Living with Dual Minority Identities: Intersectional Stigma and Resilience among Chinese Seropositive Men Who Have Sex with Men

Abstract

Seropositive (HIV+) men who have sex with men (MSM) face severe challenges related to their dual disadvantaged minority identities. Guided by the minority stress theory, numerous studies have examined the distinct impacts of stigma on people living with HIV and on MSM. However, several gaps remain in this field of research. First, little research has examined the Chinese context despite minority stress being a contextualized process. Second, researchers have treated the effects of each minority identity in isolation and thus ignored how stress from various minority identities intersects in an individual. Third, viewing minority groups as disadvantaged has led to research on intersectionality of dual minority identities focused on oppression and neglected the resilience people demonstrate in facing adversities. Fourth, most previous studies using a cross-sectional design have failed to illuminate the prolonged impact of intersectional stigma on people with dual minority identities and the long-term capacity of protective factors to mitigate that detrimental impact.

Guided by the intersectional framework, this dissertation addressed the following research questions: (1) How do Chinese HIV+ MSM perceive stress related to their dual minority identities? (2) How do the stigmas related to those two minority identities intersect with each other? (3) How do the stigma and resilience related to each minority identity intersect with each other and generate a compound impact on Chinese HIV+ MSM? (4) How does intersectional stigma affect Chinese HIV+ MSM’s psychological adjustment over time, and to what extent are the effects mitigated by resilience?

Study 1 examined the perception of multidimensional stress related to dual minority identities. We conducted semi-structured, in-depth interviews with 21 Chinese HIV+ MSM. Applying thematic analysis, we extracted five themes within a multilevel socio-ecological system: Psychological and physical threats and Externalization and concealing conditions at the identity-representation level, Self-identification at the intrapersonal level, Family pressure at the family level, and Community engagement at the community level. Our interviewees narrated their stigma experiences pertaining to each theme for both minority identities. Stigma experiences interact bidirectionally across levels. The results highlighted that culturally salient components of minority stress, such as pass off to comply with norms and family pressure (i.e., stigma brought to the family and the stress of forming a new family and perpetuating the family lineage), are prominent in Chinese HIV+ MSM’s interpersonal relationships.

Study 2 investigated the intersecting process of multidimensional stigma constructs—those related to both HIV status and MSM identity—across identities. We investigated the interrelations and interdependence among the constructs of intersectional stigma related to the HIV+ and MSM identities. A total of 111 Chinese HIV+ MSM completed the self-report stigma survey that measured negative self-image, family stigma, and disclosure concerns related to HIV+ and MSM identities. Network analysis findings illustrated the interrelated connections between stigma constructs. The interdependence mediation model findings demonstrated the interdependent nature of these constructs and identified the mediating role of family stigma within and across the two identities.

To go beyond illuminating the consequences brought by stigma associated with minority identities, Study 3 integrated an empowerment-based perspective with an intersectional lens to examine the manifestation of intersectional stigma and resilience at multiple levels and investigated their compound impacts on Chinese HIV+ MSM. A total of 21 Chinese HIV+ MSM participated in semi-structured interviews. Using thematic analysis, we identified two overarching themes and six subthemes. The theme of Intersectional manifestation consisted of the Aggravating effects and the Alleviating effect at the intrapersonal, interpersonal, community, and structural levels. The theme of Compound intersectional effects arising from two minority identities included the psychological burden of Continuing familial lineage, Health disparities, Psychological distress and growth, and Financial concerns.

Study 4 examined the effects of the intersectional, multidimensional dual stigma arising from HIV+ and MSM identities on psychological adjustment and resilience’s moderating role over time. One hundred and twelve Chinese MSM who were newly diagnosed HIV+ were surveyed twice, with six months in between surveys. The results indicated that dual stigma related to HIV and MSM identities at baseline increased distress symptoms six months later. Resilience moderated these effects that as the dual stigma increased, distress symptoms intensified more rapidly among individuals with lower levels of resilience than among those with higher levels of resilience.

This thesis applied the minority stress theory to Chinese HIV+ MSM and provided new knowledge on a culturally specific minority stress process by investigating that minority stress across multiple dimensions (seropositive and sexual minority status) at multiple levels and found the bidirectional interactions of stigma across levels. The interdependence among stigma constructs across minority identities depicted the intersecting process of dual stigma. Together with the intersecting and compound impacts of intersectional stigma, this dissertation contributed to the theoretical elaboration of the intersectional framework and expanded the intersectional framework to incorporate an empowerment-based viewpoint by identifying multilevel resilience resources that is conducive to psychological adjustment. The quantitative study’s longitudinal research design allowed for uncovering evidence of intersectional stigma’s long-term impact and of resilience’s protective role. These findings inform the development of culturally responsive stigma measures for assessing minority stress and culturally tailored services and interventions to alleviate it. The results also provide insights for future health practices by integrating the deficiency-empowerment paradigm, such as reducing intersectional stigma while building resilience for psychological adjustment among HIV+ MSM.

Date of Award	30 Jun 2023
Original language	English
Awarding Institution	City University of Hong Kong
Supervisor	Xiaonan Nancy YU (Supervisor)