Stigma and the Intersection of Ethnicity, Gender, Romantic Relationships, and Serious Mental Illness: Perspectives from Latinxs with Schizophrenia and Their Family Members

Abstract

Romantic relationships are a fundamental part of the human experience and contribute to quality of life and recovery of people with serious mental illness (SMI). However, few psychosocial interventions exist to address this issue among people with schizophrenia, and no existing intervention focuses on Latinxs. The intersectionality of being Latinx and having schizophrenia can create a unique experience regarding stigma, romantic relationships, and gender. Guided by intersectionality theory, this study used qualitative content analysis and an intersectionality template analysis to examine data from interviews with 22 participants—11 people with diagnosed schizophrenia and their identified primary family member. Overall, findings illustrate perspectives about romantic relationships in a sample of Latinxs with schizophrenia and highlight the stigma that people with schizophrenia and their families can experience. Five key themes emerged from the data: obstacles to romantic relationships, advantages of romantic relationships, disadvantages of romantic relationships, gender-role issues and satisfaction with life, and hope for the future. Participants reported that stigma related to schizophrenia and the lack of employment were the main obstacles to establishing and maintaining romantic relationships. These findings provide an insider perspective on romantic relationships in a sample of Latinxs with schizophrenia and elucidate the importance of using an intersectionality lens to guide culturally responsive approaches.

Supportive romantic relationships, defined as positive, mutual, ongoing, and voluntary interactions between two partners characterized by specific expressions of affection and intimacy (W. A. Collins et al., 2009), are associated with good health and quality of life in the general population (Loving & Slatcher, 2013). Although people with SMI can be vulnerable to experiencing abuse and violence in romantic relationships (Khalifeh et al., 2015; Latalova et al., 2014; Oram et al., 2014), supportive romantic relationships can have a positive impact on their symptomatology and recovery (Boucher et al., 2016; Corrigan & Phelan, 2004; Padgett et al., 2008; Schön et al., 2009; Yanos et al., 2001). Supportive romantic relationships contribute to a sense of normalcy and belongingness (Boucher et al., 2016; Redmond et al., 2010) and persons with SMI regard having a meaningful relationship as a key facilitator and indicator of recovery (Boucher et al., 2016). Furthermore, the inability of people with SMI to establish romantic relationships and practice sexual expression due to illness-related barriers can lead to low self-esteem and decreased quality of life (de Jager et al., 2017; Segalovich et al., 2013). Qualitative and quantitative systematic reviews indicate that most persons with SMI aspire to be in a fulfilling romantic relationship but few are (Boucher et al., 2016; Cloutier et al., 2021; Helu-Brown & Aranda, 2016; McCann, 2010; McCann et al., 2019; White et al., 2021).

SMI includes disorders such as schizophrenia, bipolar disorder, and major depression that result in functional impairment that interferes with one or more life activities (National Institute of Mental Health, n.d., para. 4). Psychotic symptoms can occur in these conditions, particularly schizophrenia, featuring hallucinations, delusions, and blunted affect, which can impair a person’s ability to establish and maintain relationships (Cloutier et al., 2021; Östman & Björkman, 2013). Psychosis can make it difficult to make interpersonal connections that can lead to a romantic relationship (Boysen, 2017; Cloutier et al., 2021; Wright et al., 2007). Such barriers are compounded by widespread stigmatizing beliefs toward people with mental illness across all races, ages, and genders in the United States (DuPont-Reyes et al., 2020; Parcesepe & Cabassa, 2013). Stigma has a negative impact on persons with SMI, particularly because it leads them to internalize prejudice and discrimination, resulting in self-stigma (Corrigan & Rao, 2012). The internalization of stigma affects self-esteem and functioning in daily life and in turn, the ability to form romantic attachments (Blalock & Wood, 2015; P. Y. Collins, Elkington, et al., 2008; P. Y. Collins, von Unger, et al., 2008; Elkington et al., 2013; McCann et al., 2019; Ponting et al., 2020; Rüsch et al., 2005; Segalovich et al., 2013).

Although there is evolving research evidence on romantic relationships among adults with SMI and other disabilities (Brown & McCann, 2018; White et al., 2021) and greater attention has been paid to demographic diversity, few studies have reported ethnicity data or analyses by race and ethnicity or gender (White et al., 2021). These obstacles limit our understanding of the unique experience of Latinxs with schizophrenia and other minoritized groups disproportionally affected by documented disparities in mental health (Helu-Brown & Barrio, 2020; López et al., 2012). A qualitative study of people with schizophrenia in Mexico examined their gendered experiences as related to their illness and revealed role changes and expected prognoses as underlying themes (Ponting et al., 2020). Findings highlighted employment concerns, changes in romantic relationships, stigma, and symptoms that made it difficult to start a family as the main concerns tied to gender. These authors underscored the importance of further exploring gendered experiences and relationships in this population and including the perspectives of family members providing care (Ponting et al., 2020).

As a theoretical framework, intersectionality has been helpful in explaining and understanding the experiences of marginalized groups. Coined by Kimberlé Crenshaw (1989), intersectionality theory posits that social categories, such as sex, gender, sexuality, race, ethnicity, ability, and immigration status, are inextricably linked and reciprocally influence one another (Crenshaw, 1989; P. H. Collins, 2015; P. H. Collins & Bilge, 2016; Hancock, 2016).

According to Else-Quest and Hyde (2016), an intersectionality framework can be applied as both a critical theory and an analytic approach in psychological research. As a critical lens, intersectionality clarifies complex experiences of marginalization to facilitate greater understanding and guide more holistic solutions to address structural inequality (Abrams et al., 2020). As an analytic tool, it can be used to assess individual and structural or group factors and examine the axes of multiple social categories and linked identities to understand experiences and social processes (P. H. Collins & Bilge, 2016; Else-Quest et al., 2022; Torres et al., 2018).

Thus, an intersectional approach might consider how stigma may be more burdensome for a person who is Latinx and has a schizophrenia diagnosis. A California statewide campaign revealed that most Latinx adults with SMI had higher levels of self-stigma and were more likely to conceal a mental health issue from peers compared to Whites (Wong et al., 2021). Latinxs are often socialized to believe that people with mental illness are dangerous and out of control and that mental illness is incurable, which results in rejection, distancing from others, and delaying treatment until symptoms became more severe (Caplan, 2019). Even when they seek treatment, intersecting stigma remains a barrier for Latinxs with SMI (Collado et al., 2019). Stigma among Latinxs with SMI can be understood as an intersection of social categories—being an ethnic minority and having a disability—each of which represents a source of oppression (Mizock & Russinova, 2015). Gender can also contribute to the burden of stigma and oppression for Latinxs with SMI, because adherence to traditional gender roles has been correlated with emotional distress (Nuñez et al., 2016) and understanding the influence of gender on people’s lived experience of schizophrenia is important for mental health care and treatment (Ponting et al., 2020). Additionally, discrimination and undocumented immigration status can further compound the burden of mental illness on Latinx communities (Corrigan et al., 2017; Helu-Brown & Barrio, 2020; Ortega et al., 2018).

The family context for Latinxs with SMI is especially salient because more of them live with family members compared to other demographic groups (Barrio et al., 2003; Hernandez & Barrio, 2017; Hernandez et al., 2019), but most studies examining supportive romantic relationships have not included the family perspective. Considering the perspectives of people with SMI and their primary family caregiver has revealed sources of strength and burden, generating a more nuanced understanding of the influence of family dynamics that may inform psychosocial approaches (Hernandez & Barrio, 2017; Hernandez et al., 2019).

To address the knowledge gap in existing research, the present exploratory study examined how people with schizophrenia and their family members experience stigma related to romantic relationships and gender in the context of ethnicity and schizophrenia. We also explored how participant narratives reflected the intersection of ethnicity, romantic relationships, gender, and mental illness to shed light on these relationships.

Method

Author Positionality

We provide our positionality to elucidate our lens on the data and how our identities and backgrounds relate to the research topic and the participants’ identities (Abrams et al., 2020; Roberts et al., 2020). All three authors are Mexican-origin, Spanish–English bilingual–bicultural licensed clinicians with extensive practice and research experience in the Latinx community. One researcher has lived experience as a sibling of an individual with schizophrenia, and another researcher has personal lived experience of mental illness. The second and third author carried out the parent study, whereas the first author framed the subsequent studies based on her research interest in relationships, gender, and sexuality. We used an intersectionality framework to guide the conceptualization, data collection, and analysis. Reflexivity practices were applied to data coding, analysis, and interpretation to heighten awareness of the influence of our identities and power differentials in relation to the participants (Abrams et al., 2020).

Sample and Data Collection

Participants were initially part of a family intervention study for Latinx family members of people with schizophrenia receiving community-based mental health services (Barrio & Yamada, 2010). Latinx outpatient adults diagnosed with schizophrenia were recruited from two outpatient community mental health clinics and asked to identify a key family member to participate in family-focused treatment (Hernandez et al., 2022). During the parent study, several themes emerged regarding barriers to treatment and recovery and perceptions of treatment outcomes. This led to Substudy 1, involving 14 participants and 20 family members from the intervention group in the parent study. Participants in Substudy 1 talked about hope for the future, including romantic relationships, as a motivator for well-being. Therefore, using an inductive approach, the current study (Substudy 2) examined romantic relationships.

Of the initial pool of participants from the parent study and Substudy 1, a convenience sample of 13 family members and 11 people with schizophrenia from the intervention group agreed to participate in Substudy 2; however, only data from complete dyads were used. The final sample consisted of 22 participants (11 people with schizophrenia, hereafter referred to as participants, and 11 family members; see Table 1). Interviews took approximately 60 to 90 minutes. All participants provided informed consent and received compensation for their time. The study was approved by the university institutional review board.

Table 1.

Characteristics of Family Members and Participants with Schizophrenia

	Family Members (n = 11) M or n (%)	Participants with Schizophrenia (n = 11) M or n (%)
Agea	61	34
Gender
Female	9 (81)	2 (19)
Male	2 (19)	9 (81)
Marital status
Married	8 (73)	0 (0)
Separated	1 (9)	1 (9)
Divorced	0 (0)	1 (9)
Widowed	1 (9)	1 (9)
Single, never married	1 (9)	7 (64)
Cohabitating	0 (0)	1 (9)
Relation to person with SMI
Mother	8 (73)
Father	2 (19)
Son or daughter	1 (9)
Place of birth
Mexico	10 (91)	3 (27)
El Salvador	1 (10)	1 (10)
United States	0 (0)	7 (63)

Note. Percentage values may not total 100% due to rounding error. SMI = serious mental illness.

^aRange was 30–63 for family members and 24–69 for participants with schizophrenia.

To accommodate participants’ needs and respect their preferences and level of comfort, the interviews were conducted in their preferred location and language. Six participants were interviewed individually and five preferred to be interviewed with their family member. Qualitative analysis of the observations and notes by interviewers indicated that people who preferred to be interviewed with their family member in the room appeared comfortable and indicated no inhibition. Ten participants were interviewed in English, and all 11 family members and one participant were interviewed in Spanish.

All interviews included open-ended questions, designed through an intersectionality framework, to elicit the participants’ experiences of romantic relationships, mental illness, and the role of gender in their lives. Questions for participants included: How would you describe your relationship status? How has your illness affected how you connect with others romantically or intimately? Is there anything about your relationships that concerns you? What do you think needs to happen for you to feel satisfied with your life as a [man or woman]? Questions for family members included: What are your hopes and expectations about your family member’s personal life? What do you think needs to happen for your family member to feel satisfied with [his or her] life as a [man or woman]? How has your family member’s illness affected [his or her] ability to connect with others romantically or intimately? Interviews were recorded, transcribed, and checked to ensure accuracy.

Analysis

We employed a multistage analysis that combined an inductive content analysis in Phase 1 with a deductive intersectionality template approach in Phase 2.

Phase 1

We used qualitative content analysis, in which questions from in-depth interviews were used to identify information on romantic relationships, gender, and mental illness (Schreier, 2014). The three bilingual–bicultural team members performed the coding. Using NVivo qualitative software, two members reviewed and coded segments from the first eight interviews (four participants, four family participants) that highlighted themes related to the research questions and the intersectionality framework as the initial categories. They also established coding rules to develop a coding agenda. Next, team members analyzed four more interviews (two participants, two family members) and revised the initial categories. Any emerging themes were either added to the coding agenda as a new category or subsumed in previous categories, resulting in the final coding agenda. Finally, team members examined the co-occurrence of codes and used ongoing comparative analysis to reach a final consensus on themes (Charmaz, 2014).

Phase 2

The template analysis consisted of a reinterpretation of the Phase 1 themes through an intersectionality-informed analytic template. Sirma Bilge (2009) introduced this form of analysis to allow researchers to make connections among participants, social categories, and broader social relations reflective of sociohistorical and structural inequality after an initial phase of analysis (Bilge, 2009; Bowleg, 2008; Hunting, 2014). Phase 1 of the analysis organized the data and determined overall themes, whereas the intersectionality template facilitated the reorganization of preliminary results in a deeper, more meaningful manner that illuminated the intersections among the overarching themes (Bilge, 2009; Brooks et al., 2015).

Initially, articulating the participants’ experiences regarding ethnicity and mental illness for the template analysis made the most theoretical sense. Thus, the intersectionality of Latinx and SMI identities was inextricable from participants’ narratives and allowed us to analyze their interplay with respect to gender and romantic relationships. Guided by Bilge’s (2009) approach, the template focused on the question: How do ethnicity and SMI inform the participants’ narratives? Because intersectionality guided our template, we also asked: How do ethnicity and SMI interact with other social categories in the participants’ narratives? Quotes from participants’ narratives were extracted to examine instances of intersectionality and added to the final template (Table 2).

Table 2.

Intersectionality Template

Category and Theme	Social Category	Discrete Consideration	Intersectional Consideration
Obstacles: Unemployment and lack of confidence	Ethnicity, SMI, and gender	Honestly, it’s difficult to find someone. For one, I don’t find it comfortable for me myself, because I know the questions. “How much do you make? Where do you work? What do you drive? And where do you live?” And a lot of them normally look at you and [say], “I don’t know about that one.” Very rarely will you find someone who will accept you.	Gender intersects with a cultural belief that men must provide for a woman to be considered able or worthy to have a romantic relationship. This seems to be particularly oppressive for men with schizophrenia because their symptomatology can make them unable to obtain or maintain gainful employment.
Obstacles: Unemployment and lack of confidence	Gender, ethnicity, SMI, and immigration status	That’s when she got angry and I said some things because she made me feel insecure, like I had nothing to offer. But I told her, “You don’t have anything either. You might be receiving SSI or government support, but you have papers. Those of us without them could do much more, and you girls have them and do nothing.”	For Latino men with schizophrenia, being undocumented can further the strain on them to find employment, and this is amplified by their inability to receive government assistance. By not having any means to obtain money, they are less able to establish and maintain a romantic relationship.
Obstacles: Unemployment	Ethnicity, SMI, and gender	In order for him to have a relationship I tell him he has to work. I tell him, “A family needs money, a woman needs to eat and dress and have shoes and an apartment.” … Sit down and do the math. … He needs to be stable and get a job because I say, “You are not going to be bringing a woman to this house, you need to work and be on your own.”	This intersectional consideration reflects the disadvantage for Latino men with schizophrenia regarding romantic relationships. It appears from the narratives of both family members and people with schizophrenia that their worthiness of a relationship is tied to having a job and money to support a partner. However, for people with schizophrenia, obtaining and maintaining gainful employment can be difficult.
Obstacles: Unemployment, gender-role issues, and satisfaction with life	Ethnicity, SMI, and gender	Well, as a man he has an aspiration to get married one day, but he needs to have a steady job. His goal is to see life as normal, like everyone else.	All family members who shared about gender-related life satisfaction stated that a romantic relationship would help the person with schizophrenia feel satisfied with life. However, the family members of males with schizophrenia said that for this to happen, they first need a job. This coincides with previously stated beliefs that men must have a job to have a romantic relationship. This may make it more difficult for Latino men with schizophrenia to establish and maintain a romantic relationship.
Obstacles: Reproductive ability	Ethnicity, SMI, gender, and fertility	I can’t have children. So, it makes it difficult in the future if you find a man and he wants … a baby. It’ll be a difficult thing.	Being female and unable to have children can be a disadvantage for Latina women with schizophrenia. There was an overall hope and desire from family members to have those with schizophrenia find a partner and have a family, but this may be even more difficult for women who are unable to have children. It may affect their ability to find or maintain a partner if the partner wishes to have children. Being female could also be a barrier if the woman wants to seek assistive reproductive services, as they often require psychological evaluation before certain procedures (Rich & Domar, 2016).
Hope for the future	Ethnicity and SMI	I hope for him to be a man, to form a home and find a girl who understands him. I hope God is willing. I have that wish that one day a medication will make him better and he will find a woman who will love him and he can form a life.	Ethnicity seemed to offer protections when it comes to Latinxs with schizophrenia. Their family members had a common desire for them to find a partner and start a family. Although some participants shared discouragement and it was included as an obstacle, most family members seemed supportive of this desire which might also speak of a strong family identity in Latinx culture (Bostean et al., 2019).

Note. SMI = serious mental illness.

Results

Sample Demographics

The study sample (see Table 1) consisted of 11 adults diagnosed with schizophrenia (age: M = 34, range = 24–69) and their respective family members providing care (age: M = 61, range = 30–63). Nine participants were male and nine family members were female; none identified as trans or nonbinary, and all identified as heterosexual. All family members were born outside of the United States; 10 were born in Mexico and one was born in El Salvador. Seven participants were born in the United States, three in Mexico, and one in El Salvador. Family members were eight mothers, two fathers, and one daughter. All except one participant lived with family. Two participants were in relationships; one was cohabitating with their partner, and the other was in a dating relationship but is included in the “single, never married” group in Table 1.

Phase 1

All participants responded to all prompts; however, some responses were general. For example, when asked about what they need to be satisfied with their life, a typical response was “I just want to be happy.” As such, the results only include data considered relevant and specific to an intersectionality-framed thematic analysis. Phase 1 revealed five main thematic categories: obstacles to romantic relationships, advantages of romantic relationships, disadvantages of romantic relationships, gender-role issues and satisfaction with life, and hope for the future (Table 3). Each category includes subthemes illustrated with examples from the narrative data.

Table 3.

Romantic Relationships and Gender in Relation to Schizophrenia: Themes Identified by Latinx Participants and Their Family Members

Themes	Family Members	Participants with Schizophrenia
	n	n
Obstacles to romantic relationships
Stigma	5	8
Unemployment	4	5
Lack of confidence	1	2
Symptoms and side effects	2	4
Lack of opportunity	1	3
Family discouragement	2	1
Previous negative experience	1	2
Culture and religion	1	0
Lack of dating skills	2	0
Inability to have children	0	1
Advantages of romantic relationships
Sense of normalcy	6	4
Motivation	4	2
Reducing boredom	2	2
Bonding and care	2	2
Stability	1	1
Happiness	1	0
Disadvantages of romantic relationships
Breakups can affect treatment	1	1
Being taken advantage of	2	0
Dealing with a partner with serious mental illness	1	2
Gender-role issues and satisfaction with life	6	4
Hope for the future	6	6

Obstacles to Romantic Relationships

Participants noted several obstacles to establishing romantic relationships. The emergent themes were stigma, unemployment, lack of confidence, symptoms and side effects, lack of opportunities to meet people, family discouragement, previous negative experiences, culture and religion, lack of dating skills, and inability to have children.

Stigma.

Stigma was the most prominent theme among the obstacles to romantic relationships. Five family members and eight participants expressed that perceived stigma and fear of disclosure of the illness made it difficult for participants to pursue or maintain romantic relationships. A male participant (aged 31) shared his struggle:

There is stigma because of my illness. Let me give you an example. During the time I was being hospitalized, I met a girl and she told me her story … that she had a date … and basically this person … found out she was bipolar [and] he just, like, cut her loose, like, why? … And you know, things like that make me not to start socializing, ‘cause I’m hurt as it is, I’m going to get even more hurt.

Unemployment.

Five participants and four family members stated that not having employment was a main reason why individuals with SMI are unable to establish or maintain a romantic relationship. Several participants mentioned that not having a job made it difficult to support a partner or family, therefore making dating difficult or not feasible. A male participant (aged 28) illustrated this sentiment:

Honestly, it’s difficult to find someone. For one, I don’t find it comfortable for me myself, because I know the questions. “How much do you make? Where do you work? What do you drive? And where do you live?” And a lot of them normally look at you and [say], “I don’t know about that one.” Very rarely will you find someone who will accept you.

Family members agreed with that sentiment, sharing that they believe individuals with SMI need a job and financial security to establish and maintain a romantic relationship

Lack of Confidence.

Three participants mentioned a lack of confidence as an obstacle for engaging with potential partners and maintaining relationships. Some participants expressed that this lack of confidence involved shyness or insecurities. For example, a male participant (aged 24) stated:

That’s when she got angry and I said some things because she made me feel insecure, like I had nothing to offer. But I told her, “You don’t have anything either, you might be receiving SSI [Supplemental Security Income] or government support, but you have papers. Those of us without them could do much more, and you girls have them and do nothing.”

One mother (aged 53) said she would want her son to have a romantic experience without necessarily having to commit to a relationship. She described having offered to pay for a sex worker based on her belief that her son could benefit from having experience with a woman.

I have told him, “Look, if you are stressed out and don’t have money, I can give you some and you can pay for a woman”—that I would pay for one of those women who sell themselves. I say, “Go spend some time with one of those women, but don’t do drugs.” Maybe he will get more courage and find himself a girlfriend.

Symptoms and Side Effects.

Two family members and four participants shared their perspectives on this theme, including a mother (aged 61), who noted: “Maybe the medication affects him more, maybe the medication … suppresses the sexual need of a girl or I think the medication gets him down and it gets … like headaches.”

Lack of Opportunities to Meet Potential Partners.

Three participants and one family member shared that a lack of opportunities to meet potential partners was an obstacle to romantic relationships. A male participant (aged 31) shared his experience: “Just have the guts to ask someone whom I like or whomever, just for their number and just call them and take them out on a date, ‘cause I don’t. I mean, at my age group, it’s very few that are single; most of them are married with kids, so unfortunately I don’t meet many, that’s the fact.”

Family Discouragement.

One participant and two family members mentioned this theme. The family members expressed that at times, they actively discouraged participants from having relationships out of fear of worsening symptoms. A father (aged 66) described his son’s experience: “One time my wife told him, ‘Get a girlfriend,’ and I looked at him and said, ‘No, no, no.’ Why a girlfriend? … He can’t handle that.”

Previous Negative Experiences.

For some participants, having previous negative experiences discouraged them from seeking new romantic relationships. A mother–son dyad shared similar views. The son (aged 39) said, “One time my ex hit me, and they put me in jail. That’s when I said, ‘Never again.’” The mother (aged 59) shared what her son told her when she tried to encourage him to find a partner: “I told him, ‘Go on, go find a partner or something,’ and he said ‘What for? You remember how it was last time.’”

Culture and Religion.

Culture and religion were referenced as obstacles to romantic relationships. The daughter (aged 30) of a participant described why she believes her mother has not been in a romantic relationship since her husband died: “She comes from a one-marriage culture. Her religion doesn’t allow it either. If she didn’t have cultural and religious barriers, maybe she would.”

Lack of Dating Skills.

Two family members raised this concern. A mother (aged 49) said she believed her son lacked the dating skills to ask someone on a date. She followed this statement by saying that her son would benefit from addressing that issue in therapy, particularly learning how to interact with potential partners. “He doesn’t know how to treat a woman because he hasn’t had a relationship since he got sick. I think he would need therapy support for that.”

Inability to Have Children.

For a female participant (aged 31), not being able to have children was an obstacle to establishing a romantic relationship. She noted: “I can’t have children. So, it makes it difficult in the future if you find a man and he wants … a baby. It’ll be a difficult thing.”

Advantages of Romantic Relationships

Participants shared several perceived advantages of having or aspiring to have a romantic relationship. The subthemes were: a sense of normalcy, motivation, reducing boredom, bonding and care, stability, and happiness.

Sense of Normalcy.

Several participants mentioned a sense of normalcy associated with having a romantic relationship. Narratives revealed that feeling normal meant feeling more satisfaction with life. For four participants and six family members, having a romantic relationship, either dating or marriage, contributed to an overall sense of normalcy. A mother (aged 49) shared: “I believe he would feel very good if he was able to get married, have a steady job, have a family—you know, a normal life like everyone else.”

Motivation.

Several participants and family members mentioned motivation as a strong positive aspect of romantic relationships. Participants described motivation to find a partner and to get a job to find and support a partner as advantages of romantic relationships. Some participants expressed that having a relationship or working toward establishing one are great motivators for treatment adherence to “get better,” as exhibited by the following quote from a male participant (aged 24): “Wanting life; wanting a girl motivates me. Having a female companion motivates me to get better—having family, having a place to live … having a female companion next to me. That’s my motivation.”

Reducing Boredom.

Two family members and two participants perceived romantic relationships as a way to reduce boredom for people with SMI. A male participant (aged 37) said, “I don’t tend to be bored a lot these days, especially with my girlfriend living with me; we talk a lot, we joke around, we watch stuff together, we do stuff together.” Family members had similar beliefs regarding romantic relationships as a way to reduce boredom.

Bonding and Care.

Two participants and two family members shared this theme. For family members, having other people who could care for those with SMI was important; they said this assuaged their worries about what would happen to the participant if the family member were to die. One male participant (aged 31) noted, “I think I have to find me a partner for one thing … find me someone to care for, who cares for me, and … have that bonding between a relationship.”

Stability.

A participant who reported that he had been stable for several months attributed this stability to having a girlfriend and interacting with others at the mental health center. This participant (aged 37) said, “I think having a girl and friends from the center I go to has helped me be stable. I have two close friends and I have a girlfriend.” The family member’s response corroborated this perspective.

Happiness.

According to one mother, having a romantic relationship made her son happy. She said that after finding his girlfriend, he became more sociable, and she could tell that he was enjoying the experience. This mother (aged 53) stated, “I noticed that when he is with her, he’s very happy, he talks a lot. … He’s able to socialize more.”

Disadvantages to Romantic Relationships

Several issues potentially impeding a romantic relationship fell into three subthemes: breakups can affect treatment, being taken advantage of, and dealing with a partner with schizophrenia.

Breakups Can Affect Treatment.

One participant and one family member mentioned that the breakup of a relationship can negatively influence treatment, especially when both individuals receive services at the same mental health center. A male participant (aged 24) stated:

I do have a program now. And it’s not like I don’t want to go, but I used to have a girlfriend there. … It’s not that I still love her but … it’s hard to see a person from the past.

Being Taken Advantage of.

Two parents indicated that romantic relationships might make the participant vulnerable to being taken advantage of. This theme did not appear to be an obstacle for participants, but rather a fear expressed by parents. One mother (aged 53) expressed concern that a potential partner could take advantage of her son: “I do think that a woman could come along who uses drugs, and she would ask for his money and convince him to live with her so he can give her money for drugs, and them living like that.”

Dealing with a Partner with SMI.

The symptoms of a partner who also has SMI were mentioned as a disadvantage. One family member and two participants shared that having a partner with SMI can be stressful for participants because they might trigger or exacerbate each other. A male participant (aged 25) compared his experiences with his current girlfriend with an SMI to his previous girlfriend, who did not have mental illness:

[My current girlfriend] has, like, an anger issue, so I think that clouds, like, her connection with me versus my other one, [who] didn’t have an anger issue. She didn’t have no chemical imbalance, so she was like more calm.

Gender-Role Issues and Satisfaction with Life

Six family members and four participants shared their perceptions and thoughts regarding what it would take for individuals with schizophrenia to feel satisfied with their lives based on gender. Three participants and four family members described satisfaction with the gender roles of participants as dependent on some form of romantic relationship. Two family members and one participant mentioned the importance of employment and money, particularly to establish a romantic relationship and form a family, which appeared to refer to men with schizophrenia. One participant shared that having a good relationship with his father, to shape his own ideas of fatherhood, would bring him satisfaction. A male participant (aged 37) shared his thinking regarding gender roles and life satisfaction:

To be satisfied as a man, I think I’m doing part of it now … that I’m thinking of having a kid with my girlfriend. I see my relationship with me and my father; I think to be a man, for me, I have to have a good relationship with … my dad, providing for my girlfriend and child, being there for me.

Hope for the Future

Six participants and six family members shared their perspectives about the future for individuals with schizophrenia. All but one family member described hope about the future related to a romantic relationship. The other family member shared a hope for independence and self-sufficiency. For participants, the main hope for the future was to have a romantic relationship, ending their current relationship and finding a new partner, or getting an education. A male participant (aged 24) shared the following vision for the future:

I hope to find a girlfriend. Hopefully down the road, once I get back into the dating scene, maybe I can have someone, ‘cause once I find somebody, of course I’m going to care about that person and she’s going to care about me.

Phase 2

Results of Intersectionality Template Analysis

Examining participants’ narratives through the intersectionality template revealed the complex interplay of ethnicity, romantic relationships, gender, and mental illness as social categories. The template analysis highlighted how the intersection of these categories resulted in stigma, which emerged as the primary obstacle to romantic relationships for participants. The findings from the template analysis are presented with illustrations from the narrative data and interpretations of their interplay. The template is outlined in Table 2.

Regarding obstacles to romantic relationships, the analysis revealed he intersectionality of gender, ethnicity, and schizophrenia. In one account, immigration status was also observed as an intersecting identity. The findings from the analysis of the narrative data in this category revealed that unemployment and lack of confidence was related to stigma caused by cultural beliefs associated with gender roles and mental illness. For example, this intersectionality became evident when a male participant (aged 28) discussed what he considered to be an obstacle to establishing a romantic relationship:

Honestly, it’s difficult to find someone. For one, I don’t find it comfortable for me myself, because I know the questions. “How much do you make? Where do you work? What do you drive? And where do you live?” And a lot of them normally look at you and [say], “I don’t know about that one.” Very rarely will you find someone who will accept you.

Two other accounts regarding unemployment as an obstacle were analyzed through the template. One account by a father (aged 56) illustrated how expectations of employment can exert heavy pressure on Latino men with SMI.

In order for him to have a relationship, I tell him he has to work. I tell him, “A family needs money, a woman needs to eat and dress and have shoes and an apartment.” … Sit down and do the math. … He needs to be stable and get a job because I say, “You are not going to be bringing a woman to this house. You need to work and be on your own.”

For a female participant (aged 31), the interaction of gender, ethnicity, and SMI stigmatized her inability to have children. She shared that she couldn’t have children, which would make it difficult to establish a relationship if she found a partner who wants children.

Regarding gender-role issues and satisfaction with life, an intersection of gender, ethnicity, and SMI emerged. All family members who discussed gender-role issues and satisfaction with life stated that a romantic relationship would help the person with SMI feel satisfied with life. However, both participants and family members emphasized that for this to happen for men with schizophrenia, they first need a job. This coincides with previously stated beliefs that men must have a job to have a romantic relationship. This may exacerbate stigma related to mental illness and unemployment and make it more difficult for Latino men with schizophrenia to establish and maintain a romantic relationship. A mother expressed this sentiment: “Well, as a man, he has an aspiration to get married one day, but he needs to have a steady job. His goal is to see life as normal, like everyone else.”

Finally, regarding hope for the future, ethnicity seemed to offer nonstigmatizing beliefs related to romantic relationships among Latinxs with schizophrenia. Family members expressed a common desire for them to find a partner and start a family. This can serve as a motivator to interact with other people and engage in friendship and socialization. Family members in this study seemed supportive of this desire, as reflected in the following quote by a mother:

I hope for him to be a man, to form a home and find a girl who understands him. I hope God is willing. I have that wish that one day a medication will make him better and he will find a woman who will love him and he can form a life.

Discussion

The findings from this study provide a picture of the thoughts, perceptions, and lived experiences related to romantic relationships in a sample of Latinxs diagnosed with schizophrenia. Romantic relationships represented an area of concern for both participants and family members. Using an intersectionality framework, perspectives from people with schizophrenia and their family members revealed the interplay of forces that can challenge and shape opportunities for romantic relationships in the Latinx cultural context. Given the limited number of studies addressing the role or importance of romantic relationships among people with SMI, especially Latinxs with schizophrenia, these perspectives from people with schizophrenia and their family caregivers give a voice to members of this often-underrepresented community.

The findings on the prominence of stigma as an obstacle to relationships corroborate the pervasive negative impact of the stigma of mental illness on quality of life (Corrigan et al., 2013; Schmitt et al., 2014). Participants and family members frequently referenced the stigma of the illness as the main obstacle to the participants’ ability to establish and maintain romantic relationships and as a barrier to the expression of sexuality and intimacy (de Jager & McCann, 2017). As exemplified in the template analysis, many other obstacles to relationships identified by participants—such as unemployment, lack of confidence, symptoms and side effects, lack of opportunities to meet people, and lack of dating skills, among others—further compounded the influence of stigma in their lives. In particular, the findings indicate that men with schizophrenia and their families regarded the lack of meaningful employment as a consequence of schizophrenia, intensifying stigma and representing an obstacle to establishing romantic relationships. Participants considered being employed and employability as reflecting high social value (Mueser et al., 2014) and a higher likelihood of attracting a potential romantic partner. The experiences of participants show that their employment status affected their potential of having a romantic relationship. The role of employment in recovery has been well studied (Mueser et al., 2014), but more attention needs to be given to how employment status relates to romantic relationships and recovery from schizophrenia. Treatment approaches should consider addressing how stigma imbues the role of employment and affects romantic relationships among Latinxs with schizophrenia.

Participants shared several benefits and disadvantages of romantic relationships. Participants expressed awareness of the impact of the lack of romantic relationship on their lives and possibly their mental illness. Family members shared a similar awareness of the importance of supportive romantic relationships, particularly for attaining a sense of normalcy, which the illness and its stigma seemed to erode.

The intersectionality analysis indicated that this group of Latinxs with schizophrenia did not experience mental illness in isolation of their other identities, but rather as a constant interaction that often makes it difficult to enjoy their lives and establish romantic relationships. Nevertheless, some of their intersecting identities could reduce stigma, as exhibited by family support of the pursuit of romantic relationships, which highlights the need for comprehensive interventions that consider all intersecting identities of people with schizophrenia.

Findings should be considered in light of several limitations. It is important to highlight that due to the small size and characteristics of our convenience sample, the themes and concerns identified are specific to the lived experiences of these participants and should not be generalized. Furthermore, Latinxs are a heterogenous group; therefore, findings regarding our sample of majority Mexican-origin Latinxs are not generalizable to other Latinx groups. However, it is important to remember that because Latinxs with schizophrenia are more likely to live with their family compared to other groups (Barrio et al., 2003), examining perspectives of both Latinxs with schizophrenia and their family members is essential when trying to understand the interactional nuances of the illness experience (Ponting et al., 2020). Furthermore, our sample of people with schizophrenia was primarily male and heterosexual, thereby limiting the generalizability of our findings to other genders and groups.

Another limitation is that five participants chose to be interviewed with their family member present. We acknowledge that although this may have contributed to comfort among participants, it also might have generated bias because having a family member in the room could have led participants to withhold aspects of their experience. However, the interviewers did not note any discomfort among participants, and their request to have a family member in the room felt appropriate and culturally syntonic.

Lastly, the study sample was relatively small and homogenous, majority of Mexican origin, regionally specific, and predominantly male, and the caregivers were predominately female. While it is likely to be representative of a population seeking public mental health services in the Los Angeles region, it cannot be assumed to be representative of all persons with schizophrenia and their family caregivers.

Conclusion

This study’s findings support the idea that people with schizophrenia have a desire to establish and maintain a romantic relationship. Furthermore, the results identify areas of concern in a sample of Latinx individuals diagnosed with schizophrenia that illustrate their insider perspectives, providing an example of how stigma related to mental illness can intersect with ethnicity and romantic relationships. Findings also underscore the importance of considering the perspectives of family members, particularly those who care for people with SMI.