex attraction and HIV in many Asian countries, it was anticipated men's views and experiences of living as a gbMSM in Australia would be influenced by their country of origin's societal values and beliefs.

Method, research team and reflexivity
Semi-structured interviews were chosen for this study as they allowed men to share their lived experience and personal reality of being a gbMSM. The interview schedule was jointly designed by a majority of the research team, including NM (FAChSHM, PhD), a male clinical epidemiologist and consultant HIV physician; EPFC (PhD) a male epidemiologist with several years' experience in sexual health; JJO (FAChSHM, PhD), a male sexual health physician and researcher with a special interest in increasing access to sexual health services to marginalised populations; JEB (PhD), a female senior research fellow with a doctorate in public health who specialises in social research in the area of sexual and reproductive health; and TRP (PhD), a female research fellow with several years' experience working in sexual health. NM and JO particularly had extensive quantitative research experience describing trends in HIV diagnoses within newly-arrived Asian-born gbMSM. The team members have combined decades of experience in this research area, have diverse sexual identities and cultural backgrounds, including two members of Asian ethnicity. Thus, the nature of the questions chosen were influenced by the clinical and cultural experiences of the researchers themselves, which in turn will have impacted on the meanings derived from the interviews.
Interviews were conducted by TRP. Participants had no prior relationship with TRP and were informed that the study was being undertaken to understand their experiences around HIV testing and preferences for HIV prevention strategies in light of rising rates of HIV diagnoses in this population. clients attending MSHC are invited to complete a computer-assisted self-interview (CASI) on arrival, which collects demographic and sexual practice information. Men were purposively invited to participate. During the study period, all clients who self-identified on CASI as a male aged 18 years or older, reported having sex with men in the last 12 months, were HIV negative, and born in Asia, were automatically shown an invitation on CASI to take part in an interview. The invitation on CASI contained additional eligibility criteria which stated that participants needed to have been in Australia less than five years and that they needed to have been born in an Asian country, defined as: Bangladesh, Bhutan, Brunei, Cambodia, China, East Timor, Hong Kong, India, Indonesia, Japan, North Korea, South Korea, Laos, Macau, Malaysia, Maldives, Mongolia, Myanmar, Nepal, Pakistan, Philippines, Singapore, Sri Lanka, Taiwan, Thailand or Vietnam. Interested men indicated a preference for contact from the study team either via email or phone call. A research nurse (KM or RW) then contacted men using their preferred method of contact, confirmed eligibility, emailed them the plain language statement and consent form, and scheduled a time for them to attend MSHC for an interview.

Data collection
All interviews were conducted face to face, in English and in a private room at MSHC. After reviewing the plain language statement, written informed consent was obtained. Interviews were digitally recorded. To begin, participants were asked nine structured questions on demographic and sexual practices, followed by a series of open-ended questions around their experience of living as a gbMSM in their country of origin, their experience of living as a gbMSM in Australia, their HIV and STI knowledge, their HIV prevention strategies and any changes in sexual behaviour or HIV prevention strategies since coming to Australia (see Table 1). This paper reports findings on the transnational experience of living as a gbMSM in their country of origin and Australia, including societal perceptions of HIV and personal experiences of HIV testing. Findings related to men's HIV and STI knowledge and HIV prevention strategies are reported in a separate paper (as yet unpublished). Field notes were written by TRP immediately following each interview to provide contextual detail. All interviews were transcribed verbatim for thematic analysis. Following the interview, participants received a $AUD30 voucher as reimbursement for their time and travel, as well as an information packet containing information on HIV prevention (including PrEP), health resources, service providers, and information about a community-based Victorian lesbian, gay, bisexual, trans, queer, and intersex (LGBTQI) health organisation, Thorne Harbor Health (formerly the Victorian AIDS Council). Upon request, two participants were assisted in scheduling appointments with onsite counsellors. Participants were informed that they could request a copy of their interview transcripts for member checking, however all participants declined.

Data analysis
The research team met regularly to discuss the findings from the study, which involved reflecting on the research methodology and identifying areas of improvement within the interview structure as well as reflexively examining and challenging our underlying perspectives about the research participant's attitudes and cultural influences [29].
The interview schedule was revised after two interviews were completed to add additional questions around how HIV was viewed in the participant's country of origin and how their sexual practices might have changed over time. After seven interviews were completed the interview schedule was further refined to include questions about participant's perceptions of HIV risk (see Table 1). The sampling framework was refined after approximately two-thirds of the interviews were completed to broaden the countries of origin in our study population, specifically restricting recruitment of men from China to ensure this country was not over-represented in the data collection. After 24 interviews were completed, TRP and JEB reviewed the transcripts and discussed results, at which time it was decided that data saturation had been met and no further interviews were required.
Interview transcripts were reviewed for thematic analysis [30] by TRP using both a deductive (whereby themes were identified by drawing on previous literature and the interview schedule) and inductive approach (by examining emergent and recurrent themes arising independently from the data). Transcripts were imported into QSR International's NVivo 12 software for data management. Thematic analysis commenced with TRP reading each transcript and coding responses. Codes were subsequently grouped into potential themes and subthemes, and reviewed, refined and compared for similarities and differences. A subset of transcripts were independently read and analysed by JEB to cross check coding and reduce bias. Consensus was met between TRP and JEB on coding and themes with no differences in data interpretation identified between the two researchers.
Descriptive analyses of demographic information were conducted using Stata (version 14.0, College Station, TX: StataCorp LP).

Results
A total of 117 men registered their interest in the study, of whom 97 fit the eligibility criteria. There were 38 men who scheduled an interview and of those, 14 did not attend or reschedule. Twenty four men completed an interview before data saturation was met. Interviews took 42 minutes on average [range 25 to 57 minutes]. Participant demographics are reported in Table 2.
Two main themes and nine subthemes emerged from the data: Did not disclose or was not asked about religion 3 Men described a transnational duality of lived experiences as a gbMSM in their country of origin and in Australia. Almost all men reported they felt the need to hide their sexual identity in their country of origin for fear of discrimination or judgement, and immigrated to Australia where they felt there would be more acceptance for LGBTQI communities. This duality presented itself differently among the participants in terms of varying degrees of discrimination they either experienced or were exposed to in their countries of origin and the level of acceptance they felt in Australia. The essence of their shared experience however, was that they had spent much of their lives hiding part of their identity and were now living in a place where they felt they had more sexual freedom. Despite changing environments, many participants described the effects of internalised stigma on their level of openness in Australia and on anxiety with HIV testing. Additionally, acceptance of their sexual identity in Australia was for many, coupled with experiences of racial and sexual discrimination racism.

1a. Laws, religion, tradition and culture
Men originated from 12 countries in Asia, a number of which have laws in place criminalising same-sex sexual activity (Pakistan, Malaysia, and Singapore). Of the 12 countries, only one had recently (2019) legalised same-sex marriage (Taiwan), however legislation was not passed until after the participants had migrated to Australia. Last year we had a vote about gay marriage but 70 per cent refused gay marriage in Taiwan.

-Participant 10, Taiwan, 4 years in Australia
While several men were unsure of the legality of same-sex relationships in their country of origin, they felt that regardless of the law, being gay or bisexual was not acceptable in their societies.

years in Australia
One participant noted that in Vietnam the unacceptability of homosexuality went so far as to not even recognise the concept in their language, the closest interpretation being to align it with paedophilia.
[In Vietnam] basically the idea of homosexuality is considered as an idea that shouldn't exist, even as a concept. So, there's no word to describe homosexuality, it not even exists in the language. The only word that exists in the language, to describe homosexuality, is a word called pê-đê, which is basically a French origin word, and that mean paedophile, originally.

-Participant 21, Vietnam, 3 years in Australia
For others, even if homosexuality was recognised, religious 'rules' and beliefs often dictated expected behaviours if one was LGBTQI, which largely centred around 'hiding' one's sexuality.
Cuz Malaysia's like a Muslim country. . . Like, there's certain things like you can't, you can't hold each other's hand, or you can't. . . There's certain rules, and, even if there's a gay club, or a gay bar or whatever, you can't even enter if you're Muslim. So they'll check your ID and everything.

-Participant 2, Malaysia, 1.5 years in Australia
While some participants felt these 'rules' were informed by religion, others attributed them to deeply embedded sociocultural traditions and conservative beliefs held in their society or region.

year in Australia
A few participants discussed differences in views of homosexuality in their local regions versus other cities in their countries of origins or the country of origin as a whole. One participant described the interplay of different communities' (religious, social, lifestyle) attitudes towards homosexuality in his small town in East Malaysia. To him, these differing community attitudes resulted in homosexuality being viewed as a sort of open secret-people living in the area know gay people are there and while they don't condone expressions of homosexuality, they also don't chastise them for their lifestyle. - Participant 11,Malaysia,4

years in Australia
Another participant spoke of his society's conservative values even restricting what clothes people can wear. To him, being openly gay in his country of origin was not fathomable since they cannot even accept men wearing shorts. He did not place the responsibility for these rules with his religion, but rather with the society and culture in his 'Old City', which he depicted as being more traditional than other cities in India.
I'm from the Old City. It's just that I don't blame my religion but then I blame the society and the culture. They are the ones that are setting the rules. The religion has never set the rules. . .I remember this one day I went out and my friend picked me up. I was lucky. I was like, "All right. I can just go quickly". I went down and sat in the car but then on my way back I was dropped somewhere a little bit far away, like a five-minute walk to my house. I cannot forget that five-minute walk, the names I was called and the looks I got were horrible . . . Forget being gay, I can't wear shorts. No straight man can wear shorts in my country. Not my country, just my particular society. It's so weird. Being gay would probably be the end of me.

1b. Fear of, judgement, shaming and discrimination
As a consequence of how LGBTQI persons were viewed in their society, most men described a feeling of oppression and fear around being judged or discriminated against in their country of origin due to their sexual identity. Men often spoke of feeling different and alienated due to their society's judgement of people who are gay or bisexual.
[It's the] attitude of the person and of our people. They are still saying, most of the people, that if you are gay or if you are bisexual or lesbian, you are the different people. It feels alien. . .Even though you are a Chinese, you are Asian, but you are not, cannot fit in any of the group of these people. So that's what I call judgmental.

-Participant 17, China, 3 years in Australia
It was common for men to speak of their intense fear of others finding out their sexual identity, with some reporting they did not feel they would cope emotionally or psychologically with the judgment they might receive if others were to find out. A couple of participants went so far as to say they were afraid for their very lives if their sexual identity were to be revealed in their society.

I don't know [why I am afraid]. Maybe because of people around me. Maybe the judgement. It might be affected emotionally, psychologically to me and I don't know how to adjust it. I don't know how to place myself in the public being a man but actually I do some stuff like this [have sex with men]. -Participant 24, Philippines, 2 years in Australia
Being gay, we're oppressed. We have to be in the closet. Our lives could be in danger.

-Participant 8, Indonesia, 7 months in Australia
Others feared bullying and public shaming if they were to show any signs of affection in public with a same-sex partner.
. . .in Singapore, if I were to hold my boyfriend's hand and walk down the street, people would be staring, people will take photos and posting them online. Singaporeans these days, they have like this mob mentality. . . like they are against these kind of things and just share kind of thing and people would see it. Like some people even got into trouble with their school and work because they were seen in public showing affection as a gay man.
-Participant 16, Singapore, 3 months in Australia A few men reported that in their country of origin same-sex activities were regarded as purely about sexual desire, devoid of real feeling or emotional connection.
. . .if a man have sex with a man, it just purely about lust, about sexual feeling, there's nothing about true feeling, or anything like that. . .

-Participant 21, Vietnam, 3 years in Australia
. . .normally, these Asian people have this attitude about LGBTQI people are born to do sex-. . .they are kind of sex workers, kind of prostitutes. . .

1c. Repressed and hidden identities
As a consequence of entrenched religious and sociocultural views and beliefs around homosexuality in their countries of origin, and the fear of judgement and discrimination they felt they would face for their sexual identity, men often reported hiding their identities to varying degrees. One participant described needing to hide not only his actions, but his thoughts from others to make sure they did not become aware of his sexual identity.
. . .you always have to hide. If some other people know that you are gay they are always thinking bad about you and they will always-maybe talking bad words behind you, something like that. . .I have to be very discreet. I have to make sure that no one knows what I'm thinking, what I'm doing.

-Participant 13, China, 1.5 years in Australia
Others spoke of concealing their sexual identities to make others think they were "normal" or heterosexual, which meant pretending to be a different person to how they truly saw themselves.
Yes, even in my country I probably need to pretend so many things. Try to make people look at me as a normal person. - Participant 18,Laos,4

years in Australia
For some men, feeling the need to conceal their sexual identity meant they had been unable to 'come out' (i.e. disclose their sexual identity) to any family or friends in their country of origin. Their fear of being judged, unaccepted and shamed meant they never intended to tell their families or friends about their sexual identity. Back in Indonesia, so hard, especially to me, as a Muslim-you know, in Muslim rule, it's so hard to accept gay. It's so hard, my family is conservative religion, and that's why I'm never coming out with them.
-Participant 14, Indonesia, 3 years in Australia Some participants described being afraid their parents would disown them if they were to find out their sexual identity, while others were reluctant to share this information for fear it would cause their parents pain.
The topic of disownment comes up a lot when I hang around with my friends. . .and I feel that as Asian queer people, we understand the feeling of, if my identity is out there I actually could lose my entire family. And I feel like that's an issue that not a lot of my friends will understand unless they're queer and Asian as well.

months in Australia
Only a handful of men reported they had been able to come out to members of their immediate family. One man described feeling some support from his family but at the same time feeling they were ashamed or fearful for him and wanted him to conceal his sexual identity from society.
. . .but my immediate family knows that I am not straight and they support me. . ..But also, they tell me to keep it hidden because when we'd go out into society and meet other people in our circle, they don't want it to be a thing that I get labelled as. But I also feel like my parents don't want the shame that comes with that as well. . . .

-Participant 18, Laos, 4 years in Australia
Some men reported they had come out to friends or siblings but not parents or older generation family members. Several men touched on there being more acceptance and understanding in the younger generation than the older generation. [that] even though we are feminine, but we have discipline. We have the courage that you want to be. We show them all. So I'm kind of proud of that one.

-Participant 20, Malaysia, 3 years in Australia
Yes I would say I was a part of the gay community in Singapore because partly because Singapore is so small so like if you're gay you know who's who, that kind of thing. It's kind of nice because the population, the community is quite well knit. We have a lot of events and we always see the same few faces and just say hi and so on yes. . . Yes, that's a nice thing to see in Singapore. . .I guess like I got to know more gay people through those events, because even though like, how do you say this, I've not made any gay friends through school or work or anything. . .I don't usually say out that I'm gay kind of thing back in Singapore. . .

-Participant 16, Singapore, 3 months in Australia
Other participants spoke about being open about their sexual identity to close friends in their countries of origins and not just those that were also gay.

1d. Exposure to HIV-related stigma
Entrenched in the religious and sociocultural views and beliefs around homosexuality in men's countries of origin, was HIV-related misinformation and stigma. Most participants disclosed being exposed to some degree of HIV-related stigma, which they predominantly attributed to the widely held stereotype or belief in their countries of origin that HIV was an illness that exclusively affects gay men.
. . .having HIV in the Philippines is already a-you know, it's something that you should be ashamed of. That's the perception. . .because gay people are being frowned upon, so yeah, and usually, HIV is associated with gay people.
-Participant 19, Philippines, 7 months in Australia As a consequence, as one participant described, this led some men to keep their HIV diagnosis to themselves, as well as their sexual identity-in what he termed 'a very deep closet'.
They keep it [HIV diagnosis] to themselves, first because they're afraid that people would know that they're gay and secondly they are afraid that people will know that they have HIV. They have to live in a very deep closet and most of the time, in most of the cases, it's too late to ask for help. It's too late to ask for medication to make the virus undetectable. So it's pretty hard.
-Participant 8, Indonesia, 7 months in Australia Several participants described a general view in society of HIV as being a punishment for the sexually deviant behaviour of gay men. In many of the men's countries of origin, the view was held that people who have HIV only have themselves to blame for contracting it, through their amoral actions which go against 'nature' or 'God's will'.
It means just having this awful disease which you got with your actions and this is the consequences you are facing now. You've done something wrong and God is punishing you. That is how it is seen because you have laid with a man and now you have to go with the consequences, exactly how it was in the eighties in America. It's just the same. We are still in the sixties, seventies, eighties in India.

-Participant 6, India, 5 months in Australia
Others explained that people living with HIV were considered unclean; a belief particularly prevalent again among the older generations.
Like in my mum's, that generation or older generation, they think that it's a shame, it's really blame. . .This-shameful-it's shameful because they think that it's sexual disease. So it means you are a not a clean people. . .

-Participant 12, China, 1.5 years in Australia
Many participants described a fear in their societies of getting physically and emotionally close to people living with HIV because of these beliefs and misconceptions around transmission. As one participant noted, in his country of origin a cancer diagnosis would elicit sympathy from others, whereas a HIV diagnosis elicits judgment, discrimination, assumptions around deviant and immoral behaviour and a fear of transmission if the person gets too close to them.  . . . there are a lot of serious discriminations on you so it's hard for you to live. It's hard for you to get a job; it's hard for you to make friends; it's hard for you to get a partner and get married.

years in Australia
As a result of HIV-related stigma, participants often described a fear around HIV testing in their countries of origin. A couple of participants reported feeling judged or discriminated against while getting a HIV test, while others described the fear and anxiety they felt before testing due to the anticipation of being judged for being gay or of being an 'AIDS monster' and even a fear of being physically injured or killed for having the test.
The first time it took everything. I went to the local hospital, the government hospital and it was the anonymous thing as well. I mean, no identity and all but then I was scared because it was my city and if anybody got to know that I was getting testing for HIV, oh my God, it's a big thing. . . these people will kill you just for getting tested [for HIV] because, "Why are you getting tested?" They'll look for that and, "Oh, you've had a sexual relationship with a man? You can't do this".

years in Australia
See Table 3 for further quotes describing sexual identity and HIV-related stigma in participant's countries of origins.

2a. Acceptance and freedom
In contrast to their countries of origin where participants often spoke of having to hide their sexual identity, almost all participants described Australia as being more inclusive, accepting and open about people's sexuality. Many men described this acceptance in terms of feeling a sense of 'freedom' for the first time in their lives and the chance to finally be themselves and explore who they really are.
It's a huge difference compared to Singapore because here is like, everyone is so inclusive. They don't care if you're gay, they don't care whatever, race, religion, your beliefs whatsoever. It's like a huge difference, back in Singapore where everything is like, you have to hide -Participant 19, Philippines, 7 months in Australia One participant described how emotional he felt when he first arrived in Australia and realised that he could show affection in public without fear of judgement or discrimination. To him, the freedom of expression he felt and continues to feel in Australia is one of the reasons he is considering staying.

But just that freedom that I can wear whatever I want, I can hold hands with whoever I want and I can kiss whoever I want on the road. It's amazing and that's literally the best. I remember the very first day that I had here, a dude just told me, "You know what is the best thing about being in Australia? You can kiss on the road" and then he kissed me on the road and literally I had tears in my eyes. Just feeling that freedom was everything, yeah. It's honestly amazing and that's probably one of the reasons I might stay back in Australia. -Participant 6, India, 5 months in Australia
For others, the acceptance they felt in Australia was tied to the legalisation of same-sex marriage.
[Australia is different than Indonesia] because, luckily Australia, the law gay marriage already passed, that's why so happy. . .

2b. Sexual discovery and exploration
For many participants, the freedom and acceptance they felt in Australia to discover themselves for the first time meant they felt able to talk about and explore their sexuality both physically and emotionally.

Relatively to Malaysia, it's been very open, so that means in terms of being, physically, like I'm more comfortable and more relaxed with talking about certain things with colleagues, friends,
but also in terms of sexually, as well, it's more open to exploring here, whereas I would say comparatively, back home, there is a certain degree to things that we're allowed to say or do.

-Participant 11, Malaysia, 4 years in Australia
For some participants, the independence from their families and social connections in their countries of origin were the main facilitators to sexual exploration in Australia. They felt the freedom to explore their sexuality without fear of their sexual identity being exposed.
As a bisexual, since I'm the only one here so I can do whatever I want. I actually try to experience the things that I wasn't able to experience back in the Philippines because I was living with my parents. So I'm trying to discover a bit-my discovery there is limited compared to here on how to make myself more satisfied or whatever I want to do.

-Participant 24, Philippines, 2 years in Australia
One participant attributed the freedom he felt to explore his sexuality to the safe 'sex positive' environment he feels in Australia. For him, the normalisation of expressing your sexual desires and boundaries made him feel like he was safe to explore.

A lot of things that I observe, first of all how people are just openly sexual. The term that I heard was sex positive. If you need to talk about sex, it's just easy to engage and hook up. I like the culture of like, straightforward, you know, you say what you want, say [what] you're not comfortable [with]. For me, it's more comforting in a way. I have [a] secure space and place and I can just explore everything because I don't need to be afraid about myself and my
security.

-Participant 8, Indonesia, 7 months in Australia
One man described the freedom to explore his sexuality in tangible ways, such as the ease of buying condoms without judgement and access to smartphone dating applications without restrictions.
. . .just like having a lot of people who have the same identity as I am, it's quite easy for me to have the access of having sex stuff, because personally, I think that it's easier for me to buy condoms here, and then after that, there's no limitation on-for example, it's easy for me to find guys, because the dating apps is actually not blocked here. Back there, in Indonesia, it was blocked, so the thing is, it's not restricted.

2c. Internalised fear of coming out
Given the level of acceptance felt in Australia compared to their country of origin, most men described feeling they could be more open with their sexuality in Australia. However, many participants described some hesitation or limitation with how open they were willing to be with their sexuality, preferring instead to keep their sexual identity to themselves unless asked directly or only disclosing to people they felt confident would accept them.
For these men, the internalised and residual fear of coming out as a result of their experience in their country of origin reverberated to their lives in Australia. The stigma, judgement and discrimination they were exposed to or experienced in their country of origin, was still strongly ingrained and difficult to dispel despite moving to a more accepting environment.

years in Australia
Others reported feeling they could come out to some friends in Australia but not others. For some this related to friends having connections to their country of origin and a fear of their family finding out through those connections.
The thing is, I cannot [come] out to everyone, just because I still have some Indonesian community here-I mean, like, I have some relatives to those conservative Indonesians, here. . .but for others-for example, my community in the uni[versity], and then some key friends, I came out to them.

-Participant 9, Indonesia, 1 year in Australia
For others, not being able to disclose or come out to friends in Australia who were from their country of origin related to concern they might lose those friendships for fear their friends would not be accepting of them, having grown up in environments not as accepting of LGBTQI communities as Australia. One participant had his first experience of chemsex (i.e. use of recreational drugs during or before sex) in Australia during which he had sex without a condom and described the fear and anxiety he felt about getting an HIV test in the following weeks. He described feeling like he was HIV positive after the night of chemsex but was too scared to get tested because of what an HIV diagnosis would mean for his life, particularly the isolation he feared he would face living with HIV in his country of origin.
When the whole drug thing happened with me, the whole five weeks, every single day I was thinking, 'When do I go? When do I go? Why am I not going? What are you doing with yourself? Why not? Why not?' I actually thought I was positive. . ..[Having HIV] it would impact in a lot of ways. . . Now that I'm positive, who's going to be with me? . . .[HIV is seen as] Untouchable. . . Not a lot of people would know about it. Only a close set of people would know about it. I don't even know if I would tell my parents if I got positive because they'd just break down and they would be-I don't know. I've thought about it a lot of times. I don't have it but you never know.

-Participant 6, India, 5 months in Australia
Others delayed HIV testing for fear of the test itself and worrying about how clinicians would treat them given their previous negative experiences in their countries of origin.
I just didn't know how people would treat me [if I came for a HIV test], especially at the beginning. When I was in [college], everyone around me was, like, mostly Chinese students, and I didn't really deal with Australian people, and I don't know how they would see me. I don't know their opinion on anything of me. I just kind of feel like they would be similar to Chinese people. . . I didn't feel safe to do that [get tested], yeah.

-Participant 7, China, 1.5 years in Australia
For many others however, the experience of HIV testing in Australia was positive and had become easier and less anxiety provoking due to feeling supported and unjudged by clinicians.

2e. Experiences of racial discrimination in Australia
While men reported a much greater sense of freedom and acceptance around their sexual identity in Australia, and an opportunity to finally explore their sexuality and who they were, they also described the challenges of being a part of an ethnic minority group in Australia. Most men described experiences of discrimination and racism in Australia, particularly in terms of sexual racism, but others also felt they were subject to racism due to their Englishspeaking abilities. A few men framed their experience as a sacrifice; a trade-off between being sexually free in Australia and 'racially open' in their countries of origin. For some participants, these feelings of discrimination extended to the 'white-dominated' gay community in Australia where they felt they did not really fit in.
Smartphone dating applications appeared to be the predominate source of sexual racism, with men reporting seeing phrases like "No Asians" on profiles of men on dating apps. Most men describing sexual racism on dating apps were quick to follow up their observations with statements about how it did not affect them or how they try not to judge the men making racist comments. Despite raising these examples, some men felt unsure if these experiences were actual racism, or just expressions of personal preference.
When I was noting on Grindr [a smartphone dating application for gbMSM]. . .some people put in their profile or description, they might be saying, putting in words like 'Caucasians Preferred'; 'Asians Preferred' or even some words; 'No Asians'; 'No Indians', that happens. But I guess everybody has a preference. So usually when I see such words I don't think so much about that. I'm not sure if that is racist -Participant 13, China, 1. 5

years in Australia
So, dating apps is, I'd say, one of the ways that I'm more comfortable with meeting other men, so I guess that's where I experience it [racism] the most. . .. I've sort of just accepted it, to be just sexual preferences, but yeah, of course there are moments where I just think, well, maybe it's not because of preferences, maybe they're just not into Asians, maybe. Yeah, so I can't decide if that's-they always mask it as saying it's just a preference. So, not sure where I stand on that. It's, like, well you're right, it is preference, but at the same time, it's like, hmm-it is a bit racist, isn't it?

-Participant 11, Malaysia, 4 years in Australia
For other men, the discrimination and perceived racism they described occurred in public venues or places; though yet again, men commonly reported they did not take the experiences personally or rationalised that the person they perceived as being racist was maybe just having a bad day. I wouldn't say overt racism, not in a way where I've been physically harassed, but I think there has been a few times when I've been on a tram, minding my own business. And then, because I'm standing in someone's way just a little bit, there was this Australian woman once who came up, I'm sure she's from the North of Australia, and she was like, go back to China. I was like, yep. . . that's okay because she's probably having a bad day and I don't take that personally.

-Participant 18, Laos, 4 years in Australia
A few participants noted that the racism they have felt in Australia usually stems from their not speaking English as fluently as Australians.
I think that racism is actually not related to gay stuff, but it's more into the idea that we are actually not from Australia, and the way how we communicate is not as fluent or as fluid as what Australian capable to do.

-Participant 9, Indonesia, 1 year in Australia
Others felt it came from a lack of cultural understanding. I experienced that [racism], but for me, I think that is actually not the reason why I have to blame some people, or somebody, just because of their incapability of accepting my ability to speak [English]. I know that we're different, and I know those people are actually having limited understanding on that. . . I just see that they are actually not really educated on how to be culturally aware to people from different backgrounds, or be more accepting to people who have different forms of English. . . I don't say that that's insulting, but I can say that it's annoying.
-Participant 9, Indonesia, 1 year in Australia Some participants spoke of the trade-off of moving to a country where they are considered a racial minority, in order to have acceptance of their sexual identity. For these participants, feeling like they were more accepted for their sexual identity in Australia came at the expense of living in a racial minority group, and the challenges of discrimination that come with that identifier.

years in Australia
Some men also reported feeling excluded from the 'white dominated' gay community in Australia due to their race. They felt there was only room for Asian gay men to be accepted into the community if they fell into specific categories, like funny or wealthy.
It's very difficult for me to get into the white dominated gay circle. Having this Caucasian boyfriend helped a little bit, but still you can feel the differences are still there. . . the white Caucasian gay community, they prefer Asian gay guys that are more like funny guy, not someone who's very serious like me. Yeah funny is the first requirement for them to get into the circle. They can regard you as a friend but it's just a friend, it has nothing to do with real core circle of the community. You can't really get into that part. . . One participant felt that part of the difficulty in feeling a sense of belonging in the gay community in Australia was a lack of representation of Asian LGBTQI people in the media.

-Participant 3, China, 4 years in
. . .even with the media, you don't actually see a lot of Asian images in the way that people portray queer identity. It tends to be-like. . .two white, gay men, and one is very queen-like, or something like that.

years in Australia
Another acknowledged that despite feeling excluded from the gay community in some respects, there was a section of the community he felt welcomed into and felt a sense of belonging with these people.
But then again, there is a different group of people who are accepting and welcoming. I would say there is a ratio, like 70 per cent of people are like this but then the rest, 30 per cent of people-I do feel like I belong here, like I belong between these people. When I go to the voluntary things and stuff, the LGBTQ, the people just see the heart, not the outside but they see the inside.

-Participant 6, India, 5 months in Australia
While most men reported experiences or feelings of sexual and racial discrimination in Australia, not all did. A couple of participants described feeling like they were accepted and not judged.
To be honest I don't feel any racism. Since I came here, cuz, I will say especially in the city, there's, half of it is Asian as well and you don't feel that you're like, you're Asian, and you're like uh, being separated from, yeah like they don't judge you where you come from.

years in Australia
See Table 4 for further quotes on men's experiences of living as a gay or bisexual man in Australia.

Discussion
In this study that describes the experience of newly-arrived Asian-born gbMSM-a group recently emerged as being at increased risk of HIV in Australia-we found that most described hiding their sexual identities in their country of origin because of fear of stigma and discrimination related to sexual identity and HIV. These experiences translated into significant anxiety about being tested for HIV in their country of origin as well as in Australia and resulted in delayed testing. Internalised fear of stigma and discrimination is likely to be an obstacle to achieving timely and regular HIV testing in this population.
Participants attributed the fear, judgement and discrimination with regards to their sexual identities in their countries of origin to the differing traditions, religions and cultural values that shape their societies' view of homosexuality. As a result of these conservative views, most participants described hiding their sexual identities to a large degree in their countries of origin, a finding reflected in the literature from several countries in Asia [18][19][20]. While men often spoke of hiding their sexual identity to family members, it is important to note that there were some that were open to friends in their countries of origins, including a couple of men who discussed the strength they found from having friends in their countries of origin who were also gay. While measuring resilience (i.e. the ability to recover after experiencing adversity) among our participants was outside the scope of this study, peer support is a known protective process that leads to the development of resilience [31,32], which in turn may have a positive effect on mental health and well-being [33]. In our separate paper from this study (as yet unpublished), we discuss our findings that social support was a facilitator to sexual health within this group, notably some participants' positive experiences with local LGBTQI organisations that offer peer-led social support workshops. Previous research has also found that social support can impact sexual behaviours [34,35]. Increasing awareness of and opportunities to engage with peer-led services may be beneficial for men in this group in terms of bolstering their social support in Australia. Additionally, it is important for these services to have an awareness of the stigma and discrimination Asian born gbMSM can experience in Australia to enable them to factor this into culturally appropriate services which meet their needs. Further research could be done to examine mental health, resilience, and social support within this group and the implications for HIV prevention. Additionally, participants described several forms of HIV-related stigma in their countries of origin: from viewing people living with HIV as unclean or shameful to fearing discrimination or even death for getting an HIV test. This finding is reflected in the literature from China, which shows high prevalence of HIV-related [36] and sexual identity-related stigma [18] among gbMSM not living with HIV. Many men in this study expressed continued anxiety about getting tested for HIV after arriving in Australia due to the negative experiences and HIV-related stigma pervasive in their countries of origin and for some men this resulted in delayed HIV testing. Because testing is a key component of HIV prevention programs, fear of testing is likely to lead to reduced participation in HIV prevention.
While almost all participants described feeling acceptance and sexual freedom in Australia, some were still hesitant to be open with their sexual identity due to deeply embedded and internalised feelings of shame and stigma around being gay or bisexual. For men living in countries with structural stigma towards sexual minorities (for example laws criminalizing sexual activity or discriminatory cultural attitudes) sexual identity concealment serves to reduce discrimination and victimization [13]. Our finding that some men continue to conceal their sexual identity even after moving to a society where they feel they do not face this stigma suggests this stigma becomes enmeshed and has an enduring affect, the repercussions of which could be investigated in future studies.
Despite feeling acceptance of sexual identity, some participants described racial and language fluency-based discrimination in Australia in several ways; from experiencing perceived racism because of their English language skills, to widespread sexual racism on dating applications. Some men felt unwelcome in the gay community in Australia as an Asian-born gbMSM; a worrying finding given the importance of social support on mitigating the negative effects of stigma [37,38]. Our findings reflect those in a similar qualitative study from 2018 of Chinese and South Asian gbMSM living in Auckland, New Zealand; this study indicated that men in this group were hesitant to share their sexual identity with others, including healthcare professionals, despite feeling personally comfortable with identifying as gay or bisexual [39]. That study also indicated that due to the racial discrimination they faced they had weak connections with other gay and bisexual men, and thus were in a potentially vulnerable position [39].
However, it is important to highlight some of the participants' responses to racial discrimination in Australia, notably how many explained that they do not take sexual racism on dating apps personally, but rather see it as men having preferences. Similarly, several men when describing instances of discrimination, saw the experience as an indictment of the perpetrator of the discrimination and not themselves, for example rationalising that the perpetrator was having a bad day or lacked cultural understanding. These responses to racial discrimination indicate a level of self-compassion among the participants [40]. Previous research among students in the USA suggested that self-compassion may play an important role in coping with stigma among those students who were in both a sexual and racial minority [41]. Future research could investigate the level of self-compassion within this population and its effects on resilience in the face of discrimination.
This study highlights the complex set of factors that contribute to HIV-related vulnerability in newly-arrived Asian-born gbMSM. Previous reports have shown that minority stress is an important contributor to psychological distress among gbMSM [22] and that sexual identity concealment is a critical mechanism linking sexual minority stigma and depressive symptoms [42]. The findings from our study suggest the potential for considerable minority stress among Asian-born gbMSM newly arrived in Australia, not only in terms of sexual minority status but also in terms of race and ethnicity in Australia. Central to this intersectionality is the extensive HIV-related and sexual identity-related stigma faced by this population.
There were several limitations to this study. First, men were recruited from a sexual health centre and thus the experiences of these men reflect views from men already connected in some capacity to sexual health services. Similarly, men needed to have sufficient English language proficiency to conduct the interview. Thus, men who are not connected to sexual health services or those with limited English have not had their voices heard in this study. It is possible that members of these groups may be even more vulnerable to HIV due to their further marginalised status, as not speaking the host country's language has been a reported barrier to HIV testing for migrants in high-income countries [43]. Additionally, these men were willing to discuss topics with the researcher that they felt were taboo in their countries of birth and therefore they may be more open than other newly-arrived Asian-born gbMSM. This study did not ask participants to describe the degree to which they identified with a particular ethnicity, but recent research has questioned the role of ethnic identity as a protective buffer for the stress of discrimination [44]. Future research could investigate whether men in this group with stronger ethnic identity have ameliorated stress levels in the face of discrimination.
An important limitation to this study is that the experiences described by the participants in this study were centered around their sexual identity and attitudes towards HIV, and thus their responses are not indicative of their entire lived experience in their countries of origin, nor their holistic attitudes towards living in their countries of origin. The primary aim of the study was to explore strategies that newly-arrived to Australia Asian born gbMSM were using or preferred to use to prevent HIV infection, in light of rising rates of HIV in this population. This study was therefore designed to explore participant's knowledge levels about HIV prevention strategies, and what may have shaped their knowledge levels. In asking men about their knowledge levels we asked men what it was like to live as a gbMSM in Australia compared to their home country whereby they commonly described differences in acceptability of their sexual identity in their countries of birth versus in Australia. Given the topics that were explored and arose, the results of our study may lend themselves to more negative aspects or experiences of their countries of origins". Similarly, while we asked participants if they identified with a particular ethnicity or religion, we did not specifically ask about perceived differences between ethnicities or religions in their countries of birth with regards to attitudes toward sexual identity and HIV. Further research is warranted to better understand how ethnic identity and religion influences attitudes toward sexual identity and HIV among subcultures in different Asian countries.
Further to this limitation, "Asian-born" is an umbrella term applicable to a vast array of diverse ethnicities, societies and cultures, a fraction of which were discussed here. With regards to the topics presented here, there are, in addition to the variations between countries, variations in religions, cultures and attitudes within countries, as our participants touched on. Our aim was not to provide a generalizable finding applicable to all gay or bisexual men born in Asia and living in different geographic locations throughout Australia, but rather to capture the depth and breadth of experiences from people in what has been identified as a HIV vulnerable population in order to further direct targeted HIV prevention in this group. Given the sparsity of research into Asian-born gbMSM migrants living in Australia, the diversity of our study may in fact be considered a strength as our sample included men from a broad range of Asian countries, of varying ages and education levels. By focussing on newly arrived gbMSM we have been able to include narratives from several countries that have differing family, religious and cultural influences.
Another limitation that should be considered is that the interviews were all conducted by one researcher (TRP), a white female. Participants may have been reluctant sharing information with someone they did not feel was a peer or who could not fully understand their lived experience as an Asian born gbMSM. Further to this end, TRP and JEB (another white female) were responsible for the majority of the data analysis, with TRP doing the crux of the analysis and JEB conducting cross-checking on a sub-set of transcripts to confirm the coding framework and thematic analysis. One of the risks with qualitative research is that researchers can unintentionally bias various aspects of a study, with their own beliefs, values or preconceptions, which can result in an 'outsiders' view or interpretation of the data [45]. Despite TRP and JEB meeting regularly with the wider research team to discuss findings and challenge their assumptions about the attitudes and cultural backgrounds of the participants, it is possible the data were interpreted through their own cultural and gender lens as white female researchers. Additionally, had two to three researchers coded the entirety of the data (cross-coding/multiple coding) instead of one researcher doing the majority of the analysis, this would have provided more rigor to the analysis. While it would have been ideal to undertake cross coding of the data using multiple coders, which would have further assisted in mitigating bias, this was not possible due to time and resource limitations. This approach serves as a valuable strategy where these limitations apply [46].
A further limitation of this study was that participants were only offered a relatively narrow form of member checking, whereby they were asked if they would like to check the accuracy of their manuscript. While all participants indicated they were happy to be contacted again following the interview, none took up the offer to check their manuscripts for accuracy. In hindsight, having a broader approach to member checking, whereby men were re-engaged at the point of data interpretation to participate in a member check interview to offer their views on interpretation or their own interpretations of the data, would likely have ensured a more rigorous and potentially more accurate understanding of the data, thereby minimising the risk of a 'outsider' conflation or construction of Asian culture and Asian gay men's experiences. If broader member checking activities had been employed, promoting a more inclusive approach to the research, men would likely have re-engaged at a greater level, allowing for a more nuanced understanding of their experience.
This study contributes to the growing body of knowledge on the challenges facing Asianborn gbMSM living in Australia as well as enhancing the research surrounding HIV and sexual identity-related stigma. Our findings are consistent with previous literature showing prevalent sexual identity stigma in several countries in Asia and the impact of stigma on sexual identity concealment. Additionally, our data highlights the potential discrimination Asian-born gbMSM face in Australia, which has implications for social connectedness, particularly with regard to LGBTQI communities and HIV testing practices. Future studies should determine effective strategies to reduce sexual identity and HIV-related stigma in newly-arrived Asianborn gbMSM.