“Building that strong energy”: An exploration of stigma coping strategies among sexual and gender minorities in Nigeria

Abstract

Sexual and gender minority stigma (SGM stigma) affecting Nigerian sexual and gender minorities (SGM) is associated with suboptimal HIV outcomes, and one mechanism found to explain the relationship is suicidal ideation. A better understanding of coping strategies may help mitigate the harmful impacts of SGM stigma. Interviews of 25 SGM from Abuja, Nigeria participating in the [Blinded for Review] study were thematically analyzed in regards to how they coped with SGM stigma. Four coping themes emerged: avoidant behaviors, self-monitoring so as to not attract stigma, seeking support and safe spaces to be themselves, and empowerment and self-acceptance through a process of cognitive change. They utilized multiple coping strategies, often believing that stigma could be avoided through the right actions and a masculine appearance. Multi-level and person-centered interventions that increase safety and support, facilitate resiliency, and improve mental health and engagement in HIV programming could mitigate the effects of SGM stigma and coping responses of isolation, blame, and mental health stressors among Nigerian SGM.

Introduction

Sexual and gender minority stigma (SGM stigma) is the co-occurrence of labeling, stereotyping, status loss, and discrimination within a power imbalance targeted at multiple levels among persons identifying as SGM (e.g. gay, bisexual, and other men who have sex with men [MSM], and transgender [gender binary or non-binary] individuals) (Link & Phelan, 2001). SGM stigma manifests at the structural (policy, institutions, community), interpersonal (enacted stigma), and individual levels (anticipated and internalized stigma) (Stangl et al., 2019). SGM stigma was common among participants in a large HIV prevention and treatment cohort in Nigeria, the [Blinded for Review] study [Blinded for Review]. Not only does Nigeria have the second largest HIV epidemic in terms of people with HIV, but participants of our cohort had an HIV prevalence as high as 44%−66% [Blinded for Review]. In Nigeria, HIV transmission may be exacerbated by heightened fear of seeking healthcare and accessing HIV testing because of the passing of the Same-Sex Marriage Prohibition Act in 2014 [Blinded for Review]. In the [Blinded for Review] study, SGM stigma was associated with new HIV infections by way of suicidal ideation and participants who reported both SGM stigma and suicidal ideation had a 35%−54% lower odds of having had an HIV test [Blinded for Review]. At the same time, other participants who experienced SGM stigma but not suicidal ideation actively engaged with HIV services. These findings suggest the synergy of emotional responses with SGM stigma may activate differing coping behaviors.

Coping is “conscious volitional efforts to regulate emotion, thought, behavior, physiology, and the environment in response to stressful events or circumstances” (Compas et al., 2001, p. 89). Different from resiliency, it includes efforts to adapt to stress, whether effective or not, whereas resiliency is thought to result from successful or effective coping. Stressors generally only harm one’s health if they tax or exceed one’s coping resources speaking to the potential to mitigate suboptimal health by shaping coping (Miller & Kaiser, 2001). Coping is a dynamic process involving the use of many strategies that can be multifaceted and interdependent (Lazarus & Folkman, 1984). Coping with stigma characterized by disengagement or avoidance have often been linked to suboptimal mental health, whereas behaviors more consistently linked to positive mental health include problem solving, social engagement, and cognitive restructuring (Miller & Kaiser, 2001).

Research on SGM has often included coping as a mechanism in the association between stigma and mental health (Hatzenbuehler, 2009; Meyer, 2003; White Hughto et al., 2017). Most of the research, though, originates from higher-income countries where access to mental health professionals and coping resources may differ from that of low- and middle-income countries (LMICs). Studies of SGM in Nigeria suggest suboptimal mental health and hiding of one’s same-sex behavior are common, but these were not evaluated within a theoretical and empirical framework of coping (Allman et al., 2007; Sekoni et al., 2015). For the one study that used the minority stress model to frame coping behaviors, it was unable to describe the interconnectedness of various coping behaviors (Ogunbajo et al., 2020). Using the theoretically-rich lens of coping may provide cohesion for disparate behaviors previously considered unrelated as a way to highlight agency among SGM, a strengths-based approach. Coping strategies, if characterized by problem-solving, seeking social support, and cognitive restructuring, have the potential to impact health-seeking behavior as has been demonstrated among MSM in the US (Rood et al., 2015).

Our study employed qualitative methods to better contextualize coping strategies as important mechanisms of the SGM stigma-HIV relationship [Blinded for Review]. Augmenting coping behaviors conducive to good mental health may positively impact stigma mitigation strategies on multiple levels. Knowing the Nigerian coping response to SGM stigma may reveal ways to improve mental health, facilitate resiliency, and increase engagement with HIV prevention and care.

Methods

Data Collection and Study Design

The [Blinded for Review] study, is a prospective cohort of SGM recruited through respondent driven sampling into HIV prevention and treatment services at two community-based organizations (CBOs) in large urban cities, Abuja and Lagos, Nigeria [Blinded for Review]. SGM were enrolled if they were 1) assigned male sex at birth, 2) aged at least 16 years in Abuja and at least 18 years in Lagos, and 3) reported a history of anal sex in the past year.

Adapting a sequential explanatory mixed methods approach (Creswell, 2003), we designed and developed a semi-structured interview guide. Our objective was to gain richer insight and details based on our prior quantitative analyses that suggested our participants fell into three stigma subgroups—low, medium, and high [Blinded for Review]. Through implementing this design approach, we gain richer insight and details to better understand mechanistic relationships (Hanson et al., 2005; Plano Clark & Ivankova, 2018). As of July 2016, participants with medium or high stigma were purposefully sampled from the Abuja site to ensure sufficient stigma experience. We recruited several members of our CBOs, [Blinded for Review], to assess whether SGM who provided services to SGM had different coping strategies as compared to those less engaged with HIV services. This resulted in a sample of 22 participants, including two staff engaged in [Blinded for Review] and one not engaged in [Blinded for Review]. All provided written informed consent and institutional review board approval was obtained for the study.

The semi-structured interview guide was administered in English, audio recorded and transcribed. The interview captured previously significant constructs, including SGM stigma, disclosure, mental health, HIV testing, and engagement with HIV care [Blinded for Review]. Participant characteristics such as socio-demographics, psychosocial characteristics, HIV status, and self-reported indicators of anticipated and enacted stigma were accessed from the parent cohort using STATA Version 13 (StataCorp, College Station, TX).

Qualitative Analysis

Thematic analysis (Braun & Clarke, 2006) was conducted and coded by two researchers trained in qualitative research methods, using MAXQDA Analytics Pro (Version 12; Berlin, Germany 2016). The researchers used an iterative coding process allowing for the return to previously coded data and for refinement and synthesis of codes (Elliott, 2018). The first 12 interviews were double coded to establish an early codebook. Using an inductive approach for categorization and sorting, the meta-theme of coping was identified as a common signal of mental health processing subsequent to experiencing stigma. Coders grouped and labeled themes and subthemes relevant to coping patterns, highlighting supporting text to assure consonance with codes, emergent themes, and the overall narrative. Upon establishing agreement of codes for the first 12 interviews, definitions were created to guide independent coding of the remaining transcripts. To resolve coding disagreements, consensus was achieved through contestation of the coders’ reasoning and constructs from the coping literature refereed the consensus-building process. The separately coded narratives were reviewed by both coders to further resolve coding discrepancies and contextualize coded data.

Measures were taken to improve the credibility and validity of the findings. Member-checking was used to establish conceptual reliability and quality of inferences through two events: (1) a presentation and discussion in Abuja on early findings for a large group of SGM individuals; and (2) a group discussion among Nigerian SGM asylees living in New York City to review coping patterns and themes. Several individuals in both events had participated in this study. The feedback and dialogue about meta-inferences helped to establish interpretive boundaries of the analysis, contributing to interpretive rigor (Plano Clark & Ivankova, 2018).

Results

Most participants identified as men, had not disclosed same-sex sexual practices to family members, were living with HIV, experienced suicidal ideation, and experienced SGM stigma (Table 1). They described mental distress (e.g. sad, traumatized, suicidal, disheartened), lack of safety (e.g. scared, alone, unsafe to be yourself), and the belief that something may be wrong with them (e.g. embarrassed, shamed, evil, something bad inside you) (Figure 1). Some of the feelings reflected possible trauma, which aligned with their descriptions of enacted stigma involving violence. Participants frequently spoke of “set ups”, which usually involved meeting a potential online sex partner at his home and encountering several men who used violence to take money and possessions of value in exchange for freedom.

Table 1.

Prevalence of sexual and gender minority stigma, socio-demographic characteristics, HIV, suicidality, and sex work in a sample of Nigerian sexual and gender minorities.

	Qualitative Sample
Participant Characteristics	N	%
	24a	100.0
Sexual and Gender Minority Stigmab
Family Made Discriminatory Remarks	4	16.7
Friend Rejection	8	33.3
Fear of Seeking Health Care	12	50.0
Police Refused to Protect Them	9	37.5
Scared to Walk in Public	8	33.3
Verbally Harassed	13	54.2
Blackmailed	13	54.2
Extortion	14	58.3
Physical Violence	9	37.5
Rape	3	12.5
Tortured By Someone	5	20.8
Age
16–19	0	0.0
20–24	11	45.8
25–29	7	29.2
≥30	6	25.0
Gender
Male	19	79.2
Female	0	0.0
Both male and female/Versatilec	5	20.8
Sexual Orientation
Bisexual	18	75.0
Gay	6	25.0
Heterosexual	0	0.0
Disclosed Same-Sex Behavior
To A Family Member	6	25.0
To A Health Workerd	10	43.4
HIV status
Negative	5	20.8
Positive	17	70.8
Unknown	2	8.3
Ever Experienced Suicidal Ideation
No	11	45.8
Yes	13	54.2
Made a plan to commit suicide
No	15	64.3
Yes	9	37.5
Sex workd
No	12	52.2
Yes	11	47.8
Safe places in their areas to go socialize with MSM
No	9	37.5
Yes	11	45.8
Don’t Know	4	16.7

^aN=24; We did not have survey data for a staff member that was not also a study participant.

^bAll questions are asked of participants as have they ever experienced each indicator and was it because they have sex with men.

^cParticipants used the terms “both male and female” and “versatile” interchangeably. In Nigeria, gender may also be indicative of sexual position. Therefore, those that identify as versatile or both male and female may be indicating that they engage in insertive and receptive anal sex.

^dDue to answers of don’t know, refusal, or missing, the following variables are missing 1 answer: disclosure to a health care worker and sex work.

Figure 1.

Most frequently reported feelings following sexual and gender minority stigma among a sample of Nigerian sexual and gender minorities.

Four themes emerged on how they coped with stigma: avoidant behaviors, self-monitoring so as to not attract stigma, seeking support and safe spaces to be themselves, and empowerment and self-acceptance through a process of cognitive change.

Avoidant behaviors

Avoidant behaviors were commonly described by participants who had experienced violence or trauma and involved physically avoiding or removing oneself from situations that could lead to stigma: general withdrawal and social isolation from others, hiding, avoiding other SGM, avoiding people perceived to be heterosexual, and/or relocation of residence.

Those who engaged in general withdrawal or social isolation behaviors did so for a sustained period of time and often described feeling that they did not have others they could talk to, turn to for help, or trust. More so than with other avoidant behaviors, these individuals appeared to experience symptoms of suboptimal mental health in response to stigma that had been violent or public in nature. One participant described his withdrawal and loss of freedom after experiencing blackmail and extortion. He said:

Uncomfortable, scared, lonely, no one to talk to…It made me, it changed a lot of things in me. I love partying, and I love going places, I love travelling, so I hardly travel, I hardly travel to have an experience or meet with someone. If it’s not business that’s making me travel, I don’t go anywhere… Once my dad happens to know he might throw me out of the house and I might have no where to be, so I just had to like leave the house as early as possible. Get an apartment. Stay on my own and visit the family once in a blue moon.

Closely aligned but subtly different was hiding as a general behavior. These individuals greatly feared being discovered as a SGM and the stigma that could follow. They did not consistently report poor mental health as those engaged in withdrawal and appeared to use hiding as a selective strategy, periodically meeting other SGM when perceived as safe. One person said:

No, I have been hiding, I have been discreet. [What do you think would happen to you if you weren’t hiding?] Well I think if I wasn’t hiding, a lot would have happened. From my family down to my friends, the people around me, the society, it would have gone a little bit rough for me, so I think the hiding for me is making life better for me.

Some talked about avoiding other SGM. This was particularly the case in two situations: 1, when they had been set up by someone they believed to be a SGM or someone pretending to be one or 2, if a SGM friend was outed and they wanted to avoid the stigma that could occur from association. An example of the first rationale was expressed by someone who said:

It is worse enough that you cannot express yourself. Then when someone within your community is now, you know, using that against you, I felt so bad and am scared to meet people. Am scared to be on Grindr. It’s not like, you can only trust yourself.

An example of the second rationale was when a participant’s friend was arrested and needed his help but he felt that he could not help him. He said:

Last time a friend of mine got arrested in Nyanya and all that, so, because of, he called me. I said no, am not coming because he was in police station. I said no, am not coming there, am not coming there to avoid anything, any issue, talk, because of the, the country we are in.

Others relocated to another city, to another part of a city, or spoke about a desire to leave Nigeria altogether as a result of stigma. In some cases they were forced to relocate, which would not be considered coping. In other cases, relocation was a strategy to distance themselves from family who were unwelcoming and made stigmatizing comments, or was carried out preemptively in situations where they feared stigma might occur.

Self-monitoring so as not to attract stigma

Self-monitoring behaviors were very common and encompassed monitoring and modifying one’s own appearance and behavior. They also included monitoring the behavior of other SGM, caution with online dating platforms, and using coded language. Though closely related to avoidance because they both sought safety, self-monitoring was defined as more internally-directed behavior resulting from an anxious monitoring of the self whereas avoidance reflected a more externalized pattern of behavior toward situating one’s environment and relationships. Self-monitoring behaviors described their need to constantly adjust their gender performance, including their mannerisms, dress, and speech, to meet societal norms of masculinity and heterosexuality and to conceal their identity or sexual behavior. One participant’s words illustrate self-monitoring:

Frankly speaking, it’s just gotten to a stage that you have to box yourself, to shape yourself to what the environment really want. With my experiences, I know that I just have to try and restrict acting as I want to, as to try to watch football. I have to talk about things I don’t really want to talk about. Sometimes, it goes as far as changing clothes and changing cloth, like oh, this is too tight, oh, this is too short, they will think am gay, oh, is my ass looking big in this? Okay, I want my hair cut, I have to make sure I have to keep the beard even when I don’t want to so I look very manly and all that. So you have, I have to end up shaping myself into what I don’t really want to, I can’t really talk about things that I want to.

Some engaged intra-group policing of behavior by teasing or attributing blame to victims of SGM stigma, believing that this increased their personal and collective safety by remaining concealed as SGM. This coping response was most common when it was perceived that stigma was provoked by effeminate behavior, romantic or sexual pursuit of a heterosexual man (an attempt to “convert”), or behavior associated with sexual promiscuity. These “provocative” behaviors were sometimes referred to as not “playing safe.” One participant blamed his experience on a friend who behaved effeminately when visiting him at school:

So I have this friend that is very girlish, so he came to visit me in school and wanted to follow me to school. I’m like okay, you have to tone it down, my school is not, you know, well he is just himself, he is just being himself, then on our way to the campus, some group of guys just started shouting, that oh, look at them, they are gays, the way they are dressing, see the way they are cat walking, oh God, it was really embarrassing…It was because I was walking with so and so person that’s why I got this and I told him okay, this is the last time I will walk with you in public, because I don’t want any unnecessary attention for myself. [How did your friend respond?] He felt very bad, very, very bad and he was even almost crying about it. Am like oh, you shouldn’t be crying about this, we are not bashed, and, you know, he felt really bad about it and then me telling him that, oh, this should be the last time am gonna walk with you on the street and all that, like why would I say that to him, and since then, I don’t think I have seen him, yeah.

It is worth noting that monitoring behaviors helped participants to navigate potentially dangerous social interactions and settings, but they contributed to stress, isolation, constant monitoring of one’s surroundings, and a belief that individuals need to successfully avoid stigma. A participant who was blackmailed and extorted found that when he tried to warn other SGM he was blamed and shamed for it. When he persisted in talking about it, it came to light that others had been set up by the same individual. He said:

So I sent the picture out to a lot of people, and you know, there is this thing within the MSM community, sometimes when you tell your story, people tend to laugh at you, so I told some people. When you cannot even sit down in one place, you want to be jumping from one dick to another, so that’s what happened to you. You know, they will just laugh at you sometimes and you get scared sharing your story, but I don’t care, so I told everybody. They should just be careful with this guy and when I shared the picture, some people started coming out, oh this guy did the same thing to them, but they didn’t tell anybody.

Set ups were usually perpetrated by someone they had met online, so some participants became cautious or altogether stopped using online dating apps. Meeting SGM online can be easier and safer when there are scant public places designed for SGM, but it places them in danger from those who exploit the same-sex laws knowing SGM will not seek the police.

Seeking support and safe spaces to be themselves

The theme of seeking support and safe spaces to be themselves relates to the intra-community support and social capital Nigerian SGM provided each other despite stigma. They spoke of going to their SGM friends for emotional support, advice, help when stigma occurred, instrumental support, information, to joke with, for someone to check up on them during rough times, and as someone with whom they could be themselves. An important component of this was their utilization and appreciation for the services and safe space provided for by the study site. SGM friends linked each other to the facility and it was often spoken of as not only a place for HIV services, but a place they could express themselves and freely meet other SGM. To a lesser extent, family provided a social and material source of support. For some of them, at least one close family member knew their sexual orientation or gender identity and continued to support them rather than eject them from their lives. One participant described the benefits of socializing with SGM:

When you sit with your fellow community and you drink, like during birthday party like that, just once in a while, you hang out with your community people and you feel happy. Some other community people say, when you hang out with your fellow community people, even if you are living with the virus, you forget everything because you gist [gossip] and even boost your immune system. Maybe if you are thinking too much and you see your friends, your community friends and you sit down with them, gist with them, it makes you happy, so it will reduce stress.

A number of the participants had been or were currently peer educators and took great pride in improving knowledge on HIV, supporting individuals to test and engage in care, and supporting one another. A peer educator, described the support he provided:

I love coming to work here a lot, and you know, since you can’t really come out and say oh am gay, you can’t really help people by coming out, you can learn, then build your own community and educate everybody. So I just love the whole thing. I just, I just love it, talking, I love talking too, telling people, encouraging them, giving them, telling them reasons why they should stay negative and all that, you know. So it’s something that I love, interests me, like I enjoy it when am with different stories from different people, it makes me to build myself and you know. [It makes you feel better?] Yeah, it makes me feel better and it makes me feel happy. At the end of the day, they are looking for help and I was able to offer them, because I have a friend, till date, anytime he calls me, the first thing is oh, he thank you, if not because of you, I will still be having anal warts.

Not only was the collocated [Blinded for Review] a place that hosted social events and an employer of peer educators, but it allowed participants to easily engage with study and healthcare staff behaving effeminately or in other ways of their choosing. One participant said:

If it is a community place like this, you know, when you go there, you are accepted in that place. You can do anything you want to do, so even if they are asking you questions there, like all these questionnaires now…When you come, the person will feel comfortable, he will feel relaxed, because he knows it’s a community center. If any question you ask him, he will be free to answer you.

Speaking to the freedom to be themselves at [Blinded for Review], another participant said:

Any issue we have, we run up here, we come here. So when you come here, you feel happy. You can flaunt the way you want to walk, you can catwalk the way you want to catwalk. Nobody would say anything to you, because it’s a community center. But as soon as you go outside, you have a rethink of yourself, that where I am going now, I am not accepted there, so you have to behave yourself, which you will not be happy.

Empowerment and self-acceptance through a process of cognitive change

A number of participants initially felt distressed following stigma but described that over time they felt strong or courageous and came to accept themselves. One felt bold enough to challenge stigmatizing actions or to discuss the rights of SGM with heterosexual individuals, provided there was no evidence of their SGM status that could be reported to the police. Participants described a change in their thinking or spoke about their current beliefs of themselves in spite of stigma, often saying the phrase “this is who I am.” Spiritual faith, education on HIV and human rights, and a personal process of growth and self-efficacy to manage stigma, appeared to contribute to self-acceptance and empowerment.

Religion could be a source for stigma as well as a source of comfort and a way to reframe why they existed. Some reconciled their experience reasoning that God had made them the way that they were. One said:

We have Lucifer you see today was an angel in heaven. He was trying to be God. That was why God threw him down to come and dominate the earth. So I believe those attributes were something that were inside of him, do you get what am saying? This attribute now, they are things that are inside of him, now he is come to dominate the earth, what do you expect? There are so many people that are born that way. Sometimes I even tell them okay, why do we have hermaphrodites? So, do you want to tell me that God made some people different and made other people different? So there was never a time I felt bad, when I accepted who I am, I just owned up and told myself this is who you are. Nobody owns your life. Anything I do is to my God.

Education and knowledge of human rights provided a vocabulary to help frame responses when confronting stigma. One peer educator courageously confronted his harassers with human rights. He said:

It’s only when you don’t know your rights as a person, just like I said before, some lady trying to harass me, and then I walked up to her, is something wrong with you? Do I know you from Adam? Yes I challenged her, and that courage came within me, and I also went to the police station and wrote down a statement, that please if anything happens to me, it’s this lady, because I don’t know her from anywhere, so why is she harassing me? So I think the courage is just something that it builds over time, when you always look at yourself, and you feel you can never be intimidated by anybody.

A number spoke about a personal journey to self-acceptance using phrases like “developing a thick skin” or “building that strong energy.” Although self-acceptance is an important goal, coping that emphasizes self-control and emotional suppression runs the risk of placing too much of the burden of stigma on the individual. One participant said:

Yes, I guess, it’s a personal thing. You need to work on your personality. You don’t feel depressed about anything around you, because definitely it must still happen. It must come around. People must talk something silly, something funny, and you might not like, and the only way to just let that pass is for you not to pay attention. Start with yourself, try to be, try to know how to give yourself positive talk and positive thinking about yourself and definitely, things will work out smoothly...I don’t really know, because if you try as much as possible just talk things, it’s gonna cause more. So it’s just, let them be, definitely, they will still want to do more, it’s just, for those being stigmatized, it’s for them to know how to control the emotions when it comes to them so it doesn’t bring them down.

Their words demonstrate a belief in the inevitability of stigma and the use of coping strategies associated with improved mental health, distraction and cognitive change, as well as the use of suppression or emotion regulation that can deplete cognitive resources.

Discussion

A coping framework provides a strong theoretical basis for coherence across a variety of emotional and behavioral responses to SGM stigma, highlights the health ramifications of SGM stigma in a more holistic manner than does a focus on individual risk behavior, and explicates the complexity in ways that suggest actionable points of intervention. Many Nigerian SGM experienced violence, intimidation, and extortion that can result in trauma and enduring mental health effects. Coping that appeared beneficial to mental health included seeking social support, safe spaces, and framing their emotional responses through empowerment strategies of self-acceptance, education, advocacy, and spirituality. The process of coming to accept themselves is indicative of cognitive change (Gross, 2015) or reappraisal, a commonly cited coping strategy, and is an important component of cognitive behavioral therapy (CBT) and other effective mental health interventions. Coping should be complemented with strategies at the structural, interpersonal, and individual levels for a multi-level and person-centered approach.

Many of the behaviors within the avoidance and self-monitoring themes can be thought of as an effort to conceal their SGM status, akin to disengagement coping (Miller & Kaiser, 2001), with the primary goal of staying safe. Concealment can lead to suboptimal mental health (Jackson & Mohr, 2016; Pachankis et al., 2020), but it may also be protective in countries with high levels of stigma (Pachankis & Bränström, 2018). SGM concealed themselves by withdrawing socially, avoiding SGM, monitoring their appearance and speech, cautiously using dating websites, coding language, and relocating.

Avoidance is a common mediator between stigma-related stressors and psychopathology (Hatzenbuehler, 2009); it’s a form of social avoidance and isolation (Pachankis, 2007) and a situation selection strategy (Gross, 2015). Self-monitoring, on the other hand, is less understood. There was a pervasive ethos that stigma could be prevented through the right actions and a masculine appearance. As one said “Be gay and be wise. I tell them all the time, try to avoid the stigma.” Goffman wrote that stigmatized individuals try to enact behaviors deemed appropriate by society so as to be seen in the best light and modern theories discuss impression management and self-monitoring behaviors (Goffman, 1963; Pachankis, 2007). An individual attribution for stigma resonates with Meyer’s caution against shifting the weight of responsibility for societal oppression to the individual (Meyer, 2003). At the structural and interpersonal levels, it may have unintended consequences of reducing collective action to challenge stigma, intra-group support and social capital, and blaming those that do not adopt these behaviors, particularly transgender individuals. At the individual level, SGM may attribute stigma to personal shortcomings rather than their stigmatized group membership and feel shame, guilt, and low self-esteem. But, as human rights frameworks have empowered SGM, so too could SGM be empowered by the reframing of stigma as a structural problem along with supportive multilevel interventions.

At the broadest level, Nigeria needs to decriminalize same-sex sexual behavior in order to provide health services and build up social capital for SGM. Structural-level strategies reduce internalized stigma in LMICs (Pantelic et al., 2019) and could include crisis hotlines, shelters, financial strengthening to prevent transactional sex, integration of trauma-informed care within organizations, and utilizing peers to design and deliver interventions (Sprague et al., 2019). Education on how stigma manifests, its impacts on health, and multi-level solutions could be rapidly introduced into the curricula of organizations serving SGM (Lyons et al., 2017; Van Der Elst et al., 2015). Nigeria has a shortage of mental health professionals (World Health Organization, 2020) necessitating creative and tailored approaches for suboptimal mental health and trauma. Task shifting to lay mental health workers (Abas et al., 2018) and integration of care may better utilize scarce resources. As an example, the study site dually served medical needs as well as facilitated coping characterized by seeking support, empowerment, and self-acceptance.

The vulnerability of SGM to set ups that result in suboptimal mental health, trauma, and financial vulnerability is largely possible because of criminalization and the unregulated nature of web-based dating platforms in many African countries (International Gay and Lesbian Human Rights Commission, 2011). Nigerian SGM have reported high utilization of online dating sites [Blinded for Review]. They would benefit from learning how to safely navigate dating spaces (Zane, 2019) that authenticate users on these platforms to prevent set ups (Scruff Support, 2019). Some Nigerian SGM are posting, themselves, the information and pictures of people who carry out set ups to protect others (lagosheat.wordpress.com and kitodiaries.com).

At the interpersonal level, forging meaningful connections within the SGM community creates a protective solidarity (Amirkhanian, 2014; Meyer, 2003) and is a measure of resiliency (Herrick et al., 2014). Social support can be structurally supported through hosting support groups, utilizing social networks to reach non-disclosing individuals, and hiring peer workers. A number of participants had been peer educators, a role that provided a stipend in a context of widespread poverty, health education, and access to emotional support through social networks. Social support also provides an opportunity for SGM to focus on identity-affirming aspects of their lives and to savor them with their community, which may foster happiness in SGM (Jackson et al., 2020). Mhealth and anonymous means of providing support may offer another avenue for solidarity, friendship, and social support (Flickinger et al., 2018).

Families are another resource for young SGM. Young participants in the [Blinded for Review] study have decreased healthcare engagement and higher HIV incidence than older participants, speaking to increased vulnerability [Blinded for Review]. Programs like the Family Acceptance Project in California (https://familyproject.sfsu.edu) and the Gender and Family Project in New York (https://www.ackerman.org/gfp/) create safe and accepting family environments for SGM youth through a holistic set of services that include counseling and support groups for families, education, and referrals. In some cases relocation can be viewed as a problem-solving coping behavior as they were proactively removing themselves from the stressor, but in other cases it adds stress and adds new dangers such as financial hardship and transactional sex. The degree to which relocation is adaptive or maladaptive for one’s health may be determined by the circumstance, the frequency of using the strategy, and the degree to which one is able to resettle successfully. A study of coping among young MSM in Los Angeles, CA recommended counseling, to determine whether to leave home, and compensatory coping strategies, such as seeking out gay-affirming individuals or organizations (McDavitt et al., 2010).

At the individual level, the stress and trauma of stigma must be addressed and healthy coping augmented. Unhealthy or stressful forms of coping, particularly avoidance, was more strongly associated with HIV progression than stressors themselves or mental health (Chida & Vedhara, 2009). Integrating mental health counseling into HIV services provides an opportunity to screen for coping, mental health, and to administer CBT. CBT is effective in teaching individuals to redefine the meaning of threatening and stressful events. It can be adapted to the needs of SGM (Safren & Rogers, 2001) and to sub-Saharan African contexts (Murray et al., 2015). A study of MSM in New York City found that CBT was associated with reduced depressive symptoms, condomless sex, gay-related stress, rejection sensitivity, and internalized homophobia, synergistically benefiting mental health and reducing stigma and HIV risk (Pachankis et al., 2015). It’s important that an intersectional lens be used for individual-level strategies (Turan et al., 2019). This would enable multiple vulnerabilities to be addressed simultaneously that occur at the intersection of stigma, HIV, mental health, and poverty.

This study had a few limitations. Coping was not a primary objective of the qualitative study, which may have resulted in fewer details; as well, describing coping required thinking back over a span of years, which increases reporting bias. Substance use, a stigmatized coping strategy, may have been underreported because of social desirability bias. Selecting those who spoke English may have introduced selection bias and therefore may not represent non-English speaking SGM in Abuja, Nigeria. Many of the participants were peer educators and they may have higher levels of HIV education [Blinded for Review] and resiliency. It was beyond the scope of this analysis to: 1) diagnose mental illness or 2) to establish the timing of coping in relation to mental illness—participants’ behaviors may have influenced subsequent mental health or been influenced by their mental state—or 3) to tease out coping from internalized stigma. Internalized stigma is often strongly linked to mental health and certain emotions described by participants (e.g. “worthless”) may have reflected internalized stigma that influenced coping. Future research could benefit from microlongitudinal assessments and structural equation modeling of different types of stigma, coping, and mental health in order to dynamically assess potential causal pathways. Concealment, for example, may be an underlying latent variable that causes distinct but related dimensions or classes of behaviors (e.g. avoidance, self-monitoring) with unique associations with health outcomes (Jackson & Mohr, 2016).

This study strengthened the previously explored relationships of SGM stigma with HIV outcomes among Nigerian SGM [Blinded for Review] by characterizing a diversity of coping responses that may impact mental health. Our findings provide actionable and specific information on the cognitive and behavioral implications of stigma that can be addressed in a manner that is multi-level, holistic, and person-centered. A greater focus on structural-level approaches that incorporate coping strategies, can promote longer-term resiliency and well-being.