The Association between Perceived Discrimination and Suicide among Homosexuals: The Role of Self-Esteem as Mediator

Because of Malaysia’s conservative society, its homosexual citizens are often marginalized and discriminated. Past studies have shown a significant difference in psychological well-being between homosexuals and their heterosexual counterparts, which is attributed to differences in social treatment. Existing studies have discussed the underlying process of the relation between perceived discrimination and suicidal ideation among homosexuals globally. Therefore, this study aimed to investigate the relation between perceived discrimination and suicidal thoughts among homosexuals in Malaysia through the mediating effect of self-esteem. Research subjects were composed of 400 self-identified homosexuals who participated in an online survey. The Suicidal Ideation Attributes Scale, Modified Acculturative Stress Scale, and Rosenberg Self-Esteem Scale were used to measure the variables under investigation. Results indicated a negative significant correlation between the perceived discrimination–self-esteem link and between the self-esteem– suicidal ideation link among homosexuals. Positive relations were found between perceived discrimination and suicidal ideation. Moreover, a significant mediating effect of self-esteem was found in the link between perceived discrimination and suicidal ideation, which showed that high perceived discrimination and low self-esteem are risk factors for suicidal thoughts. Hence, besides promoting psychological betterment among homosexuals, self-empowerment seems critical and necessary to reduce suicidal ideation risk among homosexuals. Hubungan antara Persepsi Diskriminasi dan Bunuh Diri pada Homoseksual: Peran Self Esteem sebagai Mediator


Introduction
According to the Pew Research Center (2013), intolerance of homosexuality has been persistent in Malaysia for years. In Malaysian society, homosexual acts are punishable offenses under the civil, criminal, and Islamic laws. The penal code criminalizes "unnatural offences" deemed to be "against the order of nature," which includes homosexual practices (Penal Code, 1989). At the moment, no antidiscrimination law has been created that can protect the rights of LGBT citizens in Malaysia; thus, this minority group is often the target of discrimination.
Moreover, prolonged exposure to public pressure and stress has placed homosexuals in a poorer state of psychological well-being such as lower self-esteem, and has caused them to suffer more mental health problems, including suicide (Blosnich, Nasuti, Mays, & Cochran, 2016;Graybill & Proctor, 2016). Not surprisingly, homosexuals tend to have lower self-esteem than their heterosexual counterparts (Pachankis & Goldfried, 2006), whereas other studies have revealed that low self-esteem drives maladaptive coping strategies which can explain homosexuals' suicidality (Purvis, 2017;Wike, 2014). Sexual minorities are at risk for higher prevalence of suicide; as noted by Heeringan and Vincke (2000), these individuals have a twofold increase in the risk of suicidal ideation because of their sexual orientation. Therefore, it is important to examine the bottom line of their psychological distress.
With respect to discrimination, Meyer (2003) and Subhrajit (2014) revealed that homosexuals, as a highly stigmatized group, are often exposed to discriminatory circumstances. Schmitt, Branscombe, Postmes, and Garcia (2014) also pointed to discrimination as the bottom line for the harmful effects on the psychological well-being of homosexuals. This is further supported by different studies describing discrimination as a burden of suicidality among homo-sexuals (Kohlbrenner, Deuba, Karki, & Marrone, 2016;Matarazzo et al., 2014). Among all countries, the United States has the most advanced and well-developed LGBT rights-related laws; however, in a survey by the Pew Research Center (2013), LGBTs in the United States still perceived a higher level of discrimination in their daily lives, such as being subjected to slurs or jokes and being treated unfairly by their employers. This is consistent with a study showing that homosexuals experience both day-to-day and lifetime discrimination more often than their nonhomosexual counterparts (Mays & Cochran, 2001). As inferred by other studies, Malaysians are prone to discriminate LGBT groups more, as 86% of the population does not accept homosexuality (Pew Research Center, 2013). Gomez, Miranda, and Polanco (2011), who studied 969 adults with minority status, indicated that individuals who perceive discrimination are five times more likely to attempt suicide. This phenomenon is understandable, as homosexuals are more vulnerable to sexuality-related stress such as discrimination by a homophobic society (Purser, 2013), thus increasing the risk for depression and suicidal behaviors (Lehavot & Simoni, 2011;Math & Seshadri, 2013).
Furthermore, it is important to consider the mediating role of self-esteem in the link between perceived discrimination and suicide. Self-esteem is regarded as a remedy to different catastrophic psychological and social problems (Leary, 1999). Some findings have suggested that high self-esteem is critical to improving resilience against suicide (McLean, Maxwell, Platt, Harris, & Jepson, 2008;Skerrett, Kolves, & Leo, 2012). On the other hand, exposure to discrimination is closely associated with lower self-esteem (Graham et al., 2011;Pascoe & Richman, 2009) and doubles the risk of suicidal ideation (Huebner, Rebchook, & Kegeles, 2004). Discrimination poses a great threat to self-esteem (Chen & Tryon, 2012), resulting in negative self-perception, low self-worth, and, in severe cases, suicide (Heeringan & Vincke, 2000).
The relation between perceived discrimination, self-esteem, and suicidal ideation can be explained through the stress and coping model, minority stress theory, and lookingglass-self theory. The looking-glass-self theory posits that society plays a significant role in shaping an individual's self-concept (Dunn, 2007). That is, humans tend to shape their self-structure based on their understanding of how others perceive them. Thus, when one supposes that they are being negatively evaluated, as in discrimination, it will significantly affect their self-esteem, which could then lead to negative outcomes such as suicidal thoughts. Minority stress theory explains sexual minorities' health risk through the disparities between minority and dominant cultures. Stressors brought about by the dominant culture, such as discrimination, are greatly associated with indicators of poor mental health such as low self-esteem (Campbell & MacPhail, 2002), which increases risktaking behavior such as suicidal ideation (Michaels, Parent, & Torrey, 2016). Stress and coping theory refers to the two-way process of identifying stress, which includes the environment and one's self-appraisal (Krohne, 2002). Thus, when an individual perceives a discriminatory event as stressful, it is highly associated with developing lower self-esteem, in turn contributing to catastrophic events such as suicide.
Several studies have adopted self-esteem as a mediator in the general population (Cakar & Tagay, 2015;Kong & You, 2013;Restifo, Akse, Guzman, Benjamins, & Dick, 2009). Because of the uniqueness of the LGBT experience, results from the general population may not provide a good measure to reflect their self esteem. Furthermore, while a direct relation has been found between the variables and self-esteem, no research till date has looked into the indirect effects of self-esteem on the LGBT population. In addition, LGBT issues under Makara Hubs-Asia.
July 2018 Vol. 22  No. 1 this scope are not well-studied, leaving many questions unanswered and necessitating more research. Thus, this study intends to fill knowledge gaps on the mediating effect of self-esteem in the relation between perceived discrimination and suicidal ideation among LGBT individuals using a Malaysian sample.

Methods
Participants. A total of 400 self-identified homosexuals were recruited from Malaysia via an online survey questionnaire. There were 83.5% gay respondents with a mean age of 27.13 (standard deviation = 6.18). A majority of these respondents were Chinese (92%), followed by other ethnicities such as Melanaus and Sino-Kadazans (3.2%), Malays (2.5%), and Indians (2.3%). More than half (53.8%) of the respondents have admitted to their coming-out status.
Procedure. The respondents were recruited through the survey link posted on social media websites such as Facebook. They were allowed to complete the survey as per their own convenient time and place. Some were approached through private messages and have assisted in sharing the survey link to their friends who fulfilled the requirements for participation. The inclusion criteria for participation included Malaysians aged over 20 and who self-identify as homosexuals. Several filtering questions were embedded in the survey to ascertain the fitness for participation. Information such as the objective of the study, inclusion and exclusion criteria, respondents' rights, risk and benefit of participation, as well as privacy and confidentiality clauses were presented in the information sheet, followed by the informed consent of participants. The survey took approximately 30 minutes per participant to complete. The research procedure was reviewed and approved by the UTAR Scientific and Ethical Review Committee.
Measures. The Suicidal Ideation Attribute Scale (SIDAS; Spijker et al., 2014) was used to measure suicidal thoughts. This five-item scale evaluates the frequency of suicide attempts, level of distress, and the disturbance caused by suicidal thought in daily life. Respondents were required to respond using points ranging from 0 (never) to 10 (always) to indicate their suicidal thoughts over the past month. The total score was computed, with a high score corresponding to a high suicidal ideation. The Cronbach alpha in this study was 0.91.
The modified version of the Acculturative Stress Scale for International Students (Zakalik & Wei, 2006) was used to examine perceived discrimination. This eightitem scale is scored with a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The total score was then calculated, with a higher score indicating a higher perception of discrimination. The reliability for this scale was 0.88. The Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965) was used to assess the respondents' self-esteem. This scale comprises 10 items and is assessed on a fourpoint scale, ranging from 0 (strongly disagree) to 3 (strongly agree). The total score was computed by adding the scores for the 10 items. A higher score would signify higher self-esteem. The reliability for this scale was 0.86.
Data processing and analysis. The results of the study were analyzed using IBM SPSS statistical software version 21. The data was first tested for correlation between variables using Pearson's correlation. Next, Hayes's SPSS Marco Process (Hayes, 2013) model 4 was used to tabulate the result of mediational analysis. The significant value of all the statistical results was set at 0.05.

Correlation analyses among variables under study.
The results of the study revealed a negative relation between perceived discrimination and self-esteem, r(398) =−0., p < 0.001. A negative relation was also found between self-esteem and suicidal ideation, r(398) = −0.34, p < 0.001. In the opposite direction, perceived discrimination is positively correlated with suicidal ideation, r(398) = 0.24, p < 0.001.
The mediating effect of self-esteem in the relation between perceived discrimination and suicidal ideation. The indirect effect of perceived discrimination on suicidal ideation through self-esteem was conducted using SPSS Marco Process (Hayes, 2013). A total of 10,000 bootstrapping samples were generated, and 95% of confidence intervals (CI) were observed. A significant indirect effect was assumed when the CI does not intersect through zero. The result of the mediation analysis indicated that perceived discrimination was associated with self-esteem, B = −0.232, t = −5.

Discussion
The homosexual population is one that possesses a higher suicidal risk (Haas et al., 2011;Meyer, 2003), yet only a few studies have focused on the vulnerability of suicidal ideation and psychosocial factors among homosexuals, especially in Malaysia. The current study was intended to fill in the research gaps by investigating the possible factors explaining suicidal thoughts and examining the role of self-esteem in the relation between perceived discrimination and suicidal ideation.
Perceived discrimination of sexual minorities was found to be a common psychological threat to homosexuals in Malaysia. Results have indicated that homosexuals who perceived discrimination tend to experience higher suicidal ideation. This is consistent with previous findings, indicating alienation and interpersonal rejection due to one's sexual orientation as fuel to suicide vulnerability (Gomez et al., 2011;Hong, Espelage, & Kral, 2011;Matarazzo et al., 2014). The association between perceived discrimination and suicidal ideation may also be explained by the elevation of emotional distress, as these individuals have to deal with stressors related to a stigmatized identity, which is then linked to suicidal ideation (Rosario, Schrimshaw, & Hunter, 2005).
According to Harold, Marold, and Whitesell (1992), selfesteem is an individual's evaluation about his or her self. Such an assessment is shaped by the individual's appraisal of how significant others perceive them (Sullivan, 1953). Similar to previous literature findings, a negative relation was found between self-esteem and suicidal ideation. For instance, Proctor and Groze (1994) found that individuals who scored low on self-esteem have attempted suicide and have had suicidal thoughts. Individuals with low self-esteem have a damaged and negative selfconcept which make them more sensitive to failures and criticisms, leading to stronger feelings of hopelessness and loss of control and exposing them to the risk of suicidal ideation. Swann, Chang, and Larsen (2007) noted that one's uncertainty about his or her self-worth predisposed negative mood states. Such an uncertainty, along with a negative self-concept, makes an individual feel confused about their capabilities and selfconfidence, which, when persistent, causes catastrophic socioemotional outcomes such as suicidal tendencies (Manani & Shrama, 2013).
Previous studies have investigated the direct relation between self-esteem and perceived discrimination, but only a few have examined the indirect relation of selfesteem on perceived discrimination and suicidal ideation. The current study suggested a significant indirect role of self-esteem in the relation between perceived discrimination and suicidal ideation among homosexuals in Malaysia. Consistent with previous literature, perceived discrimination is negatively associated with self-esteem (Morrison, 2011;Schmitt et al., 2014). The mediating effect of self-esteem in the relation between perceived discrimination and suicidal ideation can be explained by recognizing the importance of the looking-glass self. Wike (2014) noted that self-esteem relates closely with identity development and self-concept, in which the importance of the looking-glass self has been highlighted. The looking-glass self is where one imagines how others regard and judge them, directly influencing their selffeelings.
According to this perspective, by perceiving discrimination, homosexuals tend to exhibit negative feelings (Crocker & Major, 1989), leading to confusion and denial of self-concept, which then significantly affects their self-esteem (Rogers, 1959). In other words, perceiving discrimination lowers an individual's selfesteem and in turn brings about more catastrophic socioemotional consequences such as suicidal thoughts. This statement is further supported by Baumeister (1990), who proposed that suicidal ideation stems from a strong desire to escape aversive self-awareness. This theory could explain the association between self-esteem and suicidal ideation in which low self-esteem contributes to negative self-attribution, which then provides a context for suicidal thoughts to emerge. Apart from that, the mediating effect can also be explained through the stress and coping model (Lazarus & Folkman, 1984). Lazarus (1993) suggested self-esteem as a facilitator between discriminatory events and stress. Lazarus and Folkman (1984) also identified stress as a two-way process: by the environment and through individual self-appraisal. For instance, when homosexuals appraised discriminatory events as stressful, they are more prone to damaging their self-image. Consequently, such an exposure may harm their self-esteem and predispose them to a higher risk of psychological distress. This is further backed by Cassidy, O'Connor, Howe, and Warden (2004), who found that during adverse events, low self-esteem leads to negative outcomes such as suicidal ideation.
Despite the findings of this study, several limitations are noteworthy. The instruments used mostly target the general population, which may not specifically reflect the conditions faced by homosexuals. Therefore, future studies should consider using measures which can more appropriately reflect the experiences of homosexuals. Also, this study was a cross-sectional study which cannot draw a causal relation between the psychosocial variables and suicidal ideation and which poses the possible risk of bias in interpreting the mediation result (Maxwell & Cole, 2007). Thus, the confirmation of the mediating effect of self-esteem was limited to the relation between perceived discrimination and suicidal ideation among homosexuals in Malaysia. Hence, future research should adopt a longitudinal research design to further validate the proposed mediation model of this study. Using online surveys also lacks concrete evidence in confirming the responses of target participants. Future studies may need to consider other methods such as intervieweradministered surveys or self-administered face-to-face surveys to confirm the identities of respondents.

Conclusion
The findings revealed that even though homosexuals experience discrimination, since they do not appraise such events as stressful, they are less likely to expose their self-esteem to threats affecting their self-image, thus reducing their risk of suicidal ideation. Although no previous studies have examined the role of self-esteem as a mediator in the relation between perceived discrimination and suicidal ideation, existing theories help researchers find out how self-esteem could facilitate the relation between perceived discrimination and suicidal ideation among LGBT individuals. Such support from different theories helps provide a clear and precise picture of the value of self-esteem in protecting minorities from psychologically distressful events and in reducing their risk of suicidal ideation.