Sexual stigma, minority stress and mental health among sexual minority women and men across Asia and the Pacific Restricted; Files Only

Abstract

Sexual minority groups across the Asia-Pacific region experience disparities in health compared to the general population. These disparities are, in part, a result of acute and chronic exposure to sexual stigma. Theories of sexual stigma describe how stigma due to one’s non-heterosexual sexuality contributes to poor health outcomes. These conceptual models, and much of the supporting evidence, derive from Western societies. However, the theories of social science are not universal across people or place. Further, where sexual minority health research is conducted across the diverse Asia-Pacific region, this literature largely focuses on individual-level experiences of stigma among sexual minority men, with less attention to sexual minority women or the structural dimensions of stigma. This three-paper dissertation aims to advance our understanding of sexual minority health in diverse global contexts by applying a culturally focused multilevel analysis of sexual stigma in the Asia-Pacific region. I apply qualitative and quantitative methods to assess what factors should be considered in the study of sexual stigma across Asia-Pacific countries, and how exposure to multilevel sexual stigma influences mental health outcomes among sexual minority women as well as men. First, drawing on an extensive review of interdisciplinary literature on gender, sexuality, health, and stigma, I evaluate what socio-cultural features of the region could be considered when adapting theories of sexual stigma in South, Southeast and East Asia. Second, I draw on household survey data from the United Nations Multi-country Study of Men and Violence to test the associations between individual- and socio-structural dimensions of stigma on depressive symptoms among sexual minority men (n=562). Finally, I use qualitative life history data with sexual minority women (n=21) in Thailand to evaluate the connections between gender non-conforming identity construction and the experience of sexual stigma. The results of these analyses demonstrate how socio-cultural features of Asian and Pacific Island societies influence the construct of sexual stigma, as well as its associations with mental health outcomes. The dissertation concludes with implications for theory building and research in sociology and public health. 

Table of Contents

Chapter 1: Introduction.............................................................................................. 1

Background............................................................................................................... 1

Research Objectives And Questions..................................................................... 5

Why Asia and the Pacific?...................................................................................... 6

Structure of the Dissertation.................................................................................. 8

Chapter 2: Theoretical Framework........................................................................ 10

Theorizing Gender................................................................................................ 10

Gender Display And Interaction............................................................................. 10

Structural and Institutional Gender......................................................................... 12

Intersectionality.................................................................................................... 13

Critical Sexuality.................................................................................................. 14

Sociology of Mental Health, Stress and Stigma................................................. 18

Mental Health........................................................................................................ 18

Stress..................................................................................................................... 19

Stigma.................................................................................................................... 21

Sociology of Culture............................................................................................. 22

Chapter 3: Socio-Cultural Dimensions of Sexual Stigma and Sexual Minority Stress in South, Southeast and East Asia      25

Abstract................................................................................................................... 25

Keywords................................................................................................................. 26

Introduction............................................................................................................ 26

Sexual Stigma, Minority Stress and Mental Health......................................... 30

Sexual Minority Mental Health in South, Southeast and East Asia............... 34

Regional Background.............................................................................................. 34

Mental Health among Sexual Minorities................................................................. 35

A Role for Cultural Analysis............................................................................... 40

Culture and Health................................................................................................. 41

Culture and Stigma................................................................................................. 42

Culture and Sexuality.............................................................................................. 43

A Socio-cultural Roadmap to Sexual Minority Stress in Asia......................... 44

Sexual Identity and Symbolic Group Boundaries...................................................... 45

Values and Strategies of Action.............................................................................. 51

Global Influences on Sexual Norms......................................................................... 57

Conclusions............................................................................................................ 63

Identity Formation and Sexual Stigma.................................................................... 63

Cultural Values and Sexual Stigma........................................................................... 65

Global Influences on Sexual Stigma......................................................................... 67

Privileging Culture?................................................................................................ 67

Chapter 4: Does Socio-structural Context Matter? A Multilevel Test of Sexual Minority Stigma and Depressive Symptoms in Four Asia-Pacific Countries...................................................................................................... 71

Abstract................................................................................................................... 71

Keywords................................................................................................................. 71

Introduction............................................................................................................ 72

Background............................................................................................................ 74

Sexual Stigma......................................................................................................... 74

Structural Sexual Stigma......................................................................................... 76

Sexual Stigma and Mental Health in Asia-Pacific.................................................... 77

Data and Methods.................................................................................................. 83

Sample................................................................................................................... 83

Measures................................................................................................................ 84

Analytic Strategy................................................................................................... 85

Results.................................................................................................................... 88

Sample Characteristics........................................................................................... 88

Multilevel Model Estimates.................................................................................... 89

Discussion............................................................................................................... 91

Limitations............................................................................................................ 96

Acknowledgements............................................................................................. 100

Notes..................................................................................................................... 101

Chapter 5: “They Called Me Ee-Tom”: A Double Burden of Gender Identity and Sexual Stigma against Toms in Urban Thailand    105

Abstract................................................................................................................. 105

Keywords.............................................................................................................. 106

Introduction......................................................................................................... 106

Theory................................................................................................................... 108

Sexual Stigma....................................................................................................... 108

Female Masculinity.............................................................................................. 111

Toms in the Thai Gender/Sex System................................................................... 113

Methods................................................................................................................ 115

Participants......................................................................................................... 115

Data Collection Procedures.................................................................................. 116

Data Analysis....................................................................................................... 117

Results.................................................................................................................. 119

Tom Identity Formation...................................................................................... 119

Stigma Processes.................................................................................................. 127

Resilience............................................................................................................. 133

Discussion............................................................................................................ 135

Chapter 6: Conclusion........................................................................................... 140

Sexual Stigma: Universal and Specific............................................................. 140

A Sociological Advantage................................................................................... 141

Future Directions................................................................................................ 144

Public Health Practice........................................................................................ 145

Concluding Remarks.......................................................................................... 147

References............................................................................................................... 149

Appendix I: Data Sharing and Access Agreements............................................ 183

Appendix II: Qualitative Life History Interview Guide..................................... 184

Appendix III: Life History Timeline Guide......................................................... 188

Appendix IV: Measurement Invariance of the CES-D Scale by Male Sexuality 191

Appendix V: Chapter 4 Supplementary Tables 192

About this Dissertation

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School	Laney Graduate School
Department	Sociology
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health Sociology, General Gender Studies
Keyword	Stress Mental Health Stigma Sexual and gender minorities Asia-Pacific
Committee Chair / Thesis Advisor	Kathryn M. Yount, Emory University
Committee Members	Megan Sinnott, Georgia State University Irene Browne, Emory University Corey L.M. Keyes, Emory University Regine Haardörfer, Emory University

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