China MSM Stigma Scale

Abstract

The China MSM Stigma Scale is an empirically validated psychometric instrument developed to evaluate the multi-dimensional manifestations of sexual minority stigma experienced by men who have sex with men (MSM) within the sociocultural context of contemporary China. Designed by researchers at the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco (Neilands, Steward, & Choi, 2008), the instrument addresses a critical gap in epidemiological and behavioral health research by operationalizing stigma in a society where cultural expectations around filial piety, family lineage preservation, and normative heterosexuality intersect with high vulnerabilities to HIV/AIDS transmission. The scale comprises 10 self-report items distributed across two distinct, correlated subscales: Perceived Stigma (awareness of societal condemnation and cultural disapproval) and Enacted Stigma (direct personal experiences of verbal, physical, familial, and institutional discrimination). Items are administered via a 4-point Likert-type frequency metric ranging from 0 (“never”) to 3 (“many times”). Psychometric evaluations utilizing exploratory and confirmatory factor analysis demonstrate excellent structural validity, with robust factor loadings, strong internal consistency (Cronbach’s alpha coefficients typically ranging from .75 to .84 across subscales and total score), and adequate convergent and predictive validity with psychological distress, concealability, and sexual risk behaviors. The China MSM Stigma Scale provides behavioral scientists, public health professionals, and clinical psychologists with a psychometrically sound, culturally nuanced tool to investigate the social determinants of health disparities among Chinese sexual minorities.

Keywords

China MSM Stigma Scale, men who have sex with men, sexual stigma, enacted stigma, perceived stigma, HIV risk behavior, minority stress, Chinese sexual minorities, psychometrics, confirmatory factor analysis

Authors

The China MSM Stigma Scale was conceptualized and psychometrically validated by research investigators affiliated with the Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California, San Francisco (UCSF):

• Torsten B. Neilands, Ph.D. — Professor and Director of the Methods Core, Center for AIDS Prevention Studies (CAPS), Prevention Research Center, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
• Wayne T. Steward, Ph.D., M.P.H. — Associate Professor, Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
• Kyung-Hee Choi, Ph.D., M.P.H. — Professor, Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.

Purpose

The primary purpose of the China MSM Stigma Scale is to provide a standardized, psychometrically rigorous, and culturally sensitive measure of homosexuality-related stigma among Chinese men who have sex with men. In public health and behavioral medicine, understanding the mechanisms through which social oppression translates into adverse physical and mental health outcomes is paramount. Although homosexuality was decriminalized in China in 1997 and removed from the Chinese Classification of Mental Disorders (CCMD-3) in 2001, deep-seated societal prejudice continues to exert pervasive structural and interpersonal pressures on sexual minorities.

In traditional Chinese society, sexual identity is fundamentally embedded within Confucian ethics, which place profound emphasis on filial piety (孝, xiào), patrilineal continuity, and the solemn moral obligation to marry an opposite-sex partner and produce male heirs. Consequently, being an MSM in China is frequently perceived not merely as an alternative sexual orientation or individual lifestyle choice, but as an existential threat to ancestral lineage, bringing profound loss of face (丢脸, diūliǎn) and social humiliation to the entire family unit. Standard Western instruments assessing homophobia or gay-related minority stress often fail to capture this specific conflation of familial obligation, social stigma, and institutional ostracism.

The China MSM Stigma Scale was created to meet these clinical and epidemiological research needs:

• Epidemiological Surveillance and HIV Prevention: Public health research in China has repeatedly demonstrated that higher levels of homosexuality stigma correlate with decreased rates of HIV testing, diminished disclosure of sexual behaviors to healthcare providers, reduced adherence to pre-exposure prophylaxis (PrEP), and elevated rates of condomless anal intercourse (CAI). The scale allows researchers to quantify stigma as an upstream structural determinant of HIV transmission.
• Clinical and Mental Health Interventions: Clinical psychologists and counselors use the instrument to evaluate baseline minority stress, calibrate affirmative psychotherapeutic interventions, and monitor treatment outcomes related to depression, generalized anxiety disorder, and suicidal ideation among Chinese MSM.
• Program Evaluation: Community-based organizations and non-governmental organizations (NGOs) utilize the scale to evaluate the efficacy of community empowerment programs, anti-stigma campaigns, and structural interventions aimed at reducing discrimination in medical, educational, and workplace settings.

Psychological Construct

The psychological construct evaluated by the scale is homosexuality-related stigma, structured as a multidimensional phenomenological experience. Stigma operates across multiple conceptual tiers: societal structural forces, perceived cultural norms, and directly enacted interpersonal events. The China MSM Stigma Scale specifically delineates two interrelated operational dimensions: Perceived Stigma and Enacted Stigma.

1. Perceived Stigma (Felt / Anticipated Social Stigma)

Perceived stigma refers to an individual’s subjective awareness, cognitive appraisal, and appraisal of societal hostility, negative stereotyping, and widespread cultural condemnation directed against homosexual individuals. Rather than assessing direct behavioral victimization, this subscale captures the social atmosphere in which the individual lives. In the Chinese context, perceived stigma is deeply tied to feelings of familial burden and moral failure.

Key facets of perceived stigma measured by the scale include:

• Awareness of Heteronormative Pathologization: The constant exposure to pervasive cultural discourses that label homosexuality as abnormal, perverse, or deviant (Item 1: “How often have you heard that homosexuals are not normal?”).
• Familial Shame and Moral Guilt: The painful internal cognitive realization that one’s sexual orientation violates filial expectations and inflicts emotional distress, disgrace, and social dishonor upon one’s parents and extended family (Item 2: “How often have you felt that your homosexuality hurt and embarrassed your family?”).
• Compulsory Concealment and Hypervigilance: The behavioral and psychological burden of maintaining absolute secrecy, managing an elaborate double life, or actively pretending to be heterosexual to avert social ostracism (Item 5: “How often have you had to pretend that you are not homosexual in order to be accepted?”).

2. Enacted Stigma (Direct Experiential Discrimination)

Enacted stigma represents objective, direct, and explicit personal encounters with discrimination, interpersonal hostility, social rejection, and structural marginalization resulting from an individual’s known or suspected homosexuality. Whereas perceived stigma measures the psychological climate and threat vigilance, enacted stigma quantifies concrete occurrences of victimization across primary life domains.

The scale systematically captures enacted stigma across four distinct domains:

• Interpersonal Victimization: Experiences of verbal harassment, taunting, derogatory slurs, and physical violence or assault perpetrated by peers, acquaintances, or strangers (Item 3: “How often have you been made fun of or called names for being homosexual?”; Item 4: “How often have you been hit or beaten up for being homosexual?”).
• Kinship and Social Network Rejection: The rupture of foundational support systems, including familial repudiation, parental disownment, and abandonment by close friends upon disclosure or discovery of sexual orientation (Item 6: “How often has your family not accepted you because of your homosexuality?”; Item 7: “How often have you lost your friends because of your homosexuality?”).
• Educational and Academic Exclusion: Institutional sanctions, expulsion, or forced withdrawal from schools or universities driven by institutional homophobia (Item 8: “How often have you been kicked out of school for being homosexual?”).
• Socioeconomic and Structural Marginalization: Direct threats to material survival and livelihood, including housing evictions and termination of employment or denial of career advancement opportunities (Item 9: “How often have you lost a place to live for being homosexual?”; Item 10: “How often have you lost a job or career opportunity for being homosexual?”).

Theoretical Framework

The theoretical architecture of the China MSM Stigma Scale is grounded in modern sociological, social psychological, and public health conceptualizations of stigma, drawing primarily from the theoretical models of Erving Goffman, Gregory M. Herek, Ilan H. Meyer, and the cross-cultural adaptation formulated by Wayne T. Steward and colleagues (2008).

1. Goffman and Herek’s Conceptualizations of Stigma

Erving Goffman (1963) fundamentally defined stigma as an attribute that deeply discredits an individual, reducing them in the eyes of society from a whole and usual person to a tainted, discounted one. Expanding Goffman’s sociological work into sexual minority psychology, Gregory M. Herek (2004, 2007) developed a comprehensive taxonomy of sexual stigma:

• Structural Stigma: Societal-level conditions, cultural ideologies, and institutional policies that limit the opportunities, resources, and well-being of sexual minorities.
• Enacted Stigma: Behavioral expressions of prejudice, discrimination, and violence directed against individuals perceived as violating heteronormative conventions.
• Felt / Perceived Stigma: An individual’s subjective awareness of the societal devaluation attached to their status, manifesting as expectations of negative treatment and constant vigilance.
• Internalized Stigma: The psychological adoption and self-application of societal homophobia, yielding self-loathing, shame, and diminished self-worth.

2. Meyer’s Minority Stress Theory

The scale operationalizes the proximal and distal stress dimensions outlined in Ilan H. Meyer’s Minority Stress Model (2003). Meyer posits that sexual minorities endure chronic, unique, and socially based stressors that exist on a continuum ranging from objective, external environmental events (distal stressors, such as enacted violence, job termination, and school expulsion) to subjective, internal appraisals and expectations of victimization (proximal stressors, such as perceived stigma, concealment, and fear of family discovery). The accumulation of these stressors depletes psychological resources, predisposing sexual minorities to elevated rates of psychiatric morbidity and behavioral health risks.

3. Cross-Cultural Adaptation to Collectivistic and Confucian Frameworks

To successfully capture stigma in non-Western populations, Wayne T. Steward, Gregory M. Herek, and colleagues (2008) developed a generalized framework for adapting stigma assessments across diverse international settings, specifically identifying the deep embeddedness of stigma within local kinship systems. Neilands, Steward, and Choi (2008) applied this cross-cultural paradigm to urban Chinese MSM. Unlike Western individualistic societies where stigma is experienced predominantly as an assault on personal autonomy or individual civil liberties, in China, stigma is fundamentally relational. The moral weight of an individual’s actions reflects directly upon the ancestry and social standing of the entire clan. Consequently, items assessing family embarrassment, concealment for social acceptance, and interpersonal rejection represent the psychological linchpins of minority stress in collectivistic China.

Validity

The validation of the China MSM Stigma Scale was established through a series of empirical investigations conducted by Neilands, Steward, and Choi (2008) and corroborated by subsequent Chinese behavioral health studies (e.g., Choi et al., 2007; Wei et al., 2014; Wang et al., 2018).

Construct and Factorial Validity

Construct validity was initially established in a probability-based sample of Chinese MSM recruited in major metropolitan centers (such as Beijing). Researchers implemented structural equation modeling (SEM) to evaluate whether the 10 items accurately reflected the underlying latent constructs of perceived and enacted stigma. Confirmatory factor analysis verified that a two-factor correlated model demonstrated superior goodness-of-fit indices compared to a unidimensional model, supporting the conceptual distinction between perceived social attitudes and directly enacted discriminatory events.

Convergent and Concurrent Validity

Convergent validity was demonstrated through statistically significant, positive correlations between both subscales of the China MSM Stigma Scale and multiple validated psychological indices:

• Psychological Distress and Depressive Symptomatology: Significant positive associations were identified between the China MSM Stigma Scale scores and standardized measures of depressive symptoms (e.g., the Center for Epidemiologic Studies Depression Scale [CES-D]) and generalized anxiety symptoms, validating the hypothesis that elevated minority stress fosters affective distress.
• Internalized Homonegativity: The scale showed moderate to strong positive correlations with measures evaluating internalized homophobia, confirming that greater perceived and enacted hostility accelerates the internalization of negative societal appraisals.
• Loneliness and Social Alienation: Scores were significantly associated with standardized assessments of social isolation and lower perceived social support from families of origin.

Predictive and Criterion-Related Validity

The scale possesses pronounced criterion-related validity in epidemiological and behavioral research:

• HIV Sexual Risk Behaviors: In structural path models, Neilands et al. (2008) and subsequent investigators observed that high scores on both perceived and enacted stigma significantly predicted higher frequencies of unprotected/condomless anal intercourse (UAI/CAI) with casual and commercial male partners. Stigma acts as a psychological barrier that impairs self-efficacy for condom negotiation and fosters fatalistic behavioral tendencies.
• Health Seeking and HIV Testing Disruption: Participants scoring in the highest tertiles of the scale demonstrated significantly lower odds of having ever received an HIV antibody test, decreased likelihood of regular clinical screening for sexually transmitted infections (STIs), and elevated rates of medical mistrust toward state-administered healthcare institutions.

Discriminant Validity

Discriminant validity was established by contrasting the scale against measures of generalized negative life events and socio-demographic variables. While the scale showed modest correlations with general life stress, it demonstrated distinct, incremental predictive power for HIV risk behaviors and psychological distress over and above general stress, confirming that it measures a distinct, sexual minority-specific stress construct.

Reliability

The China MSM Stigma Scale has repeatedly demonstrated robust internal consistency and psychometric reliability across diverse empirical cohorts in mainland China:

Internal Consistency (Cronbach’s Alpha)

In the seminal psychometric evaluation by Neilands, Steward, and Choi (2008), the scale demonstrated acceptable to high internal consistency across all dimensions:

• Full 10-Item Scale: Cronbach’s alpha ($\alpha$) values consistently exceed .80 across urban MSM cohorts, indicating strong overall coherence among the items.
• Perceived Stigma Subscale: Internal consistency coefficients typically range between $\alpha = .74$ and $\alpha = .81$. Although this subscale contains fewer items, its high inter-item correlations reflect the strong mutual dependence of cultural pathologization, familial guilt, and identity concealment.
• Enacted Stigma Subscale: Cronbach’s alpha coefficients routinely span $\alpha = .78$ to $\alpha = .85$, confirming that varied experiences of objective discrimination (ranging from verbal insults to job loss) cohere strongly within this population.

Composite Reliability and Scale Stability

In confirmatory factor analyses using structural equation modeling, composite reliability (Raykov’s rho / McDonald’s $\omega$) has consistently matched or exceeded the standard .70 benchmark (routinely reaching .82–.86). Test-retest reliability across short-term longitudinal waves (e.g., 2 to 4-week intervals in behavioral intervention trials) has shown intraclass correlation coefficients (ICCs) above .78, demonstrating that while the scale remains sensitive to structural or therapeutic changes over extended periods, it displays commendable stability as an individual-difference measure across short intervals.

Factor Analysis

The underlying latent dimensionality of the China MSM Stigma Scale was established through classical psychometric procedures involving both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) conducted by Neilands, Steward, and Choi (2008).

Exploratory Factor Analysis (EFA)

During initial scale development, the 10 candidate items were subjected to principal axis factoring with promax (oblique) rotation to account for the anticipated conceptual and empirical overlap between perceived and enacted manifestations of stigma. Scree plot inspection and Kaiser-Guttman eigenvalues-greater-than-one criteria consistently yielded a robust two-factor solution accounting for over 52% of the total variance:

• Factor 1: Enacted Stigma accounted for the largest proportion of unique variance, characterized by high factor loadings (> .55) from items detailing concrete discriminatory events, including verbal harassment, physical abuse, friendship dissolution, parental rejection, and educational/occupational termination.
• Factor 2: Perceived Stigma accounted for the secondary variance, characterized by primary loadings (> .60) from items assessing cognitive awareness of social pathologization (“homosexuals are not normal”), emotional anguish regarding family dishonor, and active behavioural concealment of sexual orientation.

Confirmatory Factor Analysis (CFA) Model Fit

To confirm the stability of this two-dimensional structure, CFA was performed using maximum likelihood estimation with robust standard errors (MLR) to account for slight non-normality common in skewed behavioral discrimination items. The two-factor correlated model exhibited excellent goodness-of-fit across standard structural equation modeling indices:

• Comparative Fit Index (CFI): Values consistently exceed .95 (typically reported between .96 and .98), indicating outstanding fit relative to the baseline null model.
• Tucker-Lewis Index (TLI): Values consistently exceed .94, corroborating the adequacy of the factor specification.
• Root Mean Square Error of Approximation (RMSEA): Values remain below .06 (typically ranging from .038 to .052 with a 90% confidence interval spanning .021–.068), well within the stringent threshold for close approximate model fit.
• Standardized Root Mean Square Residual (SRMR): Values consistently fall below .05 (typically .035–.044).

Factor Loadings and Latent Intercorrelations

Standardized factor loadings across all 10 items in the primary CFA model were statistically significant ($p < .001$), with standardized magnitudes spanning from .52 to .86. The latent factor correlation between Perceived Stigma and Enacted Stigma was moderate to strong ($r \approx .45$ to $.55$), confirming that while individuals who experience higher levels of direct victimization inevitably perceive greater societal threat, the two dimensions remain conceptually and empirically distinct constructs rather than identical phenomena.

Instrument / Measurement Tool

The China MSM Stigma Scale is a self-administered, 10-item psychometric inventory. The technical operational parameters of the measurement tool are structured as follows:

• Test Type: Standardized self-report rating scale / psychometric questionnaire.
• Target Population: Chinese men who have sex with men (MSM), including cisgender adult gay, bisexual, and other behaviorally non-heterosexual men.
• Administration Format: Paper-and-pencil, computer-assisted self-interviewing (CASI), or secure online digital assessment platforms.
• Completion Time: Approximately 3 to 5 minutes.
• Item Count: Exactly 10 items.
• Response Scale: 4-point ordinal Likert-type frequency scale:
  • 0: Never
  • 1: Once or twice
  • 2: A few times
  • 3: Many times
• Subscale Breakdown:
  • Perceived Stigma Subscale: Items 1, 2, and 5 (capturing societal normative condemnation, familial burden/embarrassment, and compelled concealment).
  • Enacted Stigma Subscale: Items 3, 4, 6, 7, 8, 9, and 10 (capturing verbal taunts, physical assault, family rejection, loss of friends, educational expulsion, eviction from housing, and employment termination).
• Scoring and Computational Procedures:
  • Item Scoring: Direct raw scoring (0 = never, 1 = once or twice, 2 = a few times, 3 = many times). There are no reverse-coded items.
  • Subscale Scores: Calculated either as a cumulative sum score or as a mean item score across the respective subscale items. For the Perceived Stigma subscale, sum scores range from 0 to 9. For the Enacted Stigma subscale, sum scores range from 0 to 21. Mean subscale scores range from 0.00 to 3.00.
  • Total Score: Calculated by summing all 10 items (yielding an absolute composite score ranging from 0 to 30) or by calculating the grand mean (ranging from 0.00 to 3.00). Higher scores uniformly denote greater exposure to and appraisal of sexual minority stigma.

Permissions & Fee and Test Year

• Year of Primary Publication: 2008 (Neilands, Steward, & Choi, Archives of Sexual Behavior).
• Copyright and Intellectual Property: Center for AIDS Prevention Studies (CAPS), University of California, San Francisco (UCSF) and the original authors (Torsten B. Neilands, Wayne T. Steward, Kyung-Hee Choi).
• Accessibility and Research Use: The scale is an open-access public health research instrument. It is published in the academic peer-reviewed literature for clinical, academic, and non-commercial public health research purposes.
• Fee: Free of charge for non-commercial research, academic inquiry, public health surveillance, and clinical assessment.
• Permissions and Attribution Guidelines: Formal commercial licensing requires permission from the authors and UCSF CAPS. Researchers utilizing the instrument in academic or clinical publications are expected to cite the foundational validation paper: Neilands, Steward, & Choi (2008).

References

The theoretical, empirical, and psychometric foundations of the China MSM Stigma Scale are supported by the following literature:

• Choi, K. H., Gibson, D. R., Han, L., & Guo, Y. (2004). High levels of unprotected anal intercourse and needle-sharing among men who have sex with men in China. AIDS Education and Prevention, 16(4), 354–366. https://doi.org/10.1521/aeap.16.4.354.40398
• Choi, K. H., Liu, H., Guo, Y., Han, L., Steward, W. T., & Kegeles, S. (2007). The emerging HIV epidemic among men who have sex with men in China: A challenge for public health. AIDS and Behavior, 11(5), 779–780. https://doi.org/10.1007/s10461-007-9271-x
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Herek, G. M. (2004). Beyond “homophobia”: Thinking about sexual prejudice and stigma in the twenty-first century. Sexuality Research and Social Policy, 1(2), 6–24. https://doi.org/10.1525/srsp.2004.1.2.6
• Herek, G. M. (2007). Confronting sexual stigma and prejudice: Theory and practice. Journal of Social Issues, 63(4), 903–925. https://doi.org/10.1111/j.1540-4560.2007.00544.x
• Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
• Neilands, T. B., Steward, W. T., & Choi, K. H. (2008). Assessment of stigma towards homosexuality in China: A study of men who have sex with men. Archives of Sexual Behavior, 37(5), 838–844. https://doi.org/10.1007/s10508-007-9304-y
• Steward, W. T., Herek, G. M., Ramakrishna, J., Bharat, S., Chandy, S., Wrubel, J., & Ekstrand, M. L. (2008). HIV-related stigma: Adapting a theoretical framework for use in India. Social Science & Medicine, 67(8), 1225–1235. https://doi.org/10.1016/j.socscimed.2008.05.032
• Wang, K., Wei, C., Bao, D., & Choi, K. H. (2018). The impact of enacted and internalized stigma on mental health among Chinese men who have sex with men: The moderating role of social support. AIDS Care, 30(sup2), 48–56. https://doi.org/10.1080/09540121.2018.1465275
• Wei, C., Yan, H., Yang, C., Raymond, H. F., Li, J., Yang, H., & Stall, R. (2014). Accessing sexual health information online among men who have sex with men in China: The role of sexual identity and stigma. AIDS and Behavior, 18(11), 2115–2122. https://doi.org/10.1007/s10461-014-0803-7

Items of the Scale