A pilot cultural adaptation of LGB-affirmative CBT for young Chinese sexual minority men’s mental and sexual health

Abstract

Young men who have sex with men (YMSM) represent one of the most at-risk groups for HIV infection and experience sexual minority stress especially in high-stigma settings, which affects their psychological health and increases likelihood of HIV-risk behaviors. The HIV epidemic in China is increasing rapidly among YMSM. However, no evidence-based intervention has specifically targeted Chinese YMSM’s minority stress to improve their mental and sexual health. Adaptation of evidence-based interventions to promote the mental and sexual health of YMSM is one promising way to achieve the global target of HIV epidemic control. The current adaptation study followed the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. YMSM (n = 41) and key stakeholders (n = 16) in China provided feedback into the selected intervention, a cognitive-behavioral therapy (CBT) called ESTEEM, originally developed with efficacy in the U.S. An open pilot (n= 8) was also then conducted. Qualitative and quantitative data collected from each adaptation phase were analyzed to form the adapted intervention: “Yi Si Tang (益思堂).” Adaptations addressed a cultural context prioritizing family needs, limited support from the health system, as well as YMSM delivery preferences. YMSM and key stakeholders deemed the intervention acceptable and preliminarily feasible for the Chinese context. The pre-post comparison of mental and sexual health outcomes indicated improvement in mental health and sexual health of Chinese YMSM. Outcomes of the small initial pilot suggest future promise for this first-of-its-kind intervention for Chinese YMSM.

Globally, young men who have sex with men (YMSM) represent one of the most at-risk groups for new HIV infection (Beyrer et al., 2012; WHO, 2015), and in China particularly the HIV epidemic among YMSM is increasing rapidly (G. Li, Jiang, & Zhang, 2019; Wu, 2018). According to data released by the Chinese Center of Disease Prevention and Control (CDC), HIV prevalence among MSM had increased from 0.9% in 2003 to 8.0% in 2015 (China National Health and Family Planning Commission, 2016), and if these trends continue unabated, experts estimate that one in six Chinese MSM will be infected by HIV in 2025 (Zhuang et al., 2018). As is true for at-risk MSM globally, condomless anal sex (CAS) represents the primary route of HIV transmission among Chinese YMSM (G. Li et al., 2019; Wu, 2018; L. Zhang, Chow, & Wilson, 2012); pre-exposure prophylaxis (PrEP) has not been adopted in China (Han et al., 2019). A recent meta-analysis indicated that 65.2% of Chinese YMSM had CAS with casual partners in the past six months (Yang et al., 2015). These HIV risk behaviors combine with disproportionately high rates of mental health disorders experienced by Chinese YMSM, including anxiety and depression (Hu et al., 2015; Zheng, Xu, & Zhang, 2005), to fuel risk of HIV transmission. Specifically, previous research has reported that the rate of anxiety and depression among Chinese MSM is 32% and 46%, respectively (Hu et al., 2015), and that these psychological burdens co-occur with health-risk behaviors.

Growing evidence suggests that YMSM experience early and ongoing stigma-related stress, also known as sexual minority stress (Meyer, 2003), which contributes to these mental and sexual health risks (Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Pachankis et al., 2015a; Wang & Pachankis, 2016). Recently, evidence from China also shows a strong link between minority stress and YMSM’s mental health problems and HIV-risk behaviors (Choi, Steward, Miege, Hudes, & Gregorich, 2016; Sun, Pachankis, Li, & Operario, 2020; Zhu, Liu, Chen, Zhang, & Qu, 2018). Improving YMSM’s ability to cope with minority stress might be an effective strategy to address both mental health and associated HIV-risk behaviors among YMSM in China.

Although previous studies of minority stress theory were rooted in a western context, scholars have recently explored minority stress in the Chinese cultural context (Sun et al., 2020a). In China, YMSM face legal barriers such as no rights to same-sex marriage and no legal protection against discrimination (Choi et al., 2016; Steward, Pierre, & Choi, 2013), as well as a lack of comprehensive sex education (G. Li et al., 2019). Further, Chinese YMSM often experience culturally-based, family-oriented expectations to fulfill their social roles, including pressure to form a heterosexual marriage and have children (Choi et al., 2016; Steward et al., 2013). These structural and cultural conditions translate into sexual minority stress (Hatzenbuehler, 2014; Meyer, 2003) and suggest potential extensions for Chinese YMSM, at least in the degree to which some of these specific stressors manifest. Moreover, empirical evidence from China has found that internalized and anticipated stigma are associated with YMSM’s poorer behavioral and mental health (Choi et al., 2016; Zhu et al., 2018). Cross-cultural qualitative research exploring minority stress-related processes among Chinese MSM illustrate a similar operation of minority stress theory in China as in the US with the possible addition of culturally-specific factors, such as norm conformity (e.g., a construct reflecting Chinese culture’s collectivistic orientation) as an exacerbating factor of the minority stressors identified by minority stress theory (Sun, et al., 2020a). Overall, however, the primary tenets of minority stress theory (e.g., excess stress in this minority population linked to its excess disease burden) appear to be relevant across cultures.

Despite the clear relevance of minority stress and stigma-related processes to YMSM’s sexual health, current HIV-prevention efforts in China primarily focus on educational interventions, such as the “100% condom use project;” CBO-based outreach programs; educational brochure dissemination; and peer health education interventions (Chen et al., 2016; H. Zhang et al., 2009; Tang et al., 2019). The effects of these interventions are modest: Though they improve HIV-related knowledge and lower high-risk sexual behavior to some extent, the HIV-infection rate among Chinese MSM continues to rise (Lu et al., 2013). Further, research also confirms that psychological distress among Chinese YMSM compromises engagement in such health-promotion programs (Zheng et al., 2005), and as reviewed above, that culturally-related stressors and structural disadvantage experienced by Chinese YMSM exacerbate high-risk sexual behaviors.

A recent cognitive-behavioral therapy (CBT) intervention has been developed to reduce YMSM’s minority stress to improve their mental and sexual health. This intervention, called ESTEEM (Effective Skills to Empower Effective Men; Pachankis, 2014), has been tested in a randomized controlled trial (RCT), and represents the first LGB-affirmative CBT intervention that addresses minority stress to improve the transdiagnostic spectrum of YMSM’s mental and sexual health (Burton, Wang, & Pachankis, 2019; Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). The ESTEEM intervention was developed through an extensive process involving consultation with 41 YMSM and mental and sexual health providers in the US. The treatment addresses the mental and sexual health impact of minority stress through modified CBT-based principles and techniques (e.g., normalizing and self-monitoring the emotional impact of minority stress, reworking minority stress cognitions, reducing avoidance behaviors resulting from minority stress; Pachankis, 2014). The intervention has demonstrated efficacy in reducing depression and anxiety symptoms, alcohol use problems, and HIV-risk behaviors in a waitlist-controlled trial in the US (Pachankis et al., 2015b). Moreover, ESTEEM’s effects on these outcomes are greatest among those YMSM who experience higher levels of minority stressors, namely internalized homophobia (Millar, Wang, & Pachankis, 2016). Given its theoretical coherence and established empirical basis, at least in a US context (Pachankis et al., 2015b), and the similarity of minority stress experiences and their determinants worldwide that vary as a matter of degree rather than kind (Choi et al., 2016; Pachankis & Bränström, 2018, 2019; Sullivan, 2001), the ESTEEM intervention which integrates LGB-affirmative and CBT treatment likely represents an appropriate platform for potential adaptation to a Chinese context. Because ESTEEM has only been tested in a waitlist-controlled trial, whether it works through CBT-specific mechanisms, minority stress mechanisms, or common factors remains to be determined in future trails.

Still, an effective adaptation requires taking cultural nuances and the target population’s needs into account before delivery to a new cultural context, such as among Chinese YMSM (Castro, Manuel, & Charles, 2004; Soto, Smith, Griner, Domenech Rodríguez, & Bernal, 2018). In the present study, we followed the “Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing” (ADAPT-ITT) model (Wingood & DiClemente, 2008), a prescriptive method for adapting existing evidence-based interventions for new contexts or populations. Although other extant adaptation models have been proved valuable, the ADAPT-ITT model has several particularly relevant features. For instance, it encourages direct involvement of the key stakeholders who will themselves be recipients or deliverers throughout the adaptation process. Also, it employs a mixed methods approach to arriving at adaptation targets, specifically using both qualitative assessments (i.e., focus group, interview and process measures) and quantitative evaluation (i.e., questionnaires and pre-post assessments in the pilot trial).

In order to adapt the first minority stress-focused intervention for the Chinese cultural context, potentially capable of improving YMSM’s mental and sexual health, we focused on two research questions: (1) How should the ESTEEM intervention be adapted to best address the needs of our target population (i.e., Chinese YMSM)? And (2) Is this culturally-adapted CBT-based intervention feasible and acceptable for improving Chinese YMSM’s mental and sexual health?

Method

Participants

YMSM participants.

Forty-one YMSM participated in the intervention adaptation process. Among them, 25 YMSM participated in the focus groups (M age=28.6 years), 8 attended the theater presentation (M age=27.1 years), and 8 participated in the pilot test (M age=27.9 years). Following the inclusion criteria of Pachankis and colleagues (2015), individuals were eligible to participate if they: (1) were assigned male at birth; (2) were aged 18–35 years old; (3) were HIV negative or unknown-status; (4) had at least one CAS act with an HIV-positive or status-unknown male partner during the past 3 months; (5) endorsed anxiety and/or depressive symptoms assessed with the Chinese-validated 9-item Patient Health Questionnaire (PHQ-9) (Y. Zhang et al., 2013) and 7-item Generalized Anxiety Disorder (GAD-7) scale (He, Li, Qian, Cui, & Wei, 2010); and (6) were not currently receiving or engaged in regular mental health services in the last 3 months. A score between 5 – 15 on either the depression or anxiety scale, which represents mild-to-moderate symptom severity, was chosen as an inclusion criterion in this study. Participants whose score was 15 or greater, which indicates high risk of major depression or anxiety (Kroenke, Spiter, & Williams, 2001; He et al., 2010), were excluded and referred to a local hospital for treatment during the screening assessment.

YMSM participants in this study were recruited through advertisements posted on social networking platforms used by YMSM (e.g., QQ, WeChat), as well as in the lobby of Zuo An Cai Hong (Cai Hong means “rainbow” in English), an LGBTQ-friendly community-based organization (CBO), in Changsha, the capital city of Hunan province in South Central China. All potential participants were screened for eligibility via an online assessment survey. After providing written informed consent, eligible participants were assigned to attend different stages of the adaptation process. All participants were offered voluntary HIV counseling and testing (VCT). The characteristics of YMSM participants (n=41) are shown in Table 1.

Table 1.

Characteristics of YMSM participants (N=41)

Demographic Characteristic	Focus groups n=25	Theater test n=8	Pilot test n=8
Variable	n (%)	n	n
Age (year)
16–20	1(4)	1	2
21–30	17(68)	4	3
>30	7(28)	3	3
Sexual orientation
Gay	23(92)	7	6
Bisexual	2(8)	1	2
Education degree
Junior high school, high school or less	4(16)	0	0
College or associates	3(12)	1	1
4-year College	16(64)	6	7
Graduate school	2(8)	1	0
Relationship status
Married	2(8)	0	1
Single	17(68)	6	6
In a relationship	6(24)	2	1
Employment status
Full time	14(56)	4	6
Part time	2(8)	2	1
Unemployed	9(36)	2	1
Income (yuan/per month)
Less than 5000	9(36)	7	5
5000 to 8000	5(20)	1	0
More than 8000	11(44)	0	3
HIV status
Unknown	2(8)	2	1
Negative	23(92)	6	7

Stakeholders.

Four CBO staff, two site coordinators, three counselors who were familiar with CBT, and seven healthcare providers with expertise either in HIV prevention, patient care, or mental health counseling with MSM provided their input into the development of the adapted intervention. Of these stakeholders, two counselors, two CBO staff, and five experts provided specific content expertise and technical assistance throughout the adaptation process consistent with the “Topical Experts Discussion” process of our formal adaptation procedure, described below. These experts self-reported an average of 7.5 (SD=3.2) years’ experience working with MSM. Characteristics of these stakeholders are shown in Table 2.

Table 2.

Socio-demographic characteristics of stakeholders (N=16)

Characteristic	CBO staff n=4	Experts n=7	Counselor n=3	Site coordinator n=2	Total N=16
Participation stage
Theater test	2	2	1	1	6
Topic experts	2	5	2	1	10
Sexual orientation
Gay/queer	3	2	2	0	7
Bisexual	1	0	0	0	1
Heterosexual	0	5	1	2	8
Relationship status
Married	0	6	1	0	7
Single	2	1	1	1	5
In a relationship	2	0	1	1	4
Research/knowledge field
HIV prevention	4	7	2	2	15
Psychological intervention	1	5	1	1	8
Providing service for MSM (e.g., VCT, sexual health)	3	3	3	1	10

Note. CBO, Community-based organization; MSM, men who have sex with men; VCT, voluntary counseling and testing.

Adaption procedures

We elaborate on each step of the ADAPT-ITT model and the adaptation process below and in Table 3.

Table 3.

Applying the ADAPT-ITT framework to adapt ESTEEM: Phases and Corresponding Actions.

Phase	Corresponding Actions	Intervention Manual Version
1. Assessment	● Conducted 3 focus groups and a needs assessment with Chinese YMSM with anxiety or depressive symptoms and one focus group with CBO staff	N/A
	● Analyzed the interview results
2. Decision	● Decided to adapt the ESTEEM intervention	Original
3. Training	● Trained the potential counselors, research assessors, and data staff on the original ESTEEM protocol
	● Analyzed the trainees’ feedback to form potential adaptations
4. Administration/Adaptation	● Created a stakeholder Community Advisory Board (CAB) and a YMSM Advisory Board	Original
	● Administered theater demonstration with Chinese YMSM and CBO staff
	● Analyzed the results of theater demonstration
5. Producing	● Produced the first draft of the adapted ESTEEM protocol	Draft 1
	● Developed the process evaluation sheets for supervisors to supervise the intervention delivery and identified the measurement tools to assess session-to-session progress in the pilot trial
6. Topic Experts	● Involved five experts knowledgeable about HIV prevention and psychological counseling with Chinese YMSM	Draft 1
7. Integration	● Integrated content from topic experts workshop, CAB, and theater demonstration and created the second draft of the adapted ESTEEM	Draft 2
	● Conducted readability testing to create the third draft	Draft 3
8. Training &Testing	● Trained the counselors and research assistant to implement the third draft of the adapted ESTEEM
	● Conducted an open trial
	● Analyzed the results and feedback of the open trial	Final

Step 1 and Step 2: Assessment and Decision.

Three focus groups of YMSM participants and one focus group of CBO staff were conducted to achieve two major aims. The first aim was to assess the needs of the target population through understanding their experiences of minority stress, the perceived impact of minority stress on mental health and HIV-risk behavior, and learned responses to minority stress. The second aim was to select an intervention for Chinese YMSM and to discuss how the selected intervention could be directly utilized or whether it should instead be adapted from the original. During this process, the YMSM participants and CBO staff, with the guidance of two investigators, reviewed common and popular HIV interventions, mostly developed in the US. Between each focus group, we iteratively fine-tuned our questions in response to issues raised by the previous group. Among CBO staff, additional discussions involved CBO capacity to implement the adapted intervention and the availability of potential resources (i.e., time, staff and space) from the CBO and its community stakeholders. All focus groups were conducted in private rooms at Zuo An Cai Hong. Focus group length ranged between 60 to 90 minutes.

Step 3: Training personnel.

Prior to designing an adaptation plan, the ADAPT-ITT model recommends first becoming familiar with the core elements or principles of the proposed intervention-to-be-adapted and learning key techniques of the original intervention. Upon selecting ESTEEM as the treatment to be adapted, two investigators independently translated the original intervention manual from English to Mandarin Chinese and invited a bilingual expert to review and revise to ensure accuracy. Five potential counselors who had basic CBT knowledge and counseling skills were then selected to receive a 4-day training on implementing the original counseling intervention from the last author, who developed the ESTEEM intervention, and his clinical research team in the US. These five counselors and the Chinese investigator (i.e., the third author) traveled to the US for this training. After the training, several potential adaptations (shown in Results) were discussed among the China and US team. Upon returning to China, the counselors met weekly and performed role plays for 4–5 hours for each counseling session for a total of two months until they had mastered the key theoretical and technical skills required to deliver the ESTEEM intervention. The 10-week practice and regular role-plays were digitally recorded by video or voice recorder and used for supervision with experienced senior clinicians.

Step 4: Administration/adaptation.

To culturally adapt the intervention, we collected suggestions and comments from three sources. First, we created a stakeholder Community Advisory Board (CAB) to capture the stakeholders’ perspectives. The stakeholder CAB included the original intervention developer as the study supervisor, a behavioral interventionist who had conducted some HIV-preventive interventions for YMSM, a psychologist who works with YMSM around issues concerning minority stress, two psychological counselors who primarily work with Chinese sexual minorities, a study coordinator, and one CBO staff working with Chinese YMSM for 8 years (Table 2). Second, we created a YMSM Advisory Board (n=8) that included YMSM participants recruited from the CBO, Zuo An Cai Hong. The two advisory boards met separately to facilitate discussion free of perceived judgment. Third, we conducted a theater demonstration among eight YMSM to seek their feedback about the proposed adapted intervention. Two CBO staff were invited to observe this theater demonstration. During the demonstration, each session of ESTEEM was illustrated with one or two brief role-plays to demonstrate the delivery of each session. Group interviewing and a brief survey were then used to elicit the participants’ feedback and reactions to the theater test, including points of needed further adaptation and details about how those adaptations should occur.

Step 5: Producing.

Integrating the adaptation recommendations from the previous step, we developed a plan to adapt the original ESTEEM manual. Based on the discussion of all feedback collected from the adaption process above, we produced the first draft of the adapted ESTEEM manual. Meanwhile, we developed process evaluation sheets for each session for supervisors to use when supervising the intervention delivery. We also identified measurement tools for evaluating session-to-session progress in the pilot test.

Step 6: Topical Expert Workshop.

Five topical experts, two counselors, and one study coordinator participated in a one-day topical expert workshop. The draft of the adapted intervention manual, the adaptation plan, and the original ESTEEM manual were reviewed in the workshop to elicit discussion. The main discussion topics included (1) aims of the adaptation; (2) review of the existing ESTEEM intervention materials (handouts, therapist guides, participant guides); (3) characteristics of the new target population and context; (4) elements of the original ESTEEM intervention needing preservation; and (5) justifications for and relevance of new materials and/or activities in the adapted intervention.

Step7: Integrating.

The integration of the feedback from the topic experts, CAB, and theater demonstration resulted in the second draft of the adapted ESTEEM materials. To gauge the readability of the adapted materials and enhance its potential for implementation, we utilized the readability test in creating the final version.

Step 8: Pilot Testing.

For the final ADAPT-ITT phase, we conducted an open trial with eight YMSM who reported symptoms of depression or anxiety and self-reported recent HIV-risk behaviors. The purpose of this pilot test was to preliminarily evaluate the acceptability, feasibility, and potential efficacy of Chinese ESTEEM. At the end of each session, YMSM participated in a brief interview to provide feedback about whether the intervention content, activities, materials, and delivery mode were relevant, appropriate, and helpful.

Data collection and analysis

Focus groups in the first adaptation step, discussions with the CAB, and the theater demonstration and topical expert workshop were digitally recorded. These qualitative data were then transcribed verbatim for analysis. To analyze these qualitative data, we employed thematic analysis (Braun & Clarke, 2006). By following the six stages, we uncovered themes demonstrating perceived minority stress, perceived barriers to condom use, perceived support, learned coping strategies, and the impact of the above on risk behaviors and mental health. Most relevant to the proposed adaptation, this analysis also uncovered themes regarding the contextual and social-cultural characteristics to be considered during the adaptation process.

Data regarding participant demographics were collected via questionnaire. Additionally, during the pilot test, a structured questionnaire was used to assess YMSM’s mental health and sexual behavior before and after the intervention. Four psychosocial and behavioral health indicators were assessed: depression was assessed by the Chinese version of the PHQ-9 (Y. Zhang et al., 2013), anxiety by the Chinese version of the GAD-7 (He et al, 2010), HIV-risk behaviors as past-30-day CAS and number of new past-30-day casual partners were self-reported by YMSM participants. The Chinese version of the PHQ-9 and GAD-7 were widely used in the Chinese population, and the internal reliability of two scales was strong, with Cronbach’ s α being 0.85 and 0.90, respectively (Y. Zhang et al., 2013; He et al, 2010). Past-week psychological distress and CAS were also assessed after each session during the delivery of the intervention. We also calculated the pre-post changes from baseline enrollment to 1-month follow-up in the primary outcome measures using paired sample t-tests with participants retained at follow-up.

To explore the feasibility and acceptability of the adapted intervention during the pilot test, descriptive statistics were computed to describe participant characteristics, session attendance, and participants’ evaluation ratings of the intervention.

Results

High need for mental and sexual health promotion among Chinese YMSM

Chinese YMSM participants reported that they often experienced anxiety and depression and engaged in HIV-risk behaviors as a result of the cumulative effect of minority stress. Among 41 YMSM participants, seven had previously sought mental health treatment. All YMSM participants expressed a high need for efficacious psychological counseling. They explained difficulty finding providers due to the lack of LGBTQ-friendly psychological counselors in local hospitals and CBOs. CBO staff discussed barriers related to providing professional mental health care. Specially, CBO staff acknowledged their inability to provide mental health support due to their primary role to deliver VCT services. YMSM and stakeholders noted reasons for the absence of stigma-coping mental health interventions, including discrimination against MSM, limited resources (i.e., time, staff, and space) for providing professional help, lack of training in counseling skills specifically for YMSM in most healthcare institutions and CBOs, and some therapists’ unfriendly attitudes toward working with YMSM. During the topical expert workshop and pilot testing, experts and CDC staff echoed the high need to provide psychological counseling to YMSM and believed that reducing mental health problems could potentially reduce HIV-risk behaviors.

“Well, when I first sought out counseling, I saw that patients in the office were trying to conceal themselves by covering their faces, which was really shocking to me… The doctor asked me only one simple question about my perception of sexual arousal, and then he made the decision quickly. He thought that I am not gay, which didn’t make any sense. His words, along with that kind of environment, repeatedly confused me. You know, I really wanted to acquire some useful knowledge about sexual orientation and ease into a more comfortable state of mind.”

(YMSM, gay men, from focus group 2).

“Every time when I am asked about the marriage issue, I feel very awkward. It stresses me out. This is a paradoxical feeling. I want somebody to come to help me, just a few words or a hug. While, you know, it’s almost impossible in this society.”

(YMSM, gay men, from focus group 3)

“We recognize the importance of the implementation of mental health services. However, none of us CBO members have previously been systematically and formally trained to deliver counseling to MSM who have psychological needs. Also, the CDC would like us to increase the coverage of free VCT service, so we do not have enough time to provide counseling.”

(CBO staff, bisexual men, from the topical expert workshop)

Proposed adaptations to the ESTEEM intervention

The core elements and philosophy of the original intervention, namely its CBT principles and LGB-affirmative stance, are maintained, due to their fit both with Chinese culture (e.g., CBT’s skills-focused approach) and the LGBTQ community’s needs for affirmative counseling in a high-stigma environment. We explored similarities and differences between the original intervention and its adapted version for Chinese MSM (see Supplementary Table 1). Similarities include the role of minority stress in MSM’s mental health, stigma associated with both sexual orientation and HIV status, and coping strategies for mental health problems. Differences between the original and adapted intervention include contextual and cultural differences in Chinese MSM’s experiences of, and coping with, minority stress and delivery-related factors. Specific considerations for cultural adaptation included (a) men’s roles and responsibilities in a family-oriented Chinese culture and (b) a collectivistic culture with an emphasis on interpersonal harmony, norm conformity, and emotional control/suppression. Mental health delivery-related adaptations encompassed a general lack of professional mental health services in China as well as MSM’s preferences in delivery format and mode. We describe these cultural and delivery-related considerations for adaptations below.

Cultural considerations in minority stress experiences and coping among MSM in China

Regarding the family-oriented Chinese cultural adaptation considerations, the degree of family importance in the lives of YMSM emerged as a primary difference from the original intervention. Indeed, the obligation to carry on the family name was the biggest minority stressor for most Chinese YMSM. Although both Chinese and North American YMSM perceive parental expectations as a kind of minority stress (Choi et al., 2016; X. Li et al., 2013; Pachankis, Sullivan, & Moore, 2018), Chinese YMSM seem to possess a stronger sense of collective identity, giving more weight to the need to respect the values and norms set forth by family versus their needs as individuals (Shao, Chang, & Chen, 2018). Chinese YMSM also shared values that they have to pay their filial piety to their parents like anyone else in China, such as following their parents or grandparents’ wishes to marry a woman. In this study, YMSM participants reported that they were often overwhelmed by the “ethical responsibilities” of the family and society. For instance, many Chinese YMSM shared experiences of being urged by their parents and relatives to get married as soon as possible.

Given the strong family-related minority stress experiences among Chinese YMSM, some content and activities of the ESTEEM intervention were enhanced to specifically address these family issues associated with Chinese culture. For example, Session 8 in original intervention, which mainly involved assertiveness training, was raised many times as a point of necessary adaptation. Both YMSM participants and counselors thought that the principle “Empower Gay and Bisexual Men to Communicate Openly and Assertively Across Contexts,” which explicitly guides this session, was very meaningful. In Chinese culture, however, MSM expressed concerns about this approach due to their desire not to cause “harm” to their parents by coming out and asserting themselves, reflecting the cultural values of filial piety and interpersonal harmony (Steward et al., 2013). Further, assertiveness training – an individualistic approach – that teaches YMSM to express themselves openly, could contradict Chinese YMSM’s prevalent self-concealment, a learned coping mechanism to facilitate belonging to the mainstream Chinese society (Shao et al., 2018). Therefore, the adapted intervention takes a more gradual and relationship-oriented approach: it first seeks to help YMSM participants gain a sense of self-validation and affirmation about their sexual orientation; building on this foundation, it encourages YMSM to communicate sincerely with others including parents to the degree that they feel comfortable. Thus, in a largely non-affirmative environment where most Chinese MSM conceal their sexual identity (Pachankis & Bränström, 2019), instead of encouraging coming out as a singular good, the adaptation included (a) normalizing fears of rejection or expected rejection as a response to one’s stigmatizing environment; (b) enhancing focus on helping MSM to distinguish between social contexts where concealment may be an adaptive strategy (e.g., where negative attitudes toward MSM are promulgated) and contexts where disclosure could be beneficial (e.g., contexts involving strong relationships and trusted individuals); and (c) setting realistic expectations about the coming out process as well as others’ response (e.g., skills training to respond to potential exposure of discrimination as a result of disclosure).

Mental health delivery considerations

Potential mental health delivery adaptations were considered in light of the current state of mental health services in China overall, the lack of resources in the LGBTQ community for such services, and the variety of potential delivery modes. First, the adaptation recognizes that although YMSM involved in both the original and adapted intervention regarded the LGBTQ community as an important source of support, Chinese YMSM reported that they were particularly reliant on the services provided by the community, especially VCT services from LGBTQ-friendly CBOs rather than other health care institutes due to pervasive social stigma in non-LGBTQ-specific settings. However, the LGBTQ community cannot offer Chinese YMSM sufficient mental and sexual health services due to limited financial support from the government and lack of trained health providers and peer educators in the CBOs.

Mental health delivery adaptations considered format, duration, and delivery mode. YMSM participants reported that they preferred that the intervention contain fewer sessions of longer duration (e.g., eight weekly sessions with 1 hour for each session versus the 10 50-min sessions of the original intervention). Some participants thought that the face-to-face format was helpful for encouraging them to share minority stress experiences with counselors more deeply. Yet, other YMSM participants considered the combination of a small group plus individual sessions as a better counseling format for several specific session activities, which could help them process their personal experiences with others, receive support, and elicit more accurate reflections of YMSM life. For example, when preparing a role-play, a participant who attended our preliminary focus group, said, “These tasks were good practice. If I could communicate with other MSM together, I would feel safer, and it would engage me more in the activities.” Notably, this adaptation advice would require an entirely new delivery format in future research and therefore was not included in the current adaptation. Further, YMSM participants were unfamiliar with CBT-specific terminology. In response, some Chinese metaphors or allegories were added to better translate standard CBT terminology for this context.

Several concerns about counselor factors and therapeutic relationship factors were mentioned by both CAB members and YMSM participants. YMSM participants indicated that they would like to communicate with counselors who were LGBTQ-friendly and open to clients’ experiences. Given the collectivistic traditions in China and the overall underdeveloped state of the mental health field (Castro et al., 2004; Hwang, 2009), some YMSM participants viewed counselors as authority experts and had expectations for immediate symptom improvement. As such, the adapted intervention spends more time encouraging YMSM to actively engage in formulating their treatment goals in collaboration with their counselor. That is, the adapted intervention devotes space to clarifying the collaborative nature of the therapeutic relationship. Person-centered methods for addressing the resistance were added when delivering the first session of the adapted treatment (e.g., telling participants the counselors’ role is not to direct them but to assist them in understanding their own minority stress experience; and believing participants have the ability to make positive changes for themselves). The HIV prevention and psychological experts also emphasized the importance of the counseling relationship. Specifically, they suggested some practical strategies to establish an effective counseling relationship, including stating one’s affirmative stance as part of the introduction, providing a thorough explanation of confidentiality, and self-disclosing appropriately to the participants.

Overall, the information and feedback collected from YMSM participants and key stakeholders allowed us to integrate the proposed changes into the final version of the intervention. The name ESTEEM was translated by pronunciation into “益思堂(Yi Si Tang).” The first character “益” means benefit for a population; the second character “思” means thinking; and the third character “堂” means a holding space for all (this word is widely used in traditional Chinese medicine store names). We also created a motto for this program as “勇 敢做自己”(To be yourself).

The acceptability of the adapted intervention

Satisfaction with ESTEEM was high among YMSM participants and key stakeholders. Of participants who attended the theater test or topical expert workshop, about 80% reported being “very satisfied,” 14% “satisfied,” and 6% “neutral” about the principles, content, and delivery of ESTEEM. In the theater test, some YMSM participants compared ESTEEM with other domestic health services that they had received from hospitals and CBOs, and all of them believed that, as an LGB-affirmative mental health intervention, ESTEEM had the promise of improving sexual minority men’s mental health, and they expressed strong willingness to receive this intervention. During the topical expert workshop, experts and counselors uniformly supported the ESTEEM intervention. One expert from the China CDC indicated that ESTEEM would be a novel and promising HIV-prevention strategy. Some experts thought that the intervention would ultimately be most acceptable if counselors could be trained to attend to minority stress experiences among YMSM, such as the emotional impact of minority stress and avoidant coping strategies as a result of minority stress.

“It was fun. I liked it. It could remind me of my strengths. More important, it could help me to make the connections between my behaviors, how I felt about and what I think about situations, which was helpful. I liked the activities, particularly the monitoring sexual minority stress worksheet and exploring how I felt as a result of gay-related stress.”

(gay men, from the theater test)

“You know, nowadays the increasing number of new HIV cases is from male-to-male transmission. If continuing to follow the current HIV-prevention strategies, their (YMSM’s) risk behaviors wouldn’t be effectively controlled. So, in my view, the ESTEEM intervention is likely to represent a promising strategy.”

(CDC staff, from the topical expert workshop)

The feasibility of the adapted intervention

In total, 50 YMSM were screened for eligibility in the open trail. Among them, 24 did not complete the baseline assessment, 12 reported no CAS in previous 3 months, and 6 indicated high risk of major depression on the PHQ-9. Finally, 8 participants who met inclusion criteria (endorsed psychologically distress and reported CAS with a status-unknown or HIV-positive partner in the past 3 months), were enrolled between May and October in 2019 to receive the adapted intervention.

Of the eight participants, five completed all 10 sessions, two attended at least half of the sessions, yet discontinued due to severe depressive symptoms, and one completed only the first session due to moving out of the city. The average number of sessions completed was 7.8. All except the one moved out of city were retained at the 1-month follow-up assessment resulting in the analytic sample of 7 for pre-post analysis (see Figure 1). Of the four psychological and sexual health outcomes, all demonstrated a decline. Illustrated in Table 4, the average score of depression and anxiety symptoms was reduced by approximately 7 and 5, respectively, indicating a medium-to-large improvement in psychological health in this small sample. We also observed a reduction in the number of self-reported CAS with casual partners (i.e., from an average of 1.86 instances at baseline to an average of 0.43 instances at 1-month follow-up). The average number of casual male sex partners was also reduced by nearly two partners. There was between-session variability in psychological outcomes from baseline to 1-month follow-up, with a peak at sessions 4, 5, and 6, which could be associated with the specific tasks of those sessions (e.g., raised awareness of minority stress and tolerance of uncomfortable emotions) (see Figure 2–3).

Figure 1.

This figure displays the CONSORT model for the adapted ESTEEM with a pilot trial

Table 4.

Pre-post changes in psychological and sexual health outcomes (N=7)

	BL		1M		BL VS 1M
	M	SD	M	SD	t (6)	p
Depressive symptoms (PHQ-9)	10.43	3.46	3.86	4.45	5.92	0.001***
Anxiety symptoms (GAD-7)	7.43	2.57	2.86	3.02	6.08	0.001***
Condomless anal sex	1.86	1.21	0.43	0.53	3.33	0.016*
Number of casual male partners	2.29	1.38	0.57	0.53	2.66	0.037*

^ŧp ≤.10,

^*p ≤ .05,

^**p ≤ .01,

^***p ≤ .001

Note. BL=baseline; 1M=1-month follow-up; M=mean; SD=standard deviation.

Figure 2.

Treatment change in psychological symptoms (n=8).

Figure 3.

Treatment change in condomless anal sex (n=8).

In terms of the overall perception of the adapted intervention, YMSM participants and counselors evaluated it favorably. Specifically, 76.9% (n=10) of stakeholders rated it “excellent,” 15.4% “good,” and 7.7% “neutral.” In the brief qualitative interviews at the end of each session, YMSM participants described their experiences with the adapted intervention as “meaningful” and “helpful.” Five participants said that they enjoyed participating in each session with the counselors and regaining control of their emotions and life. Seven participants said that they would recommend the therapy to their friends.

Discussion

In this study, we documented the cultural adaptation of a CBT-based intervention, ESTEEM, designed to reduce Chinese YMSM’s minority stress reactions and improve their mental and sexual health. Although a growing number of HIV-prevention interventions address Chinese MSM’s HIV-risk behaviors (H. Zhang et al., 2009; Lu et al., 2013; Tang et al., 2019), these interventions largely focus on health-promoting sex education without addressing minority stress as a source of YMSM’s mental and behavioral health challenges (Hong & Li, 2009; Lu et al., 2013; Sun et al., 2020b). Thus, no evidence-based interventions currently have specifically targeted minority stress and mental health issues to reducing Chinese YMSM’s HIV risk. The current study therefore serves as the first endeavor to adapt such an intervention for Chinese YMSM.

Specifically, positive feedback from YMSM, CBO staff, counselors, experts, and pilot recipients of the intervention demonstrated that the adapted intervention was acceptable and feasible to carry out with Chinese YMSM. The principles and core elements of ESTEEM were uniformly acceptable to the YMSM and key stakeholders. Participants who attended the pilot trial and received the adapted intervention conducted in the local CBO also showed high acceptance and willingness to receive the counseling service in CBOs. Despite the trajectories of treatment change were diverse across participants, the overall reduction across psychological and sexual risk outcomes suggest that the adapted intervention might represent a promising means to help YMSM address their co-occurring health risks.

Although an individual-level intervention such as ESTEEM might theoretically conflict with collective societal norms, the preliminary findings, derived from our thorough application of the ADAPT-ITT model, suggested that the adapted version of ESTEEM had the flexibility to empower YMSM to balance assertiveness and self-expression with their need for collective and family harmony, by preserving the core principles and theoretical underpinnings of the original ESTEEM intervention such as its identity-affirmative approach, while also integrating culturally-appropriate, adaptive coping strategies. Moreover, this adapted intervention encourages sexual minorities to meld their new cognitive and behavioral coping skills into their real-world experience of the Chinese culture context. Therefore, this study preliminarily demonstrates that a minority-stress-focused intervention could be adapted for different cultural contexts globally, especially in countries where high-stigma is prevalent against sexual minorities.

Given the emerging call for interventions to curb HIV transmission among Chinese YMSM by China CDC (Chow et al., 2014; G. Li et al., 2019), this study, as the first cultural adaptation of an empirically supported CBT-based treatment for YMSM’s minority stress and associated health risks, can serve as a step toward disseminating and implementing such a needed intervention for the most at-risk YMSM in China. More immediately, our findings can serve as the basis of a future trial to test the efficacy of this intervention within LGBTQ-friendly CBOs and HIV-prevention and care settings.

Limitations and Future Research Directions

There are several limitations of the present study. First, our participants largely identified as gay and bisexual and the study took place in Changsha, which is a capital city in southcentral China and relatively liberal compared to rural and more moderately-sized cities. Thus, results may not be generalizable to non-gay identifying MSM as well as MSM living in more conservative settings, which arguably characterizes most Chinese MSM (Pachankis & Bränström, 2019). Second, despite 50 participants expressing interest in participating, not all could be enrolled given the inclusion criteria focused on the highest-risk MSM and practical and perhaps structural and motivational barriers. Because the purpose of the intervention is to reduce HIV risk, CAS was a necessary inclusion criterion for the trial, and 28.6% (12/42) of participants did not report such risk during screening. Further, many (57.1%) participants did not complete the baseline assessment, which may reflect stigma- or motivation-related barriers to engage in face-to-face interventions. Although three participants were not retained during the delivery of the adapted intervention, that the treatment could link-to-care two participants who might not have otherwise been referred to such care indicates another benefit that our treatment study could provide (in addition to upholding ethical research conduct). Further, one participant discontinued because of a move which suggests the potential need for remote delivery of this intervention. Finally, the study design was incapable of evaluating the efficacy of the adapted “Yi Si Tang,” specifically due to the small sample size and lack of control conditions; confounding factors should also be considered when interpreting results, including any outside treatment received, particularly relevant in the case of the two referred participants.

These limitations notwithstanding, study findings have implications for future intervention research with MSM in China. First, given the pre-post design and small sample size, a future trial using a randomized-controlled design with a larger sample is needed to determine whether the preliminary findings are statistically and clinically meaningful. Further, recent meta-analytic research demonstrated the general efficacy of culturally adapted treatments over their non-adapted counterparts (Soto et al., 2018), but the question of whether the current work could achieve similar findings remains to be explored. Specifically, comparing “Yi Si Tang” to non-LGBTQ-adapted psychological treatments as usual or even to standard CBT would allow the future community to examine Yi Si Tang’s treatment efficacy over-and-above these existing treatments. The inclusion of larger samples and multiple follow-up assessment periods would allow for comparisons of underlying treatment mechanisms of all examined treatments. Indeed, such an approach would parallel the more robust testing of the non-adapted ESTEEM treatment currently taking place (Pachankis et al., 2019), given that non-adapted ESTEEM has currently only been tested in a waitlist-controlled trial. The current study showed a relatively large deterioration rate (2/8), however, whether such deterioration is a result of the intervention or reflects the high-risk nature of the sample remains to be determined in a larger future trial employing interim outcome monitoring and strong clinical protocols for responding to increases in participant distress. Further, detecting latent trajectories of between-session changes in future larger studies can also allow future researchers to identify session-specific response, necessary and sufficient session dose, and any iatrogenic treatment effects. A diversified delivery approach (e.g., group format, online) may help maximize the reach of this intervention and perhaps also address retention challenges. Second, given the relative costliness of this treatment against the backdrop of relatively scarce public health resources in middle-income countries such as China, this treatment is intended for the most synergistically affected MSM (i.e., those experiencing mental health problems and sexual risk). Thus, despite challenges to enrolling the highest-risk YMSM, given the size of the Chinese MSM population and documented very high need and demand (Beijing LGBT Center, 2014), future steps to test and deliver this intervention with synergistically-affected MSM are expected to be successful. In fact, trials with synergistically-affected MSM in the US and other middle-income countries have been successful (e.g., Lelutiu-Weinberger et al., 2018). Third, if this intervention is shown to be effective, research would be needed to assess barriers and facilitators surrounding its implementation in HIV-prevention settings. Fourth, because both the original and adapted intervention take an individual-level approach to stigma reduction, future clinical research may expand this approach to empower Chinese YMSM to ultimately advocate for more affirmative environments in their local communities in order to stanch stigma at its source (Cook, Purdie-Vaughns, Meyer & Busch, 2014). Fifth, future research could explore the potential benefit of other evidence-based approaches, such as those focused on interpersonal processes within and outside of the therapeutic relationship (e.g., Eubanks, Burckell, & Goldfried, 2018; Klerman & Weissman, 1991) adapted to address minority stress to positively affect YMSM mental and sexual health. If found to be efficacious, such approaches could either be combined within Chinese-adapted ESTEEM as appropriate or delivered as stand-alone interventions. Finally, future research might consider expanding the treatment beyond urban and surrounding rural areas using diverse recruiting approaches, which would increase the geographic representation of YMSM who might be otherwise isolated. Training in LGB-affirmative care represents a promising initial implementation strategy with potential for reaching larger number of sexual minorities in China. Our results can lay the initial groundwork for such implementation. Such training efforts, if successful, could also provide needed data necessary for advocating for expanded, affirmative mental health policies for sexual minority individuals.

Conclusion

This study culturally adapted and preliminarily tested the acceptability and feasibility of a CBT-based, LGB-affirmative therapy to improve Chinese YMSM’s mental health and reduce their HIV-related risk behaviors by addressing the pathways through which minority stress affects these outcomes. The systematic adaptation process allowed us to identify any potential mismatch between the original cultural context and the Chinese adaptation context to strike a balance between the fidelity to core intervention elements and cultural resonance. The adapted intervention, 益思堂(Yi Si Tang), demonstrated feasibility, acceptability, and potential for efficacy. Future research is needed to further establish the efficacy of the adapted ESTEEM intervention for Chinese YMSM’s mental and sexual health and explore barriers and facilitators to ultimate implementation. Such efforts are needed to reach the largest numbers of the most vulnerable YMSM as possible to curb the increasing HIV epidemic surrounding this population.

Clinical Impact Statement.

Question:

Can an efficacious US-based minority-stress-focused cognitive-behavioral intervention be adapted to meet the needs of Chinese young men who have sex with men (YMSM), and used by key stakeholders to address this populations minority stress and co-occurring health risks?

Findings:

The adaptation incorporated Chinese-specific adaptations while preserving the core principles and theoretic underpinnings of the original ESTEEM intervention. The study also demonstrated that the adapted ESTEEM was highly acceptable and feasible to carry out with Chinese YMSM, and had preliminary efficacy in improving YMSM’s stigma coping, mental health, and HIV-related risk behaviors.

Meaning:

This study, as the first cultural adaptation of an empirically supported cognitive-behavioral treatment for YMSM’s minority stress and associated health risks, can serve as a first step toward disseminating and implementing such a needed intervention for the most at-risk YMSM in China.

Next Steps:

Future research will further establish the efficacy of the adapted intervention for Chinese YMSM’s mental and sexual health and explore barriers and facilitators to ultimate implementation to reach the largest numbers of the most vulnerable YMSM as possible to curb the increasing HIV epidemic surrounding this population.