LGBTQ Stigma

Abstract

Lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) individuals face significant stigma globally. Examples of stigma range from extreme acts of violence, such as murder, to more subtle yet pervasive forms of marginalization and social exclusion, such as being socially rejected, denied employment opportunities, and given poor healthcare. Stigma has been identified as a fundamental cause of global LGBTQ health inequities. This chapter summarizes research on and theory that defines LGBTQ stigma, documents ways in which stigma is manifested and experienced by LGBTQ individuals, articulates how stigma leads to health inequities among LGBTQ populations, and identifies evidence-based intervention strategies to address LGBTQ stigma. Moreover, recommendations for addressing stigma to promote LGBTQ health equity globally are provided. As examples, promoting policy change and investing in social norm campaigns can reduce stigma at the structural level, enhancing education and providing opportunities for interpersonal contact can reduce stigma among individuals who perpetrate stigma, and bolstering resilience can protect LGBTQ individuals from stigma. Intervention strategies that have been developed in the Global South are being applied in the Global North (e.g., participatory theatre) and vice versa. As the field moves toward addressing stigma to achieve LGBTQ health equity, it is worth bearing in mind that stigma is neither fixed nor insurmountable. Rather, it is malleable and intervenable: it has changed and will continue to change with time. Public health researchers, practitioners, policy makers, and other stakeholders have key roles to play in advocating for continued change in LGBTQ stigma worldwide.

Lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) individuals face significant stigma globally. As examples, Viccky Gutierrez, a young transgender woman from Honduras, was the first of two dozen transgender women to be killed in the United States in 2018 (Human Rights Campaign Foundation 2019). In early January, she was stabbed to death before her body was set on fire in her Los Angeles home. By summer, the Humans Rights Campaign would characterize fatal violence toward transgender women of color as a “national epidemic” in the United States. In August 2018, police and government officials raided a LGBTQ night club in Kuala Lumpur, Malaysia (Ellis-Peterson 2018). Twenty men were detained and ultimately ordered into counseling, and a government official released a statement that “hopefully this initiative can mitigate the LGBT culture from spreading into our society.” News broke of a “gay purge” in Chechnya in December, wherein approximately 40 men and women were detained and tortured, and two killed, upon suspicion of being sexual minorities (Vasilyeva 2019). This is only the most recent of a series of “detentions, torture and killings of gay people” in Chechnya, some of which were reported in 2017.Globally, stigma experienced by LGBTQ individuals ranges from extreme acts of violence, including those described above, to more subtle yet pervasive forms of marginalization and social exclusion, including being socially rejected, denied employment opportunities, and receiving poor healthcare. Stigma has been identified as a fundamental cause of health that leads to significant health inequities (Carroll & Ramón Mendos 2017; Hatzenbuehler, Phelan & Link 2013). Public health researchers, practitioners, policy makers, and other stakeholders have a key role to play in addressing stigma to improve the wellbeing of LGBTQ individuals worldwide. In this chapter, we summarize research and theory that defines LGBTQ stigma, documents ways in which stigma is manifested and experienced by LGBTQ individuals, articulates how stigma leads to health inequities among LGBTQ populations, and identifies evidence-based intervention strategies to address LGBTQ stigma. In doing so, we provide recommendations to readers for addressing stigma to promote LGBTQ health equity globally.

2.1 Stigma Definitions and Key Concepts

Theorists and researchers from several disciplines, including sociology, anthropology, psychology, and public health, have defined stigma and articulated key concepts relevant to stigma and health inequities. In 1963, Erving Goffman defined stigma as social devaluation and discrediting (Goffman, 1963). In 1981, Virginia Brooks introduced minority stress theory (Brooks, 1981). Ilan Meyer built on this theory when he characterized LGBTQ stigma as a significant and chronic stressor that undermines the health of gay men (Meyer, 1995). Minority stress theory, which was developed in the United States, continues to be the most widely used theory for understanding and addressing LGBTQ stigma globally (Nakamura & Logie, 2019). It is applied by LGBTQ communities around the world that have found it to be useful for their local socio-cultural contexts. Theorists have moved beyond individual-level conceptualizations of stigma by adopting a sociological lens, and stigma has been described as a social process that exists when labeling, stereotyping, separation, status loss, and discrimination occur within a power context (Link & Phelan, 2001). This social process is expressed or experienced as stigma manifestations within structures (e.g., codified within laws) and individuals (e.g., experienced as discrimination), and in turn, these stigma manifestations affect the health of stigmatized individuals both directly and through mediating mechanisms (Hatzenbuehler et al., 2013; Stangl et al., 2019). In this way, stigma leads to health inequities or disparities among stigmatized groups, which are avoidable health differences between groups of people (Braveman, 2006). In the sections below, we further elaborate on stigma manifestations and describe how they are related to health outcomes among LGBTQ people. First, we highlight several key concepts related to stigma and health inequities.

2.1.1 Functions of Stigma

Stigma is theorized to play societal functions across socio-cultural contexts (Kurzban & Leary, 2001). Phelan, Link, and Dovidio theorize that LGBTQ stigma operates to “keep people in” their expected gender roles, enforcing social norms surrounding sexuality and gender (2008). Although we used the term LGBTQ stigma, we recognize there are rich bodies of literature that focus on stigma toward sexually diverse persons (lesbian, bisexual, gay, and queer, among other nonheterosexual identities; Herek, 2007) as well as a growing body of literature documenting stigma targeting transgender persons (Hughto White et al., 2015). Sexually diverse persons may be cisgender (identify their gender with the sex they were assigned at birth), transgender (do not identify their gender with the sex assigned at birth), non-binary (identifying with no gender, or across genders), or other genders. The implications are that persons under the LGBTQ umbrella may experience both sexual stigma and trans stigma; for instance, a gay trans man can experience marginalization due to their sexuality and gender identity.

Stigma functions to define the boundaries of acceptable sexual and gender identities, practices, expressions, and communities and creates social consequences for violating these boundaries. Heterosexism operates across social, cultural, religious, political, and legal domains to erase the representation of, and devalue, sexual and gender diversity and to produce heterosexuality as normal, natural, and universal (Rubin, 1994). This has been conceptualized as compulsory heterosexuality: where all persons are assumed to be heterosexual and where it is assumed that all persons should be heterosexual (Fish, 2008). Compulsory heterosexuality is enacted in society by punishing persons who are not heterosexual (e.g., with stigma) and by having incentives at material (e.g., ability to marry) and ideological (e.g., acceptance by religion) levels for heterosexual persons (Rich, 1980). The parallel term cisnormativity refers to the ways in which sociocultural norms and expectations surround gender in ways that assume all persons are, and should be, cisgender (Bauer et al., 2009). Compulsory heterosexuality maps onto what Phelan, Link, and Dovidio describe as functions of LGBTQ stigma and other stigmas to “keep people in” (i.e., keep people within the “in group” by enforcing social norms) and may be applied to characteristics that are perceived to be voluntary or chosen. LGBTQ stigma reproduces the discourse that persons who do not adopt heterosexual and/or binary gender norms do so voluntarily, and thus, their sexuality and gender can be changed. There continues to be a long-standing debate over whether or not gender and sexuality are innate (something that one is born with) or whether they are fluid and changing (thus may change over one’s life). Regardless of this debate, stigma reproduces inequities that pressure conformity with hegemonic gender norms and punish those that do not conform.

Historically, compulsory heterosexuality and cisnormativity were often introduced during colonization, thereby creating new hegemonic gender norms within colonized societies. In some places, such as among many indigenous societies in the Americas, compulsory heterosexuality and cisnormativity were enforced among people who previously recognized and accepted gender and sexual diversity (Jacobs et al., 1997). In other places, such as among the Yorùbá in Western Africa, gender binaries were introduced to people who had not previously recognized an overarching gender system (Oyěwùmí, 1997). By introducing and enforcing compulsory heterosexuality and cisnormativity, LGBTQ stigma was essentially created in some societies where it did not previously exist. The creation of hierarchical social categories, spanning sexual orientation, gender, race, and other lines, was a tool of exploitation that helped colonizers establish power and control over indigenous people (Lugones, 2010).

2.1.2 Stigma Contextualized

Norms surrounding gender and sexuality vary across cultural contexts, and thus LGBTQ stigma manifests differently across cultural contexts. For example, holding hands is a normative behavior for heterosexual men in many areas of the world, including Saudi Arabia, India, and Bangladesh. In these contexts, holding hands is within the boundaries of acceptable masculine behaviors, and there are no negative social consequences associated with the behavior. In many Western countries, however, holding hands, as well as other casual physical contacts between men, is not normative and violates accepted norms of masculinity. In these settings, two men holding hands is a clear violation of the proscribed norms of masculinity, and such behaviors are policed by others in the culture who may respond with behaviors ranging from disapproving looks to physical assault (Logie et al., 2016). Yet the expectations to adhere to gender norms, and the stigma and negative consequences that follow from breaking these gender norms, reflect the concept of hegemonic masculinity (Gibbs et al., 2014). Relational approaches to conceptualizing gender suggest that gender hierarchies underpin the ways that masculinity and femininity are constructed and controlled (Connell, 2012). Although gender and sexuality norms may vary between contexts, most are centered on gender inequity and the use of violence as a way of gaining power and reproducing adherence to gender norms (Gibbs et al., 2014; Torres et al., 2012).

Stigma is further theorized to be dependent on, or rooted in, specific historical, social, and cultural contexts (Crocker & Major, 1989; Yang et al., 2007). Although stigma seems to exist everywhere, the extent to which certain characteristics and identities are stigmatized, the ways in which stigma is manifested, and how stigma affects health may vary across time and place. For example, the transgender stigma has both waxed and waned in India over the last several centuries (Michelraj, 2015). Historically, India recognized a “third sex” called hijras, which included persons who do not conform to binary conceptions of gender. Throughout history, hijras played socially valued positions within society, including as political advisors and generals. Starting in the eighteenth century, however, hijras were criminalized under British colonial law, leading to a growing anti-transgender sentiment in India and stigma toward the hijra community. During this time, myths spread that hijras kidnapped young boys for sex, and many hijras were forced to turn to sex work as other forms of employment and economic empowerment were denied to them (Nanda, 1986). In 2014, India’s Supreme Court officially recognized a third gender, both reflecting and contributing to weakening transgender stigma.

Yang and colleagues (Yang et al., 2014) propose that stigma undermines individuals’ capacity to participate in “what matters most” within a cultural context, thereby preventing individuals from achieving full status within their cultural group. For example, contributing to family lineage through heterosexual marriage and having children is valued in many Asian cultures (Raymo et al., 2015). South Asian gay men describe experiencing shame and bringing dishonor to their families if they do not participate in these social obligations (Mckeown et al., 2010). In African and Caribbean cultures, wherein heterosexual conceptualizations of masculinity are valued, being gay is viewed as a “white/European” disease, and African and Caribbean gay men are accused of rejecting their cultural background (Mckeown et al., 2010; Semugoma et al., 2012).

2.1.3 Intersectional Stigma

Intersectionality theory emphasizes that individuals live with multiple interconnected identities and characteristics that represent dimensions of both marginalization and privilege (Crenshaw, 1991; hooks, 1990; Rosenthal, 2016). In addition to experiencing stigma associated with their sexual orientation and/or gender identity, LGBTQ individuals may experience stigma associated with other identities and characteristics such as their race or ethnicity, socio-economic status, or physical or mental health. Similarly, LGBTQ individuals may also experience privilege associated with other identities and characteristics. Thus, intersectionality theory draws attention to the great amount of variability in stigma-related experiences among LGBTQ individuals. For example, a gay man from New York City in the United States may experience stigma very differently than a lesbian woman from Islamabad in Pakistan. Although both individuals may experience stigma related to their sexual orientation, the ways in which they experience and respond to this stigma, and the extent to which it undermines their health, may be shaped by how their sexual identity intersects with their other identities including race, ethnicity, gender, and/or religion (Logie, 2014). The current chapter focuses on LGBTQ stigma but considers how experiences related to individuals’ other identities and characteristics intersect with their experiences of LGBTQ stigma.

2.2 LGBTQ Stigma Manifestations and Experiences

2.2.1 Structural Stigma

LGBTQ stigma is manifested at multiple levels, and stigma at each level has both direct and indirect effects on LGBTQ health inequities. At the structural level, stigma is manifested within common and/or civil laws, religious teachings and laws, and historical traumatic assaults. Notably, the overlap between common/civil and religious law exists on a continuum globally (Sands, 2007). That is, there is much overlap between common/civil and religious law in some countries, wherein religious law dictates or overlaps with common/civil law. For example, in some Islamic countries, there is a great deal of overlap between Shariah law, which is Islamic law, and common/civil law. In other countries, there is a greater separation of common/civil and religious laws. We differentiate between common/civil and religious law below but recognize the overlap between the two in many areas of the world.

2.2.1.1 Common and Civil Law

Worldwide, there are a range of government laws that criminalize the gender expression and/or sexual practice of LGBTQ individuals. According to the International Lesbian, Gay, Bisexual, Trans and Intersex Association’s State-Sponsored Homophobia Report, 71 countries (37% of all UN countries) criminalized same-sex acts between men, and 45 countries criminalized acts between women in 2017 (Carroll & Mendos, 2017). For example, Burundi’s Article 567 states, “Whoever has sexual relations with someone of the same sex shall be punished with imprisonment for three months to two years and a fine of fifty thousand to one hundred thousand francs or one of those penalties” (Carroll & Mendos, 2017). This law applies to both men and women. Some countries with such laws enforce them very rarely or never, but Article 567 was enforced in Burundi between 2014 and 2017. Eight countries apply the death penalty as a consequence of violation of the law. For example, areas held by Daesh (i.e., ISIS/ISIL) in Iraq and Syria have a law entitled “Punishment for Sodomy,” which states, “The religiously sanctioned penalty for sodomy is death, whether it is consensual or not. Those who are proven to have committed sodomy, whether sodomiser or sodomised, should be killed.” Several additional countries, including Afghanistan, Pakistan, Qatar, the United Arab Emirates, and Mauritania, have codified the death penalty into the law but have not enforced it for same-sex practices in recent years.

There are also laws that criminalize the gender expression of transgender individuals and/or deny the affirmation of their gender identity. Malaysian states have had laws prohibiting a “male person posing as woman” or “female person posing as man” (Human Rights Watch, 2014). In 2014, 16 Malaysian transgender women were arrested for engaging in so-called cross-dressing behavior and sentenced to seven days in jail. The ruling was appealed, and the appeals court ruled the cross-dressing law to be unconstitutional, describing it as “discriminatory and oppressive and denies the appellants the equal protection of the law” (Human Rights Watch, 2014). In Iran, the law requires individuals to wear “gender-appropriate” clothes in public (Bagri, 2017). As examples, women must wear the hijab and cover their heads, arms, and legs, and men cannot have long hair or plucked eyebrows. Transgender individuals in Iran report frequent harassment from the police for violating clothing laws. Laws limiting access to bathrooms and locker rooms that match individuals’ gender identity, which have been proposed and sometimes passed in the United States, represent additional forms of structural stigma (Barnett et al., 2018).

In addition to civil laws criminalizing same-sex practices or gender expression specifically, 19 countries (10% of UN countries) had promotion (“propaganda”) and morality laws limiting freedom of expression related to sexual orientation and gender identity in 2017 (Carroll & Mendos, 2017). For example, Article 198 of Kuwait’s Penal Code states: “Whoever makes a lewd signal or act in a public place or such that one may see it or hear it from a public place, or appears like the opposite sex in any way, shall be punished for a period not exceeding one year and a fine not exceeding 1000 Dinar or one either of these punishments.” In the United States, seven states have enacted local laws that restrict health/sexuality education teachers from discussing LGBTQ people and/or topics in a positive light (GLSEN, 2019). The Gay, Lesbian and Straight Education Network has criticized these laws because they prevent LGBTQ students from learning important health information and provide false, misleading, and/or incomplete information about LGBTQ people. Moreover, 25 countries (13% of UN countries) have laws preventing the formation, establishment, or registration of LGBTQ-related nongovernmental organizations (NGOs; Carroll & Mendos, 2017). These laws prevent nonprofit advocacy and service organizations from formally representing LGBTQ groups in national and international forums, wherein they can advocate for LGBTQ rights. For example, Bahrain’s Law 21 Article 3 details that groups which “contradict(s) the public order or moral” or undermine the “social order” are illegal.

2.2.1.2 Religious Teaching and Law

LGBTQ stigma is further manifested at the structural level within religious teachings and laws. The most popular religions globally include Christianity (31.2% of the world population in 2015), Islam (24.1%), and Hinduism (15.1%) (Hackett & McClendon, 2017). Notably, there is variability in how members of all religions view and treat LGBTQ individuals, with some sects and members of each religion adopting more accepting and welcoming approaches than others. Given the focus of this chapter, we focus on stigmatizing aspects of religious teachings and laws herein but acknowledge this variability.

Christianity has historically held that sex should be engaged in for reproductive purposes only, and nonreproductive sex, including sex between men or women, was deemed unnatural and immoral (Sands, 2007). Many Christian denominations teach that same-sex practices are sinful. Several denominations acknowledge that attraction to members of the same sex is not voluntary, or a personal choice, but recommend that individuals who are attracted to members of the same sex practice chastity. Christian organizations have supported conversion therapy and camps, which aim to change the sexual orientation, gender identity, and/or gender expression of LGBTQ people (Mallory et al., 2018). The Williams Institute estimates that 698,000 LGBT adults have received conversion therapy in the United States, about half of whom were exposed to this therapy as adolescents. Although several professional health associations, including the American Medical Association and American Psychological Association, have issued statements opposing conversion therapy, they remain legal in most states in the United States and countries globally (Mallory et al., 2018). Notably, some Christian denominations, including the Church of England, are changing their stances and calling for bans on conversion therapy (Sherwood, 2017).

Similar to Christianity, sex outside of marriage is prohibited within Islam, and marriage must be between a man and a woman (Siker, 2007). Shariah law, or Islamic religious teachings, defines various punishments for same-sex sexual practices in different contexts, ranging from fines, flogging, and imprisonment to death (Sands, 2007). As an example, sexual intercourse between men is defined as a misdemeanor under Shariah law in Saudi Arabia (Carroll & Mendos, 2017). Although same-sex sexual practices are not specifically described as punishable by death, same-sex marriage is not legal, and having sex outside of marriage is punishable by death by stoning. Shariah law additionally targets the gender expression of transgender individuals by prohibiting men from “posing” as women or women from “posing” as men (Human Rights Watch, 2014). Gender-affirming surgery is treated differently in various Muslim countries. For example, gender-affirming surgery among Muslims in Malaysia is prohibited by a fatwa (i.e., religious ruling) (Human Rights Watch, 2014). Although this rule does not technically apply to non-Muslims, transgender individuals of all faiths have difficulty accessing gender-affirming surgery. In contrast, Iran partially subsidizes gender-affirming medication and surgery (Bagri, 2017; Carter, 2010). A fatwa permits sex changes for individuals with gender identity disorders, which may be diagnosed by a doctor, judge, or Imam (Carter, 2010). Medication and surgery are offered, in part, because transgender individuals are viewed as having a psychological problem in need of treatment. Moreover, medication and surgery reinforce traditional conceptualizations of binary genders. The alternative to undergoing medication and surgery is the death penalty (Bagri, 2017).

In Hinduism, religious law is somewhat more ambiguous in its treatment of same-sex practices (Sands, 2007). Several religious texts, including the Dharma and Arthaśāstra, forbid and/or penalize same-sex sexual practices. Yet, some traditional aspects of Hinduism support same-sex sexual practices. The Kama Sutra includes instruction on same-sex sexual pleasure, and hijras represent a third-sex tradition who are born male but may assume feminine identities and have sex with men. In 2014, India’s supreme court recognized transgender people as an official third gender, thereby granting hijras legal status, protections, and rights (Khaleeli, 2014).

2.2.1.3 Historic Traumatic Assaults

Recent stigma scholarship has increasingly recognized the role of historical traumatic assaults on health inequities (Sotero, 2006). Historic traumatic assaults include historical examples of extreme discrimination, typically at the structural level, toward LGBTQ people. The spread of criminalization of same-sex sexual practices under British colonialism represents a key example of historic traumatic assaults that has had a pronounced and lasting legacy (Han et al., 2014). Starting in 1860, the British Empire spread legal codes to its colonies that criminalized same-sex sexual practices with punishments including fines and lengthy imprisonment. For example, Section 377 of the British Penal Code criminalized “unnatural” sexual acts, including those between men (Carroll & Mendos, 2017). These codes were designed to prevent both British soldiers and colonial administrators from engaging in same-sex sexual practices as well as enforce heterosexual Christian values (Han et al., 2014). Today, former British colonies are more likely than others to have laws that criminalize same-sex sexual practices (Han et al., 2014). For example, countries including Bangladesh, Brunei, Malaysia, Myanmar, Pakistan, Singapore, and Tanzania continue to uphold Section 377. Some have commented on the “irony of African homophobia,” whereby countries that kept colonial laws have been constructed as “backward” by former colonizers such as Britain who has since changed those laws (Semugoma et al., 2012).

More recently, the Nazis persecuted LGBTQ populations as part of their efforts to morally and culturally purify Germany (Plant, 1986; United States Holocaust Memorial Museum, 2019). Between 1933 and 1945, an estimated 100,000 men were arrested for violating laws against homosexuality, 50,000 were sentenced to prison, and 5000 to 15,000 were sent to concentration camps. During this time period, the police raided the Institute for Sexual Science in Berlin and burned a collection of tens of thousands of books and pictures documenting LGBTQ culture. Other examples of historical trauma may be characterized as less violent in nature, but still impactful. In the United States, the Diagnostic and Statistical Manual of Mental Disorders pathologized homosexuality until 1973 (Drescher, 2015). This licensed psychologists and physicians to attempt to “cure” sexual minorities via a range of so-called “conversion therapies.” Although the impact of historic traumatic assaults on health inequities is understudied in comparison to other stigma manifestations, evidence suggests that awareness of these historic events and traumas leads to psychological distress and unhealthy behaviors (e.g., elevated substance use, perhaps as a coping mechanism) (Sotero, 2006).

2.2.1.4 Other Institutional and Organizational Policies

Structural stigma is further manifested within institutional and organizational policies, which exist outside of civil and religious laws. These include institutional policies that prohibit the changing of gender or sex and name on identification cards, legal documents, and medical records, thereby denying transgender individuals’ affirmation of their gender identity. There are also policies that prohibit same-sex couples from adopting children, thereby denying gay and lesbian couples rights to parenthood. This structural stigma may additionally affect the health of LGBTQ individuals who live in, work for, or receive healthcare from these institutions and organizations.

2.2.2 Individual Level

At the individual level, stigma is manifested both among people who do not identify as LGBTQ as well as people who do identify as (or are perceived by others to be) LGBTQ. People who do not identify as LGBTQ may be referred to as “perceivers” or “perpetrators” (Bos et al., 2013) These may include members of the general public, healthcare workers, the police, religious leaders, friends and family members, employers and coworkers, and others. Stigma is further manifested among LGBTQ individuals who may be referred to as “targets” of stigma (Bos et al., 2013).

2.2.2.1 Perceivers

Stigma among perceivers is manifested as perceived stigma, prejudice, stereotypes, and discrimination. Perceived stigma involves the awareness of and perception that people with minority sexual orientations and gender expressions/identities are socially devalued and discredited (Herek, 2007; Stangl et al., 2019). Prejudice involves negative emotions and feelings that people feel toward LGBTQ individuals, such as discomfort and disgust (Herek, 2007; Stangl et al., 2019). Stereotypes are thoughts and beliefs that people hold about LGBTQ individuals, such as gay men being effeminate or lesbian women being masculine (Herek, 2007; Stangl et al., 2019). Discrimination includes unfair or unjust treatment of LGBTQ individuals (Herek, 2007; Stangl et al., 2019). As previously noted, discrimination may range from subtle treatment, such as social rejection, to more extreme treatment, such as physical violence. Evidence suggests that prejudice, stereotyping, and discrimination may be explicit, wherein perceivers are aware of their own bias toward LGBTQ individuals, or implicit, wherein perceivers are unaware of their own bias toward LGBTQ individuals (Dovidio et al., 2008; Dovidio & Gaertner, 2004).

There is a great deal of variability in these individual-level stigma manifestations globally. In 2016, the International Lesbian, Gay, Bisexual and Trans and Intersex Association and RIWI (Real-Time Interactive World-Wide Intelligence) Corp surveyed 96,331 people in 54 countries about their attitudes toward LGBTI (lesbian, gay, bisexual, transgender, and intersex) people (Carroll & Robotham, 2016). Responses to several survey items, including indicators of prejudice and discrimination, are displayed in Fig. 2.1. Results generally suggest the most negative attitudes toward LGBTI people among respondents in Africa, followed by Asia, the Americas, and Europe, and the most positive attitudes in Oceania.

Fig. 2.1

Regional differences in attitudes toward LGBTI people. (Data are from the 2016 ILGA/RIWI Global Attitudes Survey on LGBTI People (Carroll & Robotham, 2016))

Stigma theory suggests that individual-level stigma manifestations are shaped, in part, by sociocultural context. A 2009 study including data from individuals in 19 countries found that 29% of the variance in individuals’ attitudes toward LGB people was shaped by their country context (i.e., between-nation variance), with the remainder shaped by individual beliefs and characteristics (i.e., within-nation variance, including sociodemographics and religious affiliation) (Adamczyk & Pitt, 2009). This study additionally found that individuals living in Muslim-majority countries have more disapproving attitudes toward LGB people than individuals living in Catholic- and Protestant-majority countries, regardless of their personal religious affiliation. Finally, individuals living in nations characterized by survivalist orientations, which often arise from political and economic uncertainty and insecurity, had more disapproving attitudes toward LGB people.

2.2.2.2 Targets

Similar to perceivers of stigma, targets may experience perceived stigma. That is, they may be aware of LGBTQ stigma and perceive that people with minority sexual orientations and gender expressions/identities are socially devalued and discredited (Herek, 2007; Logie et al., 2016, 2018b, c; Stangl et al., 2019). Targets of stigma may additionally experience several unique stigma mechanisms, including internalized stigma, enacted stigma, and anticipated stigma. Internalized stigma has also been called internalized homophobia and self-stigma, and refers to the degree to which LGBTQ individuals are aware of the negative beliefs and feelings about LGBTQ individuals and apply them to the self (Herek, 2007; Stangl et al., 2019). According to minority stress theory (Meyer, 1995), LGBTQ people are aware of these negative beliefs and feelings early in life, even before they begin to develop their own sexual and gender identities. As LGBTQ individuals begin to become aware of their sexual and gender identities, they may also begin to apply these negative beliefs and feelings to the self. On average, internalized stigma is theorized to be highest during the early stages of LGBTQ identity development and then decreases over time (Meyer, 1995). Internalized stigma may be shaped, in part, by sociocultural context. For example, LGBTQ individuals with strong Christian religious and spiritual affiliations describe intense feelings of shame, fear, and guilt during adolescence that led to psychological distress (Kubicek et al., 2009). With time, some LGBTQ individuals report beginning to more critically evaluate religious messages and develop stronger coping mechanisms, ultimately leading to decreased internalized stigma. This critical reflection and reframing of religious values and cultural identities can also be done in solidarity and conversation with other LGBTQ persons, as observed in Swaziland, Lesotho, and Jamaica (Logie et al., 2016, 2018c). For instance, participatory theater has been used to represent stories of stigma experienced by LGBTQ individuals in Swaziland and Lesotho (Logie et al,. 2019a). Audience members are called upon to identify stigmatizing experiences portrayed within a skit and develop solutions, which promotes self-reflection, empathy, and solidarity.

Enacted stigma, which has also been called the experienced stigma, involves perceptions of experiences of discrimination from others in the past or future (Herek, 2007; Stangl et al., 2019). LGBTQ individuals report a wide range of experiences of enacted stigma in a variety of social contexts (e.g., familial, employment, housing, and medical care) globally (Logie et al., 2018a). The Human Rights Campaign and Human Rights Watch have documented often extreme forms of physical and sexual violence toward LGBTQ individuals globally, including those described in the introduction to this chapter. In addition to its acute and blatant forms, enacted stigma may also be chronic and subtle. Recent scholars have developed a taxonomy of subtle forms of enacted stigma, sometimes referred to as microaggressions (Nadal et al., 2016). According to Nadal and colleagues, prominent forms of microaggressions that impact LGBTQ people include exposure to heterosexist or transphobic terminology (e.g., “that’s so gay”), being fetishized, encountering denial of LGBTQ stigma, and being expected to hide one’s sexual orientation and/or gender identity or expression. Additional forms of subtle, yet pernicious, enacted stigma experienced by transgender individuals may include dead-naming (i.e., using the birth name of someone who has since changed their name) or misgendering (i.e., referring to someone with a pronoun or word that does not reflect their gender identity).

Anticipated stigma involves expecting to experience discrimination from others in the future (Stangl et al., 2019). Given that minority sexual orientation and gender expression/identity are often concealable, LGBTQ individuals may worry about how others will respond to them if and when they learn of their LGBTQ identity. This may include fear or worry of social rejection, physical or sexual violence, or other consequences if others learn of one’s LGBTQ identity. Importantly, individuals do not have to personally experience enacted stigma to anticipate stigma. They may anticipate stigma based on perceiving stigma in their environment or becoming aware of other LGBTQ people experiencing enacted stigma. This can result in persons hiding and concealing their sexual and/or gender identities, which in turn can contribute to isolation and depression.

2.3 Processes Linking LGBTQ Stigma with Health

Stigma undermines a wide range of health outcomes among LGBTQ individuals, including those focused on within other chapters of this book. Several key mediating mechanisms linking stigma with health have been identified, including social isolation; access to resources; and psychological, behavioral, and biological responses (Chaudoir et al., 2013; Hatzenbuehler et al., 2013). Each of these mediating mechanisms represents pathways through which stigma affects health outcomes.

2.3.1 Social Isolation

Stigma leads to social isolation, which undermines health. LGBTQ people throughout the world experience rejection from family members. This rejection may be particularly harmful within cultures wherein social relationships are interdependent (as in many Global South societies), in part, because individuals’ perceptions of themselves are more strongly influenced by their relationships with their family members (i.e., interdependent self-construal) (Chow & Cheng, 2010; Markus & Kitayama, 1991). Therefore, rejection from family members may result in more internalized stigma. Among lesbian women in Hong Kong, for example, lower perceived social support from family was shown to be associated with greater shame and less outness to friends, which may lead to greater social isolation and less social support (Chow & Cheng, 2010). Social support, including comfort, information, and/or assistance from others, is a powerful predictor of positive health outcomes; social isolation prevents individuals from drawing on this health-promoting resource.

Social rejection and isolation often begin at an early age (Ryan et al., 2009) and may be experienced throughout the lifespan. LGBTQ youth experience elevated rates of bullying from peers in school, which is often characterized by social distancing and rejection, and is associated with an increased risk of suicidal ideation, attempts, and completion (Earnshaw et al., 2017). Social isolation continues into middle and older adulthood. In Thailand, relationships between young transmasculine “toms” and young cisgender women are viewed as protecting cisgender women from engaging in “real sexual” relationships with cisgender men before marriage (Sinnott, 2004). Yet, these partnerships to preserve cisgender women’s virginity are often only temporary: Once cisgender women are ready to enter into heteronormative marriages, they end their relationships with their transmasculine partners (Sinnott, 2004). This results in a multitude of middle-aged and older transmasculine tom adults who are stigmatized for being LGBTQ and single. Research in Jamaica additionally describes the role that stigma plays in preventing close, intimate, and lasting same-sex relationships, once again increasing the likelihood of persons not being able to benefit emotionally and financially from long-term relationships, if they chose (Logie et al., 2018a). In Brazil, social rejection from family members leads some transgender women of color to become overly dependent on support from romantic partners, some of whom take advantage of them (Kulick, 1998). Moreover, although LGBTQ older adults are more likely to receive caregiver support from friends, they are less likely to receive support from family members as older adults (Croghan et al., 2014).

2.3.2 Access to Resources

Stigma constrains access to resources that promote health in a wide range of contexts. For example, Badgett documented the exclusion of LGBTQ individuals from education and employment settings in India (Badgett, 2014). Educational opportunities may be denied to LGBTQ Indians, and LGBTQ Indians may leave educational settings due to enacted stigma from fellow classmates and teachers. This results in lower rates of literacy and educational achievement among LGBTQ Indians, including transgender individuals and men who have sex with men. LGBTQ Indians report being denied workplace opportunities, harassed by co-workers, and overhearing anti-gay comments at work. Badgett concludes that stigma in education and employment settings plays a role in elevated rates of poverty observed among LGBTQ Indians, which in turn affects health. Badgett further identifies LGBTQ stigma as leading to homelessness among LGBTQ Indians, who report having difficulty obtaining housing. Poverty and housing insecurity are powerful determinants of health.

Stigma additionally creates roadblocks to accessing healthcare. As documented earlier in this chapter, transgender individuals have difficulty accessing gender-affirming medications, surgeries, and treatment in many areas of the world, often due to structural stigma. At the individual level, research suggests that stigma endorsed by healthcare providers is associated with the provision of worse care to stigmatized individuals (Dovidio et al., 2008). For example, our previous work has documented substantial prejudice toward men who have sex with men among medical students in Malaysia (Jin et al., 2014), which is related to intentions to discriminate against this group within healthcare settings (Earnshaw et al., 2016b). We have found similar dynamics among medical doctors in Malaysia, who endorse prejudice toward and intend to discriminate against transgender patients (Vijay et al., 2018). Additional work suggests that providers who endorse greater LGBTQ stigma are less likely to prescribe pre-exposure prophylaxis (PrEP; i.e., an HIV prevention mediation) to men who have sex with men (Calabrese et al., 2017).

Moreover, LGBTQ individuals may avoid healthcare settings and delay needed care because they have experienced or expect to experience stigma from healthcare providers. In Jamaica, misgendering and judgment from nurses present barriers for LGBTQ persons accessing HIV testing (Logie et al., 2018a). Moreover, stigma regarding same-sex practices among men presents barriers for gay and bisexual men purchasing condoms and lubricants, and many order lubricants online from the United States to reduce experiences of stigma and discrimination when accessing these sexual health resources (Logie et al., 2018a). In Swaziland, lesbians also experience stigma and judgment from healthcare providers, including “virginity” tests where healthcare providers examine the hymen to assess if women have had penetrative sex (Logie et al., 2018c). This suggests the role that compulsory heterosexuality (not believing persons who state they are lesbian/gay) plays in shaping LGBTQ persons’ healthcare experiences.

2.3.3 Biological, Psychological, and Behavioral Responses

Stigma is additionally associated with a range of biological, psychological, and behavioral responses that have implications for health. Stress is highlighted as a central mechanism through which stigma gets “under the skin” and leads to LGBTQ health inequities (Hatzenbuehler et al., 2009; Meyer, 1995, 2010). Stigma results in physical stress and psychological stress, or perceptions that demands in the environment exceed one’s capacity (Cohen et al., 2007). Acute experiences of stress have an immediate impact on the body, including activation of the sympathetic nervous system, which leads to increases in blood pressure and heart rate, and hypothalamic-pituitary-adrenal axis, which leads to the production of corticosteroids including cortisol (Taylor & Stanton, 2007). Chronic experiences of stress, which include threats that last over long periods of time, effect the regulation of immune and inflammatory processes that may, over time, lead to a range of diseases including coronary artery disease, autoimmune disorders, cancer, and many others (see Chaps. 4 and 5) (Baum, 1990; Cohen et al., 2012, 2007). Importantly, LGBTQ individuals may experience stigma in both acute ways, such as an episode of enacted stigma involving physical violence, and chronic ways, such as anticipated stigma involving constant worry over treatment from others, all of which may undermine health. Stress additionally leads to problems with emotional regulation and cognitive processing, which increase risks for mental illness, including depression and anxiety (see Chap. 3) (Hatzenbuehler, 2009). Individuals may cope with stress resulting from stigma with health-compromising behaviors. For example, LGBTQ individuals who experience greater stigma may also engage in greater substance use and sexual practices that put them at risk for sexually transmitted infections (e.g., sex without a condom, transactional sex) (Diaz et al., 2004; Hatzenbuehler, 2009). In this way, LGBTQ stigma may play a role in HIV/STI disparities experienced by men who have sex with men and transgender women globally.

2.4 Interventions to Address LGBTQ Stigma

It is critical to develop and implement efficacious interventions that address stigma to improve the health of LGBTQ people globally. Recent theorists have emphasized that stigma interventions must be multilevel to be efficacious, spanning both structural and individual levels (Cook et al., 2014; Rao et al., 2019). Below, we summarize intervention strategies to change structural stigma, reduce stigma among perceivers, and enhance resilience to stigma among targets, many of which have been implemented globally. Cook et al. (2014) emphasize that the effects of stigma-reduction interventions are often bidirectional and reinforcing both within and between social-ecological levels. For example, an intervention to reduce stigma among perceivers may ultimately lead to structural change, which may in turn reduce stigma among targets.

2.4.1 Structural Change

At the structural level, stigma interventions include legal and policy changes, as well as education and social norm campaigns to reduce social stigma. Legal and policy changes can target repealing stigmatizing civil and religious laws, including those reviewed within this chapter, as well as enacting protections for LGBTQ people. These legal and policy changes are slowly happening throughout the world. For example, the Supreme Court of India struck down Section 377, a remnant of the British Penal Code that criminalized same-sex sexual practices, in 2018 on the basis that it violated the Constitution’s recognition that all persons are equal before the law (Narrain, 2018). The ruling followed close to a decade of court cases that both challenged (e.g., Naz Foundation vs. NCT Delhi in 2009) and upheld (e.g., Kumar Koushal vs. Naz Foundation in 2013) the constitutionality of Section 377. These cases coincided with a social movement characterized by greater visibility and acceptance of LGBTQ people (e.g., as evidenced by the release of movies with LGBTQ characters and public discourse surrounding sexuality). In his judgment, Justice Chandrachud wrote, “It is difficult to right the wrongs of history. But we can certainly set the course for the future. That we can do by saying, as I propose to say in this case, that lesbians, gays, bisexuals, and transgenders have a constitutional right to equal citizenship in all its manifestations” (p. 15) (Narrain, 2018).

The Universal Periodic Review, conducted by the United Nations, has been identified as a key mechanism for advocating for legal and policy changes (Itaborahy & Zhu, 2014). It begins with an analysis of each country’s human rights situation by other United Nations countries. The other countries then make recommendations that the state under review may either accept or reject. Itaborahy and Zhu observed that highly targeted recommendations (e.g., police education and protections against violence) were more likely to be accepted than generalist recommendations to end criminalization of or discrimination toward LGBTQ people (Itaborahy & Zhu, 2014). Social media has additionally become an important platform for LGBTQ activism for legal and policy change. For example, Southern African LGBTQ organizations use digital strategies to raise global awareness of human rights violations, share information with LGBTQ individuals globally, and mobilize for activism (Mutsvairo, 2016).

In addition to decriminalizing LGBTQ identities, sexual practices, and expressions, laws enacted to protect the rights of LGBTQ people can reduce stigma. As of 2017, 9 countries prohibit discrimination based on sexual orientation within their constitution, 72 prohibit discrimination in employment, and 43 criminalize acts of violence based on sexual orientation and/or gender identity (Carroll & Mendos, 2017). Moreover, 26 countries recognize joint adoption by same-sex couples, and 22 legally recognize marriage for same-sex couples. Evidence suggests that structural change can trickle down, benefiting the well-being of LGBTQ individuals. For example, sexual minority men living in the state of Massachusetts in the United States had a decrease in mental health and medical care visits after same-sex marriage was legalized in their state in 2003, indicating improved mental and physical health among this population following the enactment of this law (Hatzenbuehler et al., 2012).

2.4.2 Stigma Reduction Among Perceivers

Reducing LGBTQ stigma among people who do not identify as such is key to ensuring that LGBTQ individuals are not exposed to negative treatment from others. Popular intervention strategies for reducing stigma among perceivers include enhancing education and providing opportunities for interpersonal contact (Cook et al., 2014). Education involves building knowledge via courses, texts, online platforms, and other venues and can help to challenge stereotypes that perceivers may hold about LGBTQ people. Evidence from Europe, North and South America, Asia, and Australia suggests that educational interventions can reduce stigma, but may not eliminate stigma on their own (Cook et al., 2014). In Senegal, wherein same-sex practices are criminalized (Carroll & Mendos, 2017), education strategies have been implemented in conjunction with other stigma-reduction strategies to address stigma among healthcare providers (Lyons et al., 2017). Interpersonal contact, involving interaction between LGBTQ and non-LGBTQ individuals, is another popular stigma reduction intervention strategy. Research from North and Latin America, Europe, Israel, Australia, New Zealand, Africa, and Asia suggests that intergroup contact reduces prejudice by enhancing knowledge about LGBTQ people, lowering anxiety surrounding interactions with LGBTQ people, and increasing empathy toward and perspective taking with LGBTQ people (Pettigrew & Tropp, 2006, 2008). For instance, as previously discussed, a participatory theater intervention in Swaziland and Lesotho has been used to change attitudes toward LGBTQ persons (Logie et al., 2019). Findings suggest that creative strategies that engage persons in developing solutions to stigma, including healthcare providers, can increase understanding and awareness of LGBTQ stigma and its harmful impacts, can build empathy, and foster self-reflection. Such approaches should be contextually tailored and provide examples of stigma that are grounded in the lived experiences of LGBTQ persons. Importantly, the evidence indicates that contact must occur under a set of “optimal conditions,” including equal status between LGBTQ and non-LGBTQ people, common goals, intergroup cooperation, and support of authorities (Pettigrew & Tropp, 2006).

It may be important to prioritize intervention efforts targeting individuals from whom stigma is particularly detrimental to LGBTQ people. For example, childhood and adolescence are sensitive periods during which individuals may be particularly vulnerable to the negative health effects of LGBTQ bullying (Earnshaw et al., 2016a, 2017). Therefore, it may be particularly important to implement interventions to reduce LGBTQ stigma within school settings starting at young ages. The results of a recent systematic review demonstrated that interventions to address LGBTQ bullying are increasing overall but remain limited to North America, Europe, and Oceania (Earnshaw et al., 2018). Stigma from family members can lead to social rejection, which in turn leads to social isolation. The Family Acceptance Project, which was developed in the United States and is now being implemented internationally, aims to increase the acceptance of LGBTQ youth by family members (Katz-Wise et al., 2017; Ryan, 2010). Moreover, stigma endorsed by medical doctors can lead to poor provision of medical care to stigmatized individuals (Dovidio et al., 2008). In addition to enhancing education and providing opportunities for interpersonal contact, evidence suggests that interventions aiming to build clinical skills for working with stigmatized populations can reduce stigma (Stangl et al., 2013). This may involve teaching medical students and doctors about stigma-free language, how to take medical and sexual histories of LGBTQ patients, and how to deliver gender-affirming medical care to transgender individuals.

2.4.3 Enhancing Resilience Among Targets

History indicates that eliminating any kind of stigma, including LGBTQ stigma, at the structural level and among perceivers will take time. While stakeholders develop, test, and implement intervention strategies to eliminate LGBTQ stigma at these levels, it is important to enhance resilience among LGBTQ people to attenuate the effect of stigma on health. Minority stress theory emphasizes the importance of enhancing resilience to buffer LGBTQ individuals from the effects of enacted and anticipated stigma and/or reduce internalized stigma among LGBTQ individuals (Meyer, 1995, 2010). In this section we discuss participatory theater approaches, interventions that enhance coping, and interventions that enhance mindfulness.

Participatory theater approaches aim to enhance resilience to stigma among targets, reduce stigma among perceivers, and disrupt stigma within communities. Such multilevel stigma reduction interventions are recommended to create more impactful change than single-level interventions (Rao et al., 2019). Participatory theater approaches originate in Theatre of the Oppressed, which is a pedagogical tool developed in Brazil by Augusto Boal and inspired by Paulo Freire’s Pedagogy of the Oppressed (Boal, 1974). Theatre of the Oppressed is designed to promote empowerment among targets of stigma, critical consciousness among targets and perceivers of stigma, and social transformation within communities. Participatory theater approaches have been shown to build self-acceptance and feelings of solidarity among trans women of color in Canada (Logie et al., 2019b) and reduce LGBTQ stigma among healthcare providers, educators, students, and community members in Swaziland, Lesotho, Canada, and the United States (Logie et al., 2019a; Tarasoff et al., 2014; Wernick et al., 2013). Thus, participatory theater approaches represent a multilevel and multifaceted stigma-reduction tool that originated in the Global South and has been applied in the Global North.

Interventions to enhance coping among targets aim to strengthen psychosocial resources and strategies to mitigate the impact of enacted and anticipated stigma on stress responses, ultimately buffering individuals from the effect of stigma on health (Chaudoir et al., 2017). A recent systematic review of the intervention “toolkit” to address sexual minority stress identified 12 interventions to bolster skills to cope with stigma, most of which were developed in the United States (Chaudoir et al., 2017). Examples of effective intervention strategies included cognitive behavioral therapy to reduce depression and help individuals identify adaptive coping responses to stigma, expressive writing to bolster cognitive and emotional processing of enacted stigma, and attachment-based family therapy to help adolescents process stigma originating within family relationships. Interventions addressing intersectional stigma experienced by LGBTQ individuals are also being tested. The results of Still Climbin, a group-based intervention among HIV-positive Black sexual minority men in the United States, improved functional coping, humor-based coping, and cognitive/emotional debriefing in response to enacted stigma (Bogart et al., 2018). Peer-based support approaches have been used to address HIV and LGBTQ stigma among men who have sex with men in Senegal (Lyons et al., 2017). These approaches were based on previous interventions developed in Senegal, Kenya, Vietnam, and Thailand.

Interventions to enhance mindfulness have shown some success in addressing internalized stigma. Rather than attempting to reduce stigmatizing thoughts and feelings directly, these interventions focus on the relationships between thoughts, feelings, and behaviors (Luoma et al., 2008). For example, in acceptance and commitment therapy, individuals are taught to observe their thoughts and fully feel their emotions, including those reflecting internalized stigma, and then enact actions that will take them in valued directions, such as self-love and acceptance (Luoma et al., 2008; Skinta et al., 2015). Acceptance and commitment therapy has been leveraged to reduce internalized stigma among people with a range of stigmatized identities and characteristics, including LGBTQ individuals (Luoma et al., 2008; Mittal et al., 2012; Skinta et al., 2015; Yadavaia & Hayes, 2012). Other strategies to address the internalized stigma that have been implemented in the Global South and North include psychotherapy, psychoeducation, and community participation (Ma et al., 2019). For example, one study conducted in Thailand increased interactions between members of stigmatized groups, their families, and community members via educational, volunteer, and community events (Apinudecha et al., 2007).

2.5 Conclusion

Stigma is experienced by LGBTQ people worldwide and acts as a powerful and pernicious determinant of global LGBTQ health inequities. As the field moves toward addressing stigma to achieve LGBTQ health equity, it is worth bearing in mind that stigma is neither fixed nor insurmountable. Rather, it is malleable and intervenable: it has changed and will continue to change with time. Signs of change are visible everywhere. Laws that protect the civil rights of LGBTQ people are becoming more numerous. In 2017, there were 63 countries with laws designed to protect LGBTQ from various forms of discrimination (e.g., bans on blood donation, protection against bullying), 22 countries that recognized same-sex marriage, and 26 countries that recognized the rights of same-sex parents to adopt children (Carroll & Mendos, 2017). Pride, a movement that celebrates LGBTQ people, commemorates past historic traumatic assaults and civil rights victories (i.e., 1969 Stonewall police raid and riots), and protests ongoing civil rights inequities, gains momentum every year as it spreads to new cities around the world and more people attend. As this change in stigma slowly occurs, LGBTQ people are building community, and providing and receiving support, to build resilience and protect LGBTQ individuals from the effects of stigma. The Trevor Project, which provides crisis intervention and suicide prevention services in the United States, represents an example of the response from the LGBTQ community to address suicidality among LGBTQ youth (The Trevor Project, 2019). Public health researchers, practitioners, policymakers, and other stakeholders have key roles to play in supporting these efforts and advocating for continued change in LGBTQ stigma worldwide.

Lebanon map showing major population centers as well as parts of surrounding countries and the Mediterranean Sea. (Source: Central Intelligence Agency, 2021)

2.6 Case Study: Tackling LGBTQ Stigma in Lebanon

LGBTQ visibility and activism in Lebanon have been steadily increasing over the past few decades. Multiple, diverse LGBTQ organizations have formed, the local LGBTQ community has mobilized to advocate against police violence and criminalization of same-sex sexual practices, and Beirut has become one of the most socially progressive cities in the region, holding its first LGBTQ Pride event in 2017 (OutRight, 2018; McCormick, 2011; Healy, 2009).

Despite this progress, LGBTQ people face pervasive stigma at multiple socioecological levels, including the interpersonal, community/institutional, and structural levels (Wagner et al., 2013; Nasr & Zeidan, 2015). Many Lebanese citizens remain opposed to the acceptance of LGBTQ people into society, viewing LGBTQ people as psychologically or medically defective and as a threat to traditional heteropatriarchal values. Harassment and discrimination against LGBTQ individuals are common, even in healthcare facilities (OutRight, 2018). Pride 2018 was canceled after the organizer was arrested and threatened with criminal prosecution for promoting debauchery (Homsi, 2018). A law passed in 1942 criminalizing same-sex sexual practices continues to be implemented to arrest LGBTQ people, and such arrests have steadily increased in recent years (OutRight, 2018; Tohme et al., 2016).

Prior research across the globe has consistently demonstrated that social and structural stigma impacts the sexual health of sexual and gender minorities (Fitzgerald-Husek et al., 2017; Hatzenbuehler, 2016; Link & Hatzenbuehler, 2016). Stigma has been linked to high-risk sexual behaviors and low uptake of sexual healthcare services (Fitzgerald-Husek et al., 2017). Although, in general, research on LGBTQ populations in Lebanon is limited, a similar link has been demonstrated with cisgender sexual minority men in Beirut, with social and structural stigma being related to condomless anal intercourse with partners of unknown HIV status (Wagner et al., 2015). This occurs in a population where HIV is likely concentrated, where condomless anal intercourse is already common, and where HIV-related knowledge and perceived risk for HIV acquisition are low (Mumtaz et al., 2011, 2019; Wagner et al., 2014; Mahfoud et al., 2010).

The stigma experienced by LGBTQ people in Lebanon has ties to the country’s history, culture, and religious environment. The structural stigma seen in the Lebanese penal code stems from a 1942 law ratified under French colonial rule (OutRight, 2018). In addition, Lebanon has a history of sectarian conflict, and over 90% of the population identifies as Muslim or Christian (Haddad, 2002). A legacy of colonialism and sectarian conflict, the ongoing use of colonial law to arrest LGBTQ people, and the social values and practices of dominant religious institutions have no doubt played, and continue to play, a role in shaping sociocultural conditions, attitudes, and norms with regard to sexuality and gender, essentially underpinning the stigmatization of LGBTQ people.

Several local LGBTQ organizations have been integral in addressing much of this stigma and its associated sequelae. Three organizations of note are Helem, the Lebanese Medical Association for Sexual Health, (LebMASH), and Marsa Sexual Health Center, all of which are located in Beirut. The work of these three organizations provides a blueprint for multilevel stigma mitigation interventions in Lebanon that tackle both the source and effects of stigma. Helem intervenes at the policy level, targeting one of the primary drivers of stigma, and also at the community level, providing safe spaces for LGBTQ people to gather. Marsa and LebMASH both intervene across the community and institutional levels. Marsa provides stigma-free sexual healthcare services to LGBTQ people, while LebMASH engages in LGBTQ-related scholarship and education.

Since its formulation, Helem, a non-profit organization, has devoted its efforts to addressing structural issues that target LGBTQ people, particularly the law criminalizing same-sex sexual practices. Helem has spent years advocating for decriminalizing same-sex sexual behavior, and a series of court rulings over the past 10 years indicate movement toward that end. The first came in 2009, when a judge refused to apply the law to two cisgender men, reasoning that the law criminalizing same-sex behavior was no longer consistent with social change. Five years later, a judge refused to apply the law in a case involving a transgender woman and a cisgender man, reasoning that the individual’s gender identity should be accepted, rendering the application of the law null and void. In 2017, a judge again refused to apply the law, reasoning that sexual minorities have a right to the same intimate relationships as everyone else, which was later upheld on appeal. Relatedly, Helem has used targeted media campaigns to advocate for a ban on forced anal examinations, which were commonly employed to prove one’s homosexuality; in 2012, the Minister of Justice called for an end to the practice. Aside from policy advocacy, Helem also provides a safe physical space for LGBTQ people to gather and holds various events for local LGBTQ people, helping to foster a much-needed sense of community (OutRight, 2018; Mutchler et al., 2018).

LebMASH, a nonprofit, nongovernmental organization, is comprised of healthcare professionals and strives to achieve health equity for sexual and gender minorities. In 2013, LebMASH collaborated with the Lebanese Psychological Association and the Lebanese Psychiatric Society to issue public statements that homosexuality is not a mental illness and that it is not amenable to conversion therapy. LebMASH created a video series to debunk myths regarding homosexuality and holds an annual medical conference entitled National LGBT Health Week to share research and encourage scholarship in the field of LGBTQ sexual health (OutRight, 2018; LebMASH, 2017; Abdessamad & Fattal, 2014).

Marsa Sexual Health Center is a nongovernmental organization that provides confidential, anonymous sexual healthcare services to sexual and gender minorities, as well as other vulnerable, marginalized groups. Their services include free HIV testing and counseling and several subsidized services, including testing for sexually transmitted infections and psychosocial counseling, among others. Marsa explicitly markets its facility as a stigma- and discrimination-free space. Marsa has also developed LGBTQ sexual health education materials for universities and for the general public, as well as general educational materials, to increase the public’s understanding of gender minorities (Marsa, 2019; OutRight, 2018).

Sustained by such organizations, LGBTQ people in Lebanon and their allies remain steadfast in their commitment to topple homophobia and bring about a society free of stigma, where social progress and equality flourish (Harb, 2019).