Behind the paper: Between worlds: Cis-and trans-identifying diaspora Middle Eastern and North African (MENA) women in Ontario, Canada on the intersections of gender, sexuality and sexual health

In this post, we talk to the authors of the recently published paper Between worlds: Cis-and trans-identifying diaspora Middle Eastern and North African (MENA) women in Ontario, Canada on the intersections of gender, sexuality and sexual health, by Roula Kteily-Hawa, Olesya Falenchuk, Bessma Momani, Vijaya Chikermane, Susan Bartels, Praney Anand, Rania Younes, Nahla Abdel-Tawab, Nadia N. Abuelezam, Lina Hammad, Tina Pahlevan, Rama Eloulabi, Ahmad Ezzeddine, Anmar Al-Ezzawi, Mohammad Akel, and Mona Loutfy

What led you to decide on this research question?

The Greater Toronto Area in Ontario, Canada has seen a steady increase of young adults from Middle Eastern and North African (MENA) diaspora communities accessing sexual health services at local AIDS Service Organizations in the past 7-10 years. Many of these youth were newcomers to Canada, identified as sexual and gender minorities and had intersecting vulnerabilities, including language barriers, housing and employment challenges.  To address this need, some of these community-based organizations (CBOs) hired staffing to support MENA youth programming and services. A need for conducting research to produce informative and culturally responsive resources for this youth group was identified. In the absence of research and to further understand this alarming reality, the Alliance for South Asian AIDS Prevention (ASAAP), a CBO in downtown Toronto that provides sexual health programming for Arab and Farsi speaking LGBTQ+ youth reached out to the Principal Investigator, Dr. Roula Hawa to discuss potential programming built on sound research principles.    

A recurring theme of addressing the sexual health needs of MENA youth continued to emerge. A prominent, similar and uniform message arose from across Ontario and about 23 CBOs across Ontario engaged in dialogue.  CBOs serving people living with HIV or at risk of HIV in Ontario, MENA community advocates, and MENA networks across Ontario unanimously agreed that it is essential to address the alarming increase in HIV and sexually transmitted and blood borne infections (HIV/STBBIs) in MENA youth population to improve the care cascade. That gave birth to the Youth Sexual Health and HIV/STBBI Prevention in Middle Eastern and North African Communities (YSMENA) study, the first and only community-based research program in Canada that centres MENA young adults’ HIV, STBBIs and overall health needs, with a focus on LGBTQ+ communities.

Presenting our research with peer research associate Ahmad Ezzeddine at the 2023 Canadian Association for HIV Research in Quebec City

Could you talk us through how you designed your study? What was important for your team as you created the study team?

As we created the study team, it was important for us to engage the MENA community in Ontario and MENA youth in all steps of the research. We formed a Community Advisory Board comprised of community leaders and MENA youth affected by and living with HIV. In keeping with community-based participatory research principles, a peer leader model was adopted with the objective of building community capacity in research and knowledge generation and six (6) MENA Youth Peer Research Associates (PRAs) were recruited. All PRAs underwent a two-day extensive training in community-based research principles, which included: key principles of community and participatory research; social determinants of health; anti-oppression frameworks; intersectionality; research ethics and confidentiality; informed consent; administering surveys; managing difficult conversations; focus group facilitation; how to unpack privilege; and more. This extensive training equipped PRAs to support development of research tools and materials, participant recruitment and promotion, and data collection with them facilitating qualitative focus groups, and administering quantitative socio-demographic surveys.  

Given the absence of any kind of research engaging this youth community in Canada, it was important for us to develop some kind of baseline sociodemographic data and in-depth information around sexual health, mental health and access to health resources. A mixed-methods approach using a survey, journals, and sequential dialogical focus groups discussions was deemed suitable. 

Infectious disease specialist Dr. Mona Loutfy and Dr. Alan Wai, psychiatrist specializing in mental health and HIV care

What challenges did you encounter during your study?

The main challenge that we faced in this study had to do with youth recruitment due to extreme stigma. Sexual health is a taboo topic among Middle Eastern communities and the youth, particularly sexual and gender minority youth, were very hesitant to participate in research that is focused on sexual health, HIV prevention and STBBIs. Using a peer-led model helped offset some of these challenges as the peers had an established relationship with other MENA youth in the community. Despite the challenges, our team was successful in recruiting and engaging youth in all steps of the research.

What did you find most striking about your results? How will this research be used?

What was most striking about the results was shame and stigma associated with sexual health, which impacted the health-seeking behaviour of MENA youth and resulted in barriers in accessing much needed health and social services. Another noteworthy finding had to do with transphobia that all trans women experienced in spaces of service delivery translating into pervasive sexual health and HIV-related stigma and discriminatory treatment by health professionals, which exacerbated their exclusion.

This research will be used to: 1) create resources for healthcare services and providers that encourage queer and sex positive spaces; 2) provide guidelines for training for health care workers, particularly as they are serving trans and gender diverse MENA youth; 3) create awareness towards sexual health needs of diaspora MENA youth and increase service access for those with MENA language needs.

YSMENA youth digital art social

What further research questions need to be addressed in this area?

• How do you build capacity within MENA youth communities and strengthen community knowledge mobilization;
• How do you advance community-centred approaches to HIV/STBBI care for MENA youth? and
• How can we, enable and/or facilitate access to health services that address structural, social, behavioural, and biomedical determinants of health for MENA youth, particularly those identified as key populations affected by HIV/STBBIs?

Why did you choose PLOS Global Public Health as a venue for your article?

Our team chose PLOS Global Public Health because of its focus on addressing deeply entrenched global inequities in public health and amplifying the voices of underrepresented and historically excluded communities such as Middle Eastern and North African communities. Moreover, being a reputable open access journal gives us confidence that our findings will reach across disciplines and regional boundaries.