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. Author manuscript; available in PMC: 2021 May 1.
Published in final edited form as: AIDS Care. 2020 Mar 10;32(SUP2):5–13. doi: 10.1080/09540121.2020.1739205

Intersectional stigma and psychosocial well-being among MSM living with HIV in Guangxi, China

Xueying Yang 1,§, Xiaoming Li 1, Shan Qiao 1, Linda Li 2, Casey Parker 3, Zhiyong Shen 4, Yuejiao Zhou 4
PMCID: PMC7172016  NIHMSID: NIHMS1578895  PMID: 32156159

Abstract

The existing literature suggests a negative impact of intersectional stigma on multiple aspects of psychosocial well-being among individuals with multiple stigmatized identities. However, such impact remains poorly understood. This study aims to investigate the association between intersectional stigma and psychosocial well-being among a sample of 193 men who have sex with men (MSM) living with HIV in Guangxi China. Based on their responses to measures of HIV-related stigma and sexual and gender minority (SGM) stigma, the participants were grouped into “high” vs “low” on each type of stigma. The General Linear Model (GLM) was used to analyze the main effects and interaction effect of two types of stigma on multiple psychosocial measures. Our results indicated a significant interaction effect of two types of stigma on depression, anxiety, quality of life, and psychological resilience after controlling for key socio-demographic covariates. The findings suggest that experiencing both HIV-related stigma and SGM stigma may synergistically lead to poor psychosocial well-being among MSM in a more profound manner than experiencing only one type of stigma. It is critical for researchers and clinicians to consider the patients’ multiple stigmatized identities, develop effective intervention strategies to reduce health disparity, and improve the psychosocial well-being of MSM living with HIV in China and other cultural settings.

Keywords: Intersectional stigma, Men who have sex with men, Psychosocial well-being, HIV, China

Introduction

In China, men who have sex with men (MSM) are at a high risk of HIV infection, with an overall HIV prevalence of 9.9% in 2015 and an incidence of 5.6 per 100 person-year in 2016 (Qin et al., 2016; Zhang et al., 2016). Furthermore, the proportion of MSM among the newly diagnosed HIV cases has increased from 2.5% in 2006 to 26.9% in 2016 (UNAIDS, 2015; China National Center for AIDS/STD Control and Prevention, 2016; Wu, 2015). Besides HIV infection, MSM living with HIV also suffer from mental health problems. For example, the prevalence of depression among MSM living with HIV ranges from 35% to 49%, which is much higher than that of people living with HIV (PLWH) in general (Lowther, Selman, Harding, & Higginson, 2014) and that of HIV negative MSM (Bogart et al., 2011; Comulada et al., 2010; Mills et al., 2004). Moreover, MSM living with HIV also reported poor quality of life (Song, Yan, Lin, Wang, & Wang, 2016). Poor mental health has been reported to adversely affect multiple HIV-related health outcomes, resulting in limited service utilization, poor adherence to antiretroviral therapy (ART), faster progression to AIDS, and shorter survival (Cook et al., 2002; Schuster, Bornovalova, & Hunt, 2012). The existing literature suggested a number of factors, including stigma and discrimination, that contribute to the psychosocial wellbeing of MSM living with HIV in China and other cultural settings.

Minority stress theory posits that minority groups experience stress stemming from experiences of stigma and discrimination, which in turn places them at risk for tremendous negative physical and mental health outcomes (McConnell, Janulis, Phillips, Truong, & Birkett, 2018). The synergistic effect of multiple stigma is referred to intersectional stigma (Scheper-Hugher Nancy, 1991). As a sexual and gender minority (SGM) population, MSM living with HIV can be potentially stigmatized for multiple identities. For example, they are likely to perceive internalized stigma (e.g., devaluation of self) due to both HIV status and same-sex sexual behavior (Herek, Gillis, & Cogan, 2009). In much of the existing literature, the issues of gender, sexual orientation, and socioeconomic status are largely treated as discrete categories rather than interconnected issues. This may ultimately undermine the role of intersectional stigma in disease management and health outcomes among MSM who hold multiple identities, statuses, or conditions simultaneously. Intersectionality conceptual framework (PH Collins & S Bilge, 2016) thus provides ideal lens through which to consider this phenomena, as it asserts that multiple social positions associated with gender, sexual identity, and HIV infection intersect at the individual level and reflect multiple and reciprocal systems of societal oppression that affect MSM living with HIV.

Previous studies have suggested that different types of stigma may interact to affect psychological outcomes among MSM. Two quantitative studies conducted among gay and bisexual men or MSM in the U.S. found that the intersectional effects of racial, sexual identity, and HIV-related stigma could predict higher levels of depression and anxiety (Bogart et al., 2011; English, Rendina, & Parsons, 2018), even when individual main effect from these forms of discrimination were not significant (Bogart et al., 2011). However, most studies on intersectional stigma have been conducted in the U.S. and limited data are available in other cultural settings, such as China, where MSM’s stigmatized experience is likely to be shaped by the unique cultural and socioeconomic forces.

For MSM living with HIV in China, their sexual identity and sexual behaviors have been largely influenced by China’s traditional family-oriented values of filial piety and procreation and collectivistic culture that emphasizes norm conformity (Sun et al., 2020). MSM living with HIV may have a feeling of losing face as a result of not getting married and not fullfilling family obligations or face moral judgements against being infected with HIV through some culturally unacceptable practices, such as multiple sex partners, same-sex sexual behaviors, commercial sex, and drug usage (Li et al., 2015). Concerns over cultural impeity and losing face inhibited open and in-depth discussions about same-sex relationship and HIV infection, which further prohibited possible psychological adjustments to the HIV diagnosis (Li et al., 2015).

With a goal to inform intervention efforts to reduce stigma against MSM living with HIV in China, we examined the main effects and interaction effect of both SGM stigma and HIV-related stigma on multiple psychosocial measures (e.g., depression, anxiety, quality of life, and psychological resilience) within an intersectional conceptual framework.

Method

Study sites and participants

Data used in the current study were derived from the baseline survey of a longitudinal cohort study, which aimed to examine the mechanisms of the effect of HIV-related stigma on clinical outcomes of PLWH in Guangxi, China. As one of the regions with the fastest growing HIV epidemic in China, Guangxi reported a total of 124,282 HIV/AIDS cases by the end of 2017, indicating a 78.7% increase since June 2011 (69,548 HIV/AIDS cases) and placing Guangxi one of the top provinces in China in terms of HIV seropositive cases (Guangxi CDC, 2018; Zhao et al., 2015). With the assistance and collaboration of Guangxi Center for Disease Control and Prevention (CDC), we selected six hospitals/clinics in five cities with the largest number of HIV patients under care as our study sites. The volume of HIV patients ranged from 1,386 to 7,389 in these hospitals/clinics. The patient inclusion criteria of the original study included: 1) aged 18–60 years; 2) a confirmed diagnosis of HIV or AIDS; and 3) having no plan to permanently relocate outside of the Guangxi province in the next 12 months. Exclusion criteria included: 1) linguistic, mental, or physical inability to respond to assessment questions; 2) currently incarcerated or institutionalized for drug use or commercial sex; and 3) plan to permanently relocate outside of the province within a year. With an overall refusal rate of about 5%, 1198 PLWH participated in the original study and completed the baseline survey. Among the original study sample, a subsample of 193 men who self-reported having acquired HIV via same-sex sexual behavior was included for the current analysis.

Data collection procedure

An interviewer-administered questionnaire was used for data collection. Medical staff or HIV case managers at the HIV clinics referred potential participants to the local team. Local team members screened PLWH for eligibility and discussed the benefits and risks of the study and invited eligible participants to join the research. After obtaining their written informed content, the face-to-face interviews were conducted in private rooms of the clinics. Each participant received a gift (e.g., household items) equivalent to US$5.00 (1 USD≈6.5 Chinese Currency RMB at the time of survey) at the completion of the questionnaire interview. The study protocol was approved by the Institutional Review Boards at both University of South Carolina in the United States and Guangxi CDC in China.

Measures

Sample characteristics

Participants were asked about their socio-demographics including age, gender, ethnicity, education level (e.g., preliminary school, high school), employment status (e.g., full time, part time, unemployed), marital status (e.g., married, cohabitating, separated, divorced, widowed), household monthly income (e.g., less than 1000 RMB, 1000 to 1999 RMB, 2000 to 2999 RMB, 3000 RMB and above), and HIV status of regular sex partners. HIV-related information, including the dates of their HIV diagnosis and ART initiation, was also provided by the participants. Durations of HIV diagnosis and HIV treatment were calculated based on the participants’ self-report.

HIV-related stigma

Twelve items from the Negative Self-image Scale (Berger, Ferrans, & Lashley, 2001) were used to measure internalized HIV-related stigma. This scale has been used and validated in diverse PLWH populations (Berger et al., 2001). Sample items included: “I feel I’m not as good a person as others because I have HIV” and “Some people avoid touching me once they know I have HIV.” Responses of each item were rated from 1 (“strongly disagree”) to 4 (“strongly agree”). A sum score of the scale was calculated, with a higher total score indicating a higher level of HIV-related stigma. The scale exhibited a good internal consistency in our study (Cronbach alpha=0.88). For the purpose of data analysis in this study, a dichotomized measure of HIV-related stigma (“high” vs. “low”) was created by splitting the total score at its median score of 16.

SGM stigma

The SGM stigma was measured by one question: “Have you ever been treated inferiorly in employment, health care, schooling or other aspects of your life because of your sexual orientation?” with a response option of “Yes (1)” or “No (0).” A score of “1” was used to indicate that the participants experienced SGM stigma (“high SGM stigma”), while “0” indicated no experience of such stigma (“low SGM stigma”).

Psychosocial well-being

Depression

Depression was measured by the 10-item short version of Center for Epidemiologic Studies Depression Scale (CESD-10) (Andresen, Malmgren, Carter, & Patrick, 1994), which has been validated among Chinese population (Lin, 1989). The participants were asked “How often you have felt this way (a list of the ways you might have felt or behaved) during the past week?” Sample items included: “I was bothered by things that usually don’t bother me” and “My sleep was restless”. The response categories of each item were 1 (‘Rarely or None of the time [less than 1 day]’), 2 (‘Some or a Little of the time [1–2 days]’), 3 (‘Occationally or a Moderate amount of time [3–4 days]’), or 4 (‘Most or All of the Time [5–7 days]’). A sum score (range: 10–40) was formed with a higher total score representing a higher level of depression. The Cronbach alpha for this scale was 0.81 in this study.

Anxiety

The 20-item Brief Anxiety Scale was used to measure anxiety (Derogatis & Melisaratos, 1983). This scale has shown good reliability and validity in Chinese PLWH (Sun, Wu, Qu, Lu, & Wang, 2014). The participants were asked “How often you have felt this way (a list of the ways you might have felt or behaved) during the past week?” The response categories of each item were the same as CESD-10 scale. A sum score (range: 0–60) was formed, with a higher total score representing a higher level of anxiety. The Cronbach alpha was 0.80 in the current study.

Psychological resilience

The modified Connor-Davidson Resilience Scale (CD-RISC) (10-item) was employed to measure psychological resilience (Campbell-Sills & Stein, 2007). Sample items included: “Bounce back after illness or injury” and “Under pressure I stay focused.” Participants rated their agreement with these items on a 5-point response option from 0 (‘Not at all’) to 4 (‘Extremely’). A sum score was formed with a higher total score representing a higher level of resilience. The scale exhibited a good internal reliability (Cronbach alpha=0.96).

Quality of life

The Medical Outcomes Study HIV Health Survey (MOS-HIV) was employed to assess quality of life (Wachtel et al., 1992). The MOS-HIV scale has 35 items and consists of 11 subscales, including physical functioning (6 items), role functioning (2 items), pain (2 items), social functioning (1 item), emotional well-being (5 items), energy/fatigue (4 items), cognitive functioning (4 items), general health (5 items), health distress (4 items), overall quality of life (1 item), and health transition (1 item). Subscales are scored as the sum of the item scores after recoding some items so that a higher score indicates better quality of life. Following the established algorithem for scale score calculation (Wachtel et al., 1992), a total score was calculated based on the subscale scores to measure different levels of quality of life. Cronbach alpha was 0.92 for the MOS-HIV in the current study.

Statistical analysis

First, descriptive statistics were used to describe the sample’s socio-demographic characteristics and HIV-related characteristics. Second, the analysis of variance (ANOVA) was used to examine the mean difference of the four psychosocial measures by the levels of two types of stigma. To characterize the intersectional effects of two different types of stigma, we tested the mean differences between the levels of HIV-related stigma within each level of SGM stigma followed by post-hoc comparisons among the four groups (low-low, low-high, high-low, high-high) using the Least Significant Difference (LSD) test. Third, we employed the multivariate General Linear Model (GLM) using Wilks’ Lambda measure to analyze the main effects and interaction effect of two types of stigma on different psychosocial measures (e.g., depression, anxiety, resilience, and quality of life) by adjusting for key socio-demographic covariates (e.g., age, employment status, education attainment and household monthly income). For any significant interaction effects, cell mean analysis was plotted to identify the patterns and sources of interaction effects. SAS 9.4 (SAS Institute, Inc., Cary, NC, US) was used for all the statistical analyses.

Results

Sample characteristics

As presented in Table 1, the mean age of the 193 participants was 30.1 years (SD=7.0). Amongst our study sample, 68.9% were of Han ethnicity, only 8.8% have religious belief, 85.5% were single, 67.7% attended college or above, more than two-thirds (74.6%) had full-time job, and around two-thirds (67.7%) had household monthly incomes above 3,000 Chinese RMB (approximately $446 USD). In this study, less than 20% of them (16.4%) had HIV positive regular sexual partners. In terms of HIV-related characteristics, the mean duration of HIV diagnosis and ART treatment was 38.7 months (SD=25.6) and 32.1 months (SD=21.1), respectively; 59.1% of the participants had CD4 counts >500 cells/mm3 and the 72.5% of the participants has undetectable viral load (i.e., HIV RNA<50 copies/ml) (Table 1).

Table 1.

Background information of MSM living with HIV in Guangxi, China (N=193)

Items N1 (%)
Socio-demographics
Age (mean±SD, years) 30.1 ±7.0
Ethnicity
 Han 133 (68.9)
 Others 60 (31.1)
Highest education attained
 High school or below 64 (32.3)
 College or above 134 (67.7)
Whether having religion
 Yes 17 (8.8)
   No 176 (91.2)
Job status
 No job/part-time 49 (25.4)
 Full-time 144 (74.6)
Marital status
 Single 165 (85.5)
 Others (e.g., married/cohabited) 28 (14.5)
Household’s monthly income (RMB)
 <3000 62 (32.3)
 ≥3000 130 (67.7)
Regular sexual partner’s HIV status
 HIV positive 31 (16.4)
 HIV negative/unknown 158 (83.6)
Disease-related characteristics
Duration of HIV diagnosis (mean±SD, months) 38.7±25.6
The most recent CD4 count
 ≤500 79 (40.9)
 >500 114 (59.1)
The most recent viral load (copies/ml)
 ≤50 137 (72.5)
 >50 52 (27.5)
Duration of ART (mean±SD, months) 32.1±21.1
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Note:

1

The number of participants for some of the variables did not add up to the total sample size because of missing data.

The mean score of depression, anxiety, resilience, and quality of life was 17.8 (SD=5.1), 30.6 (SD=6.8), 36.9 (SD=8.4), and 123.2 (SD=16.4), respectively. The mean score of HIV-related stigma was 16.1 (SD=5.8), and 8.4% of the participants perceived that they were treated inferiorly in employment, health care, schooling or other aspects of their lives because of their sexual orientation.

Bivariate analysis

The ANOVA results revealed significant differences in depression, anxiety, quality of life, and resilience between high HIV-related stigma group and low HIV-related stigma group regardless of the SGM stigma experience (Table 2). However, the post-hoc comparisons among the four groups suggest that when participants reported high stigma experience on both types of stigma (“high-high”), their psychosocial measures become much worse than all other possible categories (i.e., low-low, low-high, high-low).

Table 2.

Bivariate analysis of the relationship between stigma and psychosocial measures

Low SGM stigma High SGM stigma Post-hoc comparisons1
HIV-related stigma Low (1) High (2) Low (3) High (4)
Depression (mean±SD) 15.7±4.2 19.1±4.9 * 17.3±4.3 27.6±6.4 * (1,2)(1, 4)(2, 4)(3, 4)
Anxiety (mean±SD) 28.6±5.6 32.4±7.2 * 28.9±6.1 42.5±2.4 * (1,2)(1, 4)(2, 4)(3, 4)
Resilience (mean±SD) 38.9±8.5 34.3±8.1 * 40.8±7.4 24.2±9.6 * (1,2)(1, 4)(2, 4)(3, 4)
Quality of life (mean±SD) 128.9±13.6 118.9±15.9 * 121.4±16.4 93.2±11.5 * (1,2)(1, 4)(2, 4)(3, 4)
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Note:

1

Only the pairs with significant mean difference (p<0.05) are listed in post-hoc comparisons with the Least Significant Difference (LSD) test.

*

p<0.05

Multivariable analysis

Main effect of SGM stigma and HIV-related stigma

The GLM analysis showed a significant multivariate test for the main effect of SGM stigma (Wilks’ Lambda=5.24, p<0.001) and HIV-related stigma (Wilks’ Lambda=9.12, p<0.001). In terms of specific psychosocial measures, the GLM results revealed the significant main effect of SGM stigma on increased scores of depression (b=5.17, p<0.001) and anxiety (b=3.84, p<0.05), and decreased score of quality of life (b=−14.70, p<0.01). However, no significant main effect of SGM stigma was observed for psychological resilience. Likewise, the GLM analysis also demonstrated the significant main effect of HIV-related stigma on increased score of depression (b=4.40, p<0.001) and anxiety (b=4.80, p<0.001), and decreased score of quality of life (b=−11.52, p<0.001) and resilience (b=−4.29, p<0.01). (Table 3)

Table 3.

Multivariate General Linear Model (GLM) analyses related to the impact of intersectional stigma on various psychosocial measures

Main effect Interaction Covariates1
SGM stigma (A) HIV-related stigma (B) A*B Age Job Income
b(SE) b(SE) b(SE) b(SE) b(SE) b(SE)
Multivariate test (Wilks’ Lambda) 5.24*** 9.12*** 3.31* 2.08 2.08 5.42***
Depression 5.17(1.36)*** 4.40(0.74)*** 10.11(2.79)*** −0.15(0.05)** −1.84(0.87)* 0.38(0.81)
Anxiety 3.84(1.96)* 4.80(1.06)*** 10.12(3.99)* −0.17(0.08)* −2.01(1.24) 0.26(1.16)
Resilience −1.63(2.54) −4.29(1.38)** −11.14 (5.19)* 0.06(0.10) 0.43(1.62) 5.63(1.51)***
Quality of life −14.70(4.47)** -11.52(2.42)*** −23.77(9.13)* 0.34(0.18) 7.08(2.84)* 3.11(2.65)
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Note:

1

The covariates that adjusted for including: age, job status, household monthly income and education attainment.

p<0.10

*

p<0.05

**

p<0.01

***

p<0.001

Effects of covariates

The key socio-demographic characteristics (e.g., age, income, employment status, education attainment) were included in the GLM as covariates. The results indicated that MSM with older age were less likely to have depression (p<0.01) and anxiety (p<0.05) than those who are younger; MSM who have full-time job were likely to report less depression (p<0.05) and a better quality of life (p<0.05) than those with no job or part-time job; MSM with a high household monthly income reported a higher resilience than those with low household monthly income (p<0.001). (Table 3)

Interaction effects

The interaction effects of two types of stigma demonstrated a significant multivariate test (Wilks’ Lambda=3.31, p<0.05) in the GLM analysis. The interaction was significantly associated with higher score of depression (b=10.11, p<0.001) and anxiety (b=10.12, p<0.05) and lower score of resilience (b=−11.14, p<0.05) and quality of life (b=−23.77, p<0.05) (Table 3). Further examination of cell means revealed that the interaction effects were the results of uneven differences in psychosocial measures between the two levels of HIV-related stigma at different levels of SGM stigma. As indicated in Figure 1, the general directions of the differences in all four psychosocial measures between high HIV-related stigma group and low HIV-related stigma group are the same across the two levels of SGM stigma (i.e., the higher HIV-related stigma, the worse psychosocial measures). However, the differences between two levels of HIV-related stigma groups become much more striking when SGM stigma is high. In other words, when SGM stigma is high, the participants reporting a high level of HIV-related stigma reported a much worse psychosocial measures than participants reporting a low level of HIV-related stigma. Specifically, when SGM stigma is low, the mean differences between high HIV-related stigma and low HIV-related stigma groups were 3.4, 3.8, −4.6, and −10 for depression, anxiety, resilience, and quality of life, respectively. In contrast, when SGM stigma is high, the mean differences between high HIV-related stigma and low HIV-related stigma groups were 10.3, 13.6, −16.6, and −28.2 for depression, anxiety, resilience, and quality of life, respectively (Table 2).

Figure 1.

Figure 1

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The interaction effects between SGM stigma and HIV-related stigma on psychosocial measures

Discussion

To the best of our knowledge, this study is one of the first efforts to assess the effects of intersectional stigma quantitatively and provides important insights about the synergistic effects of multiple stigmatized identities (e.g., sexual and gender minority, HIV infection) on their psychosocial well-being among MSM living with HIV in China. Participants who reported high levels of HIV-related stigma and SGM stigma reported the worst measures of depression, anxiety, resilience, and quality of life. This suggests that intersectional stigma among MSM living with HIV may synergistically perpetuate poor mental health in a more profound manner than either stigma alone. Future interventions targeting intersectional stigma may play an important role in addressing mental health in MSM living with HIV. Healthcare providers should specifically consider stigma associated with both HIV and SGM status among MSM when intervening to improve psychosocial well-being. These findings are consistent with results from prior studies in different populations (English et al., 2018) and highlight the importance of taking an intersectional approach to understanding mental health, resilience, and quality of life among MSM living with HIV.

Corroborating with prior research (Bogart et al., 2011; Logie, Newman, Chakrapani, & Shunmugam, 2012), we found the interaction effect of SGM stigma and HIV-related stigma on deleterious depression and anxiety as well as compromised resilience among MSM living with HIV. Future intervention strategies may consider help MSM to seek more social support and learn resilient coping to buffer the negative effects of intersectional stigma. For example, we can investigate the mediating role of individual resilience on the relationship between intersectional stigma and mental health problems, as prior research has suggested a central role of community resilience in mediating the relationship between racial/ethnic stigma and stress for LGBT minority men (McConnell et al., 2018). At the same time, the healthcare system may consider create a gay-friendly and stigma-free medical environment, where MSM can openly communicate and connect with more social network and obtain social support.

We found the negative impact of interaction effects of HIV-related stigma and SGM stigma on quality of life. The results corroborate prior studies also using an intersectional approach which suggested that multiple forms of stigma could lead to poor quality of life (Gonzalez et al., 2019; Logie et al., 2018). These previous studies were conducted either among PLWH or women living with HIV in Canada or the U.S., and used different forms of stigma (e.g., gender discrimination, racial discrimination or chronic pain). Our study contributed to expanding the literature by uniquely addressing and investigating the effects among MSM in a different setting, China.

The findings from this study may inform future stigma reduction interventions that target diverse social identities or health conditions of MSM living with HIV simutaneously. According to a 2019 systematic review (Rao et al., 2019), existing stigma reduction interventions remain limited by a nearly exclusive focus targeting only one level of stigma source. The results of the present study pinpoint the need for interventions focusing on reducing or mitigating the negative impacts of the intersectionality of SGM-related and HIV-related stigmas in healthcare settings and society as a whole. In addition, given the lack of psychosocial support services and interventions targeting PLWH in general and MSM living with HIV in particular (Sun et al., 2009; Zhao et al., 2009), interventions to reduce stigma and provision of psychosocial support have the potential to improve the psychosocial well-being of MSM living with HIV in China. For practitioners working with sexual and gender minorities living with HIV, our study underscores the importance of understanding and considering the patients’ intersectionality of their identities that may shape their experiences of stigma. Practitioners should also explore positive aspects and strengths MSM may find in living in the intersection of multiple stigmatized statuses (Bowleg, 2013).

Several limitations of the present study are worth noting. First, a key limitation of the present work is its reliance on self-reported measures of stigma, which should be validated against observational assessments or using other objective measures in the future. Second, the SGM stigma might be under-reported because of the single item measure. Given a lack of consensus on how best to characterize and analyze intersectional stigma (Turan et al., 2019), the results may also subject to limitations in methodology, such as the arbitrary dichotomization of HIV-related stigma. Third, the sample of MSM living with HIV in this study was a subgroup recruited from a longitudinal study that was not originally conducted to examine SGM stigma. Thus, caution is needed in generalizing the results to other settings. Fourth, our cross-sectional data limit the interpretation of causal relationships between stigma and psychosocial measures. Future longitudinal data are warranted to identify predictors of psychosocial well-being and gain a better understanding of the associations demonstrated in the present study.

Despite these limitations, the present study provides important contributions to understanding intersectional stigma and psychological well-being amongst stigmatized sexual and gender minorities by highlighting the important mechanisms through which intersectional stigma may cause psychological health inequities among MSM living with HIV in China. Our findings can inform future stigma reduction intervention approaches that considering the syndemic effects of multiple sources of stigma (e.g., SGM status, HIV infection). Further stigma reduction research using an intersectionality approach will continue to allow our greater understanding of the experiences of vulnerable populations with multiple stigmatized identities, such as MSM living with HIV, and how we may improve intervention strategies that can reduce stigma, increase resilience, improve mental health, and achieve overall better quality of life.

Acknowledgement

Funding: This work was supported by the National Institutes of Health (NIH) (grant number: R01MH0112376); and National Nature Science Foundation of China (NSFC) (grant number 81761128004).

Footnotes

Declaration of interest statement

The authors declare that they have no competing interests.

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