Coping styles moderate the relationships between general and minority stress and depression among sexual and gender minority populations in Thailand: a cross-sectional study

Abstract

Background:

Sexual and gender minority (SGM) individuals experience elevated rates of depression due to exposure to unique social stressors associated with membership in a stigmatised minority group. Coping style has been shown to buffer or exacerbate responses to stress. To date, little is known about the risk or protective influence of coping styles on the relationships between stressors and depression in SGM populations.

Aims:

To examine the moderating effects of coping styles on the relationships between stressors and depression in Thai SGMs.

Methods:

This cross-sectional descriptive survey was conducted between March and August 2018 using in-person and online surveys. Convenience and snowball recruitment strategies were used. Standardised measures were selected according to the Minority Stress Model. Bivariate and multivariate analyses were conducted. Hayes’s PROCESS macro was used to test for significant interactions.

Results:

Of the 411 participants, 40% of the participants reported symptoms of depression that were associated with multiple stressors. Problem-focused coping was reported by most participants (95.8%), followed by social support (83.1%) and avoidance (49.1%) coping. Problem-focused coping weakened the relationships between stressors and depression, whereas avoidance coping strengthened the relationships between depression and stress, loneliness and discrimination. Social support coping was negatively related to depression, with no statistically significant moderating effects.

Conclusions:

Problem-focused coping served to mitigate the influence of stressors on depression, whereas avoidance coping strategies exacerbated the impact. Nursing interventions aimed at improving problem-focused coping may reduce the negative consequences of stressors on the mental health of SGMs.

Introduction

The World Health Organization (WHO, 2023) estimates that approximately 280 million people experience depression globally and indicates a 25% increase in the prevalence after the COVID-19 pandemic (WHO, 2022). Depression is a significant public health priority given the negative impact on the individual in the form of disability and on society in terms of lost productivity and healthcare costs (WHO, 2017, 2023). Risk factors for depression during the pandemic are consistent with well-established risk factors, including sociodemographic characteristics such as age, biological sex and income (Shah et al., 2021; WHO, 2017). In the past two decades, sexual orientation and gender identity have been identified as additional demographic risk factors for depression (Mongelli et al., 2019). For example, research in Western countries has found that sexual and gender minority (SGM) populations experience depression at 2–4 times higher rates than their heterosexual and cisgender counterparts (Su et al., 2016). As a result of elevated risk, WHO (2023) has called for increased research to understand better the factors contributing to mental health disparities among SGM individuals.

In Thailand, an estimated 1.5 million Thais over the age of 15 (or 3%) are experiencing depressive symptoms, and another 14 million adults (or 19%) have a prior history of depression (The Excellence Center for Depression Disorder, 2022). However, a limited number of studies examining depression among Thai SGMs have been conducted. The results of two descriptive studies suggest that rates of depression in Thai SGMs range from 22.6% to 47.1%, depending on the study sample (e.g. Boonkerd and Rungreangkulkij, 2014; Kittiteerasack et al., 2020b). Additional studies have found that depression rates are higher among Thai transwomen (M = 0.83, SD = 0.71 vs M = 0.52, SD = 0.48, p < 0.001; Yadegarfard et al., 2014) and sexual minority men (OR = 1.85; Sopitarchasak et al., 2017) compared to cisgender women and men.

The World Population Review (2024) estimates that 8% of Thai individuals identify as SGM. The Tourism Authority of Thailand describes Thailand as an SGM-friendly country (The Nation, 2023); however, widespread social acceptance of non-traditional sexualities remains low (Stonewall Global Workplace Briefings, 2019). As a result, many Thai SGM individuals gravitate towards larger cities due to more liberal attitudes in urban areas; nevertheless, experiencing social stigma and discrimination remain common (Kittiteerasack et al., 2021b). Biased attitudes towards SGM populations have been associated with reduced educational and employment opportunities, poor family relationships and barriers to equitable access to healthcare, religious worship and safe environments (United Nations Development Programme, United States Agency for International Development, 2014). The resulting pressures significantly increase the risk of depression among SGM individuals compared to their heterosexual and cisgender counterparts (Newman et al., 2021).

Most research on SGM mental health outcomes has been informed by the Minority Stress Model (MSM; Meyer, 2003). The MSM hypothesises that members of stigmatised minority groups are at elevated risk for poor mental health due to higher stress exposure levels (Kittiteerasack and Matthews, 2019). In addition to the general stressors experienced by many adults (e.g. economic concerns and relationship problems), SGM individuals are also exposed to unique sources of minority-specific stressors, including internalised self-stigma (Herek et al., 2009; Michaels et al., 2016), identity concealment (Michaels et al., 2016; Mohr and Fassinger, 2000), victimisation (Mereish et al., 2014) and various forms of identity-based discrimination (Krieger et al., 2005; Michaels et al., 2016). Each of these risk factors has been associated with elevated rates of depression among SGM populations (Baams et al., 2018; Kittiteerasack et al., 2020b; Meyer, 2003).

The MSM framework also posits that individual coping responses may modify the influences of multiple stressors on mental health outcomes, either by exacerbating or reducing the negative impact (Meyer, 2003). The coping literature identifies three coping styles: problem-focused, avoidance-focused and social support-focused coping (Folkman, 2014; Lazarus, 2006; Zimmer-Gembeck and Skinner, 2011). Problem-focused coping is aimed at taking direct actions to resolve the underlying causes of the stress (Folkman, 2014; Lazarus, 2006). Alternatively, avoidance-focused coping refers to engagement in strategies that allow an individual to avoid the source or consequences of the stressor (Folkman, 2014; Lazarus, 2006). Finally, social support coping aims to seek tangible assistance from others following a stressful event (Zimmer-Gembeck and Skinner, 2011).

Consistent with this literature, studies in the United States have demonstrated the buffering roles of coping strategies between stressors and depression in SGM individuals (Baams et al., 2018; Mongelli et al., 2019). Research in Thailand has also established the relationship between coping responses and depression among SGM populations. For example, Kittiteerasack et al. (2020b) found that depression was positively and statistically significantly associated with avoidance coping (r = 0.48) but negatively associated with problem-focused (r = −0.35) and social support coping (r = −0.20). Other researchers have found that lesbians who used emotional-focused and maladaptive coping in response to stress reported higher levels of depression compared to those who did not use emotional-focused and maladaptive responses (Boonkerd and Rungreangkulkij, 2014).

Since 2018, the American Nursing Association (ANA Center for Ethics and Human Rights, 2018) has advocated for the fair and equitable treatment of SGM populations in healthcare settings. Other well-established organisations, such as the Institutes of Medicine (Garofalo, 2011), have called for more rigorously conducted research to understand factors associated with mental and physical health outcomes in SGM populations. The established literature points to the importance of understanding coping styles as a modifiable variable in depression treatment interventions for SGM populations. However, systematic research in Thailand to develop nursing interventions tailored for SGM individuals with depression remains limited (Kalka et al., 2015). Previous research studies underscore the need for SGM-sensitive approaches to enhance inclusivity and culturally competent care within healthcare settings (Ojanen, 2015; Ojanen et al., 2016). As such, this knowledge gap impedes the development of effective interventions. Consequently, further research is needed to examine the risk and protective factors associated with depression among Thai SGM individuals, thereby informing the creation of effective nursing interventions.

Guided by the MSM framework, the objective of this study was to examine whether coping styles (problem-focused, avoidance-focused and social support-focused) moderated the relationships between general stress (stress and loneliness) and minority-related stressors (SGM identity discrimination, discrimination in various social situations, victimisation experiences, SGM identity concealment and internalised homophobia) on depression among Thai SGM adults.

Methodology

Design

Data for this secondary analysis study were drawn from a more extensive cross-sectional descriptive research study examining the prevalence of mental health disparities among SGM populations across Thailand. The data for the primary study were collected between March and August 2018 and were approved by the Institutional Review Board at the University of Illinois Chicago (No. 2017-1182) and the Rainbow Sky Association of Thailand or RSAT (No. 153/2560). The primary study found a high prevalence of depression among SGM participants, with 40.3% of the sample meeting the threshold for clinically significant symptoms of depression. In addition to current depressive symptomatology, rates of suicidality were also elevated, including self-reported rates of ever-experiencing suicidal ideation (39%), past year suicidal ideation (19.0%) and a prior history of a suicide attempt (13.1%; see Kittiteerasack et al., 2021b for a full description of procedures and results).

Setting

This study was conducted with RSAT, a large community-based organisation serving Thai SGM communities’ health and social service needs. RSAT has seven clinics located throughout Thailand. To increase the diversity and generalisability of the study sample, recruitment and data collection activities were conducted at each of the geographically dispersed clinic locations.

Participants

Eligible study participants were Thai adults who were (1) aged 18–60 years, (2) identified as SGM and (3) were able to read and write in the Thai language. Since the size of the Thai SGM population is unknown, a conservative approach to estimating the sample size was applied. Guided by Cochran (1953), we used a 50% prevalence rate of depression to determine the most robust sample size. Three hundred and eighty-four participants were required to assess any proportion of depression with a 5% margin of error or smaller at the 95% confidence level. In this study, N = 458 participants accessed the survey (online N = 170, in-person N = 288). Of those, N = 411 (89.7%) consented and completed the survey. The obtained sample size was sufficient to conduct the proposed multivariate analyses.

Recruitment processes

A convenience sample was recruited using a range of strategies appropriate for obtaining a sample of SGM adults (Matthews et al., 2018), including community-based (i.e. distribution of posters and flyers), clinic-based (i.e. recruitment at RSAT clinic locations), venue-based (i.e. distribution of information cards at SGM serving coffee-shops, etc), social media strategies (i.e. Facebook page, SGM online meet-up groups) and snowball recruitment (i.e. providing recruitment information to study participants). Interested individuals who did not meet the criteria were excluded from the study. Those who met study eligibility were given the opportunity to participate via a link to an online survey or completion of a paper and pencil survey at one of the RSAT clinic locations.

Data collection

Study participation was voluntary, and all survey responses were anonymous and confidential. All eligible individuals provided informed consent before enrolling in the study. Online and in-person surveys were used for data collection. In the online version of the survey, the study questionnaires were completed using a secured Qualtrics program (Snow and Mann, 2013). Each participant was assigned a unique ID number, and the dataset was securely stored using password protection. In the paper–pencil version of the survey, potential participants were approached and given an overview of the study. After providing informed consent, individuals completed the self-administered survey at one of the RSAT clinic locations. All participants were provided recruitment materials to share with others interested in the study to facilitate further recruitment. All completed surveys were kept in a locked private cabinet and were entered or exported to SPSS daily.

Measures

Standardised measures consistent with the constructs associated with the MSM (Meyer, 2003) were used as follows:

Demographic characteristics

Demographic information collected in this study included age, sexual orientation, gender identity (SOGI), education, income, health insurance coverage, smoking status, alcohol consumption and drug use. Standardised measures of SOGI were measured, including: (1) biological sex, ‘What sex were you assigned at birth, meaning the sex listed on your original birth certificate?’ (Response options = male, female); (2) sexual orientation, ‘Do you consider yourself to be?’ (Response options = heterosexual, homosexual, or bisexual) and (3) gender identity, ‘What is your current gender identity?’ (Response options = male, female, transgender man, transgender woman, questioning and others; Gender Identity in U.S. Surveillance Group, 2014). Consistent with the recommendations of the GenIUSS Group (Gender Identity in U.S. Surveillance Group, 2014), biological males and females whose gender correspond to their biological sex at birth were categorised as cisgender, and the remaining responses were categorised as transgender. The SOGI measures were translated into a Thai version and tested among a diverse sample of Thai adults (n = 282), which showed high linguistic comprehension/acceptability and content validity (I-CVI = 1, S-CVI/Ave = 1; Kittiteerasack et al., 2019).

General stress

In this study, measures of stress included levels of general stress and loneliness. General stress levels were measured by the Srithanya Stress Test (ST-5), a standardised measure for use in Thailand developed by the Department of Mental Health, Ministry of Public Health, Thailand (Silpakit, 2012). The ST-5 comprises five questions rated on a 4-point Likert scale (0 = never to 3 = usually). Scores ranged from 0 to 15, with higher scores indicating a greater stress level (Cronbach alpha = 0.87). The conciseness and comprehensive coverage of stress symptoms of ST-5 make it a popular choice for national and international research (Department of Mental Health, Ministry of Public Health, 2023).

The UCLA Loneliness Scale (UCLA-LS 3; Russell, 1996) measured loneliness levels, including 20 items rated on a 4-point Likert scale (1 = never to 4 = often). Scores ranged from 1 to 4, with the higher scores representing higher levels of loneliness (Cronbach alpha = 0.90). Designed to assess loneliness across diverse situations, the UCLA-LS 3 has strong psychometric properties. This has led to widespread adoption in nursing research and other fields nationwide (Nuntachai, 1991).

Minority-related stress

Multiple minority-related stressors included SGM identity discrimination, discrimination in various social situations, victimisation experiences, identity concealment and internalised homophobia (Meyer, 2003).

The nine-item situation version of the Experiences of Discrimination Scale (EOD) measured discrimination in social situations. The EOD measures experiences of discrimination across several situations (i.e. school and workplace; Krieger et al., 2005). The original EOD scale was chosen given its established use in SGM research (Krieger et al., 2005). A committee of experts translated it into Thai to ensure it accurately reflects the Thai context. Three additional questions capturing discrimination towards SGMs in Thai settings were added, including at home, in religious settings and by blood/organ donation organisations. Response options were 0 = No, 1 = Yes and were summed across items. Scores ranged from 0 to 12, with higher scores indicating more situations where an individual has experienced discrimination. The EOD Thai version had high internal consistency reliability (Cronbach alpha = 0.86; Kittiteerasack et al., 2020a).

SGM identity discrimination was measured by the three questions asking whether each respondent had ever experienced any social discrimination based on their SGM identity. The questions were designed to capture direct experiences of discrimination that were perceived to be related to the individual’s sexual orientation, gender identity or gender expression. A total of three items were asked, including, ‘Do you think the discrimination you experienced was due to your (1) sexual orientation, (2) gender identity or (3) gender expression?’. Response options were 0 = No and 1 = Yes and were summed across items. Scores ranged from 0 to 3, with higher scores indicating more experiences of identity-based discrimination. The questionnaires have been reviewed by measurement and SGM experts to ensure the validity of the measures (Kittiteerasack et al., 2021b).

Victimisation was measured using two items evaluating victimisation experiences due to an SGM identity. The questions were created to measure victimisation experiences before and after age 18. Each participant was asked, ‘Had you ever been victimised or harassed for being SGM before 18?’ and/or ‘after 18?’. Response options were 0 = never happened, 1 = sometimes happened, 2 = often happened and 3 = happened almost daily. Responses were then recoded into 0 = never happened and 1 = happened. Scores ranged from 0 to 2, with higher scores representing more victimisation experiences due to having an SGM identity. The questionnaires have also been reviewed by experts in measurement and SGM knowledge to confirm the validity of the items (Kittiteerasack et al., 2021b).

SGM Identity Concealment was measured by the 11-item Outness Inventory, which assesses the level to which others know about one’s SGM, including society, family and religion (Mohr and Fassinger, 2000). In this study, the two original religious questions (leaders of my religious community and members of my religious community) were merged into one item (leaders and members of my religious community) based on Thai culture. Response options were a 7-point Likert scale ranging from 1 (person definitely does NOT know about your sexual orientation status) to 7 (person definitely knows about your sexual orientation status, and it is OPENLY talked about). Total scores ranged from 0 to 10, with higher scores indicating greater self-disclosure or ‘outness’ about one’s identity (Cronbach alpha = 0.94; Kittiteerasack et al., 2021b).

Internalised homophobia was measured by the Revised Internalised Homophobia Scale (IHP-R), which measures the extent to which negative attitudes about SGM individuals have been internalised and applied to oneself (Herek et al., 2009). The 5-items were rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Scores range from 1 to 5, with higher scores indicating higher levels of negative self-attitudes. A committee of experts adapted and translated the IHP-R into Thai, ensuring the questions were appropriate for a broad spectrum of SGM individuals. Subsequent evaluation confirmed strong psychometric properties, demonstrating the validity and reliability at a level consistent with high-quality measures (CVI = 1, Cronbach alpha = 0.87; Kittiteerasack et al., 2021a).

Coping styles

The 25-item Coping Scale (CS) survey was used to measure coping styles (Suphamongkhon and Kotrajaras, 2004). The CS Thai version is divided into three subscales: problem-focused, avoidance and social support coping. Response options were rated on a 5-point Likert-type scale (1 = none to 5 = usually). The aggregate is calculated to estimate a total score of each subscale ranging from 12 to 60 for problem-focused coping, 9–45 for avoidance coping and 4–40 for social support coping. The mean score (1–5) of each subscale indicates the level of using each coping mechanism (1.00–2.49 = less use, 2.50–2.99 = less to moderate use, 3.00–3.49 = moderate to high use and 3.50–5.00 = high use). The Cronbach alpha of problem-focused, avoidance and seeking social support coping subscales were 0.87, 0.84 and 0.77, respectively.

Depression

This study outcome was measured using the 21-item Beck Depression Inventory (BDI; Beck et al., 1988). Responses range from 0 to 3, making scores range from 0 to 63. Higher scores indicate a greater level of depression (0–9 = normal, 10–15 = mild depression, 16–19 = mild-to-moderate depression, 20–29 = moderate-to-severe depression and 30–63 = severe depression). In this study, the item asking the passive/active suicide question was excluded due to redundancy with other suicide questions from the main study. This suicide question contributed 1.48% to the total scores in one clinical study and is considered the least likely item to be endorsed of all BDI questions (Gale and Hawley, 2001). The process to estimate the 20-item BDI total score (score range 0–60) yielded scores identical to ours for BDI scores under 34 and 1 point more for scores of 34 and higher. This result suggests that the 20-item BDI measure was appropriate for use (Cronbach alpha = 0.92).

Data analysis

The study data were analysed using SPSS. Standard descriptive statistics (frequencies, percentages, means and standard deviations) were conducted. Participants with missing data were not included in these analyses. Firstly, we performed bivariate analyses (chi-square and t-tests) to examine the associations between sociodemographic variables and general and minority-related stressors with depression outcomes. The purposeful selection model-building strategy was applied to select study control variables (Bursac et al., 2008). This procedure allows for the screening-in of variables based on bivariate tests and removal of non-significant variables in the multivariable model after assessment of confounding, yielding a parsimonious set of covariates from among variables previously known to be related to depression. Lastly, covariate variables included age, health insurance coverage and alcohol consumption.

Multiple regression analyses were then conducted using the predictor variables that showed bivariate associations with depression. After adjusting for sociodemographic covariates, stress, loneliness, discrimination in social situations and SGM identity concealment remained significantly associated with depression and were examined for moderation analyses. Next, interactions of stress and coping (problem-, avoidance- and social support-focused coping strategies) were added to the models to test moderation, controlling for covariates. Separate models were used for each stress variable (4) by each coping measure (3) for 12 models. Interaction effects were tested by a statistically significant increment in R² and Wald test for β weights. Hayes’s PROCESS macro for SPSS was used to probe significant interactions (Hayes, 2017).

Results

Demographic characteristics: Table 1 summarises the sample characteristics (N = 411). The mean age of participants was 29.51 years (SD = 7.43). Most participants reported their sexual orientation as homosexual (79.3%) and their gender identity as cisgender (76.6%). Education levels were high, with 77.2% of the sample reporting at least a college degree. Despite high levels of education, 50.2% of participants reported not having health insurance coverage.

Table 1.

Participant characteristics (N = 411).

Demographic factors	N	%	M	SD
Age			29.51	7.43
Education
High school diploma	94	22.9
Bachelor’s degree	244	59.4
Graduate degree	73	17.8
Income
<10,000 THB	84	20.4
10,001–20,000 THB	118	28.7
20,001–30,000 THB	89	21.7
30,001–40,000 THB	53	12.9
>40,001 THB	67	16.3
Health insurance
Insured	204	49.8
Uninsured	206	50.2
Biological sex
Male	372	90.5
Female	39	9.5
Sexual orientation
Heterosexual	23	5.6
Homosexual	326	79.3
Bisexual	62	15.1
Gender identity
Cisgender	315	76.6
Transgender	96	23.4
Smoking status
Current smoker	48	11.7
Former smoker	67	16.3
Never smoker	296	72
Frequency of alcohol use
Several times a week	33	8
Several times a month	74	18
Once a month or less	190	46.2
Not at all	114	27.7
Drug use
Yes	52	12.7
No	359	87.3
General life stressors
Level of stress			5.48	3.42
Loneliness			1.93	0.56
Minority-specific stressors
LGBT identity discrimination
None	189	46.3
One	60	14.7
Two	51	12.5
Three	108	26.5
Discrimination from social situation			1.90	2.69
Perceived victimisation
Before age 18	294	71.5
After age 18	234	56.9
Both before and after age 18	215	52.3
LGBT identity concealment			4.67	1.72
Internalised homophobia			2.40	1.06
Depression			9.46	8.43

M: mean score; SD: standard deviation.

Depression and minority stress: The mean score for depression for the entire sample was 9.46 (SD = 8.43), which is in the normal range. However, 40.3% of participants met the criteria for clinically significant levels of depression (scores > 9). General and minority-related stressors were common among participants. Approximately half of all respondents endorsed moderate-to-severe levels of stress and loneliness (57.4%, M = 5.48, SD = 3.42 and 42.3%, M = 1.93, SD = 0.56, respectively). Most participants (53.7%) reported discrimination based on their sexual orientation or gender identity. Gender expression (43.1%) was the most endorsed reason for the discriminatory experience. More than half (56.9%) of participants reported experiencing discrimination in social situations, with school being the most common situation in which discrimination was experienced (38.9%). Victimisation experiences were high, with 71.5% of participants reporting experiencing victimisation or harassment before age 18, 56.9% after age 18, and 52.31% during both periods. The mean scores for sexual identity concealment were 4.67 (SD = 1.72). Participants were most likely to disclose to their mothers (56.6%) and family members (49.5%). Mean scores for internalised homophobia were in the average range (M = 2.40, SD = 1.06). Depression levels were also associated with general and minority-related stress in bivariate analyses, including levels of stress (r = 0.56, p = 0.01), loneliness (r = 0.53, p = 0.01), SGM identity discrimination (F (3, 403) = 2.928, p = 0.034), discrimination in social situations (r = 0.24, p = 0.01), SGM identity concealment (r = −0.14, p = 0.01) and internalised homophobia (r = 0.18, p = 0.01). Victimisation experiences were not statistically significantly related to depression outcomes.

Depression and coping response: Most participants reported problem-focused coping in the moderate to high range as a strategy for managing stress (95.8%, M = 3.98, SD = 0.57), followed by social support (83.1%) and avoidance coping (49.1%). Results of bivariate analyses indicated that avoidance-focused coping strategy was positively associated with levels of depression (r = 0.48, p = 0.01). However, lower levels of using problem-focused coping and social support-focused coping strategies were negatively associated with levels of depressive symptoms (r = −0.35, p = 0.01; r = −0.20, p = 0.01, respectively).

Interaction effects: Multiple regression models with covariate adjustment were used to finalise stress predictors before testing interaction effects. Minority stress variables that remained statistically significant in adjusted models included general stress, loneliness, discrimination in social situations and SGM identity concealment. Table 2 displays the results of interaction effects from multiple regression analyses with each pair of significant stressors and moderating variables. Among models testing moderating effects of problem-focused coping testing, only the stress-by-problem-focused coping interaction was statistically significant (R² = .495, (F (11, 383) = 34.17, p < 0.001), with higher levels of problem-focused coping attenuating the relationship of stress on depression outcomes (β = −0.669, p < 0.05). In Figure 1, stress–depression slopes are shown for three levels of coping strategies (low, moderate and high) corresponding to 16th, 50th and 83rd percentiles. SGM participants who used the lowest level of problem-focused coping (3.33) showed the strongest relationship between stress and depression compared to the groups using moderate (4.00) and high (4.58) problem-focused coping (Figure 1(a)).

Table 2.

Summary effects of general and minority stress on depression moderated by coping strategies controlling for demographic factors.

No.	Interaction affects	B	SE B	β	p	Model
Problem-focused coping (PFC)
1	PFC × Stress	−0.432	0.137	−0.669	0.002*	F (11, 383) = 34.17 p < 0.001, R2 = 0.495
2	PFC × Loneliness	−1.031	0.901	−0.256	0.253	ns
3	PFC × Social discrimination	−0.352	0.183	−0.454	0.055	ns
4	PFC × LGBT identity outness	0.216	0.313	0.201	0.491	ns
Avoidance coping (AVC)
5	AVC × Stress	0.221	0.108	0.347	0.041*	F (11, 383) = 34.10 p < 0.001, R2 = 0.495
6	AVC × Loneliness	1.810	0.696	0.592	0.010*	F (11, 383) = 34.56 p < 0.001, R2 = 0.498
7	AVC × Social discrimination	0.340	0.162	0.377	0.037*	F (11, 383) = 34.13 p < 0.001, R2 = 0.495
8	AVC × LGBT identity outness	0.112	0.223	0.084	0.614	ns
Social support coping (SSC)
9	SSC × Stress	−0.101	0.100	−0.143	0.315	ns
10	SSC × Loneliness	−0.858	0.594	−0.220	0.149	ns
11	SSC × Social discrimination	−0.150	0.156	−0.186	0.336	ns
12	SSC × LGBT identity outness	0.125	0.243	0.115	0.513	ns

B: unstandardised parameter estimates; SE: standard error; β: standardised coefficient; p: p-value; ns: not significant; control variables: age, health insurance coverage and alcohol consumption.

Figure 1.

(a) Stress levels by problem-focused coping on depression. (b) Stress levels by avoidance-focused coping on depression. (c) Loneliness levels by avoidance-focused coping on depression (d) Discrimination from social situations by avoidance-focused coping on depression

Between four models testing for interaction effects of avoidance coping, there was a statistically significant interaction effect with stress levels (β = 0.347, p < 0.05; R² = 0.495, F(11, 383) = 34.10, p < 0.001), loneliness levels (β = 0.592, p < 0.05; R² = .498, F (11, 383) = 34.56, p < 0.001) and discrimination in social situations (β = 0.377, p < 0.05; R² = .495, F (11, 383) = 34.13, p < 0.001) on depression. In each case, the use of an avoidance coping response increased the negative effect of these stressors on the level of depression. Participants with higher avoidance coping (3.78) showed higher depression scores related to stress, loneliness and discrimination from social situations compared to those who reported using lower avoidance coping responses (2.89, 2.00) (Figures 1(b)–(d)). Social support coping was negatively related to depression in multivariate models (data not shown). However, interactions between this coping strategy and general/minority-related stressors were statistically insignificant, indicating no moderating effects.

Discussion

Coping response strongly predicts emotional well-being following various stressors (Li et al., 2012). The MSM, consistent with general stress theory, posits that coping responses can buffer the effects of minority stress on mental health outcomes. The current study is the first in Thailand to examine the moderating effects of coping styles on the relationships between multiple stressors and depression among SGM individuals. Consistent with the extant literature on the mental health of SGM individuals, depression was common, with more than 40% of our study participants endorsing clinically significant levels of depression (Boonkerd and Rungreangkulkij, 2014; Kittiteerasack et al., 2020b; Su et al., 2016). In line with the MSM theory and established SGM studies in Thailand and the United States, minority-related stressors contribute to poor mental health outcomes (Baams et al., 2018; Kittiteerasack et al., 2021b; Mereish et al., 2014). In the current study, SGM individuals who had experienced identity-based discrimination, discrimination in social situations, higher levels of concealment and internalised homophobia reported higher levels of depression. Our findings contribute to a growing body of research on the influence of minority stressors as a leading cause of depression among SGM populations (Baams et al., 2018; Kittiteerasack et al., 2020b; Michaels et al., 2016).

The primary focus of this study was to examine the extent to which coping strategies altered the influence of general and minority-related stressors on depressive scores. As posited by Lazarus (2006), we found that problem-focused coping served as a protective factor and reduced the influence of stress on depression levels among participants. These findings aligned with established SGM studies affirming problem-focused coping as a protective factor in reducing depression (Keng and Liew, 2017; Toomey et al., 2018). On the other hand, avoidance coping served as a risk factor for elevated levels of depression, such that the level of depression was higher among SGM individuals who used avoidance coping in response to stress, loneliness and social discrimination. Avoidance of the source or consequence of a stressor is viewed as a maladaptive form of coping. It has been linked to depressive symptoms among the general population (Roohafza et al., 2014), the literature on SGM populations in Thailand (Boonkerd and Rungreangkulkij, 2014; Kittiteerasack et al., 2020b) and SGM populations in other countries (Seelman et al., 2017; Toomey et al., 2018).

Counter to the existing literature, social support coping did not moderate the influence of minority stressors on depression outcomes. Among our study participants, SGM identity concealment was high, even among family members. Consequently, the availability of support for coping with SGM-specific stressors from naturally occurring support systems, such as families, would be limited. Research findings suggest that receipt of social support as a form of coping is contingent on others being open and receptive to the individual seeking support (Ren et al., 2018). Given overt hostilities and lack of acceptance, it may be difficult for SGM individuals experiencing mental health difficulties to seek support from family and friends. Furthermore, high rates of social discrimination and the lack of laws protecting SGM rights may limit the availability and use of social support resources (United Nations Development Programme, United States Agency for International Development, 2014). In the United States, previous studies have recognised the role of social support coping as a resiliency factor in depression (McDonald, 2018). However, this is the first study to examine the moderation effects of coping styles on depression in Thai SGM populations. Additional research examining the role of social support in coping with depression is needed.

Implications

The study highlights the importance of understanding coping strategies among SGM individuals in response to minority stressors. Future research should further explore the factors influencing the choice of coping strategies and their effectiveness in different contexts. The current study is cross-sectional, providing a snapshot of associations. Longitudinal research could offer insights into the causal relationships between minority stressors, coping styles and depression over time. Furthermore, study results have important implications for the development of strategies for reducing the risk of depression and subsequent risk of suicide among SGM individuals. The risk for depression is extremely high in the current sample. Professional nurses in clinic and community settings should create effective approaches to screen for depression among SGM-identified clients and patients. Cultural competency training is also needed to help nurses avoid implicit bias and overtly discriminatory actions, understand SGM patients’ unique mental health issues and provide evidence-based and effective care. Based on the observed importance of coping responses, mental health interventions should focus on increasing the use of problem-focused coping responses by SGM individuals when confronted with general and minority-related sources of stress. Interventions that teach stress-reduction techniques, particularly problem-focused coping skills, could help SGM individuals manage minority-related stressors more effectively and reduce the risk of depression.

Limitations

This study is not without limitations. Although we collected data from a large volunteer sample of SGM participants living throughout Thailand, using a nonprobability sampling approach may have limited the generalisability of study findings. As can be seen, cisgender gay men and high educational attainment were overrepresented in this study. Future research studies should increase the use of effective strategies to recruit a more diverse sample of sexual and gender identity groups (e.g. lesbian/bisexual women and transgender participants) by collaborating with multiple SGM organisations, such as the Anjaree Foundation and Tangerine Clinic and educational attainment by networking with lay persons in the communities. Standardised measures with good psychometric properties were used to measure study constructs. However, key predictor and outcome variables were based on self-report. Although self-reported measures are common in behavioural and other non-clinical research studies, outcomes may over or under-represent actual rates. Finally, this cross-sectional descriptive research design limits cause and effect analysis. As such, study results need to be replicated to confirm observed associations.

Conclusions

Depression rates were prevalent among SGM participants. Minority-related stress variables have been demonstrated to have a detrimental effect on the mental health and well-being of SGM individuals. Consistent with the Minority Stress and Coping Theories, coping responses utilised in response to stressful life events had important implications for resulting mental health outcomes. Specifically, problem-focused and avoidance coping strategies significantly influenced the effect of general/minority-related stressors on depression outcomes. These study results make an important contribution to the growing literature on the mental health of SGM adults in Thailand and have implications for developing intervention approaches for SGM individuals.

Key points for policy, practice and/or research.

• The results from the study, among the first in Asian countries, reported that problem-focused coping is the most commonly used approach in sexual and gender minority individuals, followed by social support coping and avoidance-focused coping.

• Problem-focused coping weakens the relationship between stressors and depression, whereas avoidance-focused coping strengthens the relationship between stressors and depression among SGM individuals.

• Nursing intervention aimed at increasing the use of problem-focused coping and reducing avoidance coping in response to multiple stressors are key to reducing levels of depression among sexual and gender minority populations.

Biography

Priyoth Kittiteerasack is a mental health and psychiatric nurse and assistant professor at the Faculty of Nursing, Thammasat University, Thailand. His research focuses on mental health disparities among sexual and gender minority individuals, especially depression and suicidal behavior.

Alana Steffen is a research associate professor and senior biostatistician at the Department of Population Health Nursing Science, University of Illinois at Chicago.

Alicia K Matthews is nationally and internationally known for his health disparities research with underserved populations with over 25 years of research experience.