BCP Education & Psychology ESS 2022 Volume 7 (2022) 277 Double Stigma on Psychological Distress of Young Chinese Men Who Have Sex with Men Amid Covid-19 Pandemic: The Moderating Role of Affiliate Stigma Yichen Ding The High School Affiliated to Renmin University of China, Beijing, 100097, China Abstract. During the pandemic of COVID-19, some specific residence linked with virus spread is likely to be stigmatized. The oversea Chinese always perceived courtesy and affiliate stigma due to the geographic linkage to COVID-19. For the LGBTs group who are suffering from internalized stigma related to their sexual identity, affiliate stigma may deteriorate their meatal health further. This study focuses on the effect of double stigma on psychological distress of oversea Chinese LGBTs amid Covid-19 pandemic. Keywords: Affiliate Stigma; Meatal Health; LGBTs; Covid-19 Pandemic. 1. Introduction On January 30, 2020, the World Health Organization (WHO) declared the coronavirus disease 2019 (COVID-19) as a pandemic and a Public Health Emergency of International Concern (PHEIC). Stigmatization has been an important public health concern and a widely discussed topic in the context of the COVID-19 epidemic. At the early stages of the Covid-19 outbreak, the rapid spread, high infectivity, risk of infection and death, strict isolation measures, and other influencing factors have had great psychological impact on most people, especially on the mental health of overseas Chinese. Racist discrimination has always been an important factor threatening the physical and mental health of overseas Chinese. In the public health infection in 2020, due the first case of COVID- 19 appearing in China, novel coronavirus was mistakenly associated with China, and many areas called it “Chinese virus”, which further intensified racial discrimination and expanded the negative impact of racial discrimination on overseas Chinese. Overseas Chinese with the identity label feel stigma, discrimination, and even hatred from the public. Meanwhile, they frequently encounter rejection from enterprises, service organizations, and public places in daily life from society. The research shows that during the epidemic period of novel coronavirus pneumonia, Chinese students and scholars living in the United States experienced serious psychological distress. Among the 311 respondents, 69 (22.2%) reported no anxiety or depression symptoms, 63 (20.3%) reported that they were in a state of severe anxiety, and 67 (21.5%) reported that they were in a state of severe depression (Zhao et al., 2020). It is particularly noteworthy that among overseas Chinese, the situation of homosexual groups is even more difficult. As a sub-cultural group, homosexuals themselves often suffer from serious stigma, discrimination, and social isolation in their daily life. Homosexuals and sexual minorities who have been discriminated against and excluded for a long time will gradually internalize the negative attitude towards homosexuality from the outside world and agree with the outer labels imposed on them, thus generating negative attitudes towards their sexual orientation and forming internalized stigma. Studies have shown that internalized stigma is closely related to high psychological pain (Hatzenbuehler, 2009; Walch, Ngamake, Bovornusvakool, & Walker, 20l6); Internalized stigma is negatively correlated with positive emotion and positively correlated with negative emotion (Ren & Hood, 20l8). In addition, people with high internalized stigma tend to show lower resilience and more suicidal willingness (Herek, 2004). Under the condition of internalizing too many negative external attitudes, people with high internalized homosexual stigma feel less support from the surrounding environment and lack a sense of group belonging, which is difficult to establish close relationships with other homosexuals and is often more likely to experience strong loneliness and anxiety (Herek, 2004; Kaysen et al, 2014; Ren & Hood, 2018). LGBTs are more likely to experience adverse mental BCP Education & Psychology ESS 2022 Volume 7 (2022) 278 health status than the general population. A recent review of the minority stress among Chinese LGBTs reported a high prevalence of mental health issues, such as depression and anxiety (Sun, Pachankis, Li, & Operario, 2020). In China, the prevalence of depressive symptoms among MSM was estimated to be between 29.2% and 63.9%, whereas the prevalence in the overall population was between 5.3% and 23.0 percent% (Wang et al., 2017; Wim et al., 2014). In addition, MSM are stigmatized in China. A survey from the World Values Survey Association (2020) shows that sexual minorities are less tolerated in Eastern countries than in Western societies. Previous surveys reported that nearly all Chinese MSM has perceived discrimination and stigma in their lifetime (Liu & Choi, 2013), and 78.53 percent of the respondents have conservative views on homosexuality (e.g., “same- sex sexual behavior is always wrong”) (Xie & Peng, 2018). With the continuous spread of novel coronavirus pneumonia virus, under the dual influence of affiliate stigma and internalized stigma, the psychological distress and mental health of LGBT people among overseas Chinese can not be ignored. The purpose of this study is to explore the relationship between internalized stigma and psychological distress among overseas Chinese LGBT population, and to test the moderating effect of novel coronavirus-related affiliate stigma on the relationship between internalized stigma and psychological distress, so as to further explore the heterogeneity characteristics of LGBT population with different levels of affiliate stigma. 2. Theory “Stress-health” model is an important theoretical paradigm in the research of health psychology. At present, the research on mental health of sexual minorities mainly focuses on the influence of stress on their own health. Sexual Minority Stress Model put forward by Meyer holds that compared with the general population, sexual minorities will suffer more pressure from stigma, prejudice, discrimination, and internalization because of their sexual minority status and subculture status. The Sexual Minority Stress Model describes the effects of stress on mental health from three aspects: general stress, external minority stress, and internal minority stress. General stress is the stress that everyone may experience, such as financial stress, work stress, and so on. Minority status in society will also bring pressure, such as the elderly, women, disabled people, etc. These minority groups will be discriminated against because of their identity characteristics, resulting in pressure. Similarly, sexual minorities will suffer from discrimination, stigma, and other pressures because of their sexual orientation. In the external sexual minority pressure, the pressure caused by the external environment is called distal pressure, such as prejudice and discrimination against sexual minorities by external groups; Stress caused by self-awareness and evaluation is called proximal stress, such as internalized homophobia and identity disorder. Distal pressure is called external pressure, and proximal pressure is called internal pressure. Meyer believes that the stress of sexual minorities is a continuum from the external environment to itself, and the closer it is to itself, the greater the impact on individuals, so the internal stress has the greatest impact on the mental health of sexual minorities. As a proximal stress closely related to self-cognition, internalized homosexual stigma has a more direct and serious impact on individual mental health. Sexual minorities themselves face increased pressure caused by generalized minority-based stigma and internalized stigma. All these cause emotional disorders, social/interpersonal problems, and cognitive process disorders, thus increasing the risk of mental health. In addition, the LGBT group will be divided into small groups and small circles because of various individual particularities (culture, country, sexual orientation). When the group identity of LGBT group is not enough to bridge the conflict of interest or value between small groups, the internal sexual minority pressure of LGBT group will arise (Hatzenbuehler, 2009). The negative factors on the mental health of homosexuals include both stress related to sexual orientation and general factors, including negative coping strategies, interpersonal problems, and negative cognition. For LGBT groups suffering from a series of negative emotions brought by internalized stigma, social support and intra-group identity are important protective factors for their mental health. However, COVID- BCP Education & Psychology ESS 2022 Volume 7 (2022) 279 19-related affiliate stigma further destroys the scarce social support of overseas Chinese LGBT population. The loss of identity from within LGBT population and the accompanying interpersonal problems may give birth to their negative coping strategies and further worsen their mental health. 3. Method 3.1 Sample The subjects of this study are individuals who define themselves as LGBT groups. The research adopts the network survey method, and publishes the questionnaire links/posters to the active communities of sexual minorities (Twitter, Facebook, We-chat group). At the same time, volunteers are asked to fill out the questionnaire by convenient sampling and snowball sampling through acquaintance relationship offline. A total of 150 questionnaires were distributed and 127 valid questionnaires were recovered. The subjects ranged in age from 18 to 29, with 326 lesbians and 117 gays. 3.2 Measurement 3.2.1 Depression Symptoms In this study, the Patient Health Questionnaire (PHQ-9) developed by Kroenke et al. (2001) was used to measure the depression of LGBT population. The scale consists of nine items, including depression, anxiety, alcohol addiction, somatic disorder, and eating disorder. It is a simple and effective self-rating scale for depression, which shows good reliability and validity in diagnosing depression and evaluating symptom severity in Chinese cultural environment. During the evaluation process, the respondents need to report the frequency of suffering from symptoms described in the topic (such as Feeling bad about yourself-or that you are a failure or having let yourself-or your family down) as required. Each topic has four alternatives, namely Not at all (0 points), Several days (1 point), More than half the days the (2 points), and Nearly everyday (3 points). In this study, the average score of each topic of the respondents is taken as the final score of depression, with the lowest score of 0 and the highest score of 3. The higher the score, the more serious the depression. Cronbach's alpha of this scale for the sample was 0.89 3.2.2 Anxiety Generalized anxiety disorder (GAD) is one of the most common mental disorders. GAD is marked by excessive and out-of-control worry, which can have a negative impact on patients’ quality of life and interfere with important activities of daily life. Patients with GAD usually show excessive anxiety about ordinary daily affairs (such as financial situation, work and health). Anxiety is invasive, causing pain or dysfunction. Anxiety is often associated with physical symptoms such as sleep disorders, restlessness, muscle tension, gastrointestinal symptoms, and chronic headaches. In this study, the General Anxiety Scale (GAD-7), which was recommended by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by American Psychiatric Association (APA) and translated by Psychiatric Branch of Chinese Medical Association, was used to measure the anxiety. The GAD- 7 scale consists of seven questions, and the respondents will be asked to evaluate the frequency of the problems described in the questions according to their own situation in the last two weeks (such as too much worry, difficulty in relaxing, fidgeting, easy annoyance or impatience, and fear because they feel as if something terrible will happen, etc.). Cronbach’s alpha of this scale for the sample was 0.85. 3.2.3 Affiliate Stigma Affiliate stigma of the respondents was measured by COVID-19-related stigma scale developed by Li et al. for Chinese communities. The scale is a two-dimensional scale composed of perceived courtesy and affiliate stigma, with each item including five questions. Among them, the perceived courtesy section was evaluated using five items selected from the sub-scale of the HIV Stigma Scale BCP Education & Psychology ESS 2022 Volume 7 (2022) 280 (Berger et al., 2001) The affiliate stigma part is adapted from the sub-scale of Chinese politeness stigma scale (i.e. self-perceived stigma) (Liu et al., 2014). Respondents need to report their attitudes towards the viewpoints and phenomena in the topic. There are four alternative options, namely “very disagree” (1 point), “disagree” (2 points), “agree” (3 points) and “very agree” (4 points). In this study, the average score of each subject is taken as the final score of affiliate stigma, with the lowest score of 1 point and the highest score of 4 points. The higher the score, the higher the degree of Affiliate stigma. Cronbach's alpha of this scale for the sample was 0.87. 3.2.4 Internalized Stigma Internalized stigma was measured using HIV and homosexuality related stigma scales compiled by Liu et al. (2009). The scale consists of three sub-scales: public homosexual stigma (10 items), self- homosexual stigma (8 items), and public HIV stigma (7 items). In this study, the average score of each topic of the respondents is taken as the final score of internalized stigma, with the lowest score of 0 and the highest score of 3. The higher the score, the higher the degree of internalized stigma. Cronbach’s alpha of this scale for the sample was 0.90. 3.2.5 Covariant The educational level, sexual orientation, and income level of the respondents were included as control variables in the model for research. See the following table for the encoding of control variables: Table 1. The encoding of control variables Items Coding Education 1= Primary school and below; 2=Junior high school; 3=High school; 4= undergraduate course; 5=Graduate and above Income(RMB) 1=0-5000; 2=5000-8000; 3=8000-12000; 4=12000-15000; 5=15000-20000; 6=0 Sexual orientation 1=Homosexuality; 2=Bisexuality 3.2.6 Statistical Analysis First of all, the basic descriptive statistics and simple correlation analysis were carried out for each variable, and then the regression model was established to explore the predictive effect of Internalized stigma on LGBT population Depression symbols based on the analysis of other control variables. Secondly, based on the research of Hayes, the adjustment effect of Internalized stigma and affiliate stigma is analyzed by using PROCESS macro program of SPSS software. 4. Result 4.1 Descriptive Analyses Table 2. Descriptive statistics and correlations among variables BCP Education & Psychology ESS 2022 Volume 7 (2022) 281 Table 2 presents means and standard deviations for the study variables as well as covariates. In Table 3, the correlation analysis indicated that internalized stigma and affiliate stigma were significantly associated with LGBTs’ depressive symptoms. Table 3. Correlations analysis among variables Age Education Income S-orientation Depression Anxiety I-S A-S Age 1 Education 0.47* 1 Income 0.61* 0.27* 1 S-orientation -0.08 -0.05 0.07 1 Depression -0.19 -0.139 0.03 0.02 1 Anxiety -0.12 -0.09 0.16 0.07 0.32* 1 I-S -0.25* -0.08 -0.06 -0.02 0.50** 0.35* 1 A-S -0.24* -0.16 0.03 0.03 0.57** 0.52* 0.26* 1 Note. A-S: Affiliate stigma, S-S: Internalized stigma; * p<.05; ** p<.01; ***p<.001. 4.2 Interactive Effects between the Internalized Stigma and Affiliate Stigma The effects of affiliate stigma and internalized stigma on LGBT’s depressive symptoms and anxiety appeared in Table 4. Affiliate stigma and internalized stigma were positively and significantly associated with depressive symptoms and anxiety. Furthermore, affiliate stigma and internalized stigma significantly interacted to predict depressive symptoms and anxiety (For depression, the interaction effect between the internalized stigma and affiliate stigma is -2.295; For anxiety, the interaction effect between the internalized stigma and affiliate stigma is 1.577). Table 4. Two-way interactions of internalized stigma and affiliate stigma on LGBT’s depressive symptoms and anxiety Depression Anxiety Intercept 8.414*** 6.93*** Age -0.140 -0.233 Education 0.206 -0.5 Income 0.099 0.784* S-orientation -0.245 0.787 I-S 4.035*** 2.118** A-S 4.923*** 3.282*** I-S: A-S -2.295*** 1.577* R2 0.488 0.383 Table 5. Simple Slopes analysis for interaction effect between the internalized stigma and affiliate stigma on LGBT’s depressive symptoms Table 6. Simple Slopes analysis for interaction effect between the internalized stigma and affiliate stigma on LGBT’s Anxiety BCP Education & Psychology ESS 2022 Volume 7 (2022) 282 The simple slopes analysis (Table 5 and Table 6) showed us more details about the interaction effect between the internalized stigma and affiliate stigma on outcome variable. For depressive symptoms, among LGBTs with different levels of affiliate stigma, the internalized stigma can significantly and positively predict the depressive symptoms. The predictive effect of internalized stigma in the LGBT group with higher score of affiliate stigma is bigger than that in the LGBT group with lower score of affiliate stigma. For anxiety, among LGBTs with higher affiliate stigma, the internalized stigma can significantly and positively predict the anxiety(Bmean = 2.12, t = 2.89, p = 0.005; B+SD = 3.19, t = 3.69, p < 0.001). The predictive effect of internalized stigma in the LGBT group with higher score of affiliate stigma is bigger than that in the LGBT group with lower score of affiliate stigma. However, there was no significant association between internalized stigma and anxiety among LGBTs with the lowest affiliate stigma. (B = 1.05, t = 1.16, p = .25). The results suggested that lower level of affiliate stigma buffered the detrimental effects of internalized stigma. 5. Discussion For LGBTs, how their psychological mental health is affected by affiliate stigma and internalized stigma has been the focus of researchers. The current study extends previous research by finding that affiliate stigma accelerated the negative effects of internalized stigma, which indicating the importance of alleviating the perceived affiliate stigma for LGBTs. Moreover, the study corroborated with previous research that affiliate stigma and internalized stigma acted as risk factors, and extended the findings to a sample of oversea Chinese LGBTs (Almazan et al., 2021). The first aim of this study was to examine the effects of affiliate stigma and internalized stigma on oversea Chinese LGBTs’ depression and anxiety. We found that both affiliate stigma and internalized stigma were significantly associated with depression and anxiety, whereas internalized stigma were only associated with depression among LGBTs with higher score of affiliate stigma. Our results highlighted the interactor role of affiliate stigma in affecting LGBTs’ mental health, which was consistent with previous studies (Saraff et al., 2022). Furthermore, affiliate stigma and internalized stigma jointly predicted the depressive symptoms and anxiety. On the one hand, among the LGBTs with the lowest affiliate stigma, internalized stigma was not associated with their anxiety and depression, suggesting that the detrimental impact of double stigma on LGBTs’ meatal health is quite bigger than the single effect from the internalized stigma. Specifically, interventions to alleviate LGBTs depression and anxiety should focus more on the affiliate stigma that they perceived and take some action to call for more justice for those vulnerable group during the pandemic. References [1] Zhao, Y., Wang, P., Wu, J., Wang, R., & Song, Q. (2020). Evaluation of Factors Associated with Anxiety and Depression in Chinese Visiting Scholars in the United States During the COVID-19 Pandemic Assessed by Online Questionnaires. Medical science monitor : international medical journal of experimental and clinical research, 26, e926602. https://doi.org/10.12659/MSM.926602. [2] Mallory, C., Vasquez, L. A., Brown, T. N. T., Momen, R. E., & Sears, B. (2021). 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