A scoping review of the integration of empowerment-based perspectives in quantitative intersectional stigma research

ABSTRACT

The genesis of the concept of intersectionality was a call to dismantle interlocking systems of oppression – racial, sexual, heterosexual, and class-based – in order to realise liberation of Black women and other women of colour. Intersectionality holds the radical potential to amplify collective efficacy, community solidarity, and liberation. The extension of intersectionality into stigma research has resulted in an increased focus on intersectional stigma in quantitative research. This raises questions regarding how the radical and liberatory potential of intersectionality is applied in stigma research. Specifically, empowerment-based perspectives may be overlooked in quantitative intersectional stigma research. We conducted a scoping review to document if and how empowerment-based perspectives were included in intersectional stigma quantitative studies. We identified and included 32 studies in this review that examined varied stigmas, most commonly related to race, gender, HIV and sexual orientation. In total 13/32 (40.6%) of these studies reported on empowerment-based factors; most of these examined social support and/or resilience. Taken together, findings suggest that the quantitative intersectional stigma research field would benefit from expansion of concepts studied to include activism and solidarity, as well as methodological approaches to identify the protective roles of empowerment-based factors to inform health and social justice-related programmes and policy.

KEYWORDS:

• Intersectionality
• stigma
• intersectional stigma
• empowerment
• empowerment
• solidarity

Introduction

Merely naming the pejorative stereotypes attributed to Black women (e.g. mammy, matriarch, Sapphire, whore, bulldagger), let alone cataloguing the cruel, often murderous, treatment we receive, indicates how little value has been placed upon our lives during four centuries of bondage in the Western hemisphere. We realize that the only people who care enough about us to work consistently for our liberation is us. Our politics evolve from a healthy love for ourselves, our sisters and our community which allows us to continue our struggle and our work. (Combahee River Collective, 1977)

This quotation by the Black Feminist Combahee River Collective (1977) is from a statement that is widely considered the genesis of the concept of intersectionality as we know it today. Intersectionality refers to the interplay between gender, race and other social categories in daily lives, social relationships, institutional structures, socio-cultural norms, and the ways these interactions shape access to power (Davis, 2008). This statement called attention to the need to dismantle interlocking systems of oppression – racial, sexual, and classist – in order to realise liberation of Black persons and other persons of colour. It signalled the importance of political activism, coalition building, and as described above, struggle rooted in love for self and community. This statement reflects the radical potential of intersectionality to dismantle systemic oppression in ways that amplify collective efficacy, valuing of marginalised persons and their autonomy, community solidarity, liberation, and a vision of a revolutionary society.

There has been an evolution in stigma research over the last half century, from one rooted in Goffman’s (1963) conceptualisation of social processes that oppress persons associated with the moral, disabled or racialized ‘other’, towards social psychological perspectives focused on the health impacts of stigma (e.g. Meyer, 1995), to structural analyses of the ways in which stigma (re)produces social inequities grounded in class, race, gender, and sexual dominance and oppression (Parker & Aggleton, 2003). Stigma is conceptualised as multi-level, spanning intrapersonal, interpersonal, community, legal and other institutionalised processes. There are expansive literatures documenting stigma pertaining to particular groups and communities, including individual and structural racism, sex work stigma, sexual stigma, lesbian, gay, bisexual and transgender (LGBT)-related stigma, among others. There are also bodies of literature examining health-specific stigma, particularly regarding mental health and HIV. Interest in, and application of, intersectionality as an approach to assess multiple stigmatised identities is becoming more prevalent in stigma research (e.g. Logie et al., 2011; Stangl et al., 2019; Turan et al., 2019). Intersectional stigma refers to the ‘interdependent and mutually constitutive relationship between social identities and structural inequities’ (pg. 9; Logie et al., 2011). Converging experiences of stigma may target social identities (e.g. race, gender and class), practices (e.g. drug use, sex work), and/or health statuses (e.g. HIV serostatus) of individuals, groups and communities. Intersectional stigma occurs across social ecological levels, spanning intrapersonal, interpersonal, community and institutional dimensions; across these same dimensions, people can strive for positive change, exhibit coping, acquire support, and challenge stigma (e.g. Baral et al., 2013; Logie et al., 2011; Turan et al., 2019).

The resonance of intersectionality with a growing number of stigma scholars may be explained by sociology of science perspectives. As elegantly argued in ‘Intersectionality as Buzzword’ (Davis, 2008), it may in fact be intersectionality's ambiguity and lack of prescriptiveness pertaining to the methods that has enabled it to be taken up and applied to a range of research disciplines. While there is a growing body of quantitative intersectional stigma research, there is no consensus in the ways that intersectionality theory can be applied in its design, analysis, or interpretation (Logie et al., 2019; Turan et al., 2019). Accordingly, stigma researchers are currently engaging in myriad innovative approaches to integrating intersectionality into their quantitative studies.

The application of intersectionality theory to quantitative stigma research is rapidly growing, yet still nascent with regard to the development and integration of intersectional theoretical components, measurement, and methodologies (Turan et al., 2019). The increased visibility of intersectionality in the quantitative stigma field provides opportunities for advancing social justice and equity through focusing on the role of power in pathologizing stigmatised groups, and moving beyond a deficit-based perspective to amplify the agency of stigmatised groups in navigating systems of oppression via resilience, resistance and empowerment. Perhaps due to the emergent nature of quantitative intersectional stigma research there has been less attention to strengths in intersectional quantitative stigma research than in qualitative approaches (Turan et al., 2019).

This extension of intersectionality theory into stigma research raises questions regarding what and how intersectional perspectives are being applied to intersectional stigma research and what perspectives are missing. Stigma research has historically considered the ways by which persons understand, support one another, and navigate life and connections with others in the midst of stigma. For instance, Goffman (1963) discussed managing the un/concealability of stigma, Meyer’s (1995) minority stress model considered social support as a moderator between stigma and wellbeing, and Parker and Aggleton’s (2003) discussion of power and dominance recommended that interventions focus on community mobilisation, social transformation, and resistance. These theoretical perspectives have helped to shift the focus from pathologizing stigmatised persons who experience health disparities to instead focus on the structural and social conditions that produce stress and reduce opportunities that in turn harm health outcomes (Earnshaw et al., 2013; Logie, 2012).

Stigma research often focuses on the harms of stigma to argue for social justice and equitable programmes and policies – yet when incorporating intersectionality theory, it is possible that researchers can lose sight of intersectionality's focus on strengths, resistance, and empowerment. Intersectional stigma has been conceptualised as creating the conditions for both marginalisation and opportunities across macro (advocacy), meso (social support and solidarity), and micro (resilience) levels (Logie et al., 2011). Other stigma researchers have proposed a multi-level stigma resilience agenda to build resources to mitigate health impacts of stigma (Earnshaw et al., 2013). For instance, structural level strategies can focus on empowerment via economic policy change, community education and mobilisation. Empowerment also includes nurturing pride and historical knowledge of stigmatised identities – such as among Black persons and/or LGBT persons – alongside socialising people with shared identities to recognise and navigate stigma (Earnshaw et al., 2013). At the interpersonal level, social support can help people impacted by stigma to reframe and make meaning of their experiences, engage in problem solving, and generate dialogue to process stigma experiences (Earnshaw et al., 2013).

These framings of people and their communities as more than vulnerable or passive recipients of stigma experiences reflect a nuanced perspective of power. For instance, Stangl et al.'s (2019) Health Stigma and Discrimination Framework moves beyond a traditional conceptualisation of stigma ‘targets’ vs. ‘perpetrators’ to note the fluidity of power dynamics and the agency that persons have to navigate and effect change on their social contexts. Recognising that power is fluid and how persons enact relational, interpersonal and collective agency within contexts of structural inequities can challenge discourses of vulnerability (Ahmed, 2010; Logie & Daniel, 2016). It is key to move beyond a stigma=vulnerability focus; vulnerability framings are deficits-focused and can create false separations between persons and the environments they co-create, overlook social connections and relationships, and miss collective and community-based agency (Kippax et al., 2013).

The ways by which persons experiencing stigma navigate, mobilise, create communities of care, and resist stigma has been integrated in much qualitative intersectional stigma research. For instance, qualitative research studies have conceptualised intersectional stigma as inclusive of intrapersonal processes of resilience, interpersonal processes of solidarity and social support, and structural processes of resistance and challenging stigma (e.g. Holley et al., 2016; Levey & Pinsky, 2015; Logie et al., 2011; Rice et al., 2018).

There has not been the same level of integration of empowerment-based perspectives in intersectional stigma quantitative research (Turan et al., 2019). While there are contested definitions of empowerment (Cattaneo & Chapman, 2010), it can be understood as a non-linear, iterative and multi-level process that involves increasing ‘personal, interpersonal, or political power so that individuals, families, or communities can take action to improve their situations’ (p. 534; Gutiérrez et al., 1995). Multiple dimensions of empowerment include: intrapersonal, such as critical reflection, agency, self-efficacy and knowledge; interpersonal, for instance, negotiating and shifting power in relationship dynamics and acquiring social support; community, including collective agency and action; and institutional, transforming social and structural systems (Cattaneo & Chapman, 2010; Freire, 1972; Gutiérrez et al., 1995; Logie & Daniels, 2016). Whether empowerment perspectives are considered in intersectional research has theoretical and methodological implications. Merely naming and measuring ‘pejorative stereotypes’ could result in missing the lessons to be learned regarding how communities generate a ‘healthy love’ for self and others as discussed by the Combahee River Collective (1977). Crenshaw (1991), whose seminal work is referenced in intersectionality research, describes that researchers should not only focus on dominance but also on social empowerment associated with identities. Similarly, Davis (2008) raises the same concerns as in the opening quotation by Combahee River Collective (1977) regarding intersectionality's focus: ‘should it be deployed primarily for uncovering vulnerabilities or exclusions or should we be examining it as a resource, a source of empowerment’ (page 75)? In sum, applying strengths versus deficits perspectives reflects the power dynamics where researchers shape knowledge of intersectional stigma and health.

This manuscript aims to better understand the state of the quantitative intersectional stigma field. Specifically, we explored the quantitative intersectional stigma literature to understand to what extent empowerment-based aspects have been integrated and what strategies have been employed to apply empowerment-based perspectives. Synthesising this information can inform recommendations and strategies for intersectional stigma researchers to more effectively include empowerment-based perspectives in their research to align with the radical and liberatory potential of intersectionality.

Methods

The purpose of this study is to document empowerment-based perspectives included in research measures in quantitative stigma studies that identified intersectionality as a theoretical and/or methodological approach. To this end, we conducted a scoping review of the literature to identify quantitative studies that applied the concept of intersectionality across a broad range of disciplines to assess if and how empowerment-focused factors were included and how they were measured. Scoping reviews are a method that provides a broad overview of the literature to explore a general question to inform a higher level examination of a topic; while covering a broader conceptual range, they also go less in-depth into a particular literature than systematic reviews (Arksey & O’Malley, 2005). A scoping review also addresses theory and complex topics, thus is well suited for this investigation. We followed Arksey and O’Malley's framework for a scoping study, including: (a) identifying the research question (if and how have empowerment-perspectives been included in intersectional stigma research?); (b) identifying relevant studies; (c) selecting studies; (d) charting the data, and (e) summarising and reporting results (Arksey & O’Malley, 2005).

The search of English language peer-reviewed journal articles was conducted in September of 2020, and completed in consultation with an information specialist. We searched MEDLINE (313), EMBASE (325), PsycINFO (424), CINAHL (1653), LGBT Source (44), IBSS (International Bibliography of Social Sciences) (220), Gender Studies (65), Sociological Abstracts (256), and Applied Social Sciences and Index (ASSIA) (128). Search terms included (1) ‘intersectionality’ or related terms and (2) ‘social stigma’ and related terms (social stigma was a Medical Subject Headings [MeSH] term). For example, we searched intersectionality, intersection, intersecting, intersection* and stigma. The search was not time restricted.

References from this search were entered into Covidence (https://www.covidence.org), a systematic review web-based management platform, and underwent two stages of screening. First, references were screened by title and abstract by two team members with the following exclusion criteria: (a) not peer reviewed, (b) not assessing stigma, and (c) not using intersectionality theory. In the second stage, full text screening was completed by the same two team members with the following exclusion criteria: (a) not peer reviewed, (b) not a quantitative study, (c) not assessing more than one type of stigma or stigma and its intersection with health/social categories, and (d) authors not explicitly stating use of intersectionality theory in the background, methodology, or data analysis. We extracted key themes and findings pertaining to the ways in which empowerment-reated factors were (or were not) assessed.

We followed the Preferred Reporting Items for Systematic review and Meta-analysis (PRISMA) protocols guideline (Tricco et al., 2018):

• Population: This quantitative study review concerns studies that have examined stigma and applied an intersectional framework/approach to study design, theoretical framework, or analysis.

• Intervention: Studies were included if they measure stigma and mention being informed/guided by an intersectional conceptual/theoretical approach.

• Comparison or comparator: We included studies regardless of whether or not they included a comparison group. We only included quantitative studies, or mixed-methods studies with a quantitative component (and only included the quanitative data in the analysis).

• Outcomes: We examined how studies report: (a) stigma, (b) intersectionality of stigma (what types of stigma or social categories are measured), and (c) empowerment perspectives associated with living, coping with, and/or managing stigma and/or marginalised identities (including but not limited to social support, solidarity, resilience, resistance).

Results

Our initial search resulted in 2122 references without duplicates. One hundred and forty references were then moved to the second, full-text screening stage and thirty two references were selected from this second stage for inclusion in this review. (Figure 1).

Figure 1. Flow diagram of the intersectional stigma quantitative scoping review.

The types of stigma measured in the 32 studies of focus in this review are varied. As detailed in Table 1, the five most commonly examined types of stigma were: race and racism (n=19); HIV serostatus and HIV-related stigma (n=17); sexual orientation and related stigma (n=15); sex, gender, gender identity and related stigma (n=13); and substance use and substance-use related stigma (including alcohol, smoking and general substance use) (n=5).

Table 1. Studies addressing intersectional stigma included in scoping review (n=32).

Author(s)	Method	Sample Size	Study objective	Stigma and health/social identities assessed	Were empowerment-based factors measured
Algarin et al. (2019)	Quant	932	-examined associations between combinations of marginalised group identities and enacted HIV-related stigma	HIV-related stigma; marginalised group identity (age; sex; race; ethnicity; sexual orientation)	No
Bastos et al. (2018)	Quant	12,368	-examined associations between racial discrimination and health care barriers, and if racial discrimination effects varied by gender, sexual orientation and socio-economic status, and if other forms of discrimination impacted healthcare barriers	Racial discrimination; class, gender, and sexuality discrimination	No
Bouris and Hill (2017)	Quant	163	-examined associations between minority stressors (sexual orientation and gender identity stigma, racial discrimination), and protective factors (resilience, LGBT community connectedness, school-based social support, maternal resources) between sexual and gender minority (SGM) youth	Gender identity stigma; sexual orientation stigma; gender identity; sexual orientation; racial discrimination	Yes
Brown (2014)	Quant	376	-explored how gender and physical disability intersect to affect psychological distress -examined if the interaction between perceived devaluation and self/social approvals varied by gender, and examined if the interaction between functional limitation and self/social appraisal varied by gender	Disability; gender	Yes
Calabrese et al. (2018)	Quant	285	-examined sexual stereotypes associated with MSM, Black men, and white and Black MSM, including whether any unique stereotypes of Black MSM emerged	Racial stereotypes; sexual orientation stereotypes	No
DuPont-Reyes et al. (2020)	Quant	751	-co-examined effects of gender, race and ethnicity on mental illness stigma; also assessed familiarity with mental illness by level of contact with persons with mental illness	Mental illness stigma; race; ethnicity; gender	Yes
Dyar et al. (2020)	Quant	360	-examined within-group differences in stressors and health among non-monosexual persons by sexual, gender and ethnic/racial identities, also examined within group variation in associations between non-monosexual stressors and health by sex assigned at birth	Sexual orientation; gender identity; racial identity; non-monosexual stressors	No
Earnshaw et al. (2015)	Quant	85	-examined how internalized HIV stigma interacted with substance use internalized stigma and associations with depressive symptoms	HIV-related stigma; substance use stigma	No
Earnshaw et al. (2021)	Quant	151	-measured internalized stigma based on: race, sexual orientation, HIV/STI	Racial, sexual orientation and HIV/STI-related stigma	No
English et al. (2018)	Quant	376	-assessed racial discrimination and gay rejection sensitivity and their interaction with health outcomes (emotion regulation, depressive/anxiety symptoms, drug use, heavy drinking)	Racial discrimination; gay rejection sensitivity	No
Goodin et al. (2018)	Quant	60	-measured internalized HIV stigma and internalized chronic pain stigma, created a composite variable, and looked at associations with depressive symptoms	HIV stigma; chronic pain stigma	No
Haile et al. (2014)	Quant	2408	-measured differences in perceived racial inclusion, perceived racism, and positive affiliation with the gay community between Black and White MSM	Perceived racial inclusion; perceived racism	Yes
Himmelstein et al. (2017)	Quant	2378	-assessed weight stigma, weight bias internalisation, and maladaptive coping strategies (disordered eating) and racial differences	Weight stigma; weight bias internalisation; race	No*
Ion et al. (2017)	Quant	77	-examined associations between mental health, social support, and perceived racism on HIV-related stigma	HIV-related stigma; racism	Yes
Jackson et al. (2020)	Quant	131	-examined within-person associations between intersectional experiences based on race and sexual orientation and psychological wellbeing	Sexual minority stigma; racism	Yes
Lipperman-Kreda et al. (2019)	Quant	227	-examined perceptions of sexual and gender minority related discrimination and smoking-related stigma among SGM	Sexual minority; gender; smoking associated stigma	No
Logie et al. (2013)	Quant	173	-examined associations between HIV-related stigma, racial and gender discrimination, and depression, and social support and resilience coping as moderators and mediators of stigma effects on health	HIV-related stigma; racial discrimination; gender discrimination	Yes
Logie et al. (2016)	Quant	157	-examined associations between racial discrimination and: HIV-related stigma, housing insecurity, and social support	HIV-related stigma; racial discrimination; housing insecurity	Yes
Logie et al. (2018a)	Quant	556	-assessed if selling sex among MSM was associated with an increased likelihood of reporting sexual stigma or HIV-related stigma	Sex work; sexual stigma; HIV-related stigma	Yes
Logie et al. (2018b)	Quant	1425	-assessed associations between HIV-related stigma, racial discrimination and gender discrimination, and quality of life and mediating role of social support and economic insecurity	HIV-related stigma; racial discrimination; gender discrimination	Yes
Logie et al. (2019)	Quant	1422	-tested latent and observed variable approaches to an intersectional stigma construct (HIV-related stigma, racial and gender discrimination) via mediators of social support and women's centred HIV care to depressive symptoms	HIV-related stigma; racial discrimination; gender discrimination	Yes
Lyons et al. (2020)	Quant	375	-assessed longitudinal differences in stigma attributed to sex work or sexual and gender minority (SGM) status by HIV serostatus, and associations between viral suppression and stigma	Sex work stigma, sexual and gender minority stigma, stigma differences by HIV status	No
Makowski et al. (2019)	Quant	692	-assessed differences in fat phobia/obesity stigma vignettes based on the stigma target's gender and socio-economic status	Obesity stigma; gender; socioeconomic status	No
Moore et al. (2020)	Quant	185	-examined linkages between gender and multiple devalued identities (homelessness, sex work, illicit drug use) and internalized alcohol use stigma -examined associations between race, education, income, sex work, homelessness, and drug use with alcohol self-stigma	Alcohol use stigma; sex work; race, education, income, homelessness; drug use	No
Orza et al. (2015)	Mixed	832	-assessed associations between socially disadvantaged identities (e.g. sex work, drug use, incarceration history, disability, TB) and mental health outcomes	HIV; gender; mental health	No (only qualitative findings addressed strengths-based factors)
Rosengren et al. (2019)	Quant	324	-assessed HIV-related stigma and discrimination, sexual minority stigma, and racial discrimination and differences by HIV status and mobile app usage	HIV-related stigma; sexual minority stigma; racial discrimination	No
Sereda et al. (2020)	Quant	191	-examined differences in HIV stigma, substance use stigma, and/or an intersectional stigma variable that included both HIV and substance use stigma scores	HIV-related stigma; substance use stigma	Yes
Shangani et al. (2020)	Quant	396	-examined differences in minority stressors (sexual orientation stigma) by race, and the moderating impact of socio-economic status on the association between race and minority stressors	Race; socioeconomic status; sexual orientation stigma	No
Stewart et al. (2019)	Quant	729	-validated an anticipated sex work stigma scale and links to HIV and non-HIV service usage	Sex work stigma; HIV serostatus	No
Varas-Díaz et al. (2019)	Quant	237	-used standardised patients to explore intersectional stigma (HIV-related stigma, stigma towards people who use drugs, sexism, homophobia) in clinical interactions among medical students	HIV-related stigma; sexual minority stigma; substance use stigma; sexism	No
Weisz and Quinn (2018)	Quant	138	-examined independent and interactive effects of perceived homelessness stigma and perceived racial stigma and their associations with psychological distress, physical health, and service avoidance	Homelessness; race; gender; mental illness; addiction; criminal history; domestic violence history	No
Yang et al. (2020)	Quant	193	-examined main and interaction effects of HIV-related stigma and sexual and gender minority stigma on depression, anxiety, quality of life and resilience among MSM living with HIV	HIV-related stigma; sexual and gender-minority stigma	Yes

Table 1 details the varied objectives that researchers applied in their intersectional stigma work. For instance, some examined combinations of devalued group identities with experiences of different types of stigma, including HIV-related stigma, sexual and gender orientation-related stigma, and mental illness stigma (e.g. Algarin et al., 2019; Bouris & Hill, 2017; DuPont-Reyes et al., 2020). Others examined multiple combinations of stigma on particular outcomes, such as race, class, gender and/or sexuality-related stigmas on healthcare barriers and health outcomes (e.g. Bastos et al., 2018; English et al., 2018; Logie et al., 2019). Many studies examined the ways in which different stigma types interacted with or exacerbated one another, such as HIV-related stigma and substance use stigma (e.g. Earnshaw et al., 2015), chronic pain stigma and HIV-related stigma (e.g. Goodin et al., 2018), racial discrimination and HIV-related stigma (Ion et al., 2017; Logie et al., 2016), and homelessness stigma and racial stigma (Weisz & Quinn, 2018). Some looked at specific social categories, such as race, gender, and socio-economic status, and if those influenced outcomes of racism (Haile et al., 2014), fat phobia (Makowoski et al., 2019), alcohol self-stigma (Moore et al., 2020), or sexual and gender minority stressors (Shangani et al., 2020). Together, approaches signal innovation and creativity in thinking through the various ways that social categories (e.g. race) intersect with social inequities (e.g. racism) with wide ranging health effects (e.g. mental health, physical health, healthcare engagement).

In Table 2 we summarise the 13/32 (40.6%) quantitative intersectional studies that reported assessing any empowerment-based factors. Some studies examined associations between stigma and reduced levels of empowerment-based factors, while others examined if empowerment-based factors mediated or moderated the pathways from stigma(s) to wellbeing. Empowerment-based factors spanned intrapersonal (n=6 studies) (e.g. resilience), interpersonal (n=9 studies) (e.g. social support), community (n=2 studies) (e.g. LGBT connectedness), and institutional (n=3 studies) (e.g. women-centred healthcare, integrated substance use and HIV treatment) levels. Four studies looked at empowerment-based factors spanning more than one socio-ecological level.

Table 2. Quantitative intersectional stigma studies that included empowerment-based factors (n=13).

Author(s)	Empowerment-based and Protective Factors Measured, Level of factor	Empowerment-based and Protective Factors Findings
Bouris and Hill (2017)	Resilience, LGBT community connectedness, school-based social support, maternal resources; intrapersonal, interpersonal, community and institutional levels	For sexual minority youth, resilience was associated with increased condomless anal sex, while mother-to-son communication about sex was associated with reduced condomless anal sex
		For gender minority youth, maternal warmth was related to improved mental health outcomes and maternal acceptance was related to reduced condomless anal sex
Brown (2014)	Self-esteem; mastery; intrapersonal level	Self-esteem and mastery were associated with reduced depressive symptoms among men
DuPont-Reyes et al. (2020)	Familiarity with mental illness (contact with persons with mental illness); interpersonal level	Familiarity with mental illness did not interact with intersectional groupings to impact stigma outcomes
Haile et al. (2014)	Positive affiliation with the gay community, racial inclusivity within the gay community; community level	Black MSM reported less racial inclusivity, and less positive affiliation, in the gay community than white MSM
Ion et al. (2017)	Social support; interpersonal level	HIV-related stigma was associated with reduced social support in pregnancy
Jackson et al. (2020)	Positive intersectional experiences; interpersonal and intrapersonal levels	Positive intersectional experiences were associated with positive rumination and positive affect within and between persons
Logie et al. (2013)	Social support; resilient coping; interpersonal and intrapersonal levels	Social support and resilient coping did not significantly moderate depression scores and only partially mediated effects of HIV-related stigma, racial discrimination, and gender discrimination
Logie et al. (2016)	Social support; interpersonal level	Racial discrimination, HIV-related stigma, and housing insecurity were associated with reduced social support
Logie et al. (2018a)	Social support; interpersonal level	Sex work was associated with increased sexual stigma and higher needs for social support
Logie et al. (2018b)	Social support; interpersonal level	Social support mediated the relationship between gender discrimination and HIV-related stigma and mental health-related quality of life
Logie et al. (2019)	Resilience; social support; women-centred HIV care; intrapersonal, interpersonal and institutional levels	Women-centred care mediated the relationship between (a) a latent intersectional stigma construct, and (b) gender discrimination, and depression
Sereda et al. (2020)	Co-located HIV and opiod agonist treatment; institutional level	Co-located HIV and substance use treatment were not significantly associated with reduced HIV or substance use stigma
Yang et al. (2020)	Psychological resilience; intrapersonal level	There was an interaction where high levels of both SGM stigma and HIV-related stigma resulted in significantly lower psychological resilience

Intrapersonal resources were explored in different ways. For instance, positive intersectional experiences based on race or sexual orientation were associated with positive affect among Black sexual minorities, signalling the role that identity-related support plays in psychological wellbeing (Jackson et al., 2020). Self-esteem and mastery were associated with reduced depressive symptoms among men with physical disabilities (Brown, 2014). HIV-related stigma and sexual orientation stigma interacted to reduce psychological resilience among MSM living with HIV (Yang et al., 2020). These signal that resilience-related factors can promote wellbeing in stigmatising contexts, while also being depleted by the effects of stigma.

Social support was the most commonly studied interpersonal-level empowerment factor and was examined in a similar way, as a resource that could mitigate the harmful effects of stigma on wellbeing as well as be dimished by stigma. For instance, social support mediated the relationship between gender discrimination, HIV-related stigma, and mental health-related quality of life (Logie et al., 2018b). In another example with gender minority youth, positive maternal relationships were associated with positive sexual and mental health outcomes (Bouris & Hill, 2017). Others reported associations between HIV-related stigma and lower social support (e.g. Ion et al., 2017).

The two studies that explored community-level empowerment factors both assessed LGBT connectedness/inclusion but employed different approaches. The first did not find LGBT connectedness was associated with youth health outcomes (Bouris & Hill, 2017). The second found that Black MSM reported less racial inclusivity, and less positive affiliation, in the gay community than white MSM (Haile et al., 2014). Three studies examined institutional factors. For instance, a study reported women-centred HIV healthcare mediated the relationship between intersectional stigma and depression among women living with HIV (Logie et al., 2019). In another study, however, offering co-located HIV and substance use treatment with people living with HIV who used drugs did not reduce stigma, yet it increased quality of HIV care (Sereda et al., 2020). The small number and heterogenous nature of the community and institutional level factors signals the importance of future research on these and other topics.

Discussion

To sum up, the quantitative intersectional stigma field is growing, spanning marginalisation based on race, HIV, sexual orientation, substance use, and gender. More recently, there has been inclusion of experiences of homelessness, sex work, and socioeconomic status. Future intersectional stigma research can expand to examine multiple and less studied experiences of marginalisation and structural oppression. Less than half (13/32, 40.6%) of the studies included in this review measured empowerment-based factors in addition to stigma. This is an area for growth in the intersectional stigma field, as identifying what factors can mitigitate stigma's impacts on wellbeing can inform future intervention development and policy. Findings suggest that the current field of quantitative intersectional stigma research could expand both the concepts that are studied to include more empowerment-based factors, as well as build methodological roadmaps for testing the protective roles of empowerment-based factors in contexts of intersectional stigma.

Most of the intersectional stigma studies that included empowerment-based factors examined interpersonal and intrapersonal level factors. Stigma was often reported to be associated with lower social support and/or resilience, and at times social support and resilience mitigated the effects of stigma on health outcomes. Future studies could more consistently test the mediating and moderating roles of social support and resilience to inform programming. ‘Main effects model’ approaches to social support point to its health benefits via social integration, self-esteem and self-worth (Cohen & Wills, 1985). Social support also has a buffering role for stress, whereby it can shift coping strategies and self-esteem, particularly if this support is high quality and salient to the lived experiences of the person (Cohen & Wills, 1985; Lakey & Cohen, 2000). Researchers can more fully explore the dimensions of social support including quality and quantity, sources of social support including from family, friends, and significant other(s), and its role in helping people navigate intersectional stigma. Similarly, a recent review of resilience among people living with HIV calls for multi-level approaches to resilience (Dulin et al., 2018). Multi-level resilience (individual, relational, collective) is underexplored in relation to intersectional stigma.

There are other factors that warrant further attention in intersectional stigma quantitative research. These include collective empowerment, resistance, solidarity, and community mobilisation and transformation. Learning from the rich body of qualitative intersectional stigma research could inform the application and adaptation of varying measures and would also point to the need to develop tools where there are none available. For instance, building community solidarity and activism networks could have ripple effects for funding advocacy, community-level stigma reduction strategies, as well as health benefits. It is plausible that there is a need for a blueprint for intersectional stigma quantitative research with measures for multi-level empowerment-based factors congruent with intersectionality's liberatory potential. To illustrate, Earnshaw et al. (2016) examined HIV activism among persons living with HIV. Their study revealed that higher enacted HIV-related stigma was associated with increased HIV activism, and that HIV activists also reported higher social network integration, social wellbeing, life meaning, and active coping with discrimination. Yet they also caution that HIV activists had higher depressive symptoms than non-activists, calling for future nuanced explorations of stigma, activism and wellbeing (Earnshaw et al., 2016). Structural racism and other forms of intersecting structural stigma require urgent focus.

An increasing number of quantitative studies are assessing multiple forms of stigma and their intersection, with debates over whether there are more appropriate analytic methods than others (for instance, Bauer, 2014; Harnois et al., 2019; Logie et al., 2019; Turan et al., 2019). The purpose of this paper is not to serve a gatekeeping role or argue for one particular analytic approach. Turan et al. (2019) provide multiple possibilities for measurement and analyses of intersectional stigma. Indeed, our review of how intersectionality is being applied in quantitative stigma research in Table 1 shows the multitude of possibilities for integrating an intersectional approach into stigma research.

Based on our findings, we provide some recommendations for considering multi-level empowerment perspectives to enhance the liberatory potential of applying an intersectionality approach to stigma research. Researchers can theoretically situate their study in a comprehensive intersectionality framework. They may wish to revisit the Combahee River Collective Statement (1977) to consider the ways that their study can address multiple, interlocking systems of oppression, as well as assess empowerment related to intersecting identities. They can identify what systems of oppression they will be measuring, and if they will be assessing social categories (e.g. ethnoracial identity) and/or systemic oppression (e.g. racism). Researchers can consider integration of multi-level empowerment perspectives into studies and explore how study findings could advance larger social justice and equity initiatives. Documenting community and structural strengths can be leveraged in practice, programming and policy.

A few limitations should be mentioned. We included studies that addressed stigma based on multiple identities/ stigma types and mentioned being informed by intersectionality. Perhaps this broad inclusion criteria captured studies that were too different to compare. It may also be that intersectionality was peripheral to the study. These exclusion criteria, while helpful in producing a manageable sample of intersectional stigma quantitative studies to review, may have inadvertently moved the analysis from intersectionality's critical race feminist roots. Future studies could use a wider inclusion criteria to encapsulate such studies. There was a MeSH term for social stigma but not intersectionality, which made it more challenging to identify relevant studies. The exclusion of non-peer reviewed reports may have missed a broader knowledge base on empowerment-based approaches to intersectionality from the community. Finally, we focused on the budding quantitative intersectional field in order to produce more precise analyses, but there is a much larger body of qualitative intersectional stigma research that was beyond the scope of this paper that could inform future quantitative research.

Implications

The study of the integration of empowerment-based perspectives in intersectional stigma studies has practical implications. This work can inform policy recommendations to address stigma and promote health equity. Without attending to strengths and the ways that communities are navigating inequalities, interventions may not realise their potential in ‘unleashing the power of resistance on the part of stigmatized populations and communities’ (Parker & Aggleton, 2003, p. 21). Yet, empowered communities acting in solidarity have the power to change policies that derive from and reproduce intersectional stigma. Moreover, empowerment-based perspectives encourage policies that truly shift power to stigmatised groups. Historically, efforts to address stigma have centred on prohibiting discrimination. For example, civil rights legislation passed in the U.S. in the 1960s banned discrimination on the basis of race, colour, religion, sex, and national origin in employment, housing, public accommodations, and federally funded programmes. The Black Lives Matter and other activist communities also teach the importance of moving beyond these ‘do no harm’ policies that risk maintaining the status quo to those that sustainably transform power structures within society (Black Lives Matter, n.d.). In essence, an empowerment-based perspective calls for a fundamental re-envisioning of how stigma is addressed via policy. Policies should not only protect stigmatised groups from devaluation and disempowerment, but invest in valuing and empowering them.

Findings can inform the way that researchers design studies, and the very questions that are asked. Most quantitative stigma studies guided by intersectionality are not employing a radical perspective of intersectionality that addresses multi-level empowerment and the potential of individuals and communities to create a more equitable and just society. There is the possibility that by focusing only on marginalisation, researchers could inadvertently perpetuate stigmatising and hopeless perspectives regarding marginalised communities that they are studying. Tuck (2009) described that the repercussions of damage-centred research include communities ‘thinking of ourselves as broken’ (p. 409). Alternatively, studies could produce valuable knowledge of marginalisation, while simultaneously signalling the ways in which people are navigating, coping, and resisting intersecting forms of stigma. This knowledge can be leveraged to attain funding to support and grow community level activism, wisdom and strength. Such an approach aligns with Tuck’s (2009) invitation to research desire, a concept that encapsulates complexity, nuance, and self-determination. Community mobilisation, solidarity, resources and knowledge can be integrated into the development of health and social justice-related programmes and services.

We call for the examination of stigma based on marginalised identities, practices and health statuses, alongside the exploration of the myriad ways that people and communities are working to support themselves and one another and transform society. Measuring activism, stigma resistance, solidarity, social support, and multi-level resilience – among other empowerment indicators – has the potential to transform our knowledge base as researchers and in turn produce evidence to support policies and programmes to fuel social change and social justice.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by Canada Foundation for Innovation; Canada Research Chairs; Ontario Ministry of Research, Innovation and Science; Social Sciences and Humanities Research Council of Canada Insight Development Grant.