Mental health status of LGBT in Kathmandu, Nepal and the role of victimisation, discrimination, connectedness and identity affirmation: a cross-sectional study

Abstract

Background

Lesbian, gay, bisexual and transgender (LGBT) individuals are among the most oppressed, least visible and marginalised groups in Nepal. They endure persistent social marginalisation, harsh discrimination and violence in both public and private settings. Gender-related discrimination, victimisation, rejection, non-affirmation, internalised transphobia, negative expectations and non-disclosure have been linked with mental health problems among LGBT people throughout the world.

Methods

This study used a quantitative research method with a cross-sectional, descriptive and analytical design to study the LGBT population in the Kathmandu Valley. The standard tools, Gender Minority and Stress Resilience Measure and Depression, Anxiety and Stress Scale (DASS-21) were used to collect the data of 115 LGBT people through snowball sampling. The collected data were entered and analysed using SPSS IBM V.22.

Result

The participants in the study reported experiencing normal, mild, moderate, severe and extremely severe forms of stress (68.7%), anxiety (81.7%) and depression (82.6%) based on DASS-21 severity classification (normal, mild, moderate, severe and extremely severe). The research shows that more than 78% LGBT people faced gender-related discrimination, more than 87% LGBT people faced gender-related rejection and 94.8% faced gender-related victimisation at some point in their lives. The binary and multiple logistic regression analysis found that internalised transphobia is significantly associated with increased odds of stress (adjusted OR (AOR)=2.79, 95% CI 1.14 to 6.83, p=0.024). Similarly, experiencing discrimination (AOR=3.83, 95% CI 1.415 to 10.346, p=0.01), rejection (AOR=4.610, 95% CI 1.129 to 18.818, p=0.033) and stigmatisation (AOR=8.907, 95% CI 0.894 to 88.756, p=0.062) is significantly associated with anxiety. Additionally, experiencing rejection (AOR=6.081, p=0.010, 95% CI 1.541 to 23.992) and stigmatisation (AOR=5.113, p=0.009, 95% CI 1.506 to 17.366) is significantly associated with increased odds of depression.

Conclusion

Based on the results of this research, it can be concluded that a high percentage of LGBT individuals experience stress, anxiety and depression, and it is associated with gender-related discrimination, rejection, victimisation and internalised transphobia.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Lesbian, gay, bisexual and transgender (LGBT) individuals are among the most oppressed, least visible and marginalised groups in Nepal.

WHAT THIS STUDY ADDS

• The research shows that more than 78% LGBT people faced gender-related discrimination, more than 87% LGBT people faced gender-related rejection and 94.8% faced gender-related victimisation at some point in their life, resulting in mild, moderate, severe and extremely severe forms of stress (68.1%), anxiety (81.7%) and depression (82.6%).

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Addressing the mental health risks faced by LGBT individuals due to gender-related discrimination, rejection, victimisation and internalised transphobia requires a comprehensive approach involving government, Non governmental organizations (NGOs), educational institutions, healthcare providers and individuals. Policymakers can use this data to design interventions that help to make health institutions, education institutions and workplaces LGBT friendly, so that LGBT people can also enjoy all their rights in a safe and supportive environment. Future research should explore the in-depth experiences of the LGBT in Nepal.

Introduction

Gender identity is the person’s internal experience of gender that may or may not align with the sex assigned at birth.¹ It includes cisgender and transgender. Sexual orientation refers to who the person is attracted to romantically, emotionally and sexually. It includes gay, bisexual and lesbian. Lesbian, gay, bisexual and transgender (LGBT) is a term that represents different gender and sexual identities.² LGBT individuals are among the most oppressed, least visible, and marginalised groups in Nepal.³ LGBT individuals endure persistent social marginalisation, harsh discrimination and violence in both public and private settings.³ Due to the pervasiveness of heteronormative gender roles in society, very few Lesbian, gay, bisexual, transgender, intersex, queer and other sexual and gender identities (LGBTIQ+) people can expect acceptance from their families.³ Medical facilities, educational institutions, workplaces and governmental offices all exhibit this discriminating atmosphere.³ Therefore, they are less likely to seek health services, access quality education and find jobs leading to poor mental health outcomes.⁴ Although the Universal Declaration of Human Rights states, ‘All human beings are born free and equal in dignity and rights’. Homophobia, stigma and discrimination continue to affect LGBT people just because of their gender identity and sexual orientation making them more vulnerable to violence such as bullying, teasing and harassment.⁵ Thus, LGBT people encounter typical and specific obstacles to enjoying the highest attainable standard of health, quality education and employment based on sexual orientation, gender identity and expression (SOGIE).⁵

According to the LGBT+pride 2021 global survey report, globally, 55% on average support laws banning discrimination against LGBT people when it comes to employment, access to education or housing and social services, whereas 26% neither support nor oppose and 19% strongly oppose them. There is majority support for LGBT antidiscrimination laws in 21 countries, most so in Sweden (71%), Spain and Chile (70).⁶ LGBT people suffer lower education outcomes due to discrimination, bullying and violence; higher unemployment rates; and a lack of access to adequate housing and health services and financial services.⁷ Over 55% of US LGBT students feel unsafe at school, compared with 4% of students at-large and experience significantly higher rates of mental stress.⁸ Similarly, over half of the LGBT respondents to a survey in Europe-experienced verbal harassment in school.⁹ Lesbian, gay and bisexual people are more than two times as likely as heterosexuals to have a long-term mental health condition, an analysis of National Health Service (NHS).¹⁰ About 16% of LGB respondents reported having a long-term mental or behavioural disorder, compared with 6% of heterosexual adults.¹⁰

Heightened prevalence of mental health difficulties and minority stressors were found among Southeast Asian LGBTQ people, which included significant effect size differences relative to cisgender and heterosexual people.¹¹ About 20% of the transgender population in India lack access to transgender-specific healthcare needs.^12,13 They have gone through physical assault, providers refusing to touch them, rough physical exams and more.¹⁴ In addition to facing targeted discrimination, transgender people experience widespread stigma and violence due to their numerous marginalised social identities, which also contribute to economic and housing insecurity, employment discrimination and poverty.¹⁵ This creates health inequity and disparity by increasing vulnerability to health issues on several different levels and influencing transgender people’s healthcare decisions.¹⁶

A cross-sectional study conducted in Nepal on barriers to access health services to LGBT people showed that LGBT people faced physical barriers such as lack of LGBTQ+ friendly registration forms (76%), toilets (76%), the system of arrangement of queues in either male or female (20%) and changing rooms (47.4%).¹⁷ As per the research ‘Prevalence of Depression among Lesbian, Gay, Bisexual, Transgender, and Queer in Pokhara, Nepal’ about one-third of the LGBTQ respondents were found to be depressed among which transgender (31.6%) were highly depressed comparatively.¹⁸ In-depth interviews with 15 lesbians revealed that the majority of lesbians in Nepal choose not to come out because they are afraid of being rejected and not receiving quality health services.¹⁹ Torture, physical and mental abuse, and a lack of proper legal protection were all frequently documented. Improvements in the family and healthcare environments as well as access to proper legal protection were deemed to be the top priority areas.²⁰

Thus, the study employs minority stress theory, which serves as a foundational theoretical framework in explaining mental and physical health disparities experienced by sexual and gender minorities, particularly lesbian, gay and bisexual (LGB) people. Meyer’s model conceptualises multiple stressors, such as distal or external stressors and proximal or internal stressors, that can negatively affect the mental health of sexual and gender minorities and resilience factors to reduce minority stress.²¹ Distal stressors refer to the direct experiences of discrimination, victimisation, rejection or violence based on one’s identity, leading to distress and impacting mental health. In contrast, proximal stressors refer to the fear of victimisation or discrimination and mistrust of others, internalised negative beliefs about one’s identity and identity concealment stress. However, the stress that LGBT individuals face differs within community itself.

Though the constitution of Nepal recognised the LGBT right as fundamental human right in 2007 and ensured the protection of gender and sexual minorities, the LGBT people continue to face wide range of discrimination and inequalities.²² The fundamental human rights concept that all people should have access to health services without discrimination, including based on SOGIE, is the foundation for the WHO’s assistance of member States.²³ The adoption of the 2030 agenda for sustainable development, with its commitment to ‘leave no one behind’ and its foundation in the normative framework of international human rights law, has reaffirmed the necessity of understanding and enhancing the health and well-being of LGBT people, who are frequently left behind.²³

Yet, it is still unclear what impediments LGBT people face in Nepal while seeking and attending health institutions, educational institutions and other sociocultural activities as well as what those challenges are.²² As per the United Nations Women, the paucity of information about the lives and experiences of LGBTIQ individuals in Nepal is the major obstacle in advocating for the promotion of equal rights for them.²⁴ Most of the research that exists are qualitative or descriptive or reviews of healthcare for LGBT people in Nepal, pointing out that there is a lack of strong quantitative evidence on what affects mental health of LGBT individuals.²⁵ Furthermore, there are not standardised and culturally validated tools that measure the stress and stigma that LGBT people face in Nepal. For instance, one study from 2025 found that there was no tool available for sexual minority men in Nepal.²⁶ Therefore, this research attempted to explore the impact of minority stress factors, such as gender based discrimination, victimisation, rejection, etc, on the mental health of LGBT people using Gender Minority Stress and Resilience Measure (GMSR)²⁷ and the Depression Anxiety Stress Scales (DASS-21)²⁸ in consultation with Blue Diamond Society (BDS) (Nepal’s pioneer organisation working for LGBT communities).

Research objectives

General objective

• The overall objective of this study is to assess the mental health status and the role of victimisation, discrimination, connectedness and identity affirmation on the mental health status of LGBT people of the Kathmandu Valley.

Specific objectives

• To identify the gender-related discrimination, rejection, victimisation, non-affirmation, internalised transphobia, negative expectations and non-disclosure faced by LGBT people.

• To assess the depression, anxiety and stress level of LGBT people.

• To explore the resilience measures adopted by LGBT people.

• To assess the role of victimisation, discrimination, connectedness and identity affirmation on the mental health status of LGBT people.

Materials and methods

Study area and design

The study design was cross-sectional, descriptive and analytical because the research on ‘Mental Health of LGBT of Kathmandu Valley: the role of victimisation, discrimination, connectedness and identity affirmation’ aimed to assess the mental health status, factors affecting mental health and its association with the mental health of a defined population (LGBT).

The study site was the Kathmandu Valley. Since it is Nepal’s most developed area, the Kathmandu Valley has the highest level of LGBT acceptance in Nepal.

Sampling and study sample

In this study, the snowball non-probability sampling technique was used. The purpose of using snowball sampling was to identify participants from the LGBT population in the Kathmandu Valley, a hard-to-reach population that is often difficult to identify and access through other sampling methods.

To carry out this sampling method, the researchers enlisted the help of the BDS, an organisation that supports the rights and welfare of LGBT people in Nepal. BDS helped to identify and connect with LGBT individuals in the Kathmandu Valley, who then helped to identify and connect with other LGBT individuals. This process was repeated until the desired sample size of 115 participants was reached.

Sample size

The sample size was determined using the formula:

$${\displaystyle {\displaystyle n=\frac{z^{2}p(1-p)}{d^2}}}$$

where,

n=desired sample size.

z=standard normal deviate, usually set at 1.96, which corresponds to 95% CI.

p=proportion in the target population estimated to have a particular characteristic.

p=0.5 (assumption).

q=1 p =1–00.5=0.5.

d=degree of error required=10% =0.1.

Then,

$${\displaystyle {\displaystyle n=\frac{{1.96}^2\times 0.5\times 0.5}{(0.1{)}^2}=96.04\approx 96}}$$

Considering the non-response rate to be 20%,

The sample size is calculated to be (n)=96+96×0.2= 115.2≈115

Data collection

The data were collected from September 2022 to October 2022. Self-administered questionnaires and face-to-face interviews were used. Pretesting was done in 10% (n=11) of the total sample among LGBT people in Pokhara, which was not selected as the study area during the sampling procedure. The required modification was done as per the analysis of the pretested data.

Measures

The standard tool, Gender Minority Stress and Resilience Measure (GMSR)^27,29 and the Depression, Anxiety, and Stress Scale (DASS)^28,30 were chosen for data collection in this research study because of their established validity and reliability, and their previous use in studies focused on gender minority individuals. The tools were selected, translated into Nepali and modified in consultation with BDS. BDS is the first sexual and gender minorities led organisation established in 2001 to work on the human rights, equity, social justice and dignity of LGBT people. BDS advocates, provides community support and awareness on health, rights, and well-being of sexual and gender minority communities. Considering that, the tools were translated in Nepali, the required modification was done as per the analysis of the pretested data with the support of experts from BDS.

GMSR is a widely used measure that assesses the experiences of stress and resilience in gender minority individuals. This measure includes questions that assess the degree to which individuals experience stress related to their gender identity and expression as well as their coping strategies and resilience in the face of this stress. Even though GMSR was developed targeting transgender and gender non-conforming people, it also addresses the multiple factors that apply to all sexual and gender minority communities, like discrimination, victimisation, rejection, internalised stigma, community connectedness and identity affirmation, which are grounded on minority stress framework originally developed by Meyer and adopted by Hendricks and Testa.^21,31 The questions that are specific to gender minority people, like body incongruence and gender non-affirmation, were answered only by gender minorities. Since no measure has been tested and validated to work in Nepal to study the stress that LGBT people face, the GMSR is the best available comprehensive tool. Limitations of the tool have been discussed in the Limitations section.

The DASS is a self-report measure that assesses symptoms of depression, anxiety and stress. This measure consists of 21 items and assesses the presence and severity of symptoms (normal, mild, moderate, severe and extremely severe) across these three domains. The DASS is a well-validated measure that has been used in a variety of research studies and has been shown to have good reliability and validity.²⁸

Both measures were selected as standard tools for data collection in this research study because of their established validity and reliability, and their previous use in studies focused on gender minority individuals. Content validity was ensured through expert review by the research supervisor and consultation with experts from BDS. The reliability of both the tools was assessed using Cronbach’s alpha coefficients. DASS-21 showed acceptable to good reliability, with alpha values of 0.833 for depression, 0.810 for anxiety and 0.734 for stress. Similarly, the GMSR demonstrated acceptable to excellent internal consistency, with Cronbach’s alpha values for community connectedness α=0.698, non-disclosure α=0.821, negative expectation α=0.912, pride α=0.810, internalised transphobia α=0.833 and non-affirmation α=0.821, indicating satisfactory reliability in the current study. By using these two measures, the researchers were able to collect data on a range of mental health outcomes and experiences among the LGBT population in the Kathmandu Valley.

Gender-related discrimination

Refers to unfair treatment, exclusion and prejudice based on sexual orientation and gender. For example, in workplace and social settings having trouble receiving, limited opportunities, dismissal and appropriate medical care because of one’s gender identity.³² In this study, gender-related discriminations were measured using GMSR scale items like difficulties in accessing the healthcare services, using public toilets, obtaining identity documents, securing housing and finding/maintaining job due to one’s gender identity.

Gender-related rejection

Refers to experiencing social exclusion, rejection and marginalisation due to one’s gender or sexual orientation. For instance, experiencing limits belonging and recognition familial rejection due to gender identity.³³ In this study, GMSR items assess experiences of gender-related rejection in romantic relationships, religious communities, friendships, schools/workplace settings and family relationships due to one’s gender identity.

Gender-related victimisation

Refers to facing harassment, abuse, mistreatment faced because of one’s gender or sexual orientation from community and work settings, which reflects power imbalance. For instance, enduring verbal or physical abuse at interpersonal and structural level as a result of one’s gender identification.³⁴ In this study, gender-related victimisation was assessed using GMSR items like experiences such as verbal harassment, threats of blackmail, property damage, threats of physical harm, physical assault, unwanted sexual contact and exposure to negative statements on sexual orientation and gender due to one’s gender identity.

Non-affirmation

The inability to socially affirm one’s gender identification. For instance, finding it difficult to have one’s gender identification recognised. In this study, non-affirmation was assessed using GMSR items like experiences such as repeatedly explaining one’s identified gender, pressure to appear hypermasculine or hyperfeminine for acceptance, lack of respect for gender identity based on appearance or body and feeling misunderstood because others do not perceive their gender accurately.

Internalised transphobia

Refers to a discomfort with one’s own transgender and gender non-conforming identification as a result of internalising societal gender norms. For instance, being ashamed of one’s gender identity.³⁵ In this study, internalised transphobia was assessed using GMSR items such as feelings of resentment, embarrassment, unhappiness, depression, feeling abnormal or like an outcast and envy towards individuals who do not share the same gender identity or expression.

Negative expectations

Refers to anticipating rejection if one discloses their gender identification.³⁴ In this study, negative expectations were assessed using GMSR items such as expected negative outcomes of expressing gender identity, including anticipated lack of acceptance by others or employers, perceptions of being mentally ill, ‘crazy’, being looked less of me, devalued, expectations of exposure to crime violence, police harassment or denial or medical care.

Non-disclosure

Refers to altering one’s gait, gestures, posture or sitting or standing to conceal one’s gender identification. In this study, non-disclosure was assessed using GMSR items such as assess behaviours such as altering or withholding personal experiences, modifying speech patterns, adjusting dress or grooming, exposing body, wearing a bathing suit or nudity in locker rooms, changing behaviours such as walking, gestures or cover up due to one’s identity.

Pride

Feeling unique and special about one’s gender identity. In this study, pride was assessed using GMSR items such as feelings of special unique, openness and positive regarding one’s gender identity, comfort in revealing gender identity and history, viewing gender identity as meaningful or positive.

Community connectedness

Experiencing a sense of belonging to a group of people who share one’s identity. In this study, community connectedness was assessed using GMSR items such as feelings of belonging, connection, identification with a shared gender identity community as well as feelings of separation from that community.

Depression

Depression in this paper is the result of the respondents on the depression subscale of the DASS-21. Depression subscale comprised 7 items and marked out of 4 (0–3) with measurable scores of 0 representing the absence of the given symptoms and 3 the most severe symptom of depression.

Anxiety

In this paper, the term anxiety is used to describe the score that the respondents receive on the anxiety scale of the DASS-21. This subscale comprises seven questions based on a 4-point Likert scale (0–3), whereby the higher the score, the greater the level of anxiety symptoms.

Stress

Stress in this case is considered to be a score obtained by the respondents of the stress subscale of the DASS-21. The subscale has seven items with a 4-point Likert scale (0–3) with higher scores indicating higher levels of stress.

Socioeconomic status

Average income less than 1.90$ (dollars) per day is defined as below the poverty line and equal to or more than 1.90$ (dollars) per day is defined as above the poverty line.

Criteria for sample selection

Inclusion criteria

• Participants must be members of the LGBT community and had to be at least 18 years of age.

• Participants had to be interested so that it can be ensured that participants are fully engaged and motivated to provide accurate and complete information during the study.

Exclusion criteria

• Individuals who had cognitive difficulties or impairments that would prevent them from fully understanding the purpose and requirements of the study were excluded from participation.

Efforts to address bias

Participants were reached through BDS, its network organisations within the valley and peer networks to reduce selection bias by including individuals with diverse gender identities and sexual orientations. Standardised and validated tools, including GMSR and DASS-21, were used to maintain consistency and reliability in data collection. The confidentiality and anonymity of the participants were maintained throughout the study.

Statistical analyses

Data coding was done before the data collection. All questionnaires were checked for completeness during data collection and responses with missing data were excluded. Data were edited, coded and classified as well and entered manually in the computer using IBM SPSS-22 after data collection. All the data were entered and analysed in SPSS V.22. Analysis was performed (univariate analysis was calculated in proportion, mean, median, SD, SE) or bivariate (χ² test was used for analysis). The data were interpreted using tables and graphic representations. Data were analysed as per the data analysis plan. All dependent (depression, anxiety and stress) and independent variables (age, gender identity, education, employment, victimisation, discrimination, rejection, non-affirmation, internalised transphobia, negative expectations, non-disclosure, prides and community connectedness) frequency and percentage were calculated in univariate analysis. Participants with mild, moderate, severe or extremely severe symptoms of depression, anxiety and stress were classed as having the corresponding condition based on the DASS-21 cut-off scores. Whereas, in bivariate analysis, the association of independent and dependent variables was determined by cross tabulation, χ² test, binary and multiple logistic regression analysis. Variables were selected based on minority stress theory and findings from bivariate analyses and literature. At last, sociodemographic and minority stress-related variables that were conceptually relevant or showed associations in bivariate analysis were included. Multiple logistic regression analysis, ORs with p values and adjusted ORs (aORs) with 95% CIs were shown.

Ethical consideration

Ethical approval was taken from the Institutional Review Committee of the Manmohan Memorial Institute of Health Sciences. In addition, written ethical approval was obtained from the BDS, an organisation that provides support to the LGBT community in Nepal.

During data collection, the researchers obtained verbal informed consent from each and every respondent. The participants were informed about the sensitive nature of the questions and were given the option to skip any question that they did not want to answer. The confidentiality of the participants was maintained throughout the study, with no personal identifying information (such as name or phone number) being disclosed.

To ensure that the participants were fully informed about the aims, methods and benefits of the study, the researchers provided them with detailed information about the study prior to obtaining their consent. The participants were informed that their participation was voluntary and that they could withdraw from the study at any time without penalty. Several steps were taken to ensure that the study was conducted in an ethical and responsible manner.

Results

Social and demographic characteristics of the participants

The majority of the participants (ie, 71.3%) were of the age group 18–25 and the rest were above 25. More than half of the respondents belonged to the Janajati ethnicity (58.3%) and 29.5% were from the Brahmin/Chhetri group. Most of the participants were Hindu (60%). Among different gender identities and sexual orientations, 22.6% were lesbians, 27.8% gay, 21.7% bisexual and 27.8% were transgender. Overall, 60% participants were open about their sexual orientation and gender identity. Most of the participants were single (54.6%), followed by married (22.6%) and others were either in a relationship with one or more than one, engaged or divorced. Similarly, 42.6% of the participants had a secondary level of education followed by 33% with higher education and the rest were either illiterate, literate or primary level of education. Likewise, the majority of them (ie, 51.3%) were employed followed by 22.6% students and the remaining were unemployed (table 1).

Table 1. Social and demographic characteristics of the participants.

Sociodemographic characteristics	Category	Frequency (n=115)	Percentage
Age group (in years)	18–25	82	71.3
	>25	33	28.7
Ethnicity	Brahmin	15	13
	Chhetri	19	16.5
	Janjati	67	58.3
	Dalit	8	7
	Madhesi	4	3.5
	Others	2	1.7
Gender identity and sexual orientation	Lesbian	26	22.6
	Gay	32	27.8
	Bisexual	25	21.7
	Transgender	32	27.8
Socially open	No	46	40
	Yes	69	60
Relationship status	Single	63	54.8
	In a relationship	14	12.2
	In more than one relationship	7	6.1
	Married	26	22.6
	Engaged	3	2.6
	Divorced	2	1.7
Educational status	Illiterate	8	7
	Literate only	10	8.7
	Primary level	10	8.7
	Secondary level	49	42.6
	University level	38	33
Current employment status	Employed	59	51.3
	Unemployed	16	13.9
	Student	26	22.6
	Others	14	12.2

Mental health status of LGBT

The table below provides the distribution of scores and corresponding frequency and percentage of participants’ mental health status based on their stress, anxiety and depression levels. For stress level, approximately one-third of the participants (31.3%) had a normal stress level, followed by moderate (22.6%), mild (20.0%), severe (14.8%) and extremely severe (11.3%) stress levels.

Regarding anxiety level, a significant proportion of participants (37.4%) had extremely severe anxiety levels, followed by moderate (26.1%), severe (13.0%), mild (5.2%) and normal (18.3%) anxiety levels.

For depression level, the majority of participants (53.9%) had a moderate depression level, followed by mild (27.0%), extremely severe (19.1%) and normal (17.4%) depression levels. These findings suggest that a substantial proportion of participants experience high levels of anxiety and depression, with almost 40% of participants reporting extremely severe anxiety levels (table 2).

Table 2. Mental health status of LGBT.

Level	Depression		Anxiety		Stress
	Frequency (n)	Percentage	Frequency (n)	Percentage	Frequency (n)	Percentage
Normal	20	17.4	21	18.3	36	31.3
Mild	11	27.0	6	5.2	23	20.0
Moderate	62	53.9	30	26.1	26	22.6
Severe	–	–	15	13.0	17	14.8
Extremely severe	22	19.1	43	37.4	13	11.3

Cut-off scores from DASS
Level	Depression	Anxiety	Stress
Normal	0–9	0–7	0–14
Mild	10–13	8–9	15–18
Moderate	14–20	10–14	19–25
Severe	21–27	15–19	26–33
Extremely severe	28+	20+	34+

DASS, Depression, Anxiety and Stress Scale; LGBT, lesbian, gay, bisexual and transgender.

Additional information on experience of gender-related discrimination, rejection, victimisation, non-affirmation and internalised transphobia among LGBT individuals is provided in online supplemental table 1.

Binary and multiple logistic regression

Logistic regression of stress and minority stress factors

The table below shows that the odds of experiencing stress were 1.84 times more likely for those who reported experiencing discrimination compared with those who did not (aOR=1.84, 95% CI 0.56 to 6.03, p=0.315), although the association was not statistically significant. Similarly, for rejection, individuals who reported experiencing rejection at some point in their lives had a 1.56 times likelihood of experiencing stress compared with those who reported never experiencing rejection. However, the association was not statistically significant (aOR=1.56, 95% CI 0.44 to 5.60, p=0.493). The odds of experiencing stress were 7.37 times for those who reported experiencing victimisation compared with those who did not (aOR=7.37, 95% CI 0.73 to 74.27, p=0.090), although the association was not significant. Finally, the results show that individuals who reported high levels of internalised transphobia had 2.79 times more likelihood of experiencing stress compared with those who reported low levels of internalised transphobia (AOR=2.79, 95% CI 1.14 to 6.83, p=0.024) and the association was statistically significant (table 3).

Table 3. Logistic regression of stress and minority stress factors.

Variables	Category	COR	CI	P value	AOR	CI	P value
Discrimination	Never	Ref	Ref		Ref	Ref
	At some point in life	4.929	1.930 to 12.585	0.001	1.838	0.560 to 6.033	0.315
Rejection	Never	Ref	Ref		Ref	Ref
	At some point in life	2.939	0.974 to 8.867	0.056	1.563	0.436 to 5.597	0.493
Victimisation	Never	Ref	Ref		Ref	Ref
	At some point in life	12.581	1.412 to 112.073	0.023	7.365	0.730 to 74.266	0.090
Internalised transphobia	Less stigmatisation	Ref	Ref		Ref	Ref
	High stigmatisation	2.739	1.211 to 6.197	0.016	2.794	1.142 to 6.833	0.024

COR: crude odds ratio; AOR: adjusted odds ratio; CI:confidence interval.

AOR, adjusted OR.

Logistic regression of anxiety and minority stress factors

The table shows that the odds of experiencing anxiety were 3.83 times more likely for those who reported experiencing discrimination compared with those who did not (aOR=3.83, 95% CI 1.415 to 10.346, p=0.01) and the association was statistically significant. Similarly, for rejection, individuals who reported experiencing rejection at some point in their lives had 4.610 times likelihood of experiencing anxiety compared with those who reported never experiencing rejection and was statistically significant (aOR=4.610, 95% CI 1.129 to 18.818, p=0.033). The odds of experiencing anxiety were 8.907 times likelihood for those who reported experiencing victimisation compared with those who did not (aOR=8.907, 95% CI 0.894 to 88.756, p=0.062), although the association was not significant. Finally, the results show that individuals who reported high levels of internalised transphobia had 6.044 times more likely of experiencing anxiety compared with those who reported low levels of internalised transphobia (aOR=6.044, 95% CI 1.724 to 21.189, p=0.005) and association was significant (table 4).

Table 4. Logistic regression of anxiety and minority stress factors.

Variables	Category	COR	CI	P value	AOR	CI	P value
Discrimination	Never	Ref	Ref		Ref	Ref
	At some point in life	3.656	1.321 to 10.119	0.013	3.826	1.415 to 10.346	0.008
Rejection	Never	Ref	Ref		Ref	Ref
	At some point in life	5.375	1.683 to 17.164	0.005	4.610	1.129 to 18.818	0.033
Victimisation	Never	Ref	Ref		Ref	Ref
	At some point in life	10.824	1.835 to 63.829	0.009	8.907	0.894 to 88.756	0.062
Internalised transphobia	Less stigmatisation	Ref	Ref		Ref	Ref
	High stigmatisation	4.716	1.593 to 13.962	0.005	6.044	1.724 to 21.189	0.005

COR: crude odds ratio; AOR: adjusted odds ratio; CI:confidence interval.

AOR, adjusted OR.

Logistic regression of depression and minority stress factors

In the binary and multiple logistic regression analysis of depression, the results suggest that experiencing rejection at some point in life is significantly associated with 6.081 times increased odds of depression (aOR=6.081, 95% CI 1.541 to 23.992, p=0.010) while discrimination at some point in life has a non-significant association with depression (aOR=2.750, 95% CI 0.850 to 8.895, p=0.091). Victimisation at some point in life was also non-significantly associated with depression (aOR=0.616, 95% CI 0.058 to 6.500, p=0.687). Moreover, individuals with high levels of stigmatisation were found to have significantly 5.113 times increased odds of depression (aOR=5.113, 95% CI 1.506 to 17.366, p=0.009) compared with those with less stigmatisation (table 5).

Table 5. Logistic regression of depression and minority stress factors.

Variables	Category	COR	CI	P value	AOR	CI	P value
Discrimination	Never	Ref	Ref		Ref	Ref
	At some point in life	4.040	1.440 to 11.337	0.008	2.750	0.850 to 8.895	0.091
Rejection	Never	Ref	Ref		Ref	Ref
	At some point in life	5.856	1.818 to 18.865	0.003	6.081	1.541 to 23.992	0.010
Victimisation	Never	Ref	Ref		Ref	Ref
	At some point in life	2.528	0.430 to 14.856	0.305	0.616	0.058 to 6.500	0.687
Internalised transphobia	Less stigmatisation	Ref	Ref		Ref	Ref
	High stigmatisation	4.308	1.446 to 12.832	0.009	5.113	1.506 to 17.366	0.009

COR: crude odds ratio; AOR: adjusted odds ratio; CI:confidence interval.

AOR, adjusted OR.

Discussion

The results of this study are interpreted using Meyers minority stress model from 2003, which was later tailored specifically for transgender and gender non-conforming individuals by Hendricks and Testa.^21,31 Using this paradigm helps to acknowledge that people who identify as sexual and gender minorities undergo distal (discrimination, victimisation) and proximal stressors (internalised phobia) along with the everyday stress due to the stigma related to sexual and gender identity. The participants in the study reported experiencing mild, moderate, severe and extremely severe forms of stress (68.1%), anxiety (81.7%) and depression (82.6%). The findings align with the mental health burden predicted by Meyers model, exceeding the estimates for the general population in Nepal.^27,36 According to the recent survey by the National LGBTI health Alliance, conducted in Australia in 2020, 74% of LGBTIQ+people reported moderate to very high levels of psychological distress compared with 49% of the general population.³⁷ LGBTIQ+people reported: stress-86%, anxiety-79% and depression-72%.³⁷ The findings show that despite the geographical, cultural and socioeconomic differences, LGBT individuals are the high-risk groups for stress, anxiety and depression.

The high rate of anxiety and depression in this study population is closely linked to proximal minority stress processes like hypervigilance and worried about being rejected because of stigma. In Nepal’s sociocultural context, where LGBT individuals face social stigma rejection from family and limited access to supportive healthcare hypervigilance can be a major psychological burden, leading to elevated anxiety and sustained depression.²⁵ This finding matches an extension of the minority stress model. It identified anticipating stigma that not being affirmed in one’s gender identity as key drivers of anxiety and depression, among sexual and gender minority individuals.²⁷

More than 78% LGBT people reported that they faced gender-related discrimination at some point in their life. There is a significant association between gender-related discrimination and stress (p value=0.000), anxiety (p value=0.009) and depression (p value=0.006). The study conducted among the Swiss transperson exhibited significant positive association between gender-related discrimination and mental health (p<0.01).³⁴ Depression and anxiety were positively correlated with all forms of LGBTQ-based discrimination and racism.³⁸ Suicidal ideation was positively associated with LGBTQ-based discrimination harassment/rejection and work/school (p<0.01).³⁸ Satisfaction with life was negatively associated with LGBTQ-based discrimination-harassment rejection.³⁸ The findings depict that LGBT people face.

More than 87% LGBT people reported that they faced gender-related rejection at some point in their life. There is significant association between gender-related rejection and stress (p=0.048), anxiety (p=0.002) and depression (p=0.001). Nineteen percent of the sample reported being refused medical care due to their transgender or gender non-conforming status.⁶ In-depth interviews with fifteen lesbians revealed that the majority of lesbians in Nepal choose not to come out because they are afraid of being rejected and not receiving quality health services.¹⁹ The study conducted among the Swiss transperson exhibited significant positive association between gender-related rejection and stress, anxiety and depression (p<0.01).³⁴ The results show that despite the geographical, cultural and socioeconomic differences LGBT individuals face gender-related rejection which is significantly contributing to their poor mental health.

Huge number of respondents (94.8%) reported that they faced gender-related victimisation. There is significant association between gender-related victimisation and stress (p=0.005) and anxiety (p=0.002). Similarly, over half of the LGBT respondents to a survey in Europe experienced verbal harassment in school.⁹ Over 55% of US LGBT students feel unsafe at school, compared with 4% of students at-large and experience significantly higher rates of mental stress. As per the Being LGBT in Asia: Nepal country report, LGBT individuals are more likely to experience sexual harassment and employment discrimination because there are no antidiscrimination laws covering the workplace.⁵ They are more prone to homophobic and transphobic bullying leading to poor mental health.⁵ The study conducted among the Swiss transperson exhibited significant positive association between gender-related victimisation and stress, anxiety and depression (p<0.01).³⁴ The findings showed that despite the geographical, cultural and socioeconomic differences LGBT individuals are at high risk of victimisation significantly contributing to increased stress and anxiety.

However, as per the Minority Stress Model, the impact of distal stressors such as discrimination, victimisation works through proximal stress processes. For instance, internalised stigma helps to understand how external stressors lead to distress.²⁷ The finding of this study that victimisation is not directly associated with depression aligns with the Minority Stress Model as it emphasises that the internalised phobia and thinking patterns related to one’s identity lead from victimisation to depression. This interpretation matches the prior research that proximal stressors often explain the relationship between distal stressors and mental health when both are included simultaneously in multivariable models.³⁶

There was a significant association between internalised transphobia and stress (p=0.014), anxiety (p=0.003) and depression (p=0.006). The study conducted among the Swiss transperson exhibited a significant positive association between internalised transphobia and stress, anxiety and depression (p<0.01).³⁴ According to research on transgender identity, internalised transphobia is positively correlated with psychological discomfort, especially depression.³⁹ The study conducted among the Swiss transperson showed a negative association between pride and stress, anxiety and depression (p=0.14).³⁴ The reduction of mental health illnesses, such as signs of depression, suicidal thoughts, drug use, shame, school avoidance, sexual orientation violence and anxiety, was more successful for LGBTQ youth who had social support.⁴⁰

The results suggest that experiencing rejection at some point in life is significantly associated with increased odds of depression (aOR=6.081, p=0.010, 95% CI 1.541 to 23.992), while discrimination at some point in life has a non-significant association with depression (aOR=2.750, p=0.091, 95% CI 0.850 to 8.895). Victimisation at some point in life was also non-significantly associated with depression (aOR=0.616, p=0.687, 95% CI 0.058 to 6.500). Moreover, individuals with high levels of stigmatisation were found to have significantly increased odds of depression (aOR 5.113, p=0.009, 95% CI 1.506 to 17.366) compared with those with less stigmatisation.

Other research shows that the odds of any past-year mental health disorder among those who reported past-year gender discrimination alone were estimated to be more than two times likely (aOR 2.28, 95% CI 1.09 to 4.78) as respondents who reported no past-year discrimination.⁴¹ Odds were also significantly higher for those who reported sexual orientation and racial or ethnic discrimination combined (aOR 2.25, 95% CI 1.02 to 4.95) and gender and racial or ethnic discrimination combined (aOR 4.30, 95% CI 1.91 to 9.68).⁴¹ The odds of any mental health disorder in the past year for respondents who reported all three types of discrimination were estimated to be more than three times higher than those reporting no discrimination (aOR 3.31, 95% CI 1.45 to 6.74).⁴¹

The results of this research report suggest that there is a strong association between minority stressors and mental health issues among LGBT individuals. Specifically, the study found that a high percentage of LGBT individuals experienced stress, anxiety and depression and is strongly associated with gender-related discrimination, rejection and victimisation. This finding is consistent with a growing body of research that has documented the negative impact of discrimination and victimisation on the mental health and well-being of LGBTIQ individuals.⁴² Studies have consistently shown that LGBTIQ individuals experience higher rates of mental health issues compared with their heterosexual and cisgender peers, and that discrimination and victimisation based on gender identity and sexual orientation are key contributors to these disparities.⁴³

Moreover, research has demonstrated that gender-related factors can have a particularly strong association with the mental health of transgender and gender non-conforming individuals, who face unique challenges related to gender identity and expression.⁴⁴ Discrimination and victimisation based on gender identity can lead to heightened levels of stress, anxiety and depression among these individuals, and can also contribute to other negative health outcomes such as substance abuse and suicidal behaviour.⁴⁵ In light of these findings, it is clear that LGBT individuals continue to face gender-related discrimination, rejection, victimisation and internalised transphobia despite the cultural, socioeconomic and geographical differences leading to their poor mental health and well-being.

A key interpretive concern regarding the study is that the sample in the study was mostly sexual minorities, but the tool used was mainly designed for gender minorities. The stress processes discussed, like discrimination, victimisation, internalised stigma and feeling connected to the community can apply to both sexual and gender minorities. However, proximal stress that is more relevant to sexual minorities like feeling ashamed of one’s sexual identity may not have been fully captured by GMSR. So, results related to proximal stressors should be seen as mainly applying to the gender minority group in the study. Future research should use tools that are specifically designed and validated for both sexual and gender minority populations in Nepal.

Adding on to it, the study used a cross-sectional design, all observed associations should be interpreted as correlational rather than causal. For instance, the findings of the study that LGBT individuals who experienced discrimination, rejection or violence and internalised transphobia had poorer mental health is consistent with the minority stress findings. However, we cannot say that these stressors directly cause depression, anxiety or stress. To understand how these stressors change over time, we need to do longitudinal research among LGBT people of Nepal.

Limitations

• The study was conducted among lesbian, gay, bisexual and transgender (LGBT) people of Kathmandu Valley with a limited sample, so the study might not be representative of all LGBT people of Nepal.

• The use of non-probability snowball sampling through LGBT community-based organisations might have led to selection bias, as the experiences of people connected to organisations might differ from those of people who are not.

• The study employs a cross-sectional design, so the associations reported here reflect correlations only.

• Considering the stigma regarding LGBT identities in Nepal, self-reporting might lead to the possibility of social desirability bias.

• The use of the GMSR in a predominantly sexual minority sample in Nepal may introduce measurement error and misclassification, as the GMSR was primarily developed focusing on gender minority populations. GMSR lacks certain proximal stressors affecting sexual minorities like internalised homophobia and sexual identity concealment, which may lead to underestimation of the sexual minority stress burden.

Conclusion

The objective of the study was to assess the mental health status and the role of victimisation, discrimination, connectedness and identity affirmation on the mental health status of LGBT people of the Kathmandu Valley. The participants in the study reported experiencing mild, moderate, severe and extremely severe forms of stress (68.1%), anxiety (81.7%) and depression (82.6%). The research shows that more than 78% LGBT people faced gender-related discrimination, more than 87% LGBT people faced gender-related rejection and 94.8% faced gender-related victimisation at some point in their life. There was a statistically significant association between age, education and employment status and anxiety. Similarly, the study showed a strong association between relationship status, employment status and depression. Based on the results of this study, it can be concluded that a high percentage of LGBT individuals experience stress, anxiety and depression, and the mental health of LGBT is strongly associated with gender-related discrimination, rejection, victimisation and internalised transphobia. Therefore, it is important for policymakers, healthcare professionals and society as a whole to take steps to address and prevent discrimination and victimisation based on gender identity and sexual orientation.

Data availability statement

Data are available upon reasonable request.