Influence of HIV-related and Sexual Minority Stigma on Mental Health and Sexual Risk Behaviors of MSM and Transgender people in India
Dr. Venkatesan Chakrapani, M.D.
Centre for Sexuality and Health Research and Policy (C-SHaRP), India
& The Humsafar Trust, Mumbai
&
Prof. Miriam Samuel
Dept. of Social Work, Madras Christian College, India www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

• Meyer ´s minority stress model Meyer, 2003):
Sexual minority stigma
(internalised, perceived & enacted) as chronic stressor psychological distress.
• We tested a modified minority stress model:
– Influence of sexual minority stigma & HIV-related stigma on the mental health of MSM and hijras/trans people in
India.
– Social support and resilient coping as possible mediators/moderators
• In addition, we examined the influence of stigma on sexual risk.
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Testing a modified minority stress model
Independent
Variables
Sexual Stigma
(SxS)
Gender
Nonconformity
Stigma (GNS)
Transgender
Identity Stigma
(TGS)
HIV-related
Stigma (HIV-S)
Mediators/
Moderators
Social
Support
Resilient coping
Dependent
Variables
Mental health
(Depression) www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

1
Survey Questionnaire
N = 600
(300 MSM & 300 TG)
6 sites: 3 urban & 3 rural
Sequential mixed methods explanatory design
Phase 1: Quantitative (Survey)
Phase 2: Qualitative (In-depth interviews)
4
In-depth interviews (IDIs)
Selection of subsets of survey sample (n= 39)
2
Quantitative data analysis
Hierarchical linear/logistic regression
6
Inferences from quant and qual data sources www.ias2013.org
5
Qualitative data analysis
Constant comparison &
Process tracing (NVivo 10)
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Scale used
1. Sexual stigma scale (SxS)
2. Gender non-conformity (GNS) stigma scale
3. Transgender identity stigma
(TGS) scale
Modified from or original scales of -
Modified from China MSM stigma scale *
(Neilands, Steward & Choi, 2008)
Modified from ‘Exposure to Transphobia’ scale * (Sugano, Nemoto, & Operario, 2006
)
4. HIV-related stigma (HIV-S) scale Steward et al., 2008
5. Brief Resilient Coping scale Sinclair & Wallston, 2004
6. Multidimensional Scale of
Perceived Social Support
7. Beck Depression Inventory Fast-
Screen
Zimet et al.,1988
Beck, Guth, Steer, & Ball, 1997
* adapted from the Homophobia scale of Diaz et al., 2001 www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

3a. Characteristics of survey participants
(n=600: MSM=300; Hijra/TG=300)
• Mean age = 29.7 (SD 8.1)
• Mostly lower SES and lower educational status
• Graduates: 17% MSM, 7% hijra/TG
• 10% - self-reported as HIV-positive
• Sex for money (past 3 months): hijra/TG - 71%, MSM - 38%
• Subgroups of MSM: Kothi – 58%, Double-decker – 14%,
Panthi – 9%, Gay – 9%, Bisexual – 6%
• Subgroups of TG: Hijra – 67%, ‘transgender’ [English term] – 25%, Jogta – 8% www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

3b. Characteristics of qualitative in-depth interview participants (n=39)
MSM (n=20):
• Mean age = 31
• 25% - completed high school, 25% - graduate
• 10 – married (2 living with wife)
• 60% - kothis, 15% ‘gay’
Hijra/TG (n=19):
•
M ean age = 33
• 30% - high school, 25% college
•
30% - daily-wage laborers, 30% -
‘begging’
• 35% - hijras, 25% - ‘transgender’ www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

SCORES:
Gender Nonconformity Stigma (GNS), Sexual Stigma
(SxS) & Transgender identity Stigma (TGS)
100%
90%
80%
70%
60%
50%
40%
87%
30%
55% 56%
20% 38%
33%
10%
0%
7%
1% 12% 10%
GNS
(MSM: n=205/300)
SxS
(MSM: n=95/300)
TGS
(n=300)
No
Low
Moderate
Severe www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Index scores: HIV-related stigma (HIV-S): Total score and subscores
HIV-S: Total Score
Vicarious Stigma
Felt Normative Stigma
Enacted Stigma
Internalized Stigma
* p<.05
** p<.001
MSM
0.33
0.38
0.68
0.13
0.32
TG
0.35
*
0.44
**
0.68
0.21
0.39
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013

45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
42%
MSM: Mean-5.12
TG: Mean-5.9*
23%
21%
15%
32%
25%
19%
24%
MSM TG
No
Mild
Moderate
Severe www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Resilient Coping: MSM & TG
50%
40%
30%
20%
10%
0%
80%
70%
60%
68%
21%
11%
MSM
21%
13%
TG
65% www.ias2013.org
Low
Moderate
High
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Inconsistent condom use with different types of male partners
Condom use in last anal sex www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

30%
20%
10%
0%
Inconsistent condom use in anal sex with different type of male sex partners in past month
60%
50%
40%
39%
29%
26%
51%
32% 31%
Regular Casual Paying
Partner Partner Partner
Regular
Partner
Casual Paying
Partner Partner
_______________________________ ________________________________
MSM TG www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

- 27% of MSM (n=80/294)
- 32% of hijras (n=95/293) www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

3d. Survey:
Hierarchical Linear Regression Models for the influence of stigma on depression www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Modified minority stress model tested
Independent
Variables
[BLOCK-1]
Sexual Stigma
(SxS)
Gender
Nonconformity
Stigma (GNS)
Transgender
Identity Stigma
(TGS)
HIV-related
Stigma (HIV-S)
Mediators/
Moderators
[BLOCK-2]
Social
Support
Resilient coping
Dependent
Variables
Depression www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Table. Hierarchical Multiple Linear Regression Analyses Predicting
Depression Among MSM (n=300) www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Table. Hierarchical regression analysis of predictors of depression among MtF transgender people (N = 300) www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Inferences from Hierarchical linear regression
• In general, among both MSM and TG people, the regression results are consistent with the adapted minority stress model that stigma is associated with mental health, and social support and/or resilient coping are significant correlates.
• No moderation effect of social support and resilient coping www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

3e. Survey: Hierarchical logistic regression modelling of sexual risk behaviours
MSM (n=300):
Stigma (SxS, GNS, HIV-S)
• GNS/SxS was a significant predictor of inconsistent condom use with male regular partners (but not with male casual or paying partners)
• MSM with high levels of HIV-related stigma were more likely to NOT use condoms in last anal sex www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Social support
• People with moderate social support were less likely to be inconsistent condom users with male paying partners
Resilient coping
• MSM with high levels of resilient coping were less likely to be inconsistent condom users with male regular, paying or casual partners, and less likely to NOT use condoms in last anal sex
Depression
• Depression was a significant predictor of sexual risk in male casual and paying partners www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Hijras/TG (n=300):
Stigma
• Neither TG identity stigma nor HIV-related stigma was a significant predictor of sexual risk with any type of male partners (regular, causal and paying) or unprotected sex in last anal sex
Depression and Alcohol use
• TG people with severe depression and frequent use of alcohol were more likely to be inconsistent condom users with male casual and paying partners www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Social support
• TG people with moderate or high levels of social support were less likely to be inconsistent condom users with casual and paying partners, and less likely to engage in unprotected sex in last anal sex.
Resilient coping
• Not a significant predictor of sexual risk with any of the male partner types. www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

3f1.
Qualitative findings:
Mechanisms by which stigma influences mental health of
MSM/TG www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

3f-2. Qualitative findings:
Simplified version of how stigma affects mental health and condom use www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

• Mental health:
Empirical support for the adapted minority stress model that sexual minority stigma (SxS, GNS, TGS) and HIV-related stigma are associated with depression.
•
Sexual risk:
– In the survey, sexual minority stigma was not a significant predictor of sexual risk; but evidence from qualitative component suggest influence of stigma on sexual risk.
– In the survey, HIV-related stigma was a significant predictor of sexual risk among MSM, but not among TG.
– In general, depression and alcohol use were significant predictors of sexual risk among both MSM and TG.
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

• Educate and sensitize the general public and stakeholders (such as health care providers) on sexual minority issues to decrease societal stigma and discrimination in various settings
• Provide mental health counselling and referral services through existing MSM/TG HIV prevention interventions
• Promote self-acceptance by decreasing selfstigma among MSM/TG www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

• Address the reasons behind the differential use of condoms with different types of male partners
• Strengthen social support networks of MSM and TG people
• Formulate a national health policy for sexual minorities that also addresses mental health needs www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

• This study was funded by Indian Council of Medical Research (ICMR).
• Research team: Murali Shunmugam, Murugesan Sivasubramanian, Javed
Syed, Kavita Nair Bhatia, Soma Roy Karmakar ,Madhu, Najmus Khan,
Maksoom Ali.
• We thank our collaborating partner agencies:
– Social Welfare Association for Men (SWAM), Kancheepuram
– Integrated AIDS Awareness Sangam, Kumbakonam
– MookNayak Sanstha, Sangli
– Pahal Foundation, Delhi
– Solidarity and Action Against the HIV Infection in India (SAATHII) www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013