Exploring perceived and enacted stigma with related factors among gay, bisexual, and other men who have sex with men in Nepal
Md. Safaet Hossain Sujan
A , Antoine Khati A , Kiran Paudel A B , Kamal Gautam A , Anjila Pandey C , Sanjay Sharma D , Manisha Dhakal D , Jeffrey Wickersham E and Roman Shrestha A E *
A
B
C
D
E
Abstract
Stigma is multifaceted and widely prevalent among gay, bisexual and other men who have sex with men (GBMSM). Although perceived and enacted stigma are mostly common and negatively impact GBMSM’s well-being, there is limited research in Nepal to guide comprehensive interventions for effective solutions. Thus, the present study aimed to evaluate perceived and enacted stigma related to sexual behavior, as well as the associated factors, among GBMSM in Nepal.
A nationwide cross-sectional study was conducted online among 842 participants between April and May 2024. Neiland’s Sexual Stigma Scale was used to assess perceived and enacted stigma related to sexual behavior. The Patient Health Questionnaire-9 and the Sleep Quality Scale were also utilized. Exploratory factor analysis, and bivariate and multivariate linear regression analysis were used in the present study.
The mean age of the participants was 27.6 years (s.d. 7.1 years). Over half of the participants (54−76%) experienced perceived stigma, and nearly half (35−57%) experienced enacted stigma. Participants who were older (β = 0.06, P-value <0.01), had previously tested for HIV (β = 0.06, P-value 0.047), engaged in anal sex in the past 12 months (β = 0.2, P-value <0.01) or had depressive symptoms (β = 0.3, P-value <0.01) had higher perceived stigma. Participants who had been to sex parties or enganged in group sex in the past 12 months had lower perceived stigma (β = −0.09, P-value = 0.021) and higher enacted stigma (β = 0.08, P-value = 0.009). In addition, participants who had concealed their sexual orientation (β = 0.1, P-value = 0.004), had ever engaged in chemsex (β = 0.07, P-value = 0.024), had reported transactional sex (β = 0.08, P-value = 0.009) in the past 12 months or reported depressive symptoms (β = 0.3, P-value <0.01) had higher enacted stigma. Conversely, participants with adequate sleep (β = −0.1, P-value = 0.027) had a lower enacted stigma.
Our study showed a substantial presence of perceived and enacted stigma among GBMSM in Nepal. Our findings underscore the need for stigma reduction initiatives and supportive care for GBMSM in Nepal, especially for older individuals and GBMSM who engaged in chemsex or group sex or suffer from depression, to promote an LGBT-friendly community.
Keywords: depressive symptoms, discrimination, enacted stigma, gay, bisexual and other men who have sex with men, HIV, Nepal, perceived stigma, sleep.
Introduction
Stigma is a complex and multidimensional concept often experienced by gay, bisexual or other men who have sex with men (GBMSM).1,2 Sexual stigma, a type of stigma faced by GBMSM, effects individuals who engage in same-sex relationships or identify as sexual minorities.3 Such stigma can be perceived (i.e. an individual’s perception that they are abused or considered unfavorably by others), enacted (i.e. an individual’s experience of exploitation), internalized (i.e. adverse social perceptions are adopted into one’s views) or anticipated (i.e. an individual expects discrimination).4,5 Although perceived and enacted stigma are often reported, enacted stigma entails actual discrimination and exploitation by others, demonstrating the interpersonal aspect of stigma.6 Conversely, perceived stigma represents how people perceive themselves, reflecting the intrapersonal dimension.6
GBMSM often face discrimination,7 and multilevel barriers to care and support services,8 compounded by a lack of family and social support.9,10 Oftentimes, these challenges lead to low self-esteem,11 severe psychological conditions (e.g. anxiety, depression, suicidality)12 and poor sleep quality.13 To cope with these, GBMSM may engage in substance use14 and unsafe sexual behavior.15 When paired with these social prejudices, such behaviors reinforce stereotypes, often resulting in perceived9 and enacted stigma.16
In Nepal, although same-sex behavior is not criminalized, the traditional cultural norms and heteronormative attitudes create a stigmatizing environment for GBMSM.17 Research focusing on perceived and enacted stigma among GBMSM in Nepal is insufficient, despite its importance being widely acknowledged.18 Recent evidence emphasizes the necessity for a complete assessment of sexual behavior stigma among GBMSM.19 Fitzgerald-Husek et al.20 discovered that stigma measures among GBMSM mostly emphasize sexual identity, overlooking sexual behavior in same-sex relationships. In addition, the majority of the reviewed literature on sexuality-related stigma among MSM focuses primarily on internalized stigma, with half or less integrating measurement of enacted or perceived stigma.20
Identification and understanding of perceived and enacted stigma and their determinants are crucial, as they can negatively impact GBMSM’s self-perceptions, social support, well-being, access to care and utilization of HIV prevention services.21–23 Additionally, there is a pressing need in Nepal to examine the nationwide occurrence of perceived and enacted stigma, as well as its associated factors, within its sociocultural context.24 Although very few stigma studies have been carried out in Nepal, they either explore HIV-related stigma25 or are geographically limited to some parts of Nepal.26 Thus, the understanding of perceived and enacted stigma among broader GBMSM populations in Nepal remains limited. Such research can provide valuable insights to guide the development, testing and implementation of stigma-reduction interventions responsive to cultural contexts. Therefore, to fill this gap, our study aimed to evaluate perceived and enacted stigma related to sexual behavior, as well as associated factors, within the Nepali GBMSM community.
Methods
Study design and participants
A nationwide, cross-sectional online self-administered survey was conducted among Nepali GBMSM from April to May 2024. A convenience sampling technique was used. The eligibility criteria included: (1) aged ≥18 years; (2) self-identified cisgender man who has sex with men; (3) owning a smartphone; (4) being able to read and write in Nepali or English; and (5) currently living in Nepal.
Study procedure
Participants were recruited through flyers posted on social networking sites, such as Facebook and Instagram. The recruitment flyers were shared on the social media pages of community-based organizations, such as the Blue Diamond Society, serving LGBTQ populations. Individuals who were interested in participating in the survey were directed to an eligibility screener hosted by Qualtrics. Before filling out the survey, eligible participants were required to confirm their understanding of the study’s objectives, risks and benefits by completing an online consent form. Participants received compensation of NRS400 (~USD3) for completing the survey, which took approximately 15 min.
We used a standardized protocol to prevent duplicate responses, identifying duplicates by comparing variables, such as age, sexual orientation and ethnicity. During a 2-month recruitment period, we received 1256 responses; 1177 individuals met the eligibility criteria and consented to participate. However, after excluding incomplete responses and those from outside of Nepal, 842 complete responses remained and were included in the final analytic sample.
The study followed the principles of the Helsinki Declaration on Institutional Research Ethics and Human Involvement. The Nepal Health Research Council approved the study protocol with reference number 30/2024.
Measures
Sociodemographic variables
Participants’ sociodemographics included their age, sexual orientation (gay, bisexual and other MSM), education (less than high school/proficiency certificate level and high school/proficiency certificate level or above), relationship status (in a relationship/single) and ethnicity (Dalit, Janajati, Madhesi, Brahmin/Chhetri, other).
Sexual and health-related behaviors
Participants’ sexual and health-related behavior was assessed by asking questions on their lifetime and past 12-month behavior, such as whether they had to conceal sexual orientation from specific groups, such as parents and other family members, friends or peers, and members of the broader community (yes/no); had ever tested for HIV (yes/no); and what their HIV status (positive/negative/don’t know) was during the study time. Questions, such as whether they had engaged in anal sex (yes/no), condomless sex (yes/no) and sex parties (yes/no) in the past 12 months, were asked. Participants were also asked about whether they had been engaged in chemsex (yes/no) at any point in their lifetime, and engaged in transactional sex (yes/no) in the past 12 months.
Sexual stigma
The Neilands sexual stigma scale was utilized to assess perceived and enacted stigma related to sexual behavior among GBMSM.27,28 Prior studies reported excellent internal consistency, validity and reliability of this scale to measure perceived and enacted stigma among GBMSM.27,29 The scale comprises 10 items with a 4-point Likert scale ranging from ‘0 = never’ to ‘3 = many times’. Possible total scores range from 0 to 30 (e.g. 0–12 for perceived stigma and 0–18 for enacted stigma), with higher scores indicating a higher perceived and enacted stigma. Cronbach’s alpha of the perceived and enacted stigma in the present study was 0.76 and 0.87, respectively.
Sleep quality
The Sleep Quality Scale is a single-item self-reported questionnaire that uses a visual analog scale with discrete scores.30,31 Participants rated their sleep quality over a 7-day period using the visual analog scale, considering various factors, such as sleep time, ease of falling asleep, frequency of night-time and early morning awakenings, and sense of refreshment after sleep. A score of ≤6 out of 10 indicated poor sleep quality.30
Depressive symptoms
Depressive symptoms were assessed using a nine-item patient health questionnaire scale that corresponds to the Diagnostic and Statistical Manual of Mental Disoriders, Fourth Edition diagnostic criteria for symptoms of major depressive disorder.32 Responses were rated on a 4-point Likert scale ranging from ‘0 = not at all’ to ‘3 = almost every day.’ The scale includes items for current problems, such as lack of sleep, fluctuations in eating, difficulty focusing and suicidal thoughts. Depressive symptoms were defined as having a composite cutoff score of ≥10.33,34 The Cronbach’s alpha of the nine-item patient health questionnaire in the present study was 0.90.
Statistical analysis
We utilized descriptive statistics (i.e. means, standard deviations, frequencies and percentages), exploratory factor analysis, sensitivity analysis and multivariate linear regression analysis. The Neilands sexual stigma scale had not been used with GBMSM in Nepal. Therefore, we conducted an exploratory factor analysis on the 10 survey items to identify potential stigma components on each factor.
Factor analysis is a statistical method used to identify common patterns in survey responses by examining underlying structures.35 The Promax approach was used to rotate factor loadings (i.e. factor-variable correlations) to create a simple structure that assigns each item to a single component. In line with standard protocol, loadings of ≥0.40 were considered significant.27
Perceived and enacted stigma factors served as the two dependent variables for this study. However, a sensitivity analysis was added to the study without factoring in the scale and showed the analysis to reveal the robustness of the current model.
Bivariate linear regression analysis was used to identify the possible variables for multivariate regression analysis. The multivariate linear regression analysis included variables with a P-value ≤0.05 in the unadjusted model. A P-value <0.05 was considered to be statistically significant. All analyses were carried out using SPSS version 29.0 (IBM).
Results
Participants’ characteristics
Participants’ mean age was 27.6 years (s.d. 7.1 years). The majority of the participants were single (63.2%) and reported to have concealed their sexual orientation from others (77.9%). Almost half (48.2%) reported engaging in condomless sex in the past 12 months. Of the total participants, 24.7% reported having previously engaged in chemsex, and 33.8% had either moderate or severe depressive symptoms (Table 1).
| Variables | n (%) | |
|---|---|---|
| Age (years) | Mean 27.6 (s.d. 7.1) | |
| Sexual orientation | ||
| Gay or bisexual | 582 (69.1) | |
| Other MSM | 260 (30.9) | |
| Educational level | ||
| Less than high school/proficiency certificate level | 455 (54.1) | |
| High school/proficiency certificate level and above | 387 (45.9) | |
| Relationship status | ||
| In a relationship | 310 (36.8) | |
| Single | 532 (63.2) | |
| Ethnicity | ||
| Dalit | 79 (9.4) | |
| Janjati | 349 (41.5) | |
| Madhesi | 153 (18.2) | |
| Brahmin/Chhetri | 251 (29.8) | |
| Other | 10 (1.2) | |
| Concealed sexual orientation | ||
| No | 186 (22.1) | |
| Yes | 656 (77.9) | |
| Ever tested for HIV | ||
| No | 154 (18.3) | |
| Yes | 688 (81.7) | |
| HIV status (n = 688) | ||
| Positive | 85 (12.3) | |
| Negative | 568 (82.6) | |
| Don’t know | 35 (5.1) | |
| Engaged in anal sex in the past 12 months | ||
| No | 231 (27.4) | |
| Yes | 611 (72.6) | |
| Engaged in condomless sex in the past 12 months | ||
| No | 436 (51.8) | |
| Yes | 406 (48.2) | |
| Engaged in sex parties/group sex in the past 12 months | ||
| No | 511 (60.7) | |
| Yes | 331 (39.3) | |
| Ever engaged in chemsex | ||
| No | 634 (75.3) | |
| Yes | 208 (24.7) | |
| Engaged in transactional sex in the past 12 months | ||
| No | 594 (70.5) | |
| Yes | 248 (29.5) | |
| Sleep quality | ||
| Poor | 513 (60.9) | |
| Adequate | 329 (39.1) | |
| Depressive symptoms | ||
| None or mild | 557 (66.2) | |
| Moderate to severe | 285 (33.8) | |
Items and factor loadings of the Neilands sexual stigma scale
A two-component solution emerged from the analysis of the factor loading pattern. Factor 1 was made up of items measuring the sense of social rejection of same-sex behavior and its consequences. For example, hearing that men who have sex with men are not normal (Item 1) or expressing concern that being GBMSM hurts and embarrasses family (Item 2). Thus, the factor was called perceived stigma. The remaining items were Factor 2 and dealt with direct experiences of homophobia in interactions with others. For example, Item 4 measured the number of times participants had experienced physical assault because of their same-sex behavior, whereas Item 10 measured the number of times they had lost their jobs as a result of being GBMSM. This set of measures assessed a latent concept called ‘enacted stigma,’ which is consistent with the nomenclature used by researchers in other contexts. The standardized factor loadings, 95% confidence intervals and the percentages of each item experienced by individuals are shown in Table 2. Item 8 had the highest loadings (0.92), and Item 7 had the lowest (0.50). Most participants experienced Item 1 (76.6%). All items were loaded into two factors. Approximately half of the participants had experienced several forms of perceived and enacted stigma at any point in their lifetime.
| Items | Loading (95% CI) | Ever experienced (%) | |||
|---|---|---|---|---|---|
| Perceived stigma factor | |||||
| 1. | How often have you heard that men who have sex with men are not normal? | 0.82 | (0.25–0.32) | 645 (76.6) | |
| 2. | How often have you felt that your sexual engagement with other men hurt and embarrassed your family? | 0.63 | (0.23–0.28) | 459 (54.5) | |
| 3. | How often have you been made fun of or called names for being men who have sex with men? | 0.71 | (0.25–0.32) | 538 (63.9) | |
| 5 | How often have you had to pretend that you are not men who have sex with men in order to be accepted? | 0.74 | (0.18–0.24) | 550 (65.3) | |
| Mean 4.9 (s.d. 3.3) | |||||
| Enacted stigma factor | |||||
| 4. | How often have you been hit or beaten up for being men who have sex with men? | 0.73 | (0.17–0.22) | 337 (40.0) | |
| 6. | How often has your family not accepted you because of your sexual engagement with other men? | 0.60 | (0.17–0.22) | 404 (48.0) | |
| 7. | How often have you lost your friends because of your sexual engagement with other men? | 0.50 | (0.19–0.25) | 481 (57.1) | |
| 8 | How often have you been kicked out of school for being men who have sex with men? | 0.92 | (0.15–0.20) | 296 (35.2) | |
| 9. | How often have you lost a place to live for being men who have sex with men? | 0.83 | (0.18–0.23) | 337 (40.0) | |
| 10. | How often have you lost a job or career opportunity for being men who have sex with men? | 0.82 | (0.19–0.24) | 354 (42.0) | |
| Mean 4.4 (s.d. 4.5) | |||||
Notes: N = 842. Ever experienced (%) = proportions of participants who endorsed each item ‘once or twice,’ ‘a few times,’ or ‘many times.’ The factor analysis results shown are for the final confirmatory factor analysis model in which all items were included due to their excellent performance in the initial exploratory factor analysis.
Perceived stigma and associated factors
Participants who were older (β = 0.06, P-value <0.01), had previously tested for HIV (β = 0.06, P-value = 0.047), had engaged in anal sex in the past 12 months (β = 0.2, P-value <0.01) or had depressive symptoms (β = 0.3, P-value <0.01) had higher perceived stigma. In contrast, participants who had been to sex parties/engaged in group sex in the past 12 months (β = −0.09, P-value = 0.021) had lower perceived stigma (Table 3).
| Variables | Mean (s.d.) | Unadjusted | Adjusted | P-value | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| B | s.e. | t | ꞵ | B | s.e. | t | β | ||||
| Mean age, years (s.d.) | 27.6 (7.1) | 0.06 | 0.01 | 3.6 | 0.1 | 0.03 | 0.01 | 2.1 | 0.06 | 0.030 | |
| Concealed sexual orientation | |||||||||||
| No | 3.1 (2.4) | 0.085 | |||||||||
| Yes | 3.8 (2.6) | 1.1 | 0.2 | 4.1 | 0.1 | 0.4 | 0.2 | 1.7 | 0.06 | ||
| Ever tested for HIV | |||||||||||
| No | 3.1 (2.6) | 0.047 | |||||||||
| Yes | 3.8 (2.5) | 1.1 | 0.3 | 3.9 | 0.1 | 0.5 | 0.2 | 1.9 | 0.06 | ||
| Engaged in anal sex in the past 12 months | |||||||||||
| No | 3.5 (2.6) | <0.01 | |||||||||
| Yes | 4.3 (2.4) | 1.9 | 0.2 | 7.7 | 0.2 | 1.7 | 0.3 | 5.0 | 0.2 | ||
| Engaged in condomless sex in the past 12 months | |||||||||||
| No | 3.5 (2.6) | ||||||||||
| Yes | 4.0 (2.5) | 0.7 | 0.2 | 3.4 | 0.1 | −0.3 | 0.2 | −1.2 | −0.05 | 0.239 | |
| Engaged in sex parties/group sex in the past 12 months | |||||||||||
| No | 3.4 (2.6) | 0.021 | |||||||||
| Yes | 3.9 (2.4) | 0.7 | 0.3 | 3.0 | 0.1 | −0.6 | 0.2 | −2.3 | −0.09 | ||
| Engaged in transactional sex in the past 12 months | |||||||||||
| No | 3.4 (2.6) | 0.171 | |||||||||
| Yes | 4.3 (2.4) | 1.3 | 0.2 | 5.3 | 0.1 | 0.3 | 0.2 | 1.3 | 0.05 | ||
| Sleep quality | |||||||||||
| Poor | 3.9 (2.5) | 0.180 | |||||||||
| Adequate | 3.4 (2.4) | −0.7 | 0.2 | −3.3 | −0.1 | −0.3 | 0.2 | −1.3 | −0.04 | ||
| Depressive symptoms | |||||||||||
| None or mild | 3.1 (2.3) | <0.01 | |||||||||
| Moderate to severe | 4.9 (2.4) | 2.6 | 0.2 | 11.5 | 0.3 | 2.2 | 0.2 | 9.5 | 0.3 | ||
Note: B, unstandardized B; s.e., standard error; β, beta coefficients.
Enacted stigma and associated factors
Participants who had concealed their sexual orientation (β = 0.1, P-value = 0.004), had been to sex parties/group sex (β = 0.08, P-value = 0.009), had engaged in transactional sex (β = 0.08, P-value = 0.009) in the past 12 months, had previously engaged in chemsex (β = 0.07, P-value = 0.024) or had depressive symptoms (β = 0.3, P-value <0.01) had higher enacted stigma. Conversely, participants with adequate sleep (β = −0.1, P-value = 0.027) had lower enacted stigma (Table 4).
| Variables | Mean (s.d.) | Unadjusted | Adjusted | P-value | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| B | s.e. | t | ꞵ | B | s.e. | t | β | ||||
| Mean age, years (s.d.) | 27.6 (7.1) | 0.06 | 0.02 | 3.0 | 0.1 | 0.02 | 0.01 | 1.3 | 0.04 | 0.188 | |
| Concealed sexual orientation | |||||||||||
| No | 6.9 (6.2) | 0.004 | |||||||||
| Yes | 9.9 (6.9) | 1.9 | 0.3 | 5.2 | 0.1 | 0.9 | 0.3 | 2.9 | 0.1 | ||
| Ever tested for HIV | |||||||||||
| No | 7.6 (6.5) | 0.530 | |||||||||
| Yes | 9.6 (6.8) | 0.9 | 0.4 | 2.2 | 0.1 | 0.2 | 0.3 | 0.6 | 0.02 | ||
| Engaged in sex parties/group sex in the past 12 months | |||||||||||
| No | 8.3 (6.6) | 0.009 | |||||||||
| Yes | 10.9 (6.9) | 1.9 | 0.3 | 6.2 | 0.2 | 0.8 | 0.3 | 2.6 | 0.08 | ||
| Ever engaged in chemsex | |||||||||||
| No | 3.9 (4.2) | 0.024 | |||||||||
| Yes | 5.9 (4.8) | 1.9 | 0.3 | 5.4 | 0.1 | 0.7 | 0.3 | 2.2 | 0.07 | ||
| Engaged in transactional sex in the past 12 months | |||||||||||
| No | 8.2 (6.7) | 0.009 | |||||||||
| Yes | 11.8 (6.5) | 2.2 | 0.3 | 6.7 | 0.2 | 0.8 | 0.3 | 2.6 | 0.08 | ||
| Sleep quality | |||||||||||
| Poor | 10.3 (6.8) | 0.027 | |||||||||
| Adequate | 7.7 (6.5) | −0.5 | 0.1 | −2.9 | −0.1 | −0.6 | 0.2 | −2.2 | −0.1 | ||
| Depressive symptoms | |||||||||||
| None or mild | 3.9 (4.2) | <0.01 | |||||||||
| Moderate to severe | 8.8 (5.05) | 1.5 | 0.2 | 8.4 | 0.3 | 3.5 | 0.3 | 11.6 | 0.3 | ||
Note: B, unstandardized B; s.e., standard error; β, beta coefficients.
Perceived and enacted stigma and associated factors
Participants who were older (β = 0.06, P-value = 0.045), had to conceal sexual orientation from others (β = 0.1, P-value = 0.002), had engaged in transactional sex (β = 0.01, P-value = 0.005) in the past 12 months or had depressive symptoms (β = 0.4, P-value <0.01) had higher perceived and enacted stigma. Conversely, participants with adequate sleep (β = −0.06, P-value <0.01) had lower perceived and enacted stigma (Table 5).
| Variables | Mean (s.d.) | Crude | Adjusted | P-value | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| B | s.e. | t | ꞵ | B | s.e. | t | β | ||||
| Mean age, years (s.d.) | 27.6 (7.1) | 0.1 | 0.03 | 3.7 | 0.1 | 0.06 | 0.02 | 2.0 | 0.06 | 0.045 | |
| Concealed sexual orientation from others | |||||||||||
| No | 3.1 (2.4) | 0.002 | |||||||||
| Yes | 3.8 (2.6) | 3.1 | 0.6 | 5.4 | 0.2 | 1.6 | 0.5 | 3.1 | 0.1 | ||
| Ever tested for HIV | |||||||||||
| No | 3.1 (2.6) | 0.067 | |||||||||
| Yes | 3.8 (2.5) | 2.0 | 0.6 | 3.3 | 0.1 | 1.0 | 0.5 | 1.8 | 0.05 | ||
| Engaged in anal sex in the past 12 months | |||||||||||
| No | 3.5 (2.6) | 0.282 | |||||||||
| Yes | 4.3 (2.4) | 2.8 | 0.5 | 5.4 | 0.1 | 0.7 | 0.6 | 1.0 | 0.04 | ||
| Engaged in condomless sex in the past 12 months | |||||||||||
| No | 3.5 (2.6) | ||||||||||
| Yes | 4.0 (2.5) | 0.9 | 0.4 | 1.9 | 0.1 | −0.4 | 0.5 | −0.8 | −0.03 | 0.408 | |
| Engaged in sex parties/group sex in the past 12 months | |||||||||||
| No | 3.4 (2.6) | 0.170 | |||||||||
| Yes | 3.9 (2.4) | 2.6 | 0.4 | 5.5 | 0.2 | 0.7 | 0.5 | 1.3 | 0.05 | ||
| Ever engaged in chemsex | |||||||||||
| No | 8.9 (6.7) | ||||||||||
| Yes | 10.5 (7.1) | 1.6 | 0.5 | 3.0 | 0.1 | −0.2 | 0.4 | −0.5 | −0.01 | 0.609 | |
| Engaged in transactional sex in the past 12 months | |||||||||||
| No | 3.4 (2.6) | 0.005 | |||||||||
| Yes | 4.3 (2.4) | 3.6 | 0.5 | 7.0 | 0.2 | 1.4 | 0.5 | 2.8 | 0.1 | ||
| Sleep quality | |||||||||||
| Poor | 3.9 (2.5) | 0.036 | |||||||||
| Adequate | 3.4 (2.4) | −2.5 | 0.4 | −5.2 | −0.1 | −0.9 | 0.4 | −2.1 | −0.06 | ||
| Depressive symptoms | |||||||||||
| None or mild | 3.1 (2.3) | <0.01 | |||||||||
| Moderate to severe | 4.9 (2.4) | 6.8 | 0.4 | 15.3 | 0.4 | 5.8 | 0.5 | 12.8 | 0.4 | ||
Note: B, unstandardized B; s.e., standard error; β, beta coefficients.
Discussion
Our study showed that over half of the participants endorsed each perceived stigma item, and 35–57% had experienced some form of enacted stigma, highlighting the pervasive issue of stigma attached to sexual behavior among GBMSM in Nepal. These findings align with those from prior studies in various geographic settings, including Nepal,36 China,37 Malaysia,38 Senegal,39 Chile40 and the US.41 The traditional cultural norms of Nepal, alongside negative stereotyping, threats and exclusion by family members,42 may have contributed to such stigma. The increased risk of HIV among GBMSM,43 the lack of uniform legal protections44 and the barriers in healthcare services17 may have served to propagate further perceived and enacted stigma. Addressing such stigma in Nepal requires a multifaceted approach that implements, reviews and enforces anti-discrimination laws safeguarding GBMSM rights, and incorporates comprehensive sexual education into school curricula, including information about sexual orientation and the significance of diversity. Utilizing research findings to guide and inform current policies and initiatives is crucial for better meeting the evolving needs of the GBMSM community.
Our study revealed a positive association between age and perceived stigma. In contrast to present findings, an earlier study conducted among MSM living with HIV and who had a history of substance use showed that older MSM were less likely to experience perceived stigma.45 Long-term exposure to social discrimination and cultural norms that prioritize conventional responsibilities, such as marriage and fatherhood,46 may have contributed to a higher degree of perceived stigma among older individuals. According to a recent study conducted in the US, GBMSM have distinct obstacles at different stages of their lives. Their sexual behaviors and experience of stigma are shaped by developmental and sociohistorical factors, and these challenges tend to worsen as they grow older.47 Future studies should examine how age moderates perceived stigma among GBMSM in Nepal.
Our study also revealed that GBMSM who had previously tested for HIV had increased perceived stigma. In support of the present findings, earlier studies also reported similar results.25,45,48 The strong link between HIV status and same-sex behavior, which is already stigmatized,49 may have contributed to the higher perception of stigma among GBMSM in Nepal. Additionally, HIV testing may have heightened the fear of being labeled as promiscuous or sick, thereby reinforcing the stigma surrounding both HIV and sexual orientation. Implementing initiatives to reduce stigma, and improving accessible and nonjudgmental HIV testing and treatment are essential for addressing the heightened perceived stigma among GBMSM who have ever tested for HIV.
Our study further revealed that engagement in anal sex increased perceived stigma among GBMSM. Studies conducted globally support our findings.50–55 The heteronormative mindset and social misconceptions classify male-to-male anal sex behavior as unnatural or immoral, especially in same-sex relationships, which usually exacerbates the perceived stigma.56,57 In addition, negative stereotypes and unfavorable experiences with anal sex behavior might have contributed to the increased perceived stigma. Encouraging the development of good coping skills and emphasizing self-care is imperative to alleviate such stigma.
GBMSM who were involved in sex parties or group sex had a negative association with perceived stigma and a positive association with enacted stigma. A prior study conducted among MSM in the US noted that engaging in sex parties alleviates perceived stigma.58 However, another study reported that engaging in such activities can enhance enacted stigma.59 A recent study reported that involvement in sex parties or group sex is highly correlated with different types of stigma, discrimination and intolerance, regardless of whether in developed or lower- and middle-income countries.54 Involvement in sex parties or group sex might have been normalized and accepted within the participants’ circles, giving the impression that, even though these actions are condemned in broader society, they are not condemned in their immediate community. In addition, participating in such behavior might strengthen men’s collective identity, fostering solidarity and reducing feelings of loneliness, which in turn may result in negative correlations with perceived stigma. Furthermore, it appears plausible that individuals who experienced less stigma were more willing to engage in such behaviors, or, conversely, that engagement in such activities might have altered their views of stigma. However, participation in such behavior might have intensified the enacted stigma on GBMSM in Nepal, as these behaviors defy deeply set cultural norms emphasizing modesty and prudence in sexual issues.60 Moreover, engagement in such activities also increases the possibility of exposure to substance use, which might result in discrimination, public humiliation or rumors,61 and can lead to legal ramifications or police harassment, ultimately escalating enacted stigma.
Engagement in chemsex and transactional sex was positively linked with enacted stigma. Earlier studies also reported similar findings.41,62–64 In connection with inadequate understanding, legal ambiguity and enforcement, and public hostility surrounding chemsex and transactional sex, GBMSM engagement in such behavior is strongly correlated with enacted stigma.62,63 Chemsex is frequently seen as a risky and inappropriate practice that exacerbates discrimination.64 Comparably, transactional sex is highly stigmatized and believed to defy societal standards.65
Our study revealed a negative association between sleep quality and enacted stigma. In support of the present findings, prior studies also reported that sleep quality and stigma have an inverse relationship.66,67 Sleep quality and enacted stigma are inversely associated, as enacted stigma can cause psychological discomfort, anxiety and depression, disrupting sleep patterns.68 In addition, stigmatized GBMSM individuals may suffer increased stress and hypervigilance, which might impede their ability to sleep well, and result in a vicious cycle of stigma and poor sleep quality. Recent research showed that adequate sleep can help minimize stigma by improving psychological well-being, cognitive function and stress resilience.66
Our study revealed that moderate to severe depressive symptoms were positively linked with perceived and enacted stigma. Earlier studies also reported similar results.37,69,70 GBMSM with depressive symptoms often internalize negative social attitudes toward their sexual orientation, which can contribute to feelings of shame, guilt and poor self-esteem,71 resulting in perceived stigma. In addition, depressive symptoms and substance use mostly coexist,72 which might raise the likelihood of engaging in risky behaviors and result in enacted stigma. A recent study reported that GBMSM with depressive symptoms are more susceptible to perceived and enacted stigma, as their depression impairs their ability to cope with stress and unpleasant events,73 making them more susceptible to situations that are perceived as stigmatizing. Integrating culturally compatible mental health services for GBMSM into the healthcare system, along with implementing public awareness initiatives to lessen negative stereotypes, are crucial steps in overcoming such stigmas.
Understanding the routes of stigma could expose its upstream and downstream effects.74 Upstream origins, which include cultural norms and institutional policies that encourage discrimination, may result in downstream manifestations with individual-level repercussions, such as poor mental health outcomes and limited access to social or healthcare services.75 Interventions to combat stigma should therefore emphasize both upstream endeavors, such as transforming discriminatory policies and establishing prominent outreach efforts, as well as downstream approaches that assist GBMSM in dealing with the effects of stigma, including grassroots campaigns, peer support groups and easy access to healthcare settings. Although depression is usually a result of stigma,76 treatments should strive to reduce stigma at its source, and develop inclusive settings that promote mental and social well-being among this vulnerable community.
The present study has a number of strengths. First, this nationwide study in Nepal with a relatively high sample size provides a comprehensive understanding of GBMSMs’ perceived and enacted stigma occurrences in the country. Second, the validity of the findings regarding perceived and enacted stigma is strengthened by the use of validated instruments, such as the Neilands sexual stigma scale. Finally, our study is the first to use this scale, incorporating exploratory factor analysis and sensitivity analysis to measure perceived and enacted stigma among GBMSM in Nepal.
However, our study has several limitations. First, due to the study’s online nature, some participants who were hesitant to participate online, did not have internet access or were hidden, may have been overlooked, which might have resulted in selection bias. Second, for multivariate modeling, our study selected variables based on P-value, which could have excluded important predictors. Third, some of the associations found in our study may be bidirectional. Owing to the cross-sectional nature of our research, we are incapable of identifying the directionality or causation of these correlations. Our findings call for longitudinal research to investigate these potential bidirectional or opposite interactions. Fourth, our study did not investigate possible interactions of relevant factors, which might have impacted the observed results. Fifth, our study mostly used self-reported data, which is subject to recall bias or misreporting, given the delicate nature of the topics at hand, which include sexual conduct and stigmatization. Finally, our study urges an in-depth understanding of the population through a qualitative manner to better examine perceived and enacted stigma.
Conclusion
Our study highlighted a notable presence of perceived and enacted stigma among GBMSM in Nepal. Our findings emphasize the need to target GBMSM who are older, have ever tested for HIV, are involved in sex parties or group sex and chemsex, and have depressive symptoms, as those subgroups are more likely to have higher perceived and enacted stigma scores, rendering them more vulnerable to its deleterious effects. Targeted stigma reduction interventions and policies could be used to alleviate the burden of stigma on vulnerable groups and address barriers to creating an LGBT-friendly community in Nepal.
Data availability
Data from this study may be obtained from the corresponding author upon reasonable request.
Declaration of funding
We acknowledge financial support in part from a career development award from the National Institute on Drug Abuse (K01 DA051346) to Dr Roman Shrestha. The funders had no role in study design, data collection, analysis, manuscript preparation or the decision to publish.
Author contributions
RS designed and conducted the study. MSHS performed the statistical analysis and prepared the initial draft of the manuscript. All authors critically reviewed the manuscript and provided insightful feedback. RS supervised the study. All authors read, reviewed and agreed to the final version of the manuscript.
Acknowledgements
We are grateful to our participants for contributing their valuable time and effort to making the study successful.
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