Introduction

In the past 5 years, many studies about Asian lesbian, gay, bisexual, transgender, queer (LGBTQ+) sexual health have been conducted throughout Asia and the Asian diaspora. HIV/AIDS risk and prevention studies among gay men, men who has sex with men (MSM), and transgender women dominate the current research landscape on Asian sexual health with the rise of HIV infection rates. Much of this research tends to take a reductive view of LGBTQ+ communities as vectors of disease and often does not focus on the subjective experiences of individuals in these communities.

Other areas of research on Asian LGBTQ+ sexual health have examined sexual health communication, sexual health care, values and attitudes, sexual orientation and identity, and experiences with sexual violence. Much of the literature in these areas suggests that many Asian LGBTQ+ individuals do not feel safe to disclose their sexual orientation and/or gender identity to others, including healthcare providers and family members. This may lead to negative health outcomes for LGBTQ+ Asians, such as increased rates of STIs and other infections, poor mental health outcomes, and a lack of sexual health screenings, risk assessments, and treatments.

Methods

To frame this review, we looked to a recent content analysis of sexual research in the field of counseling psychology [1]. While we excluded the thematic analysis specific to counseling, we concluded that the other themes provided a robust framework to conduct our search. Those themes were the following: sexually transmitted infections; sexual orientation, identity, and minorities; sexual abuse, objectification, and victimization; sexual functioning, satisfaction, and pleasure; and sexual health, communication, and values. With those themes in mind, we conducted a search of literature published in the past 5 years (since 2015) about Asian and Pacific Islander (API) sexual health in the following databases: Academic Search Premier, Academic Search Ultimate, Alt HealthWatch, CINAHL, ERIC, Health Source, MEDLine, PsycINFO, SocINDEX, and PubMed. The search terms we used were Asian, Asian American, specific Asian ethnicities (e.g., Bangladeshi, Chinese, Filipino), and LGBTQ or lesbian or gay or homosexual or bisexual or transgender or homosexual or queer or sexual minority.

HIV/AIDS

The vast majority of recent literature on Asian LGBTQ+ people focuses on HIV/AIDS be. The research on HIV/AIDS in Asia examines prevalence, prevention, testing, and risk factors. Most of the studies focus on MSM, including studies that use the labels gay, bisexual, or homosexual [e.g., 2, 3•, 4]. Many of the studies also include transgender women, as well as other groups that are classified as high risk for contracting HIV such as sex workers, drug users, and migrants [e.g., 5, 6•]. As Ly et al. [7•] asserted, there are problems with how the term MSM gets applied and in some cases the term is inclusive of transgender women. Using the term MSM as a catchall behavioral categorization overlooks identity-based labels that people use to describe themselves. Not only can the use of terms in this way negate the identities of participants, but they also hinder recruitment and the utility of interventions. Overall, the studies on HIV/AIDS tend to focus on participants as risk groups. He et al. [3•] attempted to challenge this narrative in their qualitative study of Chinese gay men that focused on socio-cultural factors. However, overall, there is less focus on their subjective experiences that may factor into their risk behavior or what it is like to live with stigma related to sexual or gender identity or HIV.

China was the country with the highest number of studies on HIV followed by Vietnam. The studies with samples from China covered a broad range of topics: HIV prevalence among MSM and transgender women [8•], HIV prevention including use of post-exposure prophylaxis (PrEP) among MSM [2] and transgender women [9], risk factors for HIV among MSM [3•] and transgender women [10•], mental health among MSM recently diagnosed with HIV and social support seeking of Chinese gay men with HIV [4], and use of health services by gay and bisexual men [11]. Qualitative studies in China allowed participants to give voice to their own experiences, shedding light on sociocultural factors that influence sexual beliefs and behaviors for gay men [3•] and experiences of discrimination and lack of social support for transgender women [10•]. The studies with samples from Vietnam covered a variety of topics as well: HIV prevention including use of PrEP [12], HIV prevalence [13] and testing among transgender women [14], HIV prevention [15], HIV prevalence [16] and testing among MSM [17], and risk factors for HIV for MSM, including methamphetamine use and stigma [18•, 19]. A couple of the studies from Vietnam challenged the use of the term MSM highlighting the need to focus on identity instead [7•, 18•].

Other Asian countries represented in the recent literature to a lesser extent include Myanmar, Indonesia, Bangladesh, Cambodia, Japan, Malaysia, Nepal, Pakistan, the Philippines, and Thailand. These studies focused on HIV prevalence, testing, and treatment, with additional notable trends. Two studies with Malaysian LGBTQ+ samples, for example, examined the roles of Islam on their experiences [20•, 21•]. Storm and colleagues [6•] examined social and structural determinants of sexual risk among MSM and transgender women in Nepal and Usman and colleagues [22•] looked at post-diagnosis experiences of HIV-positive Hijra sex workers, which included rejection from other Hijras in their community due to HIV stigma. A study by Yi et al. [23•] examined transgender women’s experiences of discrimination in Cambodia. In the Philippines, one article examined the need to improve HIV/AIDS surveillance methodology to count the transgender population more reliably [24]. These studies provide examples of ways in which marginalization, both at interpersonal and structural levels, have negative impacts on the sexual health of MSM and transgender populations in various Asian countries. There are also a couple of studies that look at multiple Asian countries and adherence to treatment and retention to HIV care. Jiamsakul et al. [25] conducted a study in 12 Asian countries and concluded that being gay was associated with missed clinical visits among HIV-positive patients. In a study that spanned Bangladesh, Indonesia, Laos, Nepal, Pakistan, the Philippines, and Vietman, Koirala et al. [26•] found that transgender identity was one of several barriers to retention in HIV care, as were young age, sex work, imprisonment, illiteracy, rural residence, alcohol and injection drug use, perceived poor health status, lack of health insurance, fear of breach in confidentiality, self-referral for testing, and being diagnosed in a public hospital. Stigma has been identified as a barrier to HIV care. While there is recognition that there is a need to improve retention to care, there are no further recommendations for how to achieve this that addresses stigma.

Finally, there are a few studies that focus on the Asian diaspora to countries including New Zealand, Australia, the USA, and Canada. These studies were more likely to focus on culture including experiences with stigma related to being a sexual and/or racial/ethnic minority [27] and incorporating culture into HIV prevention [28, 29, 30•, 31••]. For example, one study found that changing cultural norms among immigrants could impact sexual practices [29], while another found that the cultural value of interdependency was positively correlated with safer sex practices [30•]. The role of culture should be further examined to inform HIV prevention among Asian diaspora populations and should also be considered within Asian countries.

Many of the studies reviewed in this section are co-authored by researchers from Western countries, which makes sense since these countries tend to have more resources to support research. While there is certainly a need for international collaborations to occur to support research in places that might not otherwise have the financial resources, there may be side effects in that Western values and theories may be applied to non-Western populations. There does not seem to be much exploration about what being MSM or transgender means for participants in Asian countries beyond stigma.

Sexual Violence and Abuse

The majority of the research focusing on sexual violence among Asian LGBTQ+ people focuses on MSM and transgender women. Queer women and bisexual people are notably understudied in this part of the literature. The literature from 2015 did not seem to be relegated to particular regions of Asia, as research is from different parts of Southeast Asia and South Asia, as well as from China and Japan.

There are particular variables that may increase the risk for sexual violence among MSM and transgender women’s communities. Feminine gender expression was found to be a predictor of risk for sexual violence among young MSM and transgender women in Myanmar [32•] and adult MSM and transgender women in Pakistan [33]. Problems with family members and having MSM friends with a high number of sexual partners put young MSM and transgender women in Myanmar at increased risk for sexual violence. However, those whose mothers accepted their same-sex sexual attractions and those who became aware of their same-sex sexual attractions at about the age of 16 were less likely to experience sexual violence [32•].

Substance use was associated with an increased risk for sexual- and gender-based violence. Weekly alcohol use and receiving payment for sex were also predictors of sexual violence among transgender women in Mongolia [34]. Transgender women in Cambodia who engaged in binge drinking were more likely to have experienced physical abuse (62.7%) and verbal abuse (70.9%) during childhood [35•]. Substance use among MSM and transgender women may be seen through the lens of minority stress theory [36], especially when coupled with the different risk factors for sexual violence. Substance use can likely be seen as a coping strategy in response to physical and sexual violence, sometimes in the context of sex work.

Sexual Orientation and Identity

Much of the recent literature examining sexual minority identity and sexual health among Asian and Pacific Islanders (APIs) has focused on the coming out process [37,38,39], homophobia [40, 41], and Chinese gay and bisexual cisgender men [41,42,43,44]. While many of the studies that focused on Chinese gay and bisexual cisgender men were large-scale quantitative studies, there were a few exceptions. For instance, Huang and Fang [45] interviewed 18 Chinese immigrant gay men living in Toronto about their intersectional minority identities. While participants acknowledged the marginalization and oppression they experienced, they also saw their intersectional identities as a source of strength and social support.

In another qualitative study, Liow and colleagues [46] examined 12 gay men’s perceptions of and experiences with intimate relationships in Malaysia. The men largely reported heteronormative perceptions of intimate relationships, emphasizing the importance of physical intimacy, a preference for masculine partners, emotional intimacy, and commitment. This may reflect the conservative sexual culture in Malaysia. However, the men in the study tended to engage in more liberal sexual practices, including open relationships and a fast-paced dating culture (e.g., engaging in casual sex).

Several studies also examined how gender roles (i.e., notions of masculinity and femininity) influence sexual health and behavior. Wang and colleagues conducted two studies [47, 48] exploring butch and femme identities and their relationship to body image and breast health among lesbians in Taiwan. Across both studies, Wang and colleagues found that butch-identified participants tended to hold negative views toward their breasts and were also less likely to seek out or engage in breast healthcare, relative to femme-identified participants. Chan [49] conducted a study of gay, bisexual, and queer Filipino male college students’ understanding, definition, and experiences of masculinity.

Our understanding of how various social identities affect and are influenced by perceptions and experiences of sexual health among Asians is limited. For a more robust and accurate picture of LGBTQ+ Asian sexual health, a few steps can be taken. First, more studies should use a strengths-based approach to sexual minority identities and sexual health among Asians throughout the world. Additionally, researchers should focus on the intersection of Asian sexual identities with other significant social identities, especially immigration status, gender identity, and ability. Finally, a number of groups are largely missing from the current literature on identity and sexual health and need to be studied, including LGBTQ+ adolescents and young adults, bisexual individuals, and transgender and non-binary individuals. While a handful of studies investigating the relationship between sexual identity and sexual health have been conducted in China, more attention needs to be given to populations in most other Asian countries and throughout the Asian diaspora.

Sexual Health Care

Of the studies focused on sexual health care, the majority of the studies were conducted in China [50,51,52,53,54,55,56] and Southeast Asia: Vietnam [57, 58], Cambodia [59], and Laos [60]. Some of the studies took place in the USA with diverse Asian ethnic groups [61, 62•, 63]. The majority of the studies specifically focused on urban populations in large, metropolitan areas [50, 51, 57,58,59,60,61, 64]. A diverse range of populations were sampled, including MSM, transgender individuals (primarily transgender women), lesbians, and healthcare providers serving sexual and gender minorities.

Several studies focused on the sexual health of MSM and transgender women. The sexual health risks facing MSM and transgender women include HIV [54, 59, 60], increased drug and alcohol use [54, 59], reduced physical and mental quality of life [55], reduced condom use [59], and interpersonal violence [56].

A few of these studies focused specifically on the sexual or reproductive health needs of sexual minority women, identifying as lesbian, bisexual, queer, or questioning. One study conducted in Beijing, China, examined HPV rates and cervical health among lesbians, finding a staggering HPV infection rate of 25% [50]. Another study explored the associations of sexual orientation and mental health care among lesbian and bisexual Chinese-, Korean-, and Vietnamese-American women and found that they were more likely to utilize mental health services than heterosexual women [62•]. A third study found health disparities with lesbian, bisexual, queer, and questioning women in China regarding breast health and cancer screening, while the fourth study, again in China, examined the challenges of family formation due to stigma held by providers and families [53].

Medical providers of sexual and gender minority populations were the focus of four of the studies. Two of the studies that took place in the USA examined the role of discrimination and/or bias in shared decision making between provider and patient [64, 66], whereas the other two discussed the severe lack of preparedness and knowledge of transgender women’s and MSM sexual health among providers in Vietnam [57, 58].

Notably, all of the studies pertaining to the sexual health of sexual and gender minority populations recognized the role of anti-LGBT stigma and bias as major barriers to adequate and accessible health care.

Sexual Health Communication, Attitudes, and Values

Communication with partners and health care providers is of critical importance to one’s sexual health. And yet, researchers have conducted a limited number of studies about sexual health communication among a narrow segment of Asian LGBTQ+ individuals in the past 5 years [28, 60, 65, 66]. Only one study [60] looked at communication among sex partners and it was limited to negotiations of transactional sex, in which monetary gifts or other services were exchanged among MSM in Laos. The researchers approached this study from a standpoint of STI/HIV risk prevention.

In one qualitative study, researchers explored how Chinese and South Asian gay and bisexual men living in New Zealand communicated about their sexuality and social lives [28]. Many of the men who were interviewed revealed that they had not disclosed their sexual orientation to family members or healthcare providers out of fear of rejection and stigma. In a national online study of more than 15,000 Chinese LGB individuals, researchers focused on disclosure of sexual orientation and experiences in health care settings [65]. Approximately 75% of respondents reported that they would disclose their sexual orientation to healthcare providers if asked. However, only 5.7% reported that a healthcare professional had ever asked them about their sexual orientation. Overall, respondents reported neutral or positive experiences in healthcare settings. However, about 70% said they restrained their gender expression when receiving medical care. This was particularly true for Chinese LGBs living in rural areas, those with lower levels of education and older LGBs. While these studies are limited in scope, their findings suggest that in order to provide quality sexual healthcare, they must demonstrate a high level of skill and comfort when communicating with Asian LGBs about sexuality. The last study focused on sexual health communication examined the use of technology among MSM in Vietnam seeking sexual health information [66]. Most of the MSM in the study reported using smartphones or other devices to seek out HIV/STI testing sites and information. All of these studies took a restricted approach to sexual health communication, mostly focusing on STI/HIV prevention and high-risk sexual behaviors.

Cultural attitudes toward LGBTQ+ communities in Western countries have rapidly grown more positive over the past 20 years, whereas they have been slower to do so in many Asian countries. Of the studies that have been done about Asian LGBTQ+ people, researchers have found that there is an emphasis on (heterosexual) marriage, children, and intergenerational familial relationships [67, 68]. For instance, Ren et al. [69•] conducted a study about lesbians and gay men who ostensibly enter into heterosexual marriages in China. Their findings suggested that doing so was motivated by the desire to maintain harmony in interpersonal relationships by adhering to traditional Chinese family values. Other studies showed that similar cultural values influenced LGBTQ+ individuals in Vietnam [70•], the Philippines [71], and South Korea [72].

Consequently, most studies that have been conducted about sexual health attitudes among Asian LGBTQ+ individuals have focused on internalized homonegativity (i.e., negative feeling about one’s sexual orientation that is a result of internalizing antigay cultural attitudes and stigma) in Asia and the Asian diaspora [41, 47, 71,72,73,74,75]. Across these studies, participants reported that they had disclosed their sexual orientation only to close friends and rarely to family members for fear of rejection and increased levels of stigmatization. Internalized homonegativity has been found to be associated with a host of negative psychological and physical health outcomes, including shame [73], depressive symptoms [76], suicidal ideation [72], engagement in high-risk sexual behaviors [75], and decreased quality of life and life satisfaction [77, 78] among Asian LBGs. Only one study focused on internalized stigma among transgender individuals. Researchers in the Philippines found that Filipino transmen reported higher levels of internalized transphobia than did transwomen in the study [71]. They also found that transgender men and women who reported internalized transphobia tended to also report lower self-concept clarity.

With few exceptions, nearly all of these studies were done with East Asians in the diaspora or the East Asian countries of China and South Korea. There was one study that reported that South Asian queer women regularly experienced racial microaggressions leading to erasure within LGBTQ+ communities in Toronto [79]. Another study showed variability in negative attitudes toward LGBTQ+ individuals across six Southeast Asian countries, with Indonesians showing the most homonegative attitudes and Filipinos reporting the least [70•]. Overall, more research about cultural values and attitudes toward and with LGBTQ+ communities is needed among South and Southeast Asians, transgender and non-binary individuals, and sexual minority cisgender women.

Mental Health

Much of the literature on mental health in Asian LGBTQ+ sexual health centers on depression, suicidality, and substance use. Consistent with other areas in sexual health reviewed in this article, most of the research focuses on gay men and transgender women. However, relative to other topics in sexual health, there appears to be more diversity regarding age (teens and older adults) and gender (lesbian and bisexual women). In addition, the focus of the mental health literature in these populations tends to utilize a clinical focus, rather than strengths-based approaches. While it is important to acknowledge the challenges these communities face, one inadvertent effect may be potentially over-pathologizing Asian LGBTQ+ people.

Several studies focused on suicidality among lesbian, gay, and bisexual people in China, South Korea, the Philippines, and Vietnam. Internalized negative emotions and exposure to stigma and discrimination appear to increase the risk of suicidal ideation and attempts in Filipino lesbians in two studies [80, 81] and in gay men [80]. Interpersonal support and connection with others appear to be protective factors against suicidality and depression. Among sexual minority adolescents in China, interpersonal support moderated the effects of victimization on sexuality minority status and suicidality [82•]. South Korean lesbian, gay, and bisexual adults who experienced discrimination based on sexual orientation were more likely to experience depression, unless they had high levels of community connectedness [76]. Social support fully mediated the relationship between sexual orientation and depression among Chinese sexual minority men [83]. Similarly, lesbian and gay Filipino high school students were more likely to attempt suicide if they experienced rejection and lacked maternal support [80].

Transgender mental health, particularly regarding depression and substance use, includes some overlapping features found in the LGB literature, but also contains unique factors. Over one in four transgender women sex workers from China reported depression symptoms, with low self-esteem and feelings of entrapment and defeat predicting depression [84]. About half of transgender people in China reported depression (50%) and thinking about suicide (56.4%; [85]). Similar to the literature on suicidality among API LGB people, interpersonal conflict, particularly with family, was one of the risk factors for suicidality. However, dissatisfaction with their sex assigned at birth and difficulty accessing gender affirming surgery were predictors for suicidality unique to transgender communities [84]. In South Korea, prevalence rates for both depression and suicidality were notably higher for transgender adults than in the general population [86]. Transgender people in Asian countries are reporting unmet mental health needs that are due at least in part to stigma and discrimination.

There were few studies that focused on the mental health needs of lesbian and bisexual women. Chinese, Korean, and Vietnamese lesbian and bisexual women were more likely to seek mental health services in the past year, but were also more likely to report unmet health needs compared to their heterosexual counterparts [62•]. Chinese lesbians with masculine or androgynous expression were less likely to be depressed than women with feminine expression, and self-esteem overall mediated the relationship between expression and depression [87].

Overall, Asian LGBTQ+ people tend to experience depression and suicidality at higher rates than their heterosexual, cisgender counterparts. These findings are likely more effectively viewed through minority stress theory [36]. In other words, it is likely that their greater mental health needs are due in part to lack of social support and the experience of institutional and interpersonal discrimination.

Conclusions

This review examined recent research about Asian LGBTQ+ people in Asia and the Asian diaspora. Much of this research focused on transgender women and MSM’s risk of HIV/AIDS and its prevention. The studies on HIV/AIDS primarily focused on participants as risk groups. The subjective experiences of participants were rarely discussed but may play a role in their risk behavior and experiences of stigmatization related to sexual or gender identity or HIV.

Other research on LGBTQ+ Asian sexual health examined sexual health communication and care, mental health, sexual violence, and the influence of cultural values and attitudes. Generally, it showed that LGBTQ+ Asians experience prejudice, stigma, and fear surrounding their sexual orientation and/or gender identity, preventing them from feeling safe enough to come out to healthcare providers and family members. This often puts LGBTQ+ Asians at increased risk of HIV/AIDS and other STIs, poor mental health outcomes, and increased risk of sexual violence. While much of this research approaches LGBTQ+ sexual health from a deficit perspective, we believe it would benefit from a strengths-based approach in order to get a more holistic picture.

Little is known about Asian LGBTQ+ sexual health of cisgender women, adolescents, non-binary individuals, transgender men, and asexual individuals. Thus, we recommend further research with these populations.