BY SARAH HOUSEHOLDER
On June 27th, 2015, hundreds of Americans waiting outside the Supreme Court building erupted into cheers as it was announced that the Supreme Court had officially ruled that “same-sex marriage is a legal right.”1 Celebrations across the nation broke out and couples rushed to courthouses to legalize longstanding relationships.
On such a historic day, it is easy to forget that the progress made in the West is not reflected in other parts of the world. With this motion, the US joined the ranks of 21 other countries in Western Europe and the Americas who have legalized same sex marriage.2 However homosexuality is still punishable by death in 5 countries in the world, and by incarceration in 72 others—a legal indication of the scope of intolerance.3 Beyond the well-documented burden of HIV/AIDS in the lesbian, gay, bisexual, and transgender (LGBT) community, the health effects of living in such a stigmatized community as a queer individual are unknown and largely unaddressed. By combining statistics from a region of the world with extreme discrimination, such as Southeast Asia, with data from studies on health consequences within more tolerant countries, a more accurate understanding can be achieved of how, in parts of the world, one’s sexual orientation affects health, and what interventions need to be taken.
Many Southeast Asian countries, including Brunei, Burma, Indonesia, Malaysia, the Philippines, Singapore and Thailand, share several key features, including geographical proximity, agricultural economies and highly religious societies. Though the countries differ in their religious composition, most have a dominant religion of Islam, Buddhism or Christianity, with a significant minority religious group.4 While most countries in the region have HIV/AIDS intervention for the 4-5 million infected men who have sex with men, the true number of LGBT individuals and their specific health outcomes is unknown.5 Research suggests that there are deep psychological and physiological effects of discrimination, which, in these countries, extend from a lack of legal recognition and protection to discrimination in social services, and societal backlash—the latter of which being the least quantifiable, yet the most damaging form of discrimination. Due to a lack of government initiatives and activist organizations for LGBT issues in Southeast Asia, most accounts of discrimination are anecdotal and difficult to generalize. To gain a reliable picture, the US State Department conducted a worldwide survey on Human Rights that helped shed light on the true situation of LGBT rights in the region.
Intolerance is easiest to measure when codified in the law. Queer activities are illegal in 5 of the 7 countries in the region, with consequences ranging from 14 days in jail for cross-dressing in Malaysia to 10 years of imprisonment for men who have sex with men in Brunei. In Indonesia, same gender relationships are not strictly illegal, but homosexual sex is processed under the same law that criminalizes prostitution, and transgender individuals are treated as sex workers in the eyes of the law. Additionally, the lack of protective laws in most countries makes it difficult to prosecute crimes against LGBT persons. Though countries such as Indonesia, Malaysia and the Philippines have anti-discrimination laws, they are silent in regards to violence against LGBT individuals. In Burma and Thailand, law enforcement is often the source of violence, and protection comes at the price of steep bribery.6 It is one thing for individuals to be intolerant; it is quite another to have a legal system invalidate and criminalize someone’s identity, making it dangerous for him/her to access the justice system for fear of facing charges him/herself.
In countries without the threat of incarceration, LGBT individuals are more open, and it is possible to gauge institutionalized discrimination from other sources. In the Philippines and Thailand, where non-heterosexuality is not legally punishable, the US State Department was able to collect more accurate data on discrimination in business and finance. Non-heterosexual respondents reported widespread discrimination in employment, education, access to health care and housing, which impaired them socially and fiscally. In Singapore, even undercover LGBT couples are unable to live together, as the government does not allow single individuals to share housing until the age of 35, meaning couples are not only unable to legalize their partnership, but are unable to even live together.6 Institutionalized discrimination does not solely stem from law enforcement, and, for LGBT persons, sexual orientation complicates all aspects of public life.
But in every country surveyed, the deepest stigma came from communities and families. Most countries in Southeast Asia are primarily agricultural, with tight-knit communities entrenched in tradition and resistant to change. Many perceived benefits of a close community become antagonistic when one breaks tradition, especially in a way that is seen culturally as madness, depravity or sin. In this environment, it is nearly impossible for LGBT individuals to find a supportive community among their peers or elders. In Burma, bullying against LGBT youth often turns violent, occasionally requiring hospitalization. And, due to increased Islamic radicalization in Burma, Malaysia and the Philippines, many areas have become less tolerant in the last five years, with increased violence towards and ostracism of LGBT persons.6 Though judgment from one’s community is challenging, it is easier to manage pressures healthily when supported by close family. The vast majority of LGBT persons in Southeast Asia lack this support. In Indonesia, it is common practice for families of non-heterosexual children to institutionalize them for therapy, confine them to homes, or pressure them to marry early. In Brunei, 89% of LGBT individuals reported experiences of violence within their family.6 What is perhaps the most disturbing is how incomplete, yet horrifying, the glimpses we catch are: without more data, we are left to assume that the forms of societal discrimination in one part of this region are not specific, and are experienced throughout Southeast Asia.
When people are discriminated on the basis of differences in gender, race, religion or nationality, the impact on health and mortality can be quantified from hospital records. Simple statistical analyses show that life expectancies in racially stratified neighborhoods in Baltimore differ as much as 20 years from the richest to the poorest area.7 Queer identities are different: LGBT people are able to conceal their sexuality or gender preference, making it difficult to identify what their health challenges are. Instead, we must rely on Western studies on the effects of stigmatization and assume the documented effects translate across the world to far worse environments.
The root of health consequences from stigmatization is elevated, constant stress. Despite what Yalies say, no one dies from short-term stress, which can actually have positive effects on cardiovascular and psychological health. Long-term stress, however, can have severe chronic health consequences on immune function and mental health. Uncontrollable, unpredictable stress from multiple sources is more dangerous than routine aggression. When someone is able to predict stressful episodes, his/her stress response heightens in preparation for the attack, but quickly returns to baseline, minimizing long-term effects. But without a consistent pattern of discrimination, LGBT persons maintain an elevated level of awareness in preparation for random acts of violence. This heightened stress response causes extreme psychological and physiological consequences.8
The psychological consequences are more comprehensive and also more understood. In 2015, the CDC compared the mental health of LGBT youth in the US who have supportive families to that of youth who feel that their family is either indifferent or actively opposes their sexuality. Youth without familial support were six times more likely to report high levels of depression and eight times more likely to have attempted suicide than youth with supportive families.9 A UCLA study showed the effects went beyond the obvious mental health consequences and also affected personality and emotional intelligence. Experiences of sustained discrimination affected queer individuals’ acquisition of social and personal resources, including a sense of personal mastery, self-esteem and social support—skills necessary for healthy management of daily stressors.10 Without resources to handle mental health issues, psychological effects of discrimination can have a major debilitating effect on the quality of one’s life.
Long-term experiences of stigmatization also have physiological consequences. Long-term intensified stress responses in LGBT individuals have been linked to decreased immune function, higher rates of hypertension and breast cancer, and more drastic cardiovascular responses to stressful situations.8 Additionally, stigmatized individuals are less likely to have healthy habits: LGBT persons without a support system are three times more likely to use illegal drugs and four times more likely to have risky sex.9 LGBT individuals in the US have higher rates of obesity and higher blood pressure than their heterosexual counterparts. Additionally, stigmatized people are less likely to prioritize preventative health and have fewer resources to spend on measures such as cancer screenings and diabetes prevention, leading to increased prevalence of such issues.8 Partially due to stigma and familial pressures, queer individuals are also less likely to form stable monogamous relationships, leading to an increased risk of STIs.9 Bear in mind that all of the data above was collected on queer-identifying US citizens; though their lives have certainly not been free from stigma, most have access to ever increasing social, religious and legal support. At the very least, in the US there are organizations dedicated to helping LGBT persons with identity, bullying, and social issues. We can only imagine how the above health responses might be magnified in a population that is stigmatized in a more universal, violent and permanent way.
Being gay isn’t a risk factor for poor health. Rather, it is low social capital, discrimination, and the threat of violence that causes LGBT individuals to have different health outcomes than straight persons. Actions to combat these health consequences naturally align with human rights efforts and need to involve multiple players with different approaches in order to increase surveillance, decriminalize status, improve social services, and elevate voices in the region.
First and foremost, more data must be acquired and homosexuality must be decriminalized. More information is needed to inform aid organizations on what the scope of the problem is, where it is concentrated, and where they should intervene. Without this knowledge, it is nearly impossible to be effective. As a first step towards better intelligence and assurance of basic human rights, legislation in these countries needs to evolve to not only decriminalize LGBT persons, but also protect them against acts of violence. When prejudices are institutionalized, societal hatred is legitimized and efforts to reduce stigma and violence become much more difficult.
On a different level, civil services need to be made more inclusive and accessible. With today’s conditions, queer people in need of civil services are reluctant to utilize resources due to fear of being reported or receiving discriminate treatment. This is especially true within law enforcement, where officials often become sources of violence towards the victims they are called to support.11 Law enforcement officials need to be trained on how to approach and protect LGBT individuals, and oversight is needed to dissuade abuse. Additionally, many health professionals still view homosexuality as a disease and are ignorant of health concerns specific to transgender patients. In some countries, health professionals are required to report the sexuality of their patients to federal officials, breaching their obligation of confidentiality.12 Changes need to be made to education and policies to ensure that patients can access appropriate care without reluctance to express their sexuality.
But one of the most pressing demands in this situation is the need to mobilize domestic LGBT voices. If local civil society groups were formed, LGBT persons would be able to reach out to at-risk members, advocate for political change, and direct international aid to be more effective.13 International, governmental, and not-for-profit organizations need to encourage these organizations as a necessary way to unite and support LGBT individuals and distribute resources. In order to effectively initiate change, people experiencing conditions firsthand need to be a part of the conversation.
Naturally, the demands above are extremely linked and reliant on each other. That’s part of the challenge: efforts have to be coordinated in several arenas, despite not knowing the true demand. Without reliable data, government support, or country-based organizations, it is extremely difficult to gain momentum and affect change. All that we can assume is that discrimination in intolerant parts of the world, such as Southeast Asia, is causing real psychological and physiological health effects that demand our attention. However, challenges are not indicative of hopelessness, nor grounds for a lack of effort. Change is not impossible: in the last 20 years, nearly 30 countries have decriminalized homosexuality.12 But it is not possible without specifically directing funds and energies to improve the quality of life of LGBT individuals. In global health efforts, most resources go toward ‘low hanging fruit’—interventions that cost less, yet have large potential return. Yet root causes are often still there, causing other complications that majorly affect the quality of life. In order to truly improve the health of this marginalized group, health efforts need to start at the human rights level and work up. It is only by tackling the challenge head on that, someday, the expression of one’s sexuality might be a celebration, instead of a sentence to a harder and unhealthier life.
Sarah Householder is a junior in Berkeley College. She is a Modern Middle Eastern Studies Major and a Global Health Fellow. She can be contacted at firstname.lastname@example.org.
1US Supreme Court rules gay marriage is legal nationwide. (2015). BBC. Retrieved from http://www.bbc.com/news/world-us-canada-33290341
2Masci, D., Sciupac, E., & Lipka, M. (2015). Gay Marriage Around the World. Pew Forum. Retrieved from http://www.pewforum.org/2015/06/26/gay-marriage-around-the-world-2013/
3Rodgers, L., Martin, P. G., Rees, M., & Connor, S. (2014). Where is it illegal to be gay? BBC. Retrieved from http://www.bbc.com/news/world-25927595
4Andaya, B. W. (n.d.). Introduction to Southeast Asia: History, Geography, and Livelihood. Retrieved from http://asiasociety.org/introduction-southeast-asia
5World Health Organization, Regional Office for South-East Asia. (2010). HIV/AIDS among men who have sex with men and transgender populations in South-East Asia. New Delhi, India.
6U.S. Department of State, Bureau of Democracy, Human Rights and Labor. (2015). Country Reports on Human Rights Practices for 2014. Retrieved from http://www.state.gov/j/drl/rls/hrrpt/humanrightsreport/index.htm#wrapper
7Ingraham, C. (2015). 14 Baltimore neighborhoods have lower life expectancies than North Korea. Washington Post. Retrieved from https://www.washingtonpost.com/news/wonk/wp/2015/04/30/baltimores-poorest-residents-die-20-years-earlier-than-its-richest/
8Pascoe, E. A., & Richman, L. S. (2009). Perceived Discrimination and Health: A Meta-Analytic Review. Psycho Bull, 135(4), 531-554.
9Center for Disease Control and Prevention. (2015). Gay and Bisexual Men’s Health: Stigma and Discrimination. Retrieved from http://www.cdc.gov/msmhealth/stigma-and-discrimination.htm
10Mays, V. M., & Cochran, S. D. (2001). Mental Health Correlates of Perceived Discrimination Among Lesbian, Gay, and Bisexual Adults in the United States. American Journal of Public Health, 91(11), 1869-1875.
11UN issues first report on human rights of gay and lesbian people. (2011). UN News Center. Retrieved from http://www.un.org/apps/news/story.asp?NewsID=40743#.VtG3X1srLC0
12World Health Organization. (2013). Agenda from Executive Board 133rd Session: Improving the health and well-being of lesbian, gay, bisexual and transgender persons. Geneva, Switzerland.
13The Henry J. Kaiser Family Foundation. (2014). The U.S. Government and Global LGBT Health: Opportunities and Challenges in the Current Era. Menlo Park, CA: Kates, J.