Sexual Stigma, Psychological Well-Being and Social Engagement among Men Who Have Sex with Men in Beirut, Lebanon

Abstract

This qualitative study sought to explore the sexual identity development of men who have sex with men (MSM) in Beirut, the stigma experienced by these men, and how their psychological well-being and social engagement are shaped by how they cope with this stigma. Semi-structured interviews were conducted with 31 MSM, and content analysis was used to identify emergent themes. While many men reported feeling very comfortable with their sexual orientation and had disclosed their sexual orientation to family, most men struggled at least somewhat with their sexuality, often because of perceived stigma from others and internal religious conflict about the immorality of homosexuality. Most participants described experiencing verbal harassment or ridicule, or being treated as different or lesser than in social relationships with friends or family. Mechanisms for coping with stigma included social avoidance (trying to pass as heterosexual; limiting interaction with MSM to the internet) or withdrawal from relationships in an attempt to limit exposure to stigma. Our findings suggest that effective coping with both internal and external sexual stigma is central to the psychological well-being and social engagement of MSM in Beirut, much like what has been found in Western gay communities.

Background

Sexual minorities, including men who have sex with men (MSM), experience various forms of stigma for their sexual identities, behaviour, and relationships (Altman et al. 2012; Herek 2007). Sexual stigmatisation, discrimination and being marginalised in society render sexual minorities vulnerable to mental health problems (Frisell et al. 2010; Frost and Meyer 2009; Hatzenbuehler et al. 2008; King et al. 2008; Wohl et al. 2011). Stigma and discrimination have been found to be associated with depression or psychological distress (Bontempo and D'Augelli 2002; Díaz et al. 2001; Hatzenbuehler et al. 2008), substance use (McCabe et al. 2010) and social isolation (Díaz et al. 2001) in studies of sexual minorities conducted in the USA. In contrast, little is known about the connections between experiences of sexual stigma, how one copes with such stigma, and the mental and social well-being of MSM in Muslim dominated regions such as the Middle East and North Africa (MENA), where discussing sexuality remains taboo and societal views continue to be very conservative and largely hostile towards homosexuality.

Perhaps owed to its close proximity to Europe, strong tourism, cultural and international business industries, and religious diversity, Beirut is seen as more socially progressive compared to other cities in the region. This environment has allowed the gay community to thrive in recent years in terms of freedom to organise and advocate for its rights, and societal views have become more tolerant or accepting. For example, Helem, the only NGO in the region with a specific mission to advocate for the rights of sexual minorities was founded in 2004 Beirut. A small number of gay bars, night clubs and gay-friendly cafes have taken root in the community as common meeting places, as well as mixed dance parties where men feel comfortable being able to congregate and dance with each other —all of which are signs that the community is able to go about living its life without overt harassment. As in other parts of the world, gay online social networking sites are widely used as a forum for men to connect. While societal attitudes have grown more tolerant and there is increasing coverage and support in the media, stigma remains high nonetheless and public discretion is still very much a priority in the lives of MSM in Beirut. It is worth noting that the growing acceptance of gay culture in central Beirut is not reflective of the rest of Lebanon, which continues to be predominantly intolerant of homosexuality and where “unlawful sexual acts,” including homosexual sex, remain illegal although generally not enforced.

Investigations of the psychosocial effects of sexual stigma have often drawn from the minority stress model (Meyer 1995; Meyer 2003), which posits that chronic stress from sexual stigma contributes to mental health problems among sexual minorities and that social support and coping moderate this impact. Chronic stressors from sexual stigma include internalised stigma, in which the individual accepts negative beliefs, views and feelings towards the stigmatised group and oneself, perceived stigma or awareness of negative societal attitudes, and enacted stigma, which involves receipt of overt acts of discrimination (Herek 2007; Mayer et al. 2012; Meyer 1995). As noted above, studies have documented associations between stigma and measures of mental and social well-being, but there's been little research and mixed findings regarding the role of social support and coping as moderators of such relationships(Davis et al. 2009). A recent study in India found that social support and resilient coping were associated with lower depression, but did not moderate the influence of stigma on depression among MSM (Logie et al. 2012). However, data from this same study showed that in settings within India where there is limited access to support services for MSM, social support and coping mechanisms do help to mitigate stigma and improve mental health.

In this paper, we report findings from semi-structured qualitative interviews with MSM in Beirut, Lebanon. These interviews explored experiences of stigma versus social support for their sexual identity, mechanisms used to cope with sexual stigma, and how sexual stigma relates to the social relationships and psychological well-being of these men.

Methods

Sample

In autumn 2011, we interviewed 31 MSM living in Beirut. The sample was stratified by age; 16 men were aged 18-25 years, and 15 men were above age 25. We purposively recruited men who self-identified as bisexual men, or who had sex with both men and women, in order to balance out those who self-identified as gay and have a diverse representation of MSM identities. We were unsuccessful in our attempts to recruit heterosexually identified MSM. Participants were recruited through referrals from members of the project's community advisory committee, through collaborating community organisations that provide services (e.g., human rights advocacy; testing and treatment for sexually transmitted diseases; psychosocial counseling) to sexual minorities in Beirut, and some participants referred their friends. Men who were interested in participating were instructed to call the study coordinator for a detailed description of the study and to provide verbal consent to participate. Participants were paid $30 USD for completing the interview. The study protocol was reviewed and approved by the Institutional Review Boards at the RAND Corporation and the Lebanese American University.

Instrument

Semi-structured interviews were conducted to explore participants' experiences with stigma, how they coped with stigma, and how this related to their mental health and social relationships. Unlike traditional ethnography, semi-structured interviews allow for the open-ended elicitation of ideas and experiences while simultaneously allowing for comparisons across the range of interviewees. In this study, we used the interviews to elicit themes as well as to determine how common or salient these themes were among an array of respondents. A semi-structured interview guide was developed, which included mostly open-ended questions, but also semi-structured follow-up questions and probes. After eliciting basic demographic and background related questions, the interview covered the following topic areas: 1) relationships with family and friends; 2) comfort with sexual orientation, level of disclosure and openness about their sexuality; and 3) experiences of stigma and mechanisms for coping with stigma.

Interviews were conducted in the language preferred by the participant (Arabic, French, or English). All of the interviewers had prior experience conducting qualitative interviews, and each received additional training in qualitative interview techniques prior to administering the interviews. Each interviewer had worked at community organisations that had significant numbers of MSM as clients, and thus had a high level of familiarity and comfort with MSM.

Analysis

Interviews were digitally recorded, translated into English and transcribed verbatim. Content analysis was performed to identify themes, using a staged technique described by Bernard and Ryan (Bernard and Ryan 2009). We used text management software (ATLAS.ti) to mark contiguous blocks of transcript text that pertained to the major topical domains of interest. We then pulled out all text associated with a particular domain and created subthemes within each primary code or domain. Two team members then each coded all content within three interviews to assess whether both were coding the content equivalently and to reach consensus where there was any disagreement (Bernard and Ryan 2009); the remaining interviews were then divided between the two team members and coded. For cited quotes we included the age and a false name of the respondent to ensure anonymity.

Results

Sample description

The mean age of participants was 28.4 years (SD=10.5; range: 19-65); 87% had at least some college education, and most participants were either employed (55%) or attending university (35%). The sample is diverse with regard to relationship status (29% are in a relationship) and religious affiliation (30% Muslim, 52% Christian among the 27 participants with known religious affiliations). All men self-identified as either gay (77%) or bisexual (23%), and one third (32%) reported having recent sexual activity with both men and women.

Relationships with and disclosure to family

The family plays a very important role in Lebanese culture; adult children often continue to live with their parents until they marry, and having contact with parents and siblings several times a week and even daily is common. Nineteen (61%) respondents reported having close relationships with their family, describing their family members as being affectionate and supportive, and indicated that they had been able to successfully disclose their sexual orientation to at least one of their family members. In the words of one respondent,

“My dad has been dead since I was a little boy, but my mum is still alive and I adore her. She knows that I am gay and it's fine with her. The same with my two sisters, I adore them and they have supported me all along” (John, age 29).

Three-quarters (n=24; 77%) of the sample indicated that someone in their family knew that they had sex with men, but only half (n=15; 48%) reported that at least one parent (usually the mother) was aware. Many of the men described their families as being supportive once they knew of the respondent's sexual orientation. The described support came in various forms ranging from emotional support and encouragement, to simply being accepting and not treating the respondent any differently than before.

Eight participants described themselves as having active relationships with their family, but that they were not very close. Four other participants were estranged from their families, with little or no contact with parents or other key members of the family; two refused to talk about their family members and the other two stated that this estrangement was a result of the family's disapproval of their sexual orientation. One respondent described being afraid of physical violence if his family found out, “If they know I am homosexual, especially my brother, [they] will kill me. If I knew he found out, I'd escape” (Tony, age 41). Another respondent described an ongoing emotional torment that resulted in him leaving home and his community:

“I have been treated badly since I was a teenager. At school they used to make fun of me since I used to spend my time with girls more than boys. The same in the street where I used to live. This has hurt me a lot and created a lot conflicts inside my family. That's why I left the house and the street and moved to another place. It was very hard, and I used to stay alone because I barely had friends. I felt different from the start” (Mark, age 26).

Disclosing to parents is often more challenging than disclosure to others, and respondents often described being more comfortable with indirect disclosure—with others making assumptions that were not denied or refuted by the participant or being informed by a third party—rather than directly telling their parents about their sexuality. One respondent described it this way:

“My mum has a lot of doubts. Once, I had something on my neck. My mum asked me what this was. I told her, ‘I don't know. It is from the party I had.’ She replied, ‘Is it from a man or a woman?’ I said, ‘I don't know.’ I never discussed it with my parents but I know that they know. All people know around me so I am sure that someone told my parents since we are in a small country” (Yousef, age 22).

Disclosure to friends and co-workers

While most of the men had family members who knew their sexual orientation, and 90% (n=28) of the men reported that some or most of their friends knew, far fewer men were out in the workplace or at school. Ten (32%) participants indicated that co-workers or fellow students knew of their sexual orientation. One respondent who described being increasingly comfortable with his sexuality, nonetheless remained private about his sexual orientation at work, “I am on the better side of comfortable…(but) professionally I am still uncomfortable. I want to separate my sexual identity from what I do [work-wise], especially in Lebanon because I don't think it fits” (Charbel, age 34)

Two-thirds of the sample (n=20; 65%) described the responses of others who became aware of their sexual orientation as being mostly supportive. Some of the friends who the respondents disclosed to demonstrated their support almost immediately, but others had a difficult time at first before eventually becoming supportive. Eight (26%) participants received a relatively even mix of supportive and non-supportive reactions, as exemplified in the following quote:

“The friend I told back in school didn't react in a bad way at first. He wasn't shocked or anything, but when he went around and told people, they started making fun of me in ways that didn't happen before. Two people who were already friends with me, became better friends with me when they found out.” (Philip, age 21).

Experiences of enacted stigma and discrimination

Respondents were asked to reflect on the stigma they had experienced as a result of being an MSM. Experiences of enacted stigma typically came in the form of looks of disgust or remarks of ridicule in public settings, jokes about homosexuality made in the workplace or at school, or being labeled as gay because of appearance or mannerisms. One respondent described the following experiences in school:

“In school, there are people I used to talk to before, but they stopped talking to me. I didn't understand why in the beginning but then I understood. And then there was different treatment. There are outings that I was left out of. I used to see their activities on Facebook and they didn't tell me about them. They used to tell me before. I definitely felt stigmatised. When we were younger, I used to feel targeted. I felt like groups of people would target me when I walk for example” (Philip, age 21).

Another respondent described how stigma can also be felt vicariously, when actions of stigma are directed at others, “I was never stigmatised directly, but hearing the comments of my straight friends when an effeminate guy passes by. It makes me feel anxious and annoyed” (Ahmad, age 27). A number of men also described the stigma they felt from their family who at times expressed shame and embarrassment because of the respondent's sexuality. One participant described how his parents requested that relatives not be informed of his sexual orientation, “My mom makes sure that her brothers and sisters don't know. My dad's the same of course. My dad tells me, ‘I don't want anybody's parents to know,’ like if I have friends, he doesn't want their parents to know” (Mustapha, age 33).

Although not commented on by many in the sample, enacted stigma can be experienced in various forms of discrimination, such as regarding employment or housing. One respondent, an artist who often leads seminars and workshops at universities, reported work-related discrimination because he was gay, “Once a university refused that I give a conference because I'm gay. I went to see the Dean and made a scandal. A lot of establishments don't want to have anything to do with me because I'm gay” (Robert, age 48).

Four men experienced more violent forms of stigma including being sexually or physically assaulted. One respondent described sexual harassment at school, “In schools, [people] would come up to me in bathrooms and say things like “suck me” and they used to be very pushy” (Philip, age 21). Another man described such experiences in the context of cruising areas and trying to pick up sex partners who would turn out to be violent:

“People would pick me up to drop me and they would assault me sexually. Then I found out that the whole purpose is to either rob me or take my money or just being abusive in a way to say, ‘You are gay, you go out with guys, you have sex with guys.’ A couple of times it turned violent in a way. Once a guy raised his knife on me and took everything that I had” (Ali, age 30).

Effects of stigma on psychological well-being, social engagement, and relationships

Most of the respondents spoke about the psychological effects of stigma, including lowered self-esteem, mental duress and internalised homophobia, and several men also reported effects of stigma on social relationships. A majority of the men (n=19) reported having at least some discomfort with their sexual orientation, with suggestions of internal struggles that were often a product of perceived stigma from others:

“I am very comfortable [with my sexual orientation], but because I can't do it in public, it keeps me thinking if what I am doing is wrong or right and this is what keeps me from being happy with what I am living. Everything that you want to do you have to do in secret. That is what hurts” (Khaled, age 20).

This feeling of having to hide one's sexuality from the public often created an isolating environment for the study respondents. Several respondents described a loss of confidence, being uncomfortable in social settings and generally becoming more shy and reserved as a result of feeling stigmatised. One respondent described the following, “At a certain moment, it affected me. I am a bit shy and I think this comes from the fact that I was stigmatised. You learn how to protect yourself” (George, age 23). Another described a need to feel on guard and alert at work, in fear that others might catch something that suggests he might be different, “But I am always careful at work. There is a certain level of control or attention so that people do not know that I am MSM” (Mustapha, age 33).

Internalised stigma was also prominent in how men described the lack of comfort with their sexual identity. A number of respondents described reactions to stigma that reflect internalised homophobia and a sense of self-loathing and wanting to be someone else, including the following respondent,

“I wasn't very comfortable with myself anymore. I became annoyed with many things, with my looks. I didn't like looking at myself in the mirror anymore. I still don't very much. I didn't use to participate much, and my voice wasn't heard anymore” (Philip, age 21).

Religious beliefs that homosexuality is immoral and a desire to remain true to one's faith, as well as unsuccessful attempts to avoid sexual relations with men, were prominent in the responses of several respondents who expressed being uncomfortable with their sexual orientation. This was true for both Muslims and Christians alike. One respondent stated, “I feel guilty a lot of times since I do believe that prophet Mohamed prohibited sex between men and every time I pray, I really feel guilty” (Elie, age 20). Another man described his conflict with religion as follows:

“I am not comfortable [with my sexual orientation] and at times I wanted to change it, but I came to realise that I can't. Now I try not to make it a lifestyle, but I still need to sleep with men from time to time. There are a lot of reasons [I am not comfortable]. First, there's the religious part. I am a believer and I know that in the bible homosexuality is an abomination” (Jack, age 31).

While many expressed this type of religious guilt and social pressure to conform to the hetero-normative culture, one respondent also described the counter force represented in his internal struggle that was affirmative towards his same-sex attractions:

“There is a conflict inside me like if everyone says that the thing that I am doing is wrong, it should be wrong, but then why do I feel it is right. I do love my boyfriend. It is not something I have invented or something that someone made me do. It is not in my hand to change this and yet the whole society is against you, and religion is against you. So I have this struggle” (Khaled, age 20).

It is not surprising that the attacks of stigma on one's identity and sense of self translate into psychological distress including emotional states of depression, anger and guilt. A number of men described periods of depression and sadness, which were often accompanied by social withdrawal and isolation, as reflected in the following, “I am usually a scared person and my fear has enormously isolated me. I tell myself either God created me like this and this is his will or this is a disease and God will forgive me” (Tony, age 41). Another man described withdrawing socially, even from those who supported him, to cope with depression,

“I self-medicated if you will, in dealing with this depression, and blocking off people, cutting them off. People who were close and who turned out to be the best support I had, I had a distance from. I look back and I don't have any more pictures from those years because this was a bad time” (Charbel, age 34).

Another respondent described profound feelings of sadness, loss of hope, and being alone in his pain, “I am being sad all the time and I keep thinking all the time and it is like being in a lake. I am always day dreaming for something that will never happen. All people see me fake smiling and happy” (Mohammed, age 24).

Coping with stigma

With stigma being fundamentally a social experience, many participants described mechanisms for coping with stigma and its psychosocial effects that involved some form of social avoidance or withdrawal. Some attempted to avoid stigma and its aftermath by concealing their sexual orientation and trying to pass as heterosexual, either by dating or having relationships with women, or simply flirting with women when in the company of their heterosexual friends. As described by one man, “When I am with my straight friends and a girl starts to flirt with me, I have to flirt back. It is not like I am interested. It is because I have to. I have to act like I am interested in the girl” (Khaled, age 20).

Several men described a general social withdrawal, backing away from interacting with family and friends and becoming more isolative in an attempt to avoid dealing with stigmatising experiences, “My self-esteem at the time was badly affected. I used to avoid going out and stayed home most of the time after school” (John, age 29). Others compartmentalise their social network, isolating their gay friends from their family and other segments of their social world:

“It is just that I have to hide who I am. I avoid my gay friends getting close with my university friends and my work. I avoid introducing them to my parents. Maybe because I am gay, I am afraid my parents would ask me, ‘Where did they come from? Why do you have so many friends?’” (Khaled, age 20).

Some men reported feeling uncomfortable approaching and interacting with other MSM because they were afraid to be identified as a part of the “gay scene” and the possible exposure to both external and internal stigma. Some of these men turned to the internet and social networking sites to interact with MSM in a “safer” and more anonymous format, “Because of the stigma, you can't approach a person on the street in Lebanon, even if they are gay--it is not accepted in our society --so what I do and what I think most people do is meet people through the internet, because it is easier to approach them” (Simon, age 21). Another form of social avoidance was observed in men who diverted their energy and focus away from social relations and towards work and academic performance in an attempt to both avoid stigma and to restore a sense of worthiness and competency in an area of their life in which they felt greater control: “At school, I wanted to prove that I am a smart guy and that I can be successful so the effect [of stigma] was positive. The same at my work” (Jack, age 31).

Coping with guilt or internalised stigma often involved an inner struggle between one's religious beliefs and sexuality. This conflict led some men to leave double lives and to really struggle with acceptance of their sexual identity. Some of these men stepped back from their religion in order to become more comfortable and accepting of themselves, as exemplified by one man who said the following:

“All religions are against this thing, so it creates this struggle that you are always doing something wrong, and in order to forget it, you have to step on it and walk. If all people are against me, I have to remove them and move on and so is the case with religion. I do believe in God, I don't do harmful things, but in my daily life, I have my own beliefs” (Khaled, age 20).

Others have maintained an involvement in religion and have continued to struggle with the conflict between their religious faith and their sexuality, “Because I am religious and a believer, I know that what I am doing is not permitted. So I feel sometimes a struggle” (Yousef, age 22). Another man said, “Religion affects me negatively concerning my self-esteem or the guilt that I sometimes feel. And sometimes I just get angry thinking about the reasons that I am rejected (being gay) in my religion” (Paul, age 25).

While some men felt they had to compartmentalise their sexuality and religious beliefs, several other men spoke of being able to integrate their religion and their sexual identity in a way that allowed them to maintain their belief system, while achieving a level of comfort and inner peace with their identity. Some men described achieving this integration by allowing themselves to hold onto the parts of religious doctrine that held true to them, but not necessarily all of it, “I think it's an insult to my intelligence to swallow all these stories. I kept religious philosophy, the part I figure to be necessary to have a spiritual balance” (Hassan, age 65). Another man described his struggle with the morality of homosexuality as follows:

“I am Christian, but in Christianity we (gay men) are not allowed obviously, so it is a big conflict. But I don't let it play with me. I believe in the Bible and I believe in everything, but if it was a choice, I don't think any gay person would be gay. It is like giving you two roads, telling you this is the easy way and this is the hard way, why would anybody take the hard way in life” (Simon, age 21).

Substance use

Substance use was not extensive in this sample, but substances were described by some as a way to cope with stigma. The participants often used alcohol “in a social context,” when partying with friends at clubs and restaurants where participants often reported meeting sexual partners, and as a way to relax and disarm their anxiety about socialising in gay friendly establishments or initiating interaction with other MSM, “This is what happens in gay places. You go, people drink a lot and are looking just for sex…There is a direct link between alcohol use and these places in general even for me” (Mustapha, age 33). Those who use substances often reported using them to cope with stress, to relax or to just “have fun.” Some reported using substances to fit in with the accepted social scene, “There is an association between alcohol and pubs we go to. I do not enjoy going out to gay places if I don't drink” (Omar, age 28).

While the experiences of our participants demonstrate considerable struggles and challenges with stigma associated with being gay or bisexual, it must be noted that for many of these men, these struggles had been overcome and many had achieved a strong level of self-confidence and comfort with their lives, their sexual identity and their relationships with family, friends and other MSM. A number of men described how their early experiences of stigma had helped them to become stronger emotionally, more resilient and self-confident in the face of stigma, and empowered to defend the integrity of their identity as a gay or bisexual:

“I see the period of my teenage years to my late 20s as being depressive because I was trying to deal with the stigma, but the moment I decided to let go, my confidence grew. My self-esteem was hit only in terms of sexual identity and my gender identity—am I man or not, am I this or not. But in terms of other aspects of my life, it actually fueled me. I realised that I was not going to be the standard, what is considered good. I was going to focus my energy on my education, on building a good social life, so that became added self-esteem for me. I became accomplished academically and professionally. I had a strong group of friends who created this support while I was dealing with my reality” (Charbel, age 34).

Discussion

This may be the first published qualitative study to explore the sexual identity development of gay/bisexual men in Beirut, the stigma experienced by these men, and how their psychological well-being and engagement in social relationships and interactions are shaped by how they cope with this stigma. Consistent with the application of the minority stress model to gay/bisexual men in Western countries, our findings suggest that success in navigating one's way through the processes of sexual identity development, including self-acceptance and comfort with one's sexual orientation, and learning how to effectively cope with stigma may be central to psychological well-being and healthy social engagement.

The psychological processes of sexual identity development and coping with stigma can be significant challenges for men who have sex with men, particularly in regions where societal attitudes towards homosexuality remain conservative and slow to acknowledge the rights of sexual minorities. Three-quarters of the study participants self-identified as gay, but nearly two-thirds reported have at least some discomfort with their sexuality. Those who described struggling with their sexual orientation often referred to stigmatisation and condemnation on the part of society in general and their religious beliefs.

Comfort with one's sexual orientation appeared to be related to disclosure of sexual orientation to family and parents, both of which are indicators of self-acceptance of sexual identity. Roughly three times as many men who were very comfortable with their sexual orientation had disclosed their sexual orientation to family and parents compared to men who had discomfort with their sexual orientation. Concealing one's sexual identity and living a ‘double life’ by falsely attempting to convey oneself as heterosexual has been shown to have negative consequences for psychological well-being and self-esteem in MSM (Wolitski et al. 2006), and the decision of whether and when to disclose to family, and particularly parents, often weighs heavily on MSM (D'Augelli et al. 1998; Serovich et al. 2010). These effects may be accentuated in cultures such as Lebanon where family is very important and often plays a large role in one's daily life.

The majority of participants described experiences of stigma characterised by verbal harassment or ridicule, or as being treated as different or lesser in social relationships with friends or family. A few participants reported incidents of being physically or sexually assaulted. A number of men described being ridiculed or joked about at school or at work, and one respondent reported being denied an employment opportunity because of his sexual orientation. Evidence of the external stigma experienced by these men being internalised and resulting in discomfort and even self-loathing emerged in several of the interviews. This internalised stigma was often associated with manifestations of depression, anxiety and general psychological distress.

While a number of mechanisms for coping with stigma were described, most could be viewed as avoidant coping (Folkman et al., 1986), including forms of social avoidance (trying to pass as heterosexual; limiting interaction with MSM to the internet) or withdrawal (pulling back from relationships) in an attempt to limit exposure to stigma. Beirut is fortunate to have a few community organisations that provide support services to MSM and other sexual minorities, which can be important resources for helping individuals to cope with stigma; however, none of the respondents spoke of such organisational or community level supports, which could reflect the limitations of the interview guide or be an indication of the accessibility or effectiveness of these support systems. Regardless, there remains a strong need for increased mental health and social support services that directly target the needs of sexual minorities in Lebanon.

While our findings highlight the challenges that gay/bisexual men face in coping with sexual stigma, it is important to note that several participants had overcome these challenges and described now being stronger emotionally and self-confident in their identity and ability to live their life as they wish, highlighting the resilience that many MSM display in the face of societal stigma. With the study participants being generally well educated and either employed or having the resources to be in college, it is possible that resources related to their socioeconomic status and class may have also assisted in their resilience and ability to cope with stigma. The experiences of men living in poverty and with minimal education and socioeconomic resources may be distinctly different.

Limitations of the study include the small sample size and the lack of representativeness of the study participants. Although the intention of qualitative research is not to represent the sample population, because our sample consists of mostly young men who are well educated and gay-identified, transferability of our findings is limited. We had attempted to recruit heterosexually identified MSM, but this proved more difficult than anticipated. However, nearly a third of the participants did report having recent sex with women. We readily acknowledge that the relationships we have observed between variables should only be taken as potential patterns that require confirmation with more systematic, rigorous enquiry in larger samples.

The next phase of our research will employ respondent driven sampling to examine these constructs and relationships in quantitative surveys with MSM in Beirut. We will look to examine how levels of sexual stigma, both internal and external, are related to disclosure of MSM status and mental health, as well as indices of sexual health such as condom use and HIV testing. Studies of MSM in MENA suggest high rates of unprotected anal sex, multiple sex partners, concurrent sexual relations with women, and low rates of HIV testing (Afifi et al. 2008; El-Sayyed et al. 2008; Nakib and Hermez 2002; WHO et al. 2011). Research from other regions of the world indicate that sexual stigma may affect sexual risk behaviour through its effects on mental health indicators including self-esteem and internalised homophobia (Díaz et al. 2001; Fisher Raymond et al. 2011; Mayer et al. 2012; Nelson et al. 2010; Newcomb and Mustanski 2011; Preston et al. 2007; Shoptaw et al. 2009). Greater understanding of the interplay between stigma, mental health and sexual risk behaviour will help to inform interventions to promote sexual health among MSM in Lebanon and other parts of MENA.