Stigma Burden as a Predictor of Suicidal Behavior_112954.pdf

Suicidology Online 2017; 8: 26 ISSN 2078-5488 Origin...

Suicidology Online 2017; 8: 26 ISSN 2078-5488 Original research Stigma Burden as a Predictor of Suicidal Behavior among Lesbians and Gays in the Philippines Marc Eric S. Reyes ,1, Roger D. Davis 2, Alyson Jane A. David1, Camille Joy C. Del Rosario1, Anna Patricia S. Dizon1, Julienne Lara M. Fernandez1, Michaela A. Viquiera1 1 University of Santo Tomas 2 Institute for the Study of Personality Submitted to SOL: May 14th, 2017; accepted: September 8th, 2017; published: November 1st, 2017 Abstract: Suicide is a serious concern worldwide. Understanding the dynamics of suicidal behavior may help prevent it. Meyer’s minority stress model (2003) holds that minority groups, such as the lesbian, gay, bisexual, and transgender (LGBT) community, experience group-specific stressors, collectively termed “stigma.” In the current study, stigma was divided into two portions, perceived stigma and self-stigma. Perceived stigma regards negative opinions about a minority group experienced from the majority culture. Self-stigma results when such negative opinions are internalized to become negative opinions of the self. The present study found that among 61 Filipino lesbians and 124 Filipino gays, suicidal behavior increased as a function of both internalized and self-stigma, with each making an independent to suicidal behavior. Nearly 25% of suicidal behavior could be predicted by this total stigma burden. Further, Filipino gays and lesbians differ in their suicidal behaviors with lesbians being more at risk. These findings raise awareness about the impact of stigma, prejudice, and discrimination, which in turn, may reduce suicidal behavior among the Filipino lesbian and gay community. Keywords: Internalized stigma, LGBT, minority stress, suicidal behavior Copyrights belong to the Author(s). Suicidology Online (SOL) is a peer-reviewed open-access journal publishing under the Creative Commons Licence 3.0. In October 8, 2011, the Psychological Association change in the professional practice and teaching of of the Philippines (PAP) released a statement psychology in the Philippines, resulting in an LGBT- emphasizing the importance of non-discrimination inclusive Philippine psychology. based on sexual orientation, gender identity, and According to Kann et.al. (2011), sexual identity expression (SOGIE). By this statement, the PAP refers to “how individuals identify themselves,” (2011) officially recognized that stigma, prejudice, that is, as lesbian, gay, bisexual, or even as and discrimination are still experienced by the “confused about their identity.” Research shows lesbian, gay, bisexual, and transgender (LGBT) that sexual minority youth experience stigma, community in the Philippines. This is manifested prejudice, and discrimination (Meyer, 2003b; through victimization, stereotyped media Sandfort, Bakker, Schellevis, & Vanwesenbeeck, portrayals, denial in entering commercial 2006; Conron, Mmiaga, & Landers, 2010). businesses, limited job opportunities, and reduced Internalized stigma is conceptualized as the political participation, among others. Due to the “negative perception of one’s own sexual minority support of PAP, Ofreneo (2013) envisions social or transgender identity” (Puckett & Levitt, 2015). Through repeated harassment, discrimination, and  victimization, negative perceptions of sexual Dr. Marc Eric S. Reyes Address: Department of Psychology, University of Santo Tomas, orientation eventually become “internalized” Manila, Philippines (Herek, 1990). This process occurs when minority Email address: [email protected] 1  Suicidology Online 2017; 8: 26 ISSN 2078-5488 group members begin to see and regard support, and prohibited access to deadly means themselves as the majority society sees and (HHS, 2001). regards them. Thus, the original source of The current study explores whether external internalized stigma is social stigma, that is, the perceived stigma and self-stigma predict suicidal attitude of the larger society toward LGBT persons. behavior for lesbians and gays in the Philippines. Stigma may result in (1) poor self-esteem, (2) Note that not all perceived stigma becomes self- reduced self-efficacy, (3) impaired social stigma. Individuals may reject or dismiss, or react functioning, and a (4) higher level of psychiatric against stigma, rather than incorporate it into their symptoms, including depression (Drapalski, self-concept. As such, we first hypothesized that Lucksted, Perrin, Aakre, Brown, DeForge, & Boyd, the correlation between perceived and self-stigma 2013). Internalized stigma may be said to consist of would be moderate. Second, since any form of “self-stigma” (Mak & Cheung, 2010) or stigma is aversive, we hypothesized that perceived “internalized homophobia” (Puckett & Levitt, stigma and self-stigma would both be significantly 2015). Weinberg (1972) developed the word related to suicidal behavior. Third, because homophobia to refer to “the dread of being in perceived stigma and self-stigma may logically be close quarters with homosexuals and in the case of viewed as two halves of the total “stigma burden” homosexuals themselves, self-loathing.” experienced by the individual, we hypothesized Internalized homophobia involves taking social that each would make independent contributions stereotypes about oneself as true or factual. Thus, to the prediction of suicidal behavior. anyone belonging to a sexual minority who rejects The results of the current study are intended to his or her sexual orientation is, by definition, inform the LGBT Community, its allies, and society experiencing internalized homophobia (Meyer & in general on the effects of internalized stigma and Dean, 1998). This may also be described as the its connection to suicidal behavior. Such intrapsychic conflict between one’s attraction to awareness, it is hoped, will reduce stigma, the same sex and the desire to be heterosexual in discrimination, violence, and prejudice, thereby order to gain the acceptance of family or society reducing suicidal behavior in the LGBT community. (Herek, 2004). About 1 out of 4 Filipinos would reject gay people Method as neighbors. About 28% of Filipino adults consider Study Population being gay as wholly “unacceptable” (Manalastas & Using a non-probability convenience sampling Del Pilar, 2005). As such, there is ample method, we recruited lesbian and gay youth opportunity for social stigma to produce both self- residing in Manila. A total of 185 self-identified stigma and internalized homophobia among Filipino lesbian and gay youth participated. These Filipino youth. Using American data, Russell & were comprised of 61 lesbian women and 124 gay Joyner (2001) found that the prevalence of suicide men. All signed an informed consent prior to ideation was much higher among gay and bisexual completing the research questionnaires. adolescent boys (15%) compared to other boys Evaluation of Stigma and Suicidal Behavior (1%). Suicidal behaviors are self-initiated ideations The instruments below were chosen as measures and communications that express the desire or of stigma, self-stigma, and suicidal behavior. intention to die (Van Orden, et al., 2010). Harvey Stigmatization Scale (HSS). Developed by According to the National Strategy for Suicide Harvey (2001), the HSS consists of 21 items which Prevention, suicidal behavior is comprised of measure perceived stigma. Content validity of the thinking about, attempting, and completing the act HSS was established with the assistance of experts of suicide (U.S. Department of Health and Human in the field. Harvey (2001) revised questions Services [HHS], 2001). According to the Suicide previously used by Branscombe, Schimtt, and Prevention Resource Center (2008), both suicide Harvey (1999) to measure feelings of racial risk and protective factors are helpful in predicting victimization and added questions based on the actual suicidal behavior in individuals considered responses from the interview of experts (two to be at risk. Widely researched risk factors include African American women and one African the presence of a mental disorder, lack of social American men) about their perceptions of the and emotional support, stigma and prejudice from social identity among the dominant group in heterosexuals, relationship breakup or broken society. Examples include “I do not feel victimized friendship, and access to deadly weapons. In by the society” and “Society discriminates against contrast, protective factors reduce suicidal me.” Each item is answered on a 5-point Likert behaviors. Protective factors include effective scale that ranges from (1) strongly disagree to (5) mental health care, community and family strongly agree, with five positively worded items being reverse scored. Harvey (2001) used forward 2  Suicidology Online 2017; 8: 26 ISSN 2078-5488 stepwise regression to reduce the number of items discrimination between suicidal and non-suicidal from 18 to 10, creating an abbreviated scale. Both criterion groups (Cull & Gill, 1988). Cronbach’s the long and short versions yielded high reliability alpha reliability in the present study for the total scores across racial groups (.94 for the long version SPS score was.89. and.90 for the short version) that included Research design European Americans, African Americans, and A correlational design was used to explore the Native Americans. The long version was used in the relationship between internalized homophobia current study. This yielded a Cronbach alpha and suicidal behavior. Pearson correlation was reliability of.91. used to calculate the relationship between Self-Stigma Scale (SSS). Developed by Mak and perceived stigma and self-stigma. Multiple Cheung (2010), the SSS is a 39-item scale designed regression was used to determine if level of to assess the cognitive, affective, and behavioral perceived stigma and self-stigma predict suicidal manifestations of self-stigma. Each item is behavior of Filipino lesbian and gay youth. answered on a 4-point Likert-type scale that ranges Research procedure from (1) strongly disagree to (4) strongly agree. The current study was examined and approved by Sample items include: “My identity as a an Ethical Review Board. After receiving informed lesbian/gay is a burden to me” (cognitive), “I feel consent, the participants completed a pitiful for being a lesbian/gay” (affective), “I demographic sheet along with the psychological conceal my identity as a lesbian/gay from other” tests described above. Total testing time varied (behavioral). The total score is obtained by from 30 to 45 minutes, after which the participants summing items across all three domains. Higher was debriefed and were given tokens of gratitude scores denote higher self-stigma. Initial validation (e.g. food) for their participation. The Harvey of both the long and short forms of the Self-Stigma Stigmatization Scale, Self-Stigma Scale and Suicide Scale showed excellent reliabilities. Internal Probability Scale were then scored and the data consistency with the short version (9 items) was were analyzed using the Statistical Package for measured at alpha =.91 for mental health Social Sciences (SPSS) Version 16. consumers and alpha =.84 for immigrant women. Internal consistency with the long version (39 Results items) was measured at alpha =.97 for mental Descriptive statistics were calculated to determine health consumers and alpha =.93 for immigrant perceived stigma, self-stigma, and the level of women. The SSS is negatively associated with suicidal behavior in the participants. Table 1 other self-identity measures such as self-esteem, presents the mean and standard deviation of self-efficacy, and collective self-esteem, and is subject scores on the HSS, SSS, and SPS for lesbian positively associated with greater levels of and gay subjects (we had no hypotheses or depression, anxiety, and poor life satisfaction (Mak expectations about differences between the two & Cheung, 2010). A Cronbach alpha reliability groups, so the current study should be view as measure of.96 for the SSS long version was purely exploratory in this regard). Lesbians and obtained in the present study. gays differed significantly in regard to their total Suicide Probability Scale (SPS). Developed by Cull suicidal behavior scores, t (183) = -2.79, p <.05. To and Gill (1988), the SPS is designed to determine better understand this difference, we looked at the the risk of suicidal behavior. The SPS consists of 36 four subscales of the SPS. While lesbians scored items divided into four (4) subscales, namely higher for all subscales, these differences were Hopelessness (e.g., “I feel hopeless that things will significant only for the Suicide Ideation subscale (t get better”), Suicide Ideation (e.g., “In order to (183) = 2.97, p <.05) and Hostility subscale (t (183) punish others, I think of suicide”), Negative Self- = 2.81, p <.05). The differences were not Evaluation (e.g., “I feel many people care for me significant for Negative Evaluation (t (183) = 1.08, p deeply”) and Hostility (e.g., “I feel hostile towards <.283) and Hopelessness (t (183) = 1.69, p <.093) others). Each item is answered on a 4-point Likert subscales. scale ranging from (1) None or a little of the time, (2) Some of the time, (3) a Good Part of the time, and (4) Most of the time. The ratings were scored according to the items’ respective weights and totalled to obtain the four subscale scores and the Total Weighted Score. The test is regarded as highly reliable, with internal consistencies and test- retest reliabilities greater than.90 (Cull & Cull, 1998). Criterion validity studies have shown good 3  Suicidology Online 2017; 8: 26 ISSN 2078-5488 Table 1. Summary of Data on Internalized Homophobia, Experience of Stigma, & Suicidal Behavior; Mean (SD) Lesbian Gay t-value Perceived Stigma (HSS) 58.05 57.03 -0.50 (12.91) (12.92) Self-Stigma (SSS) 66.00 63.32 -0.94 (17.97) (18.32) Suicidal Behavior 70.54 62.69 -2.79* (SPS Total Score) (20.06) (16.89) Hopelessness 22.31 20.23 1.69 (SPS Subscale) (8.16) (7.72) Suicide Ideation 19.74 16.40 2.97* (SPS Subscale) (8.20) (6.64) Negative Self-Evaluation 14.16 13.56 1.08 (SPS Subscale) (3.62) (3.60) Hostility 14.33 12.50 2.81* (SPS Subscale) (4.34) (4.07) With regard to our first hypothesis advanced in the functioning. The HSS and SSS were entered into a study, we noted that not all stigma coming from multiple regression to predict SPS Total score. the social environment is taken into the self- Results revealed that the participants’ suicidal concept. As such, we believed that the correlation behavior is most fully explained by the total 2 between HSS and SSS would be moderate. In our experienced stigma, R =.241, F(2, 182) = 28.908, p sample, the correlation was r =.350, p <.01, thus <.001. Further, each source of stigma made its supporting the first hypothesis. own contribution, with HSS at β =.473 (p <.001) With regard to our second hypothesis, we believed and the SSS at β =.264 (p <.001). Looking at the that both perceived and self-stigma would be beta values, the contribution of perceived stigma significantly related to suicidal behavior. Indeed, (HSS) to suicidal behavior appears to be greater the HSS was significantly correlated with SPS Total than the contribution of internalized stigma (SSS), Score (r =.425, p <.01), as was the SSS (r =.379, p though both are significant. <.01). This supported the second hypothesis: As shown in Table 2, the HSS correlated Suicidal behavior among Filipino lesbians and gays significantly with all the SPS subscales except for increased as the experience of experienced stigma Negative Self-Evaluation. The SSS correlated (as assessed by the HSS) increased. Moreover, significantly with all SPS subscales. We had no suicidal behavior among Filipino lesbians and gays hypotheses regarding which SPS subscales might increased as internalized stigma (as assessed by be most strongly predicted by the HSS or SSS. the SSS) increased. Perceived stigma (HSS) correlated most highly with With regard to our third hypothesis, we believed SPS hopelessness (r =.438, p <.01), while self- that external and internalized stigma would make stigma (SSS) correlated about equally with SPS independent contributions to suicidal behavior, suicide ideation (r =.356, p <.01) and SPS negative since each may be viewed as two halves of the self-evaluation (r =.346, p <.01). total stigma burden under which the individual is 4  Suicidology Online 2017; 8: 26 ISSN 2078-5488 Table 2. Correlations of Internalized Stigma (HSS & SSS) with Suicidal behavior (SPS Subscales and Total Score) Internalized Stigma Suicidal behavior (SPS) Suicide Ideation Hostility Hopelessness Negative Total Subscale Subscale Subscale Self-Evaluation Score Subscale Experience of Stigma.370*.294*.438*.102.425* (HSS) Self-Stigma (SSS).356*.227*.269*.346*.379* Discussion we hypothesized that both perceived and self - This study examined the relationship between stigma would correlate with suicidal behavior. Both stigma and suicidal behavior among lesbians and HSS and SSS were correlated with SPS Total Score, gays in the Philippines. We found no statistically with r =.425 and r =.379, respectively (p <.01). significant differences between gays and lesbians Third, we hypothesized that the total stigma on either level of perceived stigma or self-stigma. burden of the individual could be divided into two Nevertheless, lesbians were shown to exhibit logical halves, since individuals who experience significantly greater suicidal behavior than gays. As stigma may choose to dismiss it, react against it, or measured by the subscales of the SPS, lesbians to incorporate it into their self-concept as exhibited greater suicidal ideation and hostility, internalized stigma. In our sample, regression with no significant differences in level of negative results suggest that experienced stigma and total self-evaluation and hopelessness. Our findings are stigma make independent contributions to suicidal consistent with Manalastas (2016) and Liu and behavior, with experienced stigma being Mustanski (2012), who found that lesbian and somewhat stronger. In fact, nearly one quarter of 2 bisexual women are exposed to additional the total suicide risk (R =.241) was predicted from stressors (e.g. discrimination, victimization). total stigma. The current research thus supports Similarly, in a systematic literature review done by previous findings that sexual orientation and King and colleagues (2008), it was found that suicidal behaviors are strongly linked (Remafedi, lesbian and bisexual women were at particular risk French, Story, Resnick & Blum, 1998; van of suicidal ideation. Finally, according to Klonsky, Heeringen & Vincke, 2000; Russell & Joyner, 2001; May, & Saffer (2016), women in particular are at Manalastas, 2013). higher risk in poor mental health and suicidal The current level of experienced stigma is the ideation. Gender is also said to have an effect on strongest predictor of suicidal behavior. Such victimization (Otis & Skinner, 1996), which is a stigma comes directly from the majority culture strong determinant for mental health (WHO, and is experienced in the present, as indicated by 2000). According to Harper and Schneider (2003), such HSS questions as “Society discriminates being a lesbian and at the same time being a against me.” Such sources of stigma are pervasive woman is considered as a “double” minority status in the culture of the Philippines. The patriarchal at times even “triple” due to her skin color (e.g. element can be traced back to the Spanish era. African American). Consequently, lesbians Colonizers viewed women as being of lesser experience more stressors because they belong to importance than men, and encouraged the idea different minority groups (e.g. LGBT community, that men were entitled to have ownership over women). women (Rodriguez, 1990). Even though the The three research hypotheses advanced in the Philippines stood out as the most gender-equal study were supported: First, we hypothesized that nation in Asia in the 2013 Global Gender Gap experienced (or external) stigma and internalized Report of the World Economic Forum, this stigma would be moderately correlated. Results patriarchal culture is still seen in many different indicated a correlation of r =.350, p <.01. Second, ways in the country. For example, in the world 5  Suicidology Online 2017; 8: 26 ISSN 2078-5488 today, the vast majority of leaders are men in connection with internalized homophobia, making business or politics, who exemplify traditional male them at risk for committing suicide (Diamond, qualities such as power and control. Other Shilo, Jurgensen, D’Augelli, Samarova, & White, qualities such as nurturing and compassion are 2011). In our study, self-stigma was associated considered subordinate. with all forms of suicidal behavior assessed by the According to the Psychological Association of the SPS, and most strongly associated with suicidal Philippines (2011), stigma, prejudice and ideation (r =.356). discrimination are still experienced by Filipino Limitations sexual minority groups, though society may be We would like to acknowledge several limitations changing. In 2013, Pews Research Center of the current study. First, we used a sample of conducted a survey about the relationship lesbian and gay youth permanently and/or between high levels of religiosity in the Philippines temporarily residing in the National Capital Region, and negative views about homosexuality. The which consists mostly of Metro Manila. As such, survey found that although most Filipinos are we do not know the extent to which our findings religious, they are considerably tolerant of might generalize to lesbians and gays in the homosexuals. Another survey by Pews showed provinces, that is, to the Philippines as a whole. that the majority of the Filipinos agreed that Perhaps our findings generalize only to other major homosexuality should be accepted. Nevertheless, metropolitan areas, with the provinces being more acceptance is not universal, with a substantial religiously conservative, and therefore, more minority of Filipinos disagreeing with these stigmatizing. Second, although we presented findings. In the Philippines, gays and lesbians statistics contrasting gays and lesbians, there were believe that tolerance is only shown to those who only 61 lesbians versus 124 gays in the study. Our fit certain stereotypes (United Nations findings were consistent with the previous Development Programme and United States literature, but require replication. Third, it was Agency International Development, 2014). Thus, found that the level of SPS Negative Self-Evaluation these findings imply only conditional tolerance and was not significantly correlated with currently acceptance of homosexual behaviors. It is experienced stigma or with self-stigma. The significantly more likely for homosexuals and reasons for this are unknown, but may concern the bisexuals to have at least one of the five stress- composition of the scale. An example item from sensitive psychiatric disorders (major depression, SPS Negative Self-Evaluation is “I feel many people generalized anxiety disorder, panic disorder, care for me deeply,” which would be better alcohol dependence, and drug dependence). They phrased as “I do not care deeply for myself.” Since are also more likely to report sexual orientation the relationship between the SSS and other discrimination than heterosexuals (Mays & variables in the study were as expected, this may Cochran, 2001). In our study, perceived stigma was indicate problems for the construct validity of the most strongly associated with hopelessness (r = Negative Self-Evaluation subscale of the SPS..438) and suicidal ideation (r =.370). Indeed, the correlation between the SSS and SPS The second half of the total stigma burden is Negative Self-Evaluation was only.346, far from internalized stigma or self-stigma. 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