A socioecological measurement of homophobia for all countries and its public health
Aix-Marseille School of
20 Ave Appia,
2, rue de la Charité
F-13236 Marseille cedex 2
London School of Hygiene
and Tropical Medicine
Keppel Street, London
Michael W. Ross
University of Minnesota
Department of Family Medicine and
1300 South 2nd Street
Minneapolis, MN 55454
United States of America
The International Lesbian,
Gay, Bisexual, Trans and
Intersex Association (ILGA)
20 rue Rothschild
André du Plessis
The International Lesbian,
Gay, Bisexual, Trans and
Intersex Association (ILGA)
20 rue Rothschild
20 Ave Appia
Email and telephone
20 Ave Appia,
1211 Geneva, Switzerland
2, rue de la Charité
F-13236 Marseille cedex 2
+41 22 791 4505
All co-authors contributed to this article in their personal capacity. The views expressed are their own and do
not necessarily represent the views of their respective organisation.
Background: Measuring homophobia at country level is important to guide public health
policy as reductions in stigma are associated with improved health outcomes among gay men
and other men who have sex with men.
Methods: We developed a Homophobic Climate Index incorporating institutional and social
components of homophobia. Institutional homophobia was based on the level of enforcement
of laws that criminalise, protect or recognise same-sex relations. Social homophobia was
based on the level of acceptance and justifiability of homosexuality. We estimated the Index
for 158 countries and assessed its robustness and validity.
Results: Western Europe is the most inclusive region, followed by Latin America. Africa and
the Middle East are home to the most homophobic countries with two exceptions: South
Africa and Cabo Verde.
We found that a one percent decrease in the level of homophobia is associated with a 10
percent increase in the gross domestic product per capita. Countries whose citizens face
gender inequality, human rights abuses, low health expenditures and low life satisfaction are
the ones with a higher homophobic climate. Moreover, a 10 percent increase in the level of
homophobia at country level is associated with a 1.7-year loss in life expectancy for males. A
higher level of homophobia is associated with increased AIDS-related death among HIV-
Conclusion: The socioecological approach of this index demonstrates the negative social,
economic and health consequences of homophobia in low- and middle-income countries. It
provides sound evidence for public health policy in favour of the inclusion of sexual
Keywords: Homophobia; stigma and discrimination; HIV; homosexuality; economic
Despite noticeable progress in terms of inclusion of sexual minorities in the vast majority of
countries over the last 40 years, the stigma associated with gay men and other men who have
sex with men (MSM) is still prevalent in most societies.
Stigma applies when elements of labelling, stereotyping, separation, status loss, and
discrimination co-occur in a power situation that allows the components of stigma to
unfold(1). Stigma can occur at individual, interpersonal and structural levels(2, 3).
Homophobia, a particular case of stigma based on sexual orientation and gender identity,
affects primarily lesbian, gay, bisexual, transgender and intersex people (LGBTI). Several
definitions focus on the clinical aspect of a phobia, describing homophobia as “an irrational,
persistent fear or dread of homosexuals”(4). Here, we use the term homophobia to refer to
any negative attitude, belief, or action toward persons of differing sexual orientation or
gender identity. It includes laws and structural manifestations of that prejudice in institutional
settings, such as the workplace(5). This working definition encompasses the three levels of
stigma described earlier.
The level of infringement of human rights, verbal and physical violence and denial of health
services associated with homophobia is a public health issue. Stigma is a central driver of
morbidity and mortality at a population level(6). Gay men facing enacted sexual stigma are
more likely to engage in sexual risk behaviours(7, 8). They are less likely to adhere to their
antiretroviral treatment(9) and have lower HIV testing rates(9-15). Finally, internalised
homonegativity is associated with lower levels of HIV testing and lower levels of condom
use in gay and bisexual men(16). A socio-ecological approach to health-related behaviour(17)
allows for studies of stigma related to sexual orientation and gender identity in their broader
structural and social dimensions(1, 6, 18). Most studies of homophobia focused at the
individual level. Being able to identify the level of homophobia at country level is important
to guide public health policies as recent evidence shows that reductions in the homophobic
climate are associated with improved health outcomes among gay men and other MSM(19).
This study aims to propose and validate a robust index to measure homophobia at country
level, including in low- and middle-income countries (LMIC).
The availability and reliability of data on stigma and discrimination related to gender identity
and sexual orientation and gender identity is uneven from country to country. Data on HIV
and on gay men and other MSM were obtained from AIDSinfo(20) an online repository of
global AIDS data compiled and maintained by UNAIDS, as well as from scientific articles
and grey literature. Economic and development indicators such as gross domestic product,
health expenditures, proportion of seats held by women in parliaments, gender inequality,
mean years of schooling and life expectancy were drawn from the IMF World Economic
Outlook, the 2015 Human Development Report and the World Population Prospects
published by the Department of Economic and Social Affairs of the United Nations
Population Division. We used the individual data from the World Values Survey which we
aggregated at country level. The information on laws and legislation comes from the
International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA). The rule of law
index comes from the World Justice Project and the Cantril index from the Gallup World
Poll. We used the data on homophobia made available by the Pew Research Center. We used
STATA 14 for statistical analysis.
Model and analytic strategy
We propose a socio-ecological construct for measuring homophobia that translates the
important role played by institutional but also interpersonal factors. Let the level of
homophobia for a country (i) be the combination of institutional (IsH) and social (SoH)
homophobia for each country (i).
Institutional homophobia, , relates to the formal codes, such as laws and legislations that
societies adhere to. Some of these codes may establish an institutional construct for inclusion
or discrimination against people based on their sexual orientation or gender identity. These
laws in their turn influence people’s behaviour and thoughts towards persons of differing
sexual orientations and gender identities(21-24). First, we considered a set of eleven laws that
characterise the level of institutionalised of homophobia of a country. For each country, those
eleven laws are individually valued from 1 to 3 whether it is inexistent, existent and in force,
or in force only in parts of its territory. The level of implementation is the one reported by the
International Lesbian, Gay, Bisexual, Trans and Intersex Association(25).
Second, we estimated the coefficients for these eleven laws globally. To ensure a transparent
and objective weighting system, we considered the way all countries are combining (or not) a
said law with the ten other laws considered here. By doing so, we reflect the choice of
countries to enforce laws favouring inclusion and protection or, a contrario, laws
criminalising same-sex relationships. To do so, we built polychoric correlation matrices as
these variables are categorical and ordinal. Our methods demonstrated high internal
consistency with an ordinal alpha of 0.92 and 0.83 for the inclusion and the criminalising
laws respectively. The weight of each law was then estimated by a factor analysis. Laws and
their coefficients are presented in annex 1. Institutional homophobia is expressed as
where are the factor loadings for the each law n
and is the level of enforcement of law n in country i , with and
Social homophobia, , relates to interactions between communities or groups and
individuals. A key characteristic is the direct reaction of individuals towards gay men and
Social homophobia reflects societal norms and behaviours based on moral, religious and
cultural beliefs. It encompasses interpersonal processes as well as physical reactions such as
avoidance or aggression, whether sexual, verbal or physical. These reactions take form in
social networks such as family, workplace or friends. It can also be found within
communities, whether ethnic, cultural, moral or religious ones.
Markers of social homophobia are difficult to measure, particularly at country level. We
focus on the interpersonal reactions, assuming it reflects the ultimate degree of societal
penetration. We considered two representative questions asked to more than 460,000
individuals in 91 countries within the three most recent waves of World Values Survey(26),
the 2008 European Values Survey(27) and the Afrobarometer(28). The first question is “On
this list are various groups of people. Could you please mention any that you would not like
as neighbours?” This is a dichotomised answer whether respondents selected ‘homosexuals’
or not. The second question was, “Do you think [homosexuality] can always be justified,
never be justified, or something in between?” Answers were given on a scale from 1 to 10,
with 1 meaning never justifiable and 10 meaning always justifiable. For each question, we
considered the answers from all respondents for each country and calculated a country-
specific value. Following a factor analysis, we weighted these two variables equally. We
performed multiple imputations and predicted values for the remaining 45 countries with
missing values for social homophobia, representing slightly more than a quarter (28%) of the
total number of countries studied (158). The social homophobia component can be expressed
Where n= number of respondents for country i and
We also considered homophobic violence. Unfortunately, only a minority of countries,
essentially the least homophobic ones, systematically record homophobic violence and hate
crimes. Reporting homophobic violence requires that the victims reveal their sexual
orientation which, in too many countries still, may expose him/her to additional risks of
violence and retaliation. It is worth noting that there has been remarkable progress by non-
State actors in reporting hate crimes in several countries. Despite these advancements, data
are still scarce, often limited to capital cities or large urban areas. If more data become
available in the future, homophobic violence can be integrated in equation (3).
We developed the homophobic climate index by compiling institutional and social
homophobia data. Both components are weighted equally as confirmed with a factor analysis,
i.e. in equation (1).
Reliability and validity of the homophobic climate index
We measured the internal consistency of the index with a reliability coefficient, measured by
the Cronbach’s alpha. We also performed a confirmatory factor analysis to confirm that the
scale in question is unidimensional.
In order to assess the validity of the HCI, we first controlled the results from regressions of
the HCI for two subsamples of countries randomly selected, with independent social and
economic variables such as income, gender equality, human rights, satisfaction in life, health
expenditures, and compared with the results obtained with the whole set of countries.
Finally, we examined the stability of the correlation between the HCI and a control index to
assess whether our instrument measures what we want to measure. We used the Gallup(29)
question on homophobia “is the city or area where you live a good place or not a good place
for gay or lesbian people” as control index and performed iterated regressions.
The model and data available enabled the estimation of the homophobic climate index (HCI)
for 158 countries. The index shows good internal consistency, with a Cronbach’s alpha of
0.82, and the control regressions with subsamples countries as well as with the control index
enable us to consider the HCI a statistically reliable and valid index to measure homophobia.
Regression and statistical tests are presented in annex 2.
The index ranges from 0 to 1, with higher values for more homophobic countries. Figure 1
presents the map of the homophobic climate (See Annex 3 for the ranking of 158 countries).
Table 1 presents the 10 most inclusive countries, globally (1a) and among low- and middle-
income countries (1b). The 10 most homophobic countries are also listed (1.c).
The most inclusive countries are essentially in Western Europe and Uruguay. Among the
LMIC, Latin America appears as a leading region in promoting inclusion and fighting
homophobia. It is worth noting that two African countries, South Africa and Cabo Verde are
among the top ten most inclusive LMIC. The case of South Africa is particularly interesting
as it paves the way to a more comprehensive and successful response to the HIV epidemic
that could serve as an example in other countries of the region.
Homophobia and socioeconomic determinants
We performed multivariate regressions, using the country level of homophobia as
explanatory variable to predict the value of key socioeconomic and public health outcome
variables. It should be reminded that results of these regressions represent correlation and do
not necessarily imply causal relationships. Descriptive statistics of the variables are presented
in annex 4. We found a clear negative relationship between the level of homophobia and
income. A ten percent change in GDP per capita is associated with a 1 percentage point
reduction in the mean homophobic climate index (table 2, model 1). In addition, gender
inequality, measured by the share of parliamentary seats held by women, is strongly
correlated with higher homophobic climate. One can also note the statistically robust
association between the level of homophobia and abuses of human rights. There is a strong
negative relationship between the level of homophobia of a country and the level of
satisfaction in life of its citizens, measured by the Cantril ladder.
It appears from table 2 that homophobia is also negatively associated with the share of MSM
among total population; meaning that a larger share of gay men and other MSM among the
population is associated with lower degree of homophobia.
We found that a 10-percentage point reduction in public health spending as a share of GDP is
associated with an increase in the homophobic climate of 9-percentage points (table 2 model
2). Moreover, AIDS-related deaths among men living with HIV is associated homophobia
(table 2 model 3).
Finally, even after controlling for markers of economic and social inequalities, the level of
homophobia at country level is strongly associated with premature death among men. This
translates into a 1.7-year reduction in life expectancy among its male population for a 10-
percentage point increase of the level of homophobia. See annex 5. It should be reminded
here that the correlations we identified between the level of homophobia at country-level and
different markers of health, social and economic development do not necessarily imply a
In this study, we developed a statistically robust and valid index that translates institutional
and social homophobia in most low- and middle-income countries across the globe. This
socioecological approach provides a holistic picture of sexual orientation related stigma. We
showed that homophobia is associated with lower economic output at country level.
Furthermore, the level of homophobia appears to be closely related to lower investment in
health and to social inequalities, such as lack of recognition of human rights and gender
inequality. We found a negative relationship between the level of homophobia and life
expectancy among males and showed that AIDS-related deaths among HIV-positive men are
associated with higher level of homophobia.
We also found that homophobia is negatively associated with the share of MSM among the
total population. This finding raises two caveats: first, a correlation does not imply causality.
This point is important to prevent misinterpretation to justify or promote homophobia in
order “to contain” the number of men having sex with men. Second and paradoxically, it does
not imply that homophobic countries have fewer gay men and other MSM. Instead, it may
mean that in these settings, this population group is underreported and underestimated(30-
32). Cultural, moral, religious beliefs may prevent men in some countries from coming out of
the closet(33). In addition, individuals expecting negative reactions from others due to their
differing sexual orientation or gender identity are less likely to report their sexual activity. In
highly homophobic countries, gay men and other MSM cannot disclose their sexual
orientation without exposing themselves to severe prejudices. Gay men and other MSM may
conceal their sexual orientation, or have heterosexual behaviour(34), leading to additional
under-reporting. Finally, the definition of homosexuality varies among different settings. In
many countries the insertive male partner is not labelled or considered homosexual, only the
receptive partner is(35).
Two limitations should be noted. First, modelling homophobia at country level implied trade-
offs in the identification of variables and proxies that adequately translate the different
dimensions of homophobia, in addition to being available for all countries. Country-level
analysis also means that variations within countries cannot be captured. The level of
homophobia may vary from one city to another and from urban to rural areas. State and non-
State actors at country level play a key role in filling these gaps and ensuring that no sexual
minority is denied its rights and its access to care. Second, even though we controlled for
collinearity, one should keep in mind that the institutional and social homophobia are
interrelated to some extent: individuals may live in an environment where social, religious
and cultural norms deeply interact with legislation. In other settings, laws and policies may
implicitly favour stigma and discrimination against some minorities. Finally, the social
homophobia experienced by individuals in some closed societies may provide ground for
internalised homonegativity. This favours arguments for a holistic approach when identifying
interventions aiming to reduce sexual-orientation related stigma and discrimination.
Recent epidemiological evidence shows the increasing incidence of HIV among gay men and
other MSM in most countries; new HIV infections rose by almost 12% between 2011 and
2015 (36). There is growing evidence that homophobia impedes access to prevention, care
and treatment by gay men and other MSM(16, 37-40). The availability of this index of
homophobia at country level enables the better understanding of the determinants of
vulnerability to HIV infection among gay men and other MSM in low- and middle-income
The socioecological model developed here provides a robust and valid measure of
homophobia that can inform public health decision-making. Increased availability of data in
low- and middle-income countries could enable future development of the socioecological
approach to measuring homophobia. For example, internalised homonegativity and
homophobic violence are important variables that could be considered if more data are made
available at country level.
Too many people are victims of stigma and discrimination related to sexual orientation and
gender identity. Countering homophobia is part of public health policy and all actors with
influence, including civil society and policy-makers should promote more inclusive societies.
We thank Michel Sidibé and Peter Ghys for making this study possible and for supporting it.
We also thank Carole Siani and Bruno Ventelou for their invaluable technical inputs. The
views expressed in this article are those of the authors and do not necessarily reflect those of
their respective institutions.
Conflicts of interest
• There is a significant negative correlation between economic development and
• Homophobia is associated with lower life expectancy for males at country level.
• Males living with HIV are more likely to die from AIDS in homophobic countries.
• Countering homophobia and other stigma related to sexual orientation and gender identity
should be part of public health policy.
1. Link BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol. 2001;27(1):363-85.
2. Hatzenbuehler ML. Structural stigma and Health. In: Major B, Dovidio JF, Link BG,
editors. The Oxford Handbook of Stigma, Discrimination, and Health: Oxford University
Press; 2017. p. 105-21.
3. Hatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma
and health. Soc Sci Med. 2014;103:1-6.
4. MacDonald A. Homophobia: its roots and meanings. Homosexual Counseling; 1976.
5. Badgett L. The economic cost of homophobia and the exclusion of LGBT people: a
case study of India. The World Bank; Washington, 2014.
6. Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a Fundamental Cause of
Population Health Inequalities. Am J Public Health. 2013;103(5):813-21.
7. Ha H, Risser JM, Ross MW, Huynh NT, Nguyen HT. Homosexuality-related stigma
and sexual risk behaviors among men who have sex with men in Hanoi, Vietnam. Arch Sex
8. Jeffries WLt, Marks G, Lauby J, Murrill CS, Millett GA. Homophobia is associated
with sexual behavior that increases risk of acquiring and transmitting HIV infection among
black men who have sex with men. AIDS Behav. 2013;17(4):1442-53.
9. Arreola S, Santos GM, Beck J, et al. Sexual stigma, criminalization, investment, and
access to HIV services among men who have sex with men worldwide. AIDS Behav.
10. Lorenc T, Marrero-Guillamon I, Llewellyn A, et al. HIV testing among men who
have sex with men (MSM): systematic review of qualitative evidence. Health Educ Res.
11. Adebajo SB, Eluwa GI, Allman D, Myers T, Ahonsi BA. Prevalence of internalized
homophobia and HIV associated risks among men who have sex with men in Nigeria. Afr J
Reprod Health. 2012;16(4):21-8.
12. Wei C, Yan H, Yang C, et al. Accessing HIV testing and treatment among men who
have sex with men in China: a qualitative study. AIDS Care. 2013;26.
13. Risher K, Adams D, Sithole B, et al. Sexual stigma and discrimination as barriers to
seeking appropriate healthcare among men who have sex with men in Swaziland. J Int AIDS
Soc. 2013;16 Suppl 2:1-9.
14. Andrinopoulos K, Hembling J, Guardado ME, de Maria Hernandez F, Nieto AI,
Melendez G. Evidence of the negative effect of sexual minority stigma on HIV testing among
MSM and transgender women in San Salvador, El Salvador. AIDS Behav. 2015;19(1):60-71.
15. Gu J, Lau JT, Wang Z, Wu AM, Tan X. Perceived empathy of service providers
mediates the association between perceived discrimination and behavioral intention to take
up HIV antibody testing again among men who have sex with men. PLoS One. 2015;10(2).
16. Ross MW, Berg RC, Schmidt AJ, et al. Internalised homonegativity predicts HIV-
associated risk behavior in European men who have sex with men in a 38-country cross-
sectional study: some public health implications of homophobia. BMJ Open. 2013;3(2).
17. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health
promotion programs. Health educ Q. 1988;15(4):351-77.
18. Hatzenbuehler ML. Structural Stigma and the Health of Lesbian, Gay, and Bisexual
Populations. Curr Dir Psychol Sci. 2014;23(2):127-32.
19. Hatzenbuehler ML, Bränström R, Pachankis JE. Societal-level explanations for
reductions in sexual orientation mental health disparities; Results from a ten-year, population-
based study in Sweden. Stigma Health; 2016; Advance online publication.
20. UNAIDS. AIDSinfo online database: UNAIDS; 2017; http://aidsinfo.unaids.org/;
21. Hooghe M, Meeusen C. Is same-sex marriage legislation related to attitudes toward
homosexuality? Sex Res Social Policy. 2013;10(4):258-68.
22. Smith TW, Son J, Kim J. Public attitudes toward homosexuality and gay rights across
time and countries. The Williams Institute; 2014 Nov.
23. Kreitzer RJ, Hamilton AJ, Tolbert CJ. Does policy adoption change opinions on
minority rights? The effects of legalizing same-sex marriage. Polit Res Q. 2014:795–808.
24. Christaforea D, Leguizamon JS. Revisiting evidence of labor market discrimination
against homosexuals and the effects of anti-discriminatory laws. Rev Reg Stud.
25. International, Lesbian, Gay, Bisexual, Trans and Intersex Association, Carroll A.
State-sponsored homophobia: A world survey of laws: criminalisation, protection and
recognition of same-sex love. 11ed. Geneva, 2016.
26. World Values Survey Association. World Values Survey, Wave 6 2010-2014. In:
Asep/JDS MS, editor. official aggregate v.20150418 ed2015.
27. Leibniz Institute for the Social Sciences. European values study 2008: Integrated
dataset. GESIS Data Archive, Cologne, ZA4800, Data file version 3.0.0:
https://dbk.gesis.org/; Accessed 06/01/2018.
28. Dulani B, Gift S, Dionne KY. Afrobarometer Round 6. Updated 15 Sept. 2016.
Available from: http://www.afrobarometer.org/online-data-analysis; Accessed 06/01/2018.
29. Gallup, McCarthy J. Nearly 3 in 10 worldwide see their areas as good for gays. 2014.
Available from: Gallup http://news.gallup.com/poll/175520/nearly-worldwide-areas-good-
gays.aspx; Accessed 17/12/2017.
30. Wu E, Terlikbayeva A, Hunt T, Primbetova S, Gun Lee Y, Berry M. Preliminary
population size estimation of men who have sex with men in Kazakhstan: Implications for
HIV testing and surveillance. LGBT health. 2017;4(2):164-7.
31. Quaye S, Fisher Raymond H, Atuahene K, et al. Critique and lessons learned from
using multiple methods to estimate population size of men who have sex with men in Ghana.
AIDS Behav. 2015;19(1):16-23.
32. Coffman KB, Coffman LC, Ericson KMM. The size of the LGBT population and the
magnitude of anti-gay sentiment are substantially underestimated. NBER Work Pap Ser.
33. Ross MW. Married homosexual men: Prevalence and background. Marriage Fam
34. Pachankis JE, Hatzenbuehler ML, Mirandola M, et al. The geography of sexual
orientation: structural stigma and sexual attraction, behavior, and identity among men who
have sex with men across 38 European countries. Arch Sex Behav. 2017;46(5):1491-502.
35. Mitchell G. Tourist attractions: performing race and masculinity in Brazil's sexual
economy: University of Chicago Press; 2015. 264p.
36. UNAIDS. Get on the fast-track: The life-cycle approach to HIV. Geneva; 2016.
37. Pachankis JE, Hatzenbuehler ML, Hickson F, et al. Hidden from health: structural
stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM
Internet Survey. AIDS. 2015;29(10):1239-46.
38. Anderson AM, Ross MW, Nyoni JE, McCurdy SA. High prevalence of stigma-related
abuse among a sample of men who have sex with men in Tanzania: implications for HIV
prevention. AIDS Care. 2015;27(1):63-70.
39. Ross MW, Nyoni J, Ahaneku HO, Mbwambo J, McClelland RS, McCurdy SA. High
HIV seroprevalence, rectal STIs and risky sexual behaviour in men who have sex with men in
Dar es Salaam and Tanga, Tanzania. BMJ Open. 2014;4(8):e006175.
40. Ross MW, Kajubi P, Mandel JS, McFarland W, Raymond HF. Internalized
homonegativity/homophobia is associated with HIV-risk behaviours among Ugandan gay and
bisexual men. Int J STD AIDS. 2013;24(5):409-13.
Table 1: Homophobic Climate Index 2017: Top 10 most inclusive and most homophobic countries
1a: Top 10 most inclusive countries
1b: Top 10 most inclusive low-and middle-
income countries (LMIC)
1c: Top 10 most homophobic countries
Table 2: Associations between homophobia and key socioeconomic and public health
Revenue per capita
(ln GDP pc )
Share of parliament seats by
Human rights abuse (√x)
Satisfaction in life
Proportion of MSM among
Share of male AIDS death
among male HIV+ (√x)
Model fit indices
Note: Bootstrap jackknife regressions, CI Confidence Intervals. *p<0.05 **p<0.01 ***p<0.001