“Because of HIV,It Opened My Mind”: Intersectional Stigma Experiences Among Filipino Gay and Bisexual Men Living With HIV

Abstract

Previous work has demonstrated that gay, bisexual men, and other men who have sex with men (GBM) living with HIV are likely to experience intersectional stigma. However, mainstream systems often fail to recognize how power and privilege shape this experience. Such a complex psychological phenomenon requires an in-depth reflective inquiry that acknowledges individuals as experts in their own experiences. To explicate this matter, this study aimed to develop an understanding of how intersectional stigma impacts the experiences of GBM living with HIV and to illuminate how contexts (un)fuel inequities. The semi-structured interviews with five Filipino GBM living with HIV were analyzed using interpretative phenomenological analysis (IPA). Exploration of their accounts elucidated how cultural elements fueled power dynamics and privilege, which in turn shaped intersectional stigma and their experiences. Narratives accentuated how Filipino GBM living with HIV situate themselves from victims to agents of change who empower and liberate others in the community. Insights from this study underscore the critical role of collective actions in bridging gaps in inequities and guiding the improvement of policies and interventions that are well-suited to the context and culturally appropriate for people living with HIV and other multiply marginalized populations.

Introduction

The global HIV epidemic continues to add burdens to public health systems, with particular implications for multiply marginalized populations. The Philippines has the highest rapid growth of HIV infection in the Western Pacific Region with 174% incidence from 2010 to 2017 (Gangcuangco, 2019). From 2013 to 2023, a striking 411% rise in daily cases over the decade was reported (Gangcuangco & Eustaquio, 2023). In 2023, 41 people were living with HIV every day, and gay, bisexual men, and other men who have sex with men (GBM) account for the highest numbers of PLHIV (Department of Health-Epidemiology Bureau, 2024). Although HIV is becoming a manageable health condition (World Health Organization, 2022), they are still at high risk for other health conditions (e.g., hypertension, chronic kidney disease, and substance abuse) associated with HIV (Paudel et al., 2022). Additionally, mental health concerns compound the experiences of both HIV (Pereira et al., 2022; Too et al., 2021) and gender-related stigma (Brener et al., 2023). From the evidence, we contend that the compounding stressors demonstrate how experiences of HIV are embedded in complex issues such as homophobia, patriarchal cultural norms, and religious fundamentalism, which in turn fuel this silent epidemic. In particular, the complex phenomenon of overarching stigma from various elements and systems has also been visible in the lives of Filipino GBM living with HIV, which are shaped by socio-structural components and culture.

To holistically understand how GBM living with HIV can navigate these adversities, we need to understand the intersection of health-related stigma and other elements of social oppression. In this study, we are interested in exploring the intersectional stigma experiences of GBM living with HIV through a “process of in-depth reflective inquiry” (Smith et al., 2021, p. 1).

Experiences of Stigma Among GBM

Conventional understandings of stigma relate to how people who receive a mark are seen as different from others. This process delineates the person, making them different, undesirable, or discredited. This stigmatization can lead to exclusion, discrimination, and even abuse, further perpetuating negative attitudes toward them (Goffman, 1986). Link and Phelan (2001) argued that the conventional conceptualization of stigma in the psychological literature is often uninformed by the lived experiences of stigmatized people and tends to focus solely on the individual levels and eliminate the broader social and cultural dimensions that perpetuate stigmatization (Kleinman et al., 1995; Schneidre, 1988). To advance the scholarship on stigma, research is needed to contextualize how stigmatization happens by understanding different micro and macro elements that catalyze it.

The corpus of literature provided evidence that GBM living with HIV experience multiple forms of stigma (Earnshaw, Jonathon Rendina, et al., 2022; Garcia et al., 2016; Gichuru et al., 2018; Philpot et al., 2023) from their axes of stigmatized identities and are being manifested by various mechanisms (Earnshaw et al., 2013). These multiple forms of stigma were shaped and fueled by systems of power and privilege (Crenshaw, 1989). Specifically, Filipino GBM living with HIV are in a vulnerable situation where their stigmatized identities interact with their culture and structural elements.

In the Southeast Asia (SEA) region, the Philippines had the most accepting attitude toward gay men and lesbians in comparison to other SEA countries (Manalastas et al., 2017). However, despite this, Filipinos continue to show negative views toward members of the LGBTQ+ community (Abesamis & Alibudbud, 2024). In a recent survey, queer people in the SEA region, including in the Philippines, continue to experience negative attitudes (Bilon & Clemente, 2024). These negative views toward them are reflected in SEA countries’ national policies on protecting their rights. No SEA countries yet have a national policy that protects queer people from discrimination (except Thailand in some areas) and violence (except Timor-Leste on hate crimes), and queer people in the SEA region continue to be denied basic human rights such as marriage, civil union, adoption, and becoming a second parent (Mendos et al., 2020). Generally, Asia remained to have limited protection among the queer community, except Taiwan which is the first Asian country to fully recognize same-sex marriage (Lee & Lin, 2022). Recently, in a historic movement, Thailand became the second country in Asia to legalize same-sex marriage (Regan & Olarn, 2024).

Culturally, the LGBTQIA+ community is stigmatized by religious institutions in the Philippines (Ruiz Austria, 2004). Many Filipinos are religious, and this religiosity often leads to negative opinions about GBM (United States Agency for International Development [UNAIDS] & United Nations Development Program [UNDP], 2014). HIV is intertwined with sex and sexuality, positioning Filipino GBM as sinful in the Philippines (Canoy & Ofreneo, 2012). This perception is predominantly influenced by the powerful religious moralization of the Roman Catholic Church (Ruiz Austria, 2004). As Canoy and Ofreneo (2017) argued, Filipino GBM living with HIV engaging in same-sex relationships often “may feel the need to question one’s identity” (p. 582) as they characterize their struggles on contemplating their sexualities to HIV and the moralization of being sinful about the values of Roman Catholicism. Furthermore, dominated by conservative religious values, Filipinos may harbor deep-rooted stigma. This intersection of HIV stigma and being queer is associated with “morality, dirtiness, and sin” (Adia et al., 2018, p. 322).

To contextualize how multiple nexuses of stigma and oppression are fueled and experienced by Filipino GBM living with HIV, we believe it is critical to study the combined impact of stigma and oppression in a comprehensive and holistic way.

Intersectionality as a Lens

Intersectionality provides an analytical lens to untangle how a nexus of stigma is being catalyzed by systems of power and privilege and how that, in turn, impacts the lives of multiple marginalized populations (Berger, 2004; Collins, 2000; Crenshaw, 1989; Logie et al., 2011; May, 2015). Contemporary research studies of intersectionality can be traced back to the Black-feminism discourse. Specifically, Crenshaw (1989) coined the term intersectionality, highlighting how different social systems are oppressing women of color (Abrams et al., 2020). These explorations forwarded the scholarship on intersectionality, which provides a framework for understanding how multiple identities are interconnected and socially constructed, as well as how these connections “collectively shape the lived experiences” of people (Abrams et al., 2020, p. 2). Indeed, the development of scholarship on intersectionality has facilitated a leap in understandings of complex health and social issues.

There is growing momentum in applying intersectionality to various methodologies, with both quantitative (Bauer et al., 2021, 2022; Guan et al., 2021; Harari & Lee, 2021; Kalichman et al., 2022; Scheim & Bauer, 2019) and qualitative (Abrams et al., 2020; Bowleg, 2008) research advancing using intersectionality. However, researchers must be cognizant of the principles of intersectionality to harness its strength in addressing health inequities, such as its principles on deconstructing systems of power and privilege that shape oppression, and how systems influence stigma among multiply marginalized populations (Sievwright et al., 2022). Nevertheless, we contend that for us to unravel intersectional stigma, researchers should also recognize other elements that could shape systems of power and oppression. For instance, scholars should consider the critical role of place and time in stigma. Bambra (2022) argued that “place needs to be considered as an aspect of intersectionality” (p. 1). Earnshaw, Watson, et al. (2022) asserted that stigma “waxes and wanes” (p. 244) throughout time; stigma is constantly evolving. As such, for intersectionality to be more inclusive, and able to be culturally informed toward the plurality of multiply marginalized populations, we assert that intersectionality should also embrace plurality through incorporating contexts in deconstructing systems of power and privilege.

This growth of scholarship comes with significant issues. Often, quantitative methodologies use intersectionality in looking at social categories as separate independent axes (Else-Quest & Hyde, 2016; Spelman, 1988) which fail to portray the systems of oppression (Bowleg, 2008), and thus paradoxical to the principles of intersectionality (Abrams et al., 2020). Further, some scholars failed to capture intersectionality by purely focusing on the stigmatized identities rather than unraveling how to deconstruct oppression to address inequities and social justice (Rosenthal, 2016).

Often, research that claims to be intersectional fails to be grounded in the principles of intersectionality (Bauer et al., 2021; Guan et al., 2021; Harari & Lee, 2021) and primarily focuses on identifying stigmatized identities while forgetting to identify power dynamics that sustain oppression. We contend that merely focusing on identifying the stigmatized identities without acknowledging the source of oppression may lead to the categorization of stigmatized identities, resulting in a lesser understanding of the complexities and nuances of their lived experiences—a misuse of intersectionality. We aim to bridge this gap by using an inductive, reflective approach where Filipino GBM living with HIV are regarded as experts on their subjective experiences (Smith, 2018). Embedding their in-depth lived experiences within intersectionality hopes to create an opportunity for advancing scholarship on intersectionality by unpacking the complexities of intersectional stigma.

Considering the plurality of the nexus of stigma, identities, and social dimensions of Filipino GBM living with HIV, we specifically ask the following question: How do Filipino GBM who are living with HIV experience intersectional stigma?

Theoretical Framework

The fundamental tenets for addressing intersectional stigma and promoting health equity are as follows: (1) identifying how power and privilege have intersected and are felt by Filipino GBM living with HIV; (2) unpacking systems of power and privilege which foster inequity within the cultural milieu of the Filipino GBM living with HIV; (3) understanding how they used their lived experiences in addressing inequities through community engagements and lived experience leadership; and (4) promoting “collective action, cohesion, and resistance” (p. 358) among Filipino GBM living with HIV in confronting multiple nexuses of stigma through advocating for HIV prevention and education (Sievwright et al., 2022). The use of intersectionality served as an opportunity to elucidate the “complexities of minds and bodies” (p. 2) as channels of intersectional stigma and provides a “holistic representation” (p. 2) of underprivileged lived experiences and how that nexus of systems illustrates a deeper understanding of well-being, including interventions (Abrams et al., 2020). It allowed us to uncover power dynamics that influence health inequities (Bowleg, 2017).

We highlighted the role of epistemology in this present study. The scholarship on intersectionality could be seen as incomplete if researchers fail to include a meta-theory that aligns with intersectionality (Abrams et al., 2020; Bowleg, 2017; Logie et al., 2011). Hence, we utilized IPA to guide our epistemological inquiry and intersectionality served as our theoretical lens to deconstruct how power dynamics shape the nexus of stigma. Moreover, IPA is our analytical lens to understand intersectional stigma and its associated power dynamics and principles. IPA focuses on phenomenology (experiences), hermeneutics (meaning-making), and idiography (individual uniqueness; Smith & Osborn, 2015). To the best of our knowledge, this current study is among the few that explicitly employ intersectionality as a theoretical lens while simultaneously employing IPA as an epistemological and analytical inquiry among the narratives of Filipino GBM living with HIV.

Study Aim

We aimed to deconstruct the systems of power and privilege and how such systems propel the multiple axes of stigmatized identities and experiences among Filipino GBM living with HIV. To achieve this goal, we listed the following objectives:

1. To apply intersectionality as our framework in describing multiple-intersecting stigmas;

2. To explore how micro and macro elements within the participants have shaped their experiences;

3. To analyze how Filipino GBM living with HIV overcome the adversities they have faced.

Methodology

We employed a qualitative inquiry grounded in IPA (Smith & Osborn, 2015) to elucidate the intersectionality of stigma experiences among Filipino GBM living with HIV. IPA informed both the theoretical–conceptual framework and structural approaches of this qualitative exploration (Smith & Osborn, 2015; Smith et al., 2021). The use of IPA is pertinent as it offers an avenue for studying understudied cohorts and conducting subjective research where meaning construction is pivotal (Biggerstaff & Thompson, 2008; Smith, 2018).

Participants

Five Filipino GBM living with HIV were recruited using a snowball sampling approach through the aid of community-based non-government organizations (NGOs) in addressing the HIV epidemic in the Philippines. These NGOs cascaded the recruitment process to their volunteers, also known as HIV advocates. We employed inclusion criteria that required participants to (1) have been living with HIV for at least 1 year; (2) self-identify as cisgender gay or bisexual men; (3) identify as either Christian or Muslim (we explicitly identified the religious affiliation of our participants since religion is salient within the social fabric of the Philippines); (4) be HIV advocates, referring to individuals who are members of institutionalized groups advocating for the community and are likely to possess particular political awareness, social capital, and lived experiences; (5) be at least 18 years of age, and (6) be Filipino citizens. We excluded participants who resided outside the Philippines due to possible socio-cultural variations in the experiences of the study’s participants and trans-GBM due to the uniqueness of their experiences compared to cis-GBM. Although we have set exclusion criteria, all our five participants met the inclusion criteria and thus were included in the interviews. Supplement Table 1 presents the participants’ demographic information, and pseudonyms were used to ensure their privacy and confidentiality.

Procedure

We obtained ethical approval from the University of San Carlos Research Ethics Committee and sought consultation and support from various NGOs in addressing the HIV epidemic, such as AIDvocates and Culture and Arts Managers of the Philippines (CAMP) Pag-Ayo, Inc. to assist with participant recruitment. Individual interviews were conducted via Zoom with five participants, each lasting between 44 and 61 minutes. An interview schedule is provided in Supplement Table 2. Before the interviews, participants were contacted to schedule a convenient time. At the beginning of each session, we provided participants with a study overview and requested them to sign an informed consent form and provide consent for recording. Throughout the interviews, we reminded participants of their option to refrain from answering questions or terminate the interview if they experienced discomfort. Additionally, a psychologist was available at the end of each session to provide psycho-emotional support if needed. The interviews were conducted in the participants’ first language, specifically Tagalog and Cebuano, in which AHP and AF are fluent. AHP translated all transcription to English and conducted forward–backward translation to ensure consistency. Questions were designed to facilitate discussion about the participants’ experiences of stigma and how these intersect with their social identities. Participants were given gift vouchers as a token of appreciation for their time. At the end of each interview, none of the participants took advantage of the free consultation with the psychologist. However, we reminded our participants that a psychologist is available for them to seek consultations.

Data Analysis

We transcribed all recordings verbatim, capturing subtle nuances such as pauses and gestures. To ensure completeness and accuracy, we rigorously validated all transcripts by checking that the recordings matched the written transcripts. Following the principles of IPA, we treated the initial transcript as a case study and subjected it to rigorous and iterative analysis to validate and contextualize both our interpretations and those of the participants. We carefully identified key points raised by the participants, evaluating them to uncover emergent themes and investigate potential connections, including instances of “convergence and divergence” in their accounts (Nizza et al., 2021, p. 383). Once we established the groundwork with the first transcript, we proceeded to analyze the remaining transcripts. Additionally, we conducted a thorough examination of all transcripts and cross-referenced our findings to ensure consistency with the recommended interpretive approach. We synthesized our findings to develop a final table (see Supplement File 3). This approach allowed us to gain a comprehensive understanding of the participants’ perspectives and experiences while upholding the integrity and rigor of the research process.

Trustworthiness and Reflexivity

In IPA, we share our experiences conducting analysis and seek to prompt discourse on the methods used to ensure the dependability of the data (Nizza et al., 2021; Rodham et al., 2015). Throughout the transcription and analysis period, we played audio recordings and returned to them whenever we needed clarification about our analysis. After each interview, we composed fieldwork notes documenting our observations and insights (see https://osf.io/8r574/).

As researchers, we acknowledge our insider and outsider positionalities throughout the research process. We are also aware that being a cultural outsider poses an onus (Joseph et al., 2021) as we have distinct characteristics from our participants (i.e., cultural insiders) such as their culture, language, and socio-economic status which may not align with us, that is, cultural outsider (Thurairajah, 2019). Moreover, we are cognizant that sharing our worldviews alone to mitigate the limitations of conducting this present study as cultural outsiders (Ergun & Erdemir, 2010) is deemed insufficient to warrant trustworthiness and rigor. Such limitation of who were the cultural insider/outsider is an ongoing discourse within the qualitative tradition (Lu & Hodge, 2019). However, we see this limitation as an opportunity for us to be mindful of how we position ourselves in the context of our participants, data analysis, and the overall research processes.

We recognize that as researchers, we are not constrained within the dyad of cultural insider/outsider. Indeed, Fletcher (2014) and Lu and Hodge (2019) argued that flexibility is possible as to how researchers position themselves as cultural insider–outsider and this flexibility is a product of researcher–participant interaction. Benefits are seen in qualitative research when researchers are flexible in their positionality (Htong Kham, 2024) and are more aware of their views and how these views shape their research inquiry and its implications, which in return generates trustworthiness and rigor in the research (Savvides et al., 2014).

Throughout the research process, we used both our cultural outsider and insider lenses. AHP is an openly cisgender gay man, BS an openly queer, and AF a cisgender heterosexual man who identifies himself as an ally to the queer community. Our backgrounds and social identities as composed of being members of the queer community and being an ally provided us an opportunity to become cultural insiders within the overall research processes. As cultural insiders, we further acknowledge our participants’ intersecting stigmatized identities and experiences which are fueled by systemic and epistemic marginalization and stand with them in opposing all forms of marginalization. This cultural insider positionality provided an avenue for us to be reflexive in our participants’ narratives and how we as members of the queer community and allies interpret their experiences.

We also identify as academics and researchers. AHP is a researcher who explores how intersections of stigma and culture shape health outcomes. BS is a researcher working broadly in critical approaches to health services, and AF is involved in applied research work for marginalized populations. These social identities are part of our cultural outsider characteristics. We acknowledge that our expertise and experiences as academics and researchers shape how we view our research processes. As cultural outsiders, we see this as an opportunity for us to be engaged with our participants during the data collection process. In the interviews of each of our participants, we created rapport with them by asking them questions that would elicit an open and comfortable atmosphere of conversation. We also asked open-ended questions throughout the interview process which helped the participants narrate their experiences. These practices helped us create an engaging interaction between us (the cultural outsider researchers) and the participants (cultural insiders) which gave us the flexibility to use both our insider and outsider lenses.

The flexibility of our insider and outsider cultural lenses contributes to the research processes, which is an integral part of reflexivity (Htong Kham, 2024). This is possible when we are aware of our positionality, including our worldviews (Gadamer et al., 1960), and perspectives (Komalasari et al., 2022). Such reflexivity is crucial in shaping the epistemic processes of our research and also influences the positionality of the research processes, specifically when we explore and investigate the intersectional stigma experiences among our participants (Hamdan, 2010).

Although our analysis is mainly inductive, we recognize that it is not solely derived from the data. Instead, we consider our personal experiences and perspectives crucial in interpreting the data (Kelle, 2007). Therefore, we acknowledge our professional and personal backgrounds as additional methods to ensure credibility and rigor.

Results

Existential Process Is a Double-Edged Sword: A Compass in Life

Our analysis yielded one overarching theme: Existential process is a double-edged sword: a compass in life. This superordinate theme was characterized by metaphors to depict living with intersecting stigmatized identities. The double-edged sword represented the dual nature of living under intersecting stigmatized identities, showcasing narratives of fragility to resilience. This portrayal was the process when a participant who at one point was overcome by being a victim (i.e., fragile) against the participant who (now) is empowered to confront and overcome oppression. These metaphors were echoed in descriptions such as “the virus will make me quiet and unsure,” “I’ll take it as a challenge,” and “there must be a pain to endure it.” Existential process narratives represented how the participants made meaning of their experiences living with intersecting stigmatized identities. This analogy emerged in statements like “I think this is my calling [to be an HIV advocate and volunteer].” A compass symbolizes their guiding principle derived from intersecting stigmatized identities and experiences, steering them through life’s journeys. This sentiment was reflected in phrases like “At the end of the day, it’s just a matter of moving on.” Despite facing adversities, participants aspired to emancipate themselves from the stigma and oppression they endured. This superordinate theme portrayed how participants navigated their lives while juggling multiple marginalized identities. Moreover, three subordinate themes were created: (1) “It’s like a double whammy”: the synergy of unfortunate loci; (2) “I’m trying to deny myself”: a warrior living under the shadows of self and society; and (3) “That’s why I really became resilient”: a warrior’s quest for purpose in the storm. These subordinate themes delved into their experiences and narratives regarding living with multiple stigmatized identities and how they managed these experiences.

“It’s Like a Double Whammy”: The Synergy of Unfortunate Loci

This subordinate theme characterized how the stigma of intersecting identities profoundly shaped the lives of the participants. Living with intersecting stigmatized identities not only made life inherently challenging but also exacerbated difficulties through negative perceptions associated with living with HIV, being gay, existing in a society valuing religious fundamentalism, and navigating a heteronormative family structure. While participants may outwardly project resilience, beneath the surface, they grappled with the complexities of managing these intersecting stigmas. Jose’s narrative boldly exemplified these experiences of the intersecting stigmatized identities of living with HIV and being gay.

Having HIV is even more challenging; it’s like a double whammy. Being gay and having HIV at the same time. You know? That’s really unfortunate. It’s like, of all the challenges that gay individuals face in the world, you get the worst luck. Because of that illness (crying). I’m just showing people that I can handle it (crying). But truth be told, I’m still processing it.

HIV and sexuality were interdependent. HIV, as a social disease, was intricately connected within the queer community, particularly among GBM. Laypeople often assume and label that “If you have HIV, you are gay” (Alejandro). As GBM living with HIV, they frequently encountered remarks from laypeople insinuating that they harbored sexual intentions toward everyone they met, leading to social distancing from their peers: “Hey, stay away from him because he is HIV-positive” (Sebastian). Such comments may suggest how sex was perceived as immoral, linked to the identity of living with HIV and being gay or bisexual. These sexual presumptions were articulated by Alejandro.

Yeah, it’s different, and they might think I’m interested in having a sexual relationship with them or something, which is not the case. I just want to make friends or have someone to talk to at the gym, you know, just a gym buddy. That’s what I’m thinking. But people tend to perceive it differently. Most of us in the LGBT community experience this.

The contamination was not only apparent to the participants but also to the people and institutions associated with them. Participants discussed ways they would attempt to conceal such information to prevent cross-contamination with others: “She [the mother of the participant] didn’t want others to find out [about living with HIV] because it would be a disgrace to the family” (Sebastian). This cross-contamination may imply courtesy stigma. A similar account was also documented within organizations related to HIV. Participants expressed their active involvement as advocates, providing HIV-related services at the community level. Alejandro tried to conceal his identity as an HIV advocate due to the fear of negative evaluation. He was aware of how laypeople labeled those living with HIV, and the apprehension intensified when laypeople knew that they were involved in work related to HIV:

And I don’t like that I’m going to voice it out [HIV advocacy]. Because if I voice it out [HIV advocacy], and if their attitude [being rude and judgmental] is like that, how much more if they knew that I am HIV positive? They knew that I am doing volunteer work, but they did not even know that I am HIV positive. (Alejandro)

The implications of the “double whammy” were intensely manifested in one of the participants’ encounters with the law enforcement system. Instead of viewing the participant as the victim of the crime, he was perceived as the cause of that crime:

I feel like what’s happening is not right. I feel like I’m being crushed. It’s like I’m the one at fault. Instead of reporting the wrongdoing, it feels like being gay is a crime. It’s as if it’s my fault for having that orientation [gay]. (Jose)

The encounter with law enforcers forced Jose to disclose his sexual orientation:

They kept telling me, “Just tell the truth,” like that. So, said, “What is the truth then?” And they said, “What? Are you gay? Are you all gay?” like that. I said, “Yes, I am gay.” Then, you know that smirk? It’s annoying because I’m reporting something bad, a traumatic experience to the police, and suddenly I see or hear a little chuckle.

This experience also highlights the power imbalance between law enforcement authorities and gay people. The law enforcers viewed Jose as inferior to them, leading them to assert their dominance, which fueled the abuse of power. This encounter distinctly portrayed victim-blaming among sexual minority people. This phenomenon led to Jose’s self-pity and self-blame as the source of all his misfortunes:

Yeah, yeah. I think the stigma hurts more compared to what was done to me, which was already bad. Because my identity was judged (sobbing). It’s like my identity as if I have, you know, I’m the victim, but I’m the one victimizing. I’m the one more. (Crying). Anyway, sorry.

“I’m Trying to Deny Myself”: A Warrior Living Under the Shadows of Self and Society

Context is paramount in unraveling the experience of intersectional stigma among the participants. This subordinate theme illustrated how various elements within the lives of the participants fueled the experiences of oppression which positioned them in a more vulnerable position. Despite the participants’ experiences of the synergetic-deleterious impact of intersecting stigmatized identities, they embraced several strategies to dilute its impact. To portray such an experience, we employed the metaphor of a vulnerable warrior struggling to win their battles against both the shadows within themselves and those of society.

Oppression may start when people in the participants’ communities lack an understanding of what it means to be part of the LGBTQ+ community: “In the context of our community so there’s no such thing as bisexual” (Roberto) which may suggest that if the person is identifying as bisexual, they will be called gay. Such lay representation may suggest that the construct of bisexuality may not be visible among the diversity of LGBTQ+ in the Philippines. This unclear representation may fuel labeling and stereotypes among participants which could lead to stigma. Further, cultural markers in the context of the participants may fuel stigma. Participants’ identity as gender-sexual minority felt as lesser and different than their cisgender heterosexual counterparts. This may come from society embracing patriarchy and heteronormative values. Roberto utilized humor to soften the harsh realities of being an LGBTQ+ in this social context:

I experienced discrimination because of my sexuality. However, within the community as a whole, there are many instances. Yes, indeed, uhm. Let’s start with our culture. The machismo is like, as a man, you have to be strong. You should not sound like me, hahaha!

The ambiguity of representations of being LGBTQ+ has transcended to other social systems. Religious fundamentalism was a salient element in their social system that catalyzed stigma among participants: “And yeah. So, being gay is considered a sin, a mortal sin and immorality, and abomination” (Luis). These religious values have permeated into the family relations of the participants. The participant was seen as different compared to the cisgender heterosexual siblings. Such rationality may explain how fundamentalist religious values shaped family systems.

Well, yeah. I think that was one factor, considering that my mother was religious. As a born-again Protestant, she would always emphasize that God created men and women, and so forth. She really emphasized that you should think about yourself and so on. My mother still holds those beliefs even now, to the extent that she loves my siblings more because of my gender [different, gay]. So, those beliefs are still present. (Sebastian)

The participants’ family systems were uniquely embedded in the stringent religious fundamentalist and hetero-patriarchal values of the society. These interactions of two potent values create an impression on the participants: “I cannot be soft-spoken or delicate in front of them” (Jose). Hence, participants opted to suppress and deny their identities because of fear of the consequences: “What I used to think was that if I come out, they won’t support my education anymore” (Roberto). To maintain the status quo, participants continued to suppress and deny their true identities.

I’m trying to deny myself … because I grew up in a religious and masculine machismo background. Some of my uncles are from the military, and some are from the PNP or police force. Some have religious backgrounds; one of my grandfathers is a parish priest, and another became a cardinal. So, there are many complications, considering that my family members have spiritual and religious affiliations; there’s no room for this [being gay]. (Luis)

Participants had to manage the impact of their intersectional stigmatized identities. Mechanisms of this management varied depending on the participants and their contexts. For instance, participants negatively labeled themselves and anticipated that people would stigmatize their HIV seropositive status. Some noted that they are a source of the problem: “I would classify it as self-stigma” (Sebastian). Other participants conveyed that in disclosing their HIV status, they need to feel safe and asserted that if someone asks them about their status, they will disclose it. If no one asks, they will not disclose it: “The community knows that I have HIV, but on Twitter, no one knows unless they ask” (Luis). In contrast, some participants recollected that they must open up about their status despite being in a dilemma of (un)disclosing their status. For them, they saw the importance of opening up for they see this as an opportunity to establish authenticity and responsibility for their health while living with HIV. They saw it as a difficult obligation that they must resolve and overcome:

The reason I’ll be transparent [HIV status] is because from the beginning, for example, when you meet them in person, you know, sometimes I’m afraid to engage in a meet-up. I think, what if, what if I meet them, and something happens between us? After it happens, we talk, and suddenly we’re okay. Then we have fun. And there’s potential, but I can’t say it [living with HIV]. I don’t know if I should say it or not. There’s a dilemma. Should I say it or not? Because here I am again, going through that process and revisiting that feeling. And I hate that feeling. I don’t want that feeling. It’s like having HIV, yes, I already have the disease. But I take care of myself. You won’t get infected from me. But I feel disgusted. When I tell you, I sense judgment in your eyes even if you don’t say it to me. So, that kind of judgment. (Jose)

During their formative years, some participants did not have control when stigmatized for their gender and sexuality. They conformed to social pressures: “It was suppressed [sexuality] because I needed it. I felt pressure since I was a child, it seemed to be necessary [suppress sexuality]” (Jose). However, when participants gained autonomy and insights, they gained courage and stood up against systematic oppression from the community. Some found solace in reforming their beliefs:

But my rejection of the concept and doctrine of this religion is because, as I’ve delved into seeking knowledge, I’ve come to understand things better. The more I seek knowledge, the more hypocritical the doctrine appears to be. So, that’s my realization.

The deleterious effects of intersecting stigmatized identities sometimes led to an existential vacuum marked by feelings of isolation, emptiness, and lack of a sense of worth. This was evidenced by participants who were “silenced” by the stigma they received (Alejandro). When this occurred, some participants sought a sense of connection, and validation through various ways, including engaging in sexually risky behaviors:

Because before, I was like that; nobody told me about [HIV]. No one said, “You should find out your partner’s sexual status first,” right? Because I’m greedy. What’s the term, huh? I am greedy for validation. I seek validation through sex. “[If I have HIV], then I will have it [HIV].”The important thing is that I feel my emotions. The validation. I get my validation for myself. Because I feel, I felt deprived back then. (Jose)

Some participants find a sense of fulfillment when they live with HIV. In this context, HIV is no longer construed solely as a disease but as a bridge where they can build connections and a sense of community with other people living with HIV (PLHIV). To the outgroup (i.e., people who are not living with HIV), this could be viewed as a risky sexual behavior. But those who are living with HIV, they can find a community and a sense of belongingness. Such experience was boldly portrayed by Luis:

I consider myself a bug chaser, and probably I am. Because I reached a point in my life where, at that time, I felt like I was going nowhere. At the back of my mind, it’s like I was thinking, “What if I have the virus? Will I have a sense of life? Will I have another reason to live?” Ah yeah, I think that's it. At some point, I considered myself a bug chaser, you know? Because I know that what I'm doing is very risky.

“That’s Why I Really Became Resilient”: A Warrior’s Quest for Purpose in the Storm

This subordinate theme highlighted how participants interpret their experiences of living with stigmatized identities. The metaphor of the warrior’s quest characterized their ability to rebound from fragility and discover new meaning in life. At the same time, the storm serves as an illustration of the challenges they encountered.

The recollection of their experiences on intersecting stigmatized identities made participants realize how those experiences shaped who they are now. This experience made them confront the harsh reality of life, as Roberto expressed: “There must be [a] pain to endure in order to be tough.” This narrative illustrated how pain became instrumental in shaping their resilience to overcome adversities. They discovered that overcoming hardships led to acceptance. Sebastian highlighted that “the sooner we reach acceptance and move on, the faster we can heal.” This demonstrated how acceptance can facilitate healing from negative experiences. These adversities made the participants tough, fostering a sense of acceptance and resilience. This growth made them self-reliant individuals. Luis exemplifies this transformation.

So it has been really tough for me, and somehow, maybe it’s what made me who I am right now. I sort of consider myself as being tough. There is no one else that I can actually rely on but myself. So maybe that’s the effect it had on me. When it comes to being tough, I guess I can handle it, that’s why I really became resilient. It made me who I am.

Despite the stigma surrounding HIV, some individuals openly shared their HIV status, as Roberto expressed: “I have always been vocal about my condition [PLHIV]. My life is an open book since I came out as PLHIV.” This openness not only fostered communication but also encouraged hope and optimism among participants regarding the stigma surrounding their identities. Sebastian highlighted the importance of acceptance, suggesting that addressing stigma and discrimination takes time, but eventually, those who stigmatize them may become allies. This sense of acceptance can lead to optimism about reconciling with those torn between stigma. Moreover, the adversities participants faced made them more empathetic toward others’ suffering, as they can relate to the stigma experienced by others living with HIV. Luis’ experience illustrated this empathy and understanding resulting from their struggles with stigma.

It made me empathetic or sympathetic toward other people because I’ve been through it [diagnosis with HIV]. You’ve been to the lowest point of your life. It’s easier for you to empathize with these people because I was going through the same suffering that I had. So it’s easier for me to relate.

When confronted with existential threats, individuals often seek to derive meaning from their experiences. Participants grappled with existential threats stemming from their intersecting stigmatized identities, striving to find purpose amid their challenges. Despite the negative image associated with living with HIV, some of them tried to look at the meaning of living with HIV—service to others. Consequently, they committed themselves to serving their advocacies. Alejandro boldly shared his perspective:

I am okay; I feel better. I am very happy with myself. I am not saying that I am thankful that I have HIV. But without HIV, I would not do this. I would just be a normal person, walking around, working, sleeping, and then doing nothing. Because of HIV, it opened my mind to be a volunteer—to give back to the community. So, I am not saying that I am thankful [that I have HIV] but somewhat like grateful that God had given me another life.

The experiences of participants facing adversities due to their intersecting stigmatized identities foster a sense of gratitude. Despite the setbacks encountered, they remained resilient and transcended their challenges, utilizing their lived experiences to offer support and care to the PLHIV community. Transitioning from being victims to embracing their identity as survivors, they inspire and empower others who have faced similar struggles. Luis captured this sentiment.

What keeps me moving? It’s the thought that even though I’m like this [living with HIV, gay man], I can touch people’s lives. So that’s my most euphoric moment; it’s okay. Here it is. I think this is my calling [being an HIV advocate].

Discussion

This study aimed to illuminate how Filipino GBM living with HIV with multiple stigmatized identities—related to their gender, sexuality, and HIV status—experienced intersectional stigma and how they make sense of their experience. By employing IPA, we capture in-depth and nuanced narratives of their experiences which led us to contextualize and highlight the elements that perpetuate and fuel the experience of marginalization and also how they navigated this oppression, showing resilience. Exploring intersectional stigma from an inductive approach (i.e., emphasis on lived experience) is one of the “hallmarks” of intersectional stigma scholarship (Collins et al., 2021, p. 692) which we hope amplifies their voices and contributes to the growing momentum of scholarship on intersectionality.

To fully comprehend intersectional stigma, it is necessary to deconstruct the systems of oppression that perpetuate discrimination (Sievwright et al., 2022). In this study, culture emerges as a significant element fueling intersectional stigma. Culture encompasses a broad range of values, norms, beliefs, and ways of life (Hofstede, 2011; Matsumoto et al., 1996), exerting influence over all other elements, including the participants. We observed how culture shaped religion, values (such as machismo, heteronormativity, and patriarchy), and norms (lay representations), and vice versa.

We unravel how religion influences the experiences of oppression among the participants. Religion permeated society and their social systems, including their families. The values embedded within the religion became pivotal, dictating what was deemed moral or not. However, these values often do not align with the identities of the participants, leading to a disconnection between them and their social systems, which could exacerbate oppression.

Our study revealed the presence of heteronormativity, patriarchy, and machismo in the narratives that perpetuate stigma among the participants. The emphasis on “God created men and women” (Sebastian) reflects the social construct within the participants’ ecology. This heteronormative construct also encompasses expected social norms, such as the belief that “as a man, you have to be strong” (Roberto), which are translated into values, exemplified by the concept of machismo. However, such representation poses problems. This prompts us to consider how norms and lay representations may vary and could serve as drivers of oppression.

When men are expected to conform to the idea of being for women, they are often labeled as strong, a trait associated with machismo. However, this perception may not be universally shared among lay people. For example, our study revealed instances where others struggled to differentiate between gay and bisexual individuals. When GBM are expected to pursue romantic and sexual relationships outside the traditional norm of men exclusively being for women, it leads to a clash of values and representations between them and lay people. These conflicting values and lay expectations may contribute to stigma and oppression. This phenomenon has become normalized and is deeply ingrained within the cultural understanding of individuals with stigmatized identities and those who perpetuate stigma and oppression. These findings on the disconnect between how lay people and the participants have different constructions of what being gay and bisexual means align with recent findings in the literature. Within the Filipino GBM, they showed variations in how they construe their sexualities. Some GBM characterized their sexuality as similar to the Western way of constructing being gay and bisexual. In contrast, other GBM shared that their construction of being gay, and bisexual is embedded within the Filipino contexts and cultural milieu in which being gay is construed synonymously to a transgender (Adams et al., 2022).

We explored how the self, social systems, and institutions serve as proxies for intersectional stigma. We perceive these elements as interconnected and mutually influencing one another. We consider such proxies to form a continuum that acts as a driver of oppression and also interacts with culture, thereby shaping intersectional stigma and inequities overall. For instance, the results of this paper underscore how loneliness and isolation, as an implication of intersectional stigma, were one of the reasons why the participants engaged in risky sexual behaviors. Our data showed that when GBM experiences a sense of isolation and loneliness when experiencing intersecting stigmatized identities (e.g., family and community organizations), they seek belongingness and validation toward others by engaging in unprotected sexual behaviors. These findings align with the existing literature on a discourse of intimacy (Canoy, 2015). There is a contrasting discourse on gay relationships: a “desire for the [male] body” versus “something ‘higher’ rather than just casual sex” (Canoy, 2015, p. 929). Our findings showed that our participants see sexual relationships as more than just a thirst for the male body but rather a sense of intimacy, belongingness, and validation. Furthermore, our participants’ narratives described how family systems are drivers of their experiences of marginalization. Such experiences within the family might still be visible in recent literature. When GBM disclose their sexuality to their families, they feel tolerated rather than accepted (Adams et al., 2022).

Although this present study was able to illuminate the complexity of intersectional stigma experiences among Filipino GBM living with HIV, we are prompted to question whether we were able to fully grasp the complexity of this experience. We argue that to address the inequities brought by intersectional stigma, utilizing syndemics may offer a solution. As stated by Sievwright et al. (2022), a truly intersectional approach to stigma must seek to deconstruct systems of power and seek strategies to address these multiple systems. However, we also contend that to address health inequities, we must examine how systems of power shape these health outcomes and consider the broader context among the participants.

We must recognize that Filipino GBM living with HIV may have other health and social conditions aside from HIV. By doing so, we can gain a comprehensive understanding of their health outcomes. Often, the coexistence of multiple health and social conditions can exacerbate health outcomes through its synergistic effects (Bulled et al., 2022; Singer et al., 2017). Syndemics offer insight into how the simultaneous presence of two or more conditions impacts the participants (Quinn, 2022). By integrating intersectionality and syndemics, we can address both the synergistic effects of multiple health and social conditions on GBM living with HIV and at the same time deconstruct systems of power that perpetuate oppression, which influences health outcomes (Quinn, 2022).

Our results suggest promising implications regarding how cultural elements may mitigate intersectional stigma. The results of our study showed how participants showed resilience, found a sense of purpose, and used their experience as an opportunity to fight back and become agents of social change within their communities. They found solidarity and hope within advocacy groups, transforming from victims to survivors. Communities can also serve as buffers against systems of power and oppression, as evidenced by the promising implications of community engagement and leadership on stigma reduction strategies (Stangl et al., 2023). Our findings showed Filipino GBM living with HIV can emerge as resilient individuals who advocate for others. They can become leaders, fostering collective action and allyship that advance social justice (Scholz et al., 2017). This form of leadership can be seen as part of the expanding scholarship on consumer leadership and community engagements. Through our analysis, we uncovered stories and lived experiences that depict the transformation of their social identities. Previous research studies showed how PLHIV have navigated the transformation of the reconstruction of their identities through social cohesion (Carrasco et al., 2017) and how capital identity may foster positive reconstruction of their identities (Aryal, 2014).

Our findings highlight the lived experiences of these individuals and how these experiences might inform culturally responsive interventions aimed at addressing health inequities among GBM living with HIV. As individuals with lived experiences of health conditions and intersectional stigma, they have emerged as experts, and the application of this experiential expertise could constitute leadership in decision-making processes (Roper et al., 2018) regarding the delivery of HIV health services. However, despite decades of advocacy, there remains a notable exclusion of individuals with lived experiences as experts or leaders in healthcare service delivery and policy development (Scholz et al., 2024). There has been increasing tokenism, whereby organizations and initiatives claim to be lived experience–led (Scholz, 2022; Scholz et al., 2024). Thus, in calling for more involvement or inclusion of GBM living with HIV as experts in HIV health service delivery, we urge organizations to be mindful to ensure opportunities for the lived experiences of these men to contribute as active leaders who can share their breadth of experience to help shape HIV service delivery and foster the creation of more inclusive and culturally informed HIV service provisions.

Limitations and Future Recommendations

We acknowledge that this present research poses some limitations. First, our participants were HIV advocates. This could be a limitation since not all PLHIV consider themselves as advocates. The experiences of advocates represent an identity that may not be shared with PLHIV who are not advocates. Moreover, our participants were only Christians and did not include other religious denominations (i.e., Islam, another prominent religious group in the Philippines). Filipino Muslim GBM living with HIV may have complex experiences brought on by the rigid religious values of Islam (Noor et al., 2024). Future research should encompass more diverse groups of GBM living with HIV, including non-advocates and from other religious groups.

Second, our participants had lived with HIV for more than 3 years and were aged 30 years or above which could strongly influence how they view themselves and others about their identities and experiences. However, we also see this as a limitation since we did not take into account Filipino GBM who were living with HIV during the early stages of the HIV epidemic in the Philippines in comparison to those who have been living with HIV in recent years, and those who have just been diagnosed to live with HIV. Moreover, our study did not include participants who were below 30 years old. Further studies must be done on wider generations of Filipino GBM living with HIV and consider the accessibility of HIV treatments and prevention strategies (i.e., pre-exposure prophylaxis [PrEP] and post-exposure prophylaxis [PEP]).

Despite the adversities faced by Filipino GBM living with HIV, our findings contextualize how Filipino GBM living with HIV show resilience. These findings provide context for the adversities faced by GBM and how they navigate such experiences. However, our study did not further explore how the participants developed resilience, including the factors that influence it. Future studies may explore how various risk factors shape resilience, including loneliness and isolation, and how these factors contribute to mental health and the risk of having HIV.

To end the HIV crisis in the Philippines and achieve the UNAIDS “Getting to Zero” discrimination goals (UNAIDS, 2010), it is not enough to understand how Filipino GBM living with HIV experience oppression but also to address the systems of power fuel oppression. The experiences of the participants urgently call for the ongoing fight of the Filipino queer community and allies toward the passing and enacting of the Sexual Orientation, Gender Identity, and Expression (SOGIE) Equality Bill. This bill aims at protecting Filipinos regardless of their SOGIE (Ildefonso, 2024). However, this is far from reality among queer Filipinos and their allies as this bill is still pending for 20 years in the Congress of the Philippines (Gamalinda & Ofreneo, 2024). Although there have been existing national laws that aim to address the HIV crisis in the Philippines (i.e., Republic Acts of 1998 and 2018; Congress of the Philippines, 1998, 2018), these legislations failed to underscore how systems of power shape oppression among PLHIV.

Future studies could explore how to embed intersectionality within lived experience leadership and community engagements among multiply marginalized populations. Incorporating intersectionality in lived experience leadership enables people to identify systems of power that fuel stigma (Bowleg, 2012; Crenshaw, 1989) and at the same time involve people with lived experiences with HIV to be leaders in health policy and services (Scholz et al., 2024). Through this, collective actions can evolve into activism and allyship, which could be one of the stigma-reduction strategies. Further, this can lead to more representation of people with lived experiences in healthcare and improved health outcomes (Scholz et al., 2017).

Future research should integrate other frameworks that complement and enhance our understanding of how systems of power and privilege fuel oppression and how resilience, collective actions, and activism buffer marginalization, which in turn influence various health outcomes and conditions. To achieve this, an intersectionality-informed syndemics approach must be utilized (Quinn, 2022).

Conclusion

This present paper aims to illuminate how Filipino GBM living with HIV have experienced multiple stigmas from their HIV status and sexuality. Using the lens of intersectionality, it characterizes how these multiple nexuses of identities intersected with systems of power that permeated within their intrapersonal and interpersonal dimensions, contributing to the ongoing oppression and inequities they felt. Moreover, this present paper also contextualizes their resilience. Filipino GBM living with HIV narrate how they were victimized by oppression and resisted it. The present study calls for the full legal protection of the Filipino LGBTQ+ community, regardless of their gender, sexuality, and health status, against any form of stigma and discrimination, especially the passing of the Sexual Orientation, Gender Identity, and Expression (SOGIE) Equality Bill. Their narratives accentuated how resilience may lead to activism and collective action, manifested through their lived experiences of leadership in their communities, providing HIV services, and finding a sense of purpose from their experience of intersectional stigma.

Supplemental Material

Supplemental Material - “Because of HIV, It Opened My Mind”: Intersectional Stigma Experiences Among Filipino Gay and Bisexual Men Living With HIV

Supplemental Material for “Because of HIV, It Opened My Mind”: Intersectional Stigma Experiences Among Filipino Gay and Bisexual Men Living With HIV by Aron Harold G. Pamoso, Brett Scholz, and Austin Ferolino in Qualitative Health Research