Hiding in plain sight: highlighting the research gap on access to HIV and other sexual health services for underrepresented gay men in developed Western countries – insights from a scoping review with a focus on Arab men

The Arab case study

In the broader landscape of hidden GBMSM populations in the developed Western world, Arab men present a compelling case study, offering insights into the unique experiences of individuals who descend from 22 countries in the Middle East and North Africa (MENA) region with a range of ethnicities, cultures, and religions.¹³

It is likely that men from Arab backgrounds make up a meaningful part of the wider GBMSM population in developed Western countries. In countries such as Canada, the US, New Zealand, France, Germany, Italy, and Australia, Arab individuals make up significant portions (ranging from 1 to 10%)^14–19 of their total populations. In Australia, Arabic remains the third most spoken language in the country after English and Mandarin.¹⁶ Additionally, GBMSM residing within the Arab world are often motivated to migrate to the West in search of sexual freedom.^20,21 This motivation can be driven by the fact that, within the Arab world, GBMSM remain a heavily stigmatised group^22–26 and often have poor sexual health outcomes, including an increased risk of HIV and STIs.²⁷ Further, a combined fear of legal ramifications due to the illegality of homosexuality, a delay in the acknowledgement of the existence of HIV, as well as HIV and other sexual health-related stigmas, particularly from within healthcare settings,^28–30 have led to significant knowledge gaps³¹ as well as hindered testing, prevention and treatment efforts in large parts of the region.^32,33

Within the diaspora, access to HIV and other sexual health services may be more difficult for Arab GBMSM as has been reported for other ethnic minority individuals, such as Asian, Black, Native American, Pacific Islander, and Hispanic men in developed Western contexts.^4–7 These groups have reported experiencing multiple forms of discrimination due to their intersecting sexual, religious, and ethnic/cultural identities.^8–10 These experiences, which are often influenced by a complexity of other intersections such as culture, religion, sexuality, socio-economic status, language barriers, and/or migration status, can make it difficult to access appropriate health services, negatively impacting their overall health, such as sexual health outcomes, including increased risk of HIV and other STIs.^9,11,12 Similarly, heterosexist narratives prevalent in the Arab world transcend geographical borders and present themselves within diasporic Arab communities in the developed Western world.^34–39 Although there is some evidence to suggest that younger generations of Arabs are more tolerant than those who came before them,⁴⁰ homosexuality is generally still not accepted within Arab cultures. In addition to experiences of racism and exoticisation within gay communities,⁴¹ some research on migrant and refugee men, including those from Arab backgrounds, indicates that they also experience violence and abuse due to their sexual orientation from within their ethnic communities, at times creating barriers to accessing support services.^20,21 Further, very limited data suggest that these men are less likely than their non-Arab counterparts to test for HIV⁴² and have higher HIV incidence compared to other groups.⁴³

Although there is some research pertaining to access to mental health services for Arab GBMSM,⁴⁴ the bulk of Arab community-related HIV and other sexual health-related research in developed Western countries has focused only on heterosexual populations.²⁷ Although this is important, it does not reflect the epidemiology of HIV and other sexual health concerns within the context of the developed West, where rates of HIV remain highest among the GBMSM population. Thus, the aim of this paper was to identify, document, and assess the current literature pertaining to the availability and utilisation of HIV and other sexual health services among Arab GBMSM in developed Western countries.

Identifying the research question

Based on the focus of this paper, the research questions were broadly identified as:

Identifying relevant studies

A multi-method search strategy was employed to identify relevant literature. Several systematic searches were conducted on OVID EMBASE, ProQuest (Medline), PsychInfo and Scopus and were filtered in accordance with the PRISMA guidelines. No start date was set for study inclusion, and the search was conducted until October 2022.

The search strategy was drafted by the first author (BS) and further refined through team discussions with the other investigators (MK, MH and GP). In each database, the search was conducted in accordance with the corresponding guidelines for literature searches. The search strategy included variations of controlled and uncontrolled index terms of the following concepts: (1) Arab, (2) GBMSM, (3) HIV and other sexual health services, and (4) developed countries. To capture the Arab identity (1), the Boolean operator ‘OR’ was used to connecte all the Arab nationalities, as well as variations of ‘Islam/Muslim’, in order to capture Muslim-specific publications that may include Arab men. To capture the GBMSM identity (2), umbrella terms such as ‘queer’, ‘LGBT’, ‘gay’, ‘bisexual’, ‘sexual minorities’, and ‘sexuality diverse’ were used. To capture access to HIV and other sexual health services (3), umbrella terms such as ’HIV’, ‘sexual health’, ‘chlamydia’, ‘syphilis’, and ‘gonorrhea’ were used. To capture developed Western countries (4), a list of countries, including the US, Canada, Australia, New Zealand, and large parts of Europe – in accordance with the 2019 United Nations’ Country Classification report –⁴⁸ was used. The Boolean operator ‘AND’ was used to connect the four concepts. The search strategy, including all relevant search terms, is outlined in the Supplementary material. No filter searches or language restrictions were applied to capture all available research on this topic. Additionally, the snowball method and manual reference tracking of recent literature reviews on similar topics^27,49 were conducted to ensure that all potentially relevant studies were included.

Study selection

We developed selection criteria through an iterative process that involved the examination of the references and discussions between two authors (BS and MH). The authors aimed to include peer-reviewed published papers that reported on primary data outlining the experiences of Arab GBMSM in developed countries; focused on access to HIV and other sexual health services, including testing and prevention; and presented interventions aimed at addressing stigma around sexuality and sexual health. Our aim was to examine outcome measures that included sexual health perceptions and knowledge, skill development, increased testing and/or preventative uptake, and general health-seeking behaviours. Prevalence-only papers, mortality reports, studies on healthcare workers’ perspectives, and studies on sexual/erectile dysfunction were excluded.

Charting the data

A summary table was drafted by the first author (BS) with the following headings: study location, year conducted, study purpose, study focus/measures, study design, participants (including sample size, ethnicity, country of birth, gender identity, age, sexual orientation, and religion), and main sexual health findings (including definitions of access, sexual practices, sexual knowledge, access to testing, reason for testing, access to HIV preventatives [such as PrEP], regularity of engagement, and barriers and/or facilitators). Two other authors (MK and MH) aimed to independently extract and compare the relevant data from the full text of eligible studies. Due to the scarcity of literature that met the inclusion criteria, however, the summary table was not used.

Characteristics of included study

In our extensive literature review, only one article, authored by Lessard et al.,⁵⁰ met the inclusion criteria of our study. The study analysed the experiences of migrant GBMSM in Canada, specifically their use of Actuel sur Rue (AsR), a rapid HIV testing and linkage point to a local clinic – Clinique médicale l’Actuel – that specialises in the testing and treatment of HIV and sexually transmitted and blood-borne infections (STBBIs) in Montreal. From the sample of 40 GBMSM who took part in the study, only 15% of the participants (n = 6) identified themselves as migrants originating from the MENA region.

Our initial analysis revealed that the available data from this subgroup, although limited in size, offered valuable insights into the facilitators for accessing HIV testing and treatment services among Arab GBMSM in a Western context. Notably, these facilitators encompassed factors that are commonly associated with HIV risk, such as recent risk-taking behaviours, experiencing symptoms of STBBIs, and a prior lack of HIV testing. However, it is essential to clarify that the study did not directly compare the knowledge or behaviours of these men with a broader population of Arab GBMSM in Canada. Instead, it sought to understand the specific context in which these men sought HIV testing and treatment services at AsR. The study’s general findings provide valuable insights into the factors influencing HIV testing and treatment among a subgroup of migrant GBMSM. Nonetheless, it is important to acknowledge the limitations associated with the small sample size (n = 6) of men from the MENA region and the potential for recall bias due to the 2-month gap between the clinic visit and survey completion.

Barriers to research and recruitment

Challenges related to participant recruitment, including factors such as social stigma, cultural barriers, and limited representation within existing networks, contribute to the complexities encountered in conducting research on Arab GBMSM. Data from the Arab world reveals that it is common practice for gay men to conceal their identities and sexual practices from healthcare providers within their socially conservative communities.⁵⁵ In these contexts, if they are perceived as anything other than heterosexual and/or to potentially be living with HIV, a great deal of shame and disgrace would be placed on their families by the wider Arab community. In many Arab cultures, this is exacerbated by unfavourable wider Arab community labels of homosexuality as a ‘sin’ or haram, meaning ‘forbidden’.^22,23

The concealment of sexual identities and practices from healthcare providers is a phenomenon that likely transcends borders, persisting not only within the Arab world but also extending to developed Western contexts. Further, factors such as the illegality of same-sex relationships in many of their Arab ancestral countries, significant discrimination and social pressure fuelled by lack of exposure and awareness, societal and familial norms, religious and cultural factors, and associated perceptions of gender and sexuality, may also contribute to a reluctance of Arab GBMSM to acknowledge their sexuality, let alone discuss such topics with researchers.^24–26 The authors from the one study that met the inclusion criteria for our review did indeed reinforce a common understanding of confidentiality as an important factor in accessing HIV and other sexual health services for some populations of gay men.⁵⁰ This echoed Evans’ et al.⁵⁶ findings that some populations of gay men are generally harder to reach for research purposes and are more likely to provide sexual information, if any, through online or electronic devices than during in-person or face-to-face interactions. Additionally, it is plausible that researchers of Arab descent may have concerns about potential repercussions or backlash for themselves from their own Arab communities when conducting research on this topic. Fears of being identified (or ‘outed’) and/or facing experiences of homophobia or vilification themselves may further contribute to the scarcity of this research.

Inadequate data collection efforts

Insufficient attention and effort directed towards comprehensive data collection methods have contributed to the dearth of information regarding the experiences of Arab GBMSM in sexual health research studies. Arab ethnicities have often been underrepresented, misclassified, or at times pigeonholed into the ‘White’, or ‘Other’ racial category in Western data collection efforts⁵⁷ and are, therefore, undercounted. For example, historically in the US, early migrants from Lebanon and Syria fought to be considered as ‘White’ in order to be accorded citizenship and land ownership rights.⁵⁸ Ajrouch and Jamal⁵⁹ found that Lebanese and Syrians, as well as Christian Arabs, were still more likely to check ‘White’ on a racial demographic form and be less comfortable self-identifying as ‘Arab American’ compared to, for example, Yeminis and Iraqis. This dissociation for some from their Arab identities can be attributed to many migrant and ethnic minority Arabs, including GBMSM, feeling disenfranchised due to their experiences of prolonged and systemic racism.⁶⁰ This added complexity of a lack of granularity in racial categorisation, observed in various contexts, such as census data, health forms, and research surveys, may have resulted in a failure to capture key information specifically related to Arab GBMSM.