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Journal of Homosexuality
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wjhm20
Internalized Sexual Orientation Stigma and Mental
Health in a Religiously Diverse Sample of Gay and
Bisexual Men in Lebanon
Ismael Maatouk & Rusi Jaspal
To cite this article: Ismael Maatouk & Rusi Jaspal (2022): Internalized Sexual Orientation Stigma
and Mental Health in a Religiously Diverse Sample of Gay and Bisexual Men in Lebanon, Journal of
Homosexuality, DOI: 10.1080/00918369.2022.2030617
To link to this article: https://doi.org/10.1080/00918369.2022.2030617
© 2022 The Author(s). Published with
license by Taylor & Francis Group, LLC.
Published online: 28 Jan 2022.
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Internalized Sexual Orientation Stigma and Mental Health
in a Religiously Diverse Sample of Gay and Bisexual Men in
Lebanon
Ismael Maatouk, MD MPH
a
and Rusi Jaspal, PhD
b
a
Department of Psychology, Nottingham Trent University, Nottingham, UK;
b
Vice-Chancellor’s Office,
University of Brighton, Brighton, UK
ABSTRACT
This study explores the correlates of internalized sexual orienta-
tion stigma, psychological distress and depression in
a religiously diverse sample of gay and bisexual men in
Lebanon. A convenience sample of 200 participants completed
a cross-sectional survey. Bisexual men reported greater interna-
lized sexual orientation stigma and less outness to their family
and were more likely to face family pressure to have
a heterosexual marriage than gay men. People of no religion
reported more outness than Muslims and Christians but also
higher psychological distress and depression. Multiple regres-
sion analyses showed that religiosity, outness, family pressure to
marry and being bisexual were positively associated with inter-
nalized sexual orientation stigma; and that frequency of attend-
ing one’s place of worship was negatively associated with
psychological distress and depression. Individuals may be cop-
ing with adversity through engagement with institutionalized
religion, which also appears to be a source of negative social
representations concerning their sexuality.
KEYWORDS
Internalized sexual
orientation stigma;
psychological distress;
depression; religion; sexual
orientation; identity;
Lebanon
Introduction
The Lebanese population has been exposed to many psychological stressors,
such as foreign occupation, a bloody civil war (1975–1990), repeated conflicts
with Israel, a dramatic economic crisis with massive devaluation of the cur-
rency and job insecurity in the general population. All of these factors may
increase the risk of poor mental health (Al Amine & Llabre, 2008; Jaspal, Assi,
& Maatouk, 2020; Khamis, 2012). Religion plays an important role in Lebanese
society and religiosity has been shown to be protective against poor mental
health (Assi, Maatouk, & Jaspal, 2020; Khamis, 2012).
Sexual minorities in Lebanon may be at particularly high risk of psycho-
logical stress given that they may feel unable to disclose their sexual identity
to others (that is, to come out), face stigma when they do, and experience
family expectations to conform to the religious and cultural norm of
CONTACT Rusi Jaspal rusi.jaspal@cantab.net Vice-Chancellor’s Office, University of Brighton, Lewes Road,
Brighton BN2-4GJ, UK
JOURNAL OF HOMOSEXUALITY
https://doi.org/10.1080/00918369.2022.2030617
© 2022 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in
any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
a heterosexual marriage (Nagle, 2016). Furthermore, given the negative
social representations of homosexuality in their religious communities, gay
and bisexual men in Lebanon may perceive their sexuality and religion to be
incompatible (Wagner et al., 2013). Given its status as a coping mechanism
in Lebanese society, religion may constitute a paradox for gay and bisexual
men in that society—on the one hand, it may be associated with the
stigmatization of homosexuality/ bisexuality and, on the other hand, it may
facilitate coping with other stressors in life and serve as a protective group
membership.
Although there has been some research into gay men in Lebanon (e.g.
Michli & El Jamil, 2020; Obeid, Haddad, Salame, Kheir, & Hallit, 2019;
Wagner et al., 2013), none has focused specifically on differences between
gay and bisexual men in this country (Maatouk & Jaspal, 2019). Using tenets of
identity process theory (Breakwell, 1986) as an interpretative framework, we
examine the correlates of internalized sexual orientation stigma and mental
health outcomes (i.e., depression and psychological distress) in a religiously
diverse sample of gay and bisexual men in Lebanon.
Identity processes in gay and bisexual men in Lebanon
Identity process theory (Breakwell, 1986; Jaspal & Breakwell, 2014) provides
an integrative model of how people integrate changes into their identity and
how they cope with the consequences of such identity change (Amiot & Jaspal,
2014). It is noteworthy that the theory is not tested in this study—it is used as
an interpretative framework. Two processes are thought to regulate the con-
struction of identity: assimilation-accommodation and evaluation. The goal of
assimilation-accommodation is to maintain or to modify the existing content
of identity by integrating new information into the existing identity structure
(assimilation) and by making subsequent changes to the identity structure
(accommodation). In accordance with the evaluation process, the individual
appends meaning and value to the contents of identity, such as being gay or
bisexual.
For instance, upon coming out as gay or bisexual, the individual will usually
draw on social representations (which are essentially systems of values, ideas,
images and metaphors concerning any given social object, see Moscovici,
1988) derived from salient group memberships (such as religion, in the
context of Lebanon) in order to evaluate this novel identity element.
Evaluation has a reciprocal relationship with assimilation-accommodation in
that they tend to function in tandem. Internalized sexual orientation stigma
can be defined as “the individual’s direction of negative social attitudes toward
the self” and can contribute to a devaluation of the self and internal conflicts
(Meyer & Dean, 1998, p. 161). This reflects the assimilation-accommodation
and evaluation processes in action.
2I. MAATOUK AND R. JASPAL
The two identity processes are guided by various motivational principles,
which include self-esteem, self-efficacy, positive distinctiveness, and continu-
ity. Additionally, Jaspal and Cinnirella (2010) have described the concept of
psychological coherence, which refers to the perception of compatibility
between ‘interconnected’ identity elements. When elements of identity, such
as sexuality and religion, are deemed to be in conflict, individuals are moti-
vated to seek solutions to perceived incoherence in identity. This again may
initiate modifications at the level of assimilation-accommodation with some
identity elements being accentuated, others attenuated and some even
removed from the identity structure. The processes function in a way that
produces adequate levels of these motivational principles for the overall
identity structure. According to the theory, failure to produce adequate levels
of the identity principles results in identity threat.
Although identity threat is not a focus of the present study, it is noteworthy
that gay and bisexual men in Lebanon do face diverse stressors that can
threaten their identity. For instance, coming out may be psychologically
stressful if there are high levels of societal stigma in relation to one’s sexual
orientation (Obeid et al., 2019; Wagner et al., 2013). Another important
minority stressor is perceived family pressure to get married. Michli and El
Jamil (2020) found that both actual and anticipated parental rejection was
predictive of internalized sexual orientation stigma. Our study provides
greater clarification of this relationship by focusing on the specific variable
of perceived family expectation to have a heterosexual marriage. We hypothe-
size that in a collectivist society, such as that of Lebanon, in which the family
plays a significant role in people’s lives and identities (Ajrouch, 2000), the
expectation of a heterosexual marriage will be high. Moreover, as a possible
indicator of parental disapproval of, or stigma toward, one’s sexual orienta-
tion, perceived family pressure to get married may also be associated with the
internalization of sexual orientation stigma.
Despite the empirically observed importance of religion, it must be noted that
increasing numbers of young people in Lebanon are now rejecting or disidenti-
fying with religion and laying claim to a secular identity partly because religion
is sometimes viewed as the cause of division and internal conflict in the country
(Faour, 2007; Harb, Atallah, & Diab, 2021). Unlike the experiences of their
Christian and Muslim peers, people who report no religion may be hypothesized
to experience less concern about religious censure of their sexual orientation
and, thus, to report more outness about their sexual identity and less perceived
family pressure to have a heterosexual marriage.
In response to experiences that are threatening for identity, people attempt to
cope. Coping strategies refer to specific efforts—behavioral and psychological—
that people employ to master, tolerate, or minimize stressful events (Folkman &
Lazarus, 1980). In line with identity process theory, coping strategies operate at
at least three levels: the intra-psychic level (e.g., acceptance or denial of the
JOURNAL OF HOMOSEXUALITY 3
threat, reconceptualization, and compartmentalization); the inter-personal level
(e.g., self-isolation and passing or hiding); the inter-group level (e.g., shifting
between one’s group memberships and engaging in group action).
In order to manage potential conflict between their religion and sexuality,
gay and bisexual men in Lebanon may resort to keeping these identity ele-
ments separate in their mind—a strategy which has been referred to as
compartmentalization (Ho & Hu, 2016). Moreover, strategic engagement
with key social group memberships, such as religion, is an important coping
strategy, especially in more collectivist societies. In Lebanon, it has been shown
that people may engage with their religion (both in terms of spirituality and
involvement in religious community) to cope with stressors (Afifi et al., 2020;
Farhood & Dimassi, 2012; Ghandour & El Sayed, 2013; Ghandour, Karam, &
Maalouf, 2009). Engagement in institutionalized religion may be especially
important as a group-based coping strategy (Hjarvard, 2011). Thus, Lebanese
gay and bisexual men who report attending their place of worship may be at
decreased risk of poor mental health. Conversely, those who report no religion
will not have access to this significant coping strategy (in Lebanese society)
(Michli & El Jamil, 2020) and may, thus, be at increased risk of poor mental
health. We hypothesize that gay and bisexual men in Lebanon will also attempt
to engage in religious coping by developing ways of continuing to access
religion despite the homonegativity that many associate with their religious
institutions (see Assi et al., 2020).
Internalized sexual orientation stigma and mental health
Engagement with the evaluation process of identity among gay and bisexual
men in Lebanon may result in the negative valence of sexual orientation and,
thus, internalized sexual orientation stigma. It has been found that interna-
lized sexual orientation stigma among Lebanese sexual minorities is predicted
by religiosity, parental rejection, vigilance, and sense of belonging to the
lesbian, gay, bisexual and trans (LGBT) community (Michli & El Jamil,
2020). Given the importance of the family in the collectivist society of
Lebanon, parental stigma toward one’s sexual orientation may lead one to
internalize the stigma. Furthermore, religion does constitute a source of
negative social representations of homosexuality (Schuck & Liddle, 2001).
On the other hand, outness, as a facilitator of belonging to the LGBT com-
munity, is likely to be protective against internalized sexual orientation stigma
(Herek & Garnets, 2007; Hunter, 2007).
It has been found that bisexual men may be at greater risk of internalized
sexual orientation stigma than gay men (Feinstein & Dyar, 2017). Bisexuals may
experience marginalization from both the heterosexual and gay communities
given that gay men may negate bisexual identity and expect them to adopt a gay
lifestyle while heterosexuals may pressure them to conform to heterosexual
4I. MAATOUK AND R. JASPAL
norms (Dodge et al., 2016). In view of this pressure, it could be hypothesized
both that bisexual men will internalize the stigma that they encounter in relation
to their sexual orientation, on the one hand, and that they are less likely to
disclose it to other people, on the other hand. Consequently, bisexual men may
also be under increased family pressure to enter into a heterosexual marriage.
Minority stress theory (Meyer, 1995) suggests that exposure to distal and
proximal stressors, such as internalized sexual orientation stigma, may result in
poor mental health outcomes. In other societies, internalized sexual orientation
stigma has been shown to be associated with a variety of poor mental health
outcomes, including depression, anxiety, insecure attachment styles, substance
use disorders, self-harm and suicidal ideation (Frost & Meyer, 2009; Jaspal,
Lopes, & Rehman, 2021). In Lebanon, there is evidence that non-heterosexual
people, including gay and bisexual men, face greater psychological distress (Assi
et al., 2020), more disordered eating patterns (Naamani, 2018), and higher rates
of depression (Wagner et al., 2019) than their heterosexual counterparts.
Conversely, self-acceptance and outness have been found to be related to better
mental health outcomes (Michli & El Jamil, 2020; Wagner et al., 2019).
Although there is an established empirical link between internalized sexual
orientation stigma and mental health outcomes in samples of gay and bisexual
men (Herek & Garnets, 2007), this has not been studied in Lebanese gay and
bisexual men specifically. In societies with widespread stigma toward sexual
minorities, such as that of Lebanon (Obeid et al., 2019), people may focus on
other aspects of identity (other than their sexuality) and draw on religious
coping in response to stressors associated with these other aspects of identity
(such as job insecurity, COVID-19 and so on).
Hypotheses
The objective of this study was to explore the predictors of internalized sexual
orientation stigma and mental health outcomes (i.e., depression and psycho-
logical distress), respectively, in a religiously diverse sample of Lebanese gay
and bisexual men. The following hypotheses were tested in this study:
(1) Bisexual men will exhibit higher internalized stigma, less outness, and
be more likely to report family pressure to have a heterosexual marriage
than gay men.
(2) People of no religion will report higher outness and will be less likely to
report family pressure to have a heterosexual marriage but will also
report poorer mental health outcomes than Christians and Muslims.
(3) Religiosity, being bisexual and facing family pressure to have
a heterosexual marriage will be positively associated with internalized
sexual orientation stigma while outness will be negatively associated
with internalized sexual orientation stigma.
JOURNAL OF HOMOSEXUALITY 5
(4) Frequency of attending one’s place of worship will be negatively asso-
ciated with psychological distress and depression.
Method
Participants
A convenience sample of 200 gay and bisexual male service users at
a private dermatology and sexual health clinic serving as a checkpoint
for HIV and STIs testing was recruited for a survey study of identity and
mental health. Participants were aged between 18 and 50 (M = 29.77,
SD = 6.38). There were 107 (53.5%) individuals who reported sexual
attraction only to males (gay) and 88 (44%) who reported sexual attrac-
tion to both males and females (bisexual). Table 1 provides a full descrip-
tion of the participant sample.
Measures
Demographic questions included age, nationality, governorate of residence,
highest qualification and religion.
Religiosity was assessed using the 5-item Abbreviated Santa Clara
Strength of Religious Faith Scale (Plante, 2010). The scale included
items such as “I pray daily” and “I consider myself active in my faith or
place of worship” and were measured on a 5-point scale (1 = totally
disagree, 5 = totally agree). A sum score provided an overall score of
religiosity—the higher the score, the higher the level of religiosity. The
scale exhibited very good reliability (α = .89).
Frequency of attending a place of worship was measured with the following
item: “How regularly do you attend a place of worship?” with 5 possible
answers (1 = never, 5 = very regularly).
Table 1. Characteristics of the participant sample.
Nationality Lebanese Syrian Palestinian
N = 187 N = 7 N = 2
93.5% 3.5% 1%
Age Mean SD Minimum Maximum
29.77 6.38 18 50
Governorate of residence Beirut Mount Lebanon North South Bekaa
N = 132 N = 39 N = 11 N = 3 N = 6
66% 19.5% 5.5% 1.5% 3%
Qualification University Non-university
N = 174
87%
N = 19
9.5%
Sexual orientation Gay Bisexual
N = 107
53.5%
N = 88
44%
Religion Christians Muslims No religion
N = 93
46.5%
N = 62
31%
N = 42
21%
6I. MAATOUK AND R. JASPAL
Sexual orientation was captured using the following item (Copen, Chandra,
& Febo-Vazquez, 2016): “People are different in their sexual attraction to other
people. Which best describes your feelings?” with six possible answers. Those
who indicated sexual attraction to males only were categorized as gay and
those who reported sexual attraction to both males and females were categor-
ized as bisexual.
Outness was assessed using the 11-item Outness Inventory (Mohr &
Fassinger, 2000). The scale measures the extent to which an individual’s sexual
orientation is known by and openly discussed with people, such as “new
straight friends,” “work peers,” “mother,” “father,” “leaders of religious com-
munity.” Answers were measured on an 8-point scale (0 = not applicable;
1 = person definitely does not know about sexual orientation status, 7 = person
definitely knows about sexual orientation status and it is openly talked about).
The scale has three subscales: outness to family (items 1, 2, 3 and 4; α = .81),
outness to world which includes friends and coworkers (items 5, 6, 7 and 10;
α = .76) and outness in one’s religious institution (items 8 and 9). A sum score
provides an overall score of outness—the higher the score, the higher the level
of outness. The overall scale exhibited very good reliability (α = .84).
Family expectation to have a heterosexual marriage was measured using
the following item: “Does your family expect you to marry a woman?” (‘yes’
vs ‘no’).
Internalized sexual orientation stigma was assessed using the 9-item
Internalized Homophobia Scale (Martin & Dean, 1987). The scale included
items such as “I have tried to stop being attracted to same-sex people in
general” and “I wish I weren’t gay/bisexual” and were measured on a 5-point
scale (1 = totally disagree, 5 = totally agree). A sum score provides an overall
score of internalized sexual orientation stigma—the higher the score, the
higher the level of internalized sexual orientation stigma. The scale exhibited
very good reliability (α = .86).
Depression was assessed using the 10-item Center for Epidemiological
Studies Depression 10 (CES-D10) Self-Report Depression Scale
(Björgvinsson, Kertz, Bigda-Peyton, McCoy, & Aderka, 2013). The scale
included items such as “During the past week, I felt depressed” and “During
the past week, I felt hopeful about the future” and were measured on a 4-point
scale (0 = rarely/never; 3 = all of the time). A sum score provides an overall
score of depression—the higher the score, the higher the level of depression.
The scale exhibited very good reliability (α =.83).
Psychological distress was assessed using the 18-item The Brief Symptom
Inventory-18 (Derogatis, 2001). The scale included items such as “feeling no
interest in things” and “feeling hopeless about the future” which were mea-
sured on a 5-point scale (1 = not at all; 5 = extremely). A sum score provides an
JOURNAL OF HOMOSEXUALITY 7
overall score of psychological distress—the higher the score, the higher the
level of psychological distress. The scale exhibited very good reliability
(α = .93).
Statistical analyses
SPSS version 25 was used to perform the analyses. First, independent samples
t-tests bootstrapped at 1000 samples to control for statistical power were
performed to analyze differences between the main groups in the sample for
the key variables. Cohen’s ds and 95% Confidence Intervals (CIs) are reported
to control for the strength of between groups’ mean differences for the key
variables. Second, correlational matrices bootstrapped at 1000 samples were
performed to test associations between continuous variables. Third, chi-
squared tests bootstrapped at 1000 samples were performed to test associa-
tions between categorical variables. The Phi values are reported to examine
effect sizes of chi-squared relationships. Fourth, stepwise multiple regressions
were conducted with a bootstrap set at 1000 samples to test which variables
predict internalized sexual orientation stigma, depression and psychological
distress, respectively.
Results
Descriptive statistics
Table 2 provides a full summary of the descriptive statistics concerning
the key variables of interest. On average, people reported low overall
outness (M = 23.90, SD = 14.22) of which outness to family was the
highest (M = 10.66, SD = 7.23), moderate internalized sexual orientation
stigma (M = 20.09, SD = 8.18), moderate levels of religiosity (M = 12.24,
SD = 5.74), and moderate levels of depression (M = 21.49, SD = 5.68) and
psychological distress (M = 35.21, SD = 14.42).
Table 2. Descriptive statistics for the key variables of this study.
Mean SD Minimum Maximum
Religiosity 12.24 5.74 5 25
Depression 21.49 5.68 11 38
Psychological distress 35.21 14.42 18 77
Internalized sexual orientation stigma 20.09 8.18 9 43
Overall outness 23.9 14.22 0 77
Outness to family 10.66 7.23 0 28
Outness to world 8.48 6.35 0 28
Outness in one’s religious institution 3.04 2.64 0 14
Frequency of attending a place of worship 2.08 1.03 1 5
Family pressure to get married Yes No
N = 146
73.7%
N = 52
26.3%
8I. MAATOUK AND R. JASPAL
Dierences between gay and bisexual men
Chi-squared tests showed that more bisexual men (80.2%) were expected to
marry a woman compared with gay men (67.3%) [χ2(1, 193) = 4.058, p < .05;
Phi = .145, p < .05].
An independent samples t-test showed that bisexuals exhibited higher
internalized sexual orientation stigma (M = 23.56, SD = 7.89) compared
to gay men (M = 17.23, SD = 7.15) [t(167.70) = 5.64, p < .001; Cohen’s
d = .84; 95% CIs (4.299, 8.538)]. Moreover, bisexuals reported lower
outness to family (M = 9.16, SD = 6.83) compared to gay men (M =
12.21, SD = 7.40) [t(157) = −2.69, p < .01; Cohen’s d = .42; 95% CIs
(−5.295, −.813)].
Dierences between Muslims, Christians and those of no religion
One-way ANOVA tests showed that outness was the highest among people of
no religion (M = 29.29, SD = 12.79) followed by Christians (M = 23.42, SD =
13.79) and Muslims (M = 21.42, SD = 15.20) [F(2, 194) = 4.094, p = .01]. Post
hoc comparisons using the Tukey HSD test indicated that the mean outness
score was significantly different between Muslims and people of no religion
(p = .01).
Of the 3 subscales of the Outness Inventory (family; world; religion), only
the subscale of outness to one’s family was significantly different for people of
no religion (M = 14.08, SD = 7.39) followed by Muslims (M = 10.00, SD = 7.48)
and Christians (M = 9.58, SD = 6.59) [F(2, 194) = 4.094, p = .01]. Post hoc
comparisons using the Tukey HSD test indicated that outness to one’s family
was different between people of no religion and Christians (p < .01) and
Muslims (p = .02) respectively.
Moreover, depression was significantly higher in people with no religion
(M = 23.25, SD = 6.25) followed by Muslims (M = 22.13, SD = 6.03) and
Christians (M = 20.23, SD = 4.94) [F(2, 188) = 4.650, p = .01]. Post hoc
comparisons (Tukey HSD) indicated a significant difference of depression
between people of no religion and Christians (p = .01).
Similarly, psychological distress was significantly higher in people of no
religion (M = 38.10, SD = 16.08) followed by Muslims (M = 37.45, SD =
16.07) and Christians (M = 31.94, SD = 11.34) [F(2, 194) = 4.186, p =
.01]. Post hoc comparisons indicated a significant difference of psycholo-
gical distress between Christians and Muslims (p = .04). Table 3 provides
a description of religion differences for key variables of interest.
Furthermore, a chi-squared test showed that more Christians (45.8%)
reported family pressure to have a heterosexual marriage than Muslims
(37.5%) and people of no religion (16.7%) [χ2(2, 196) = 11.792, p < .01;
Phi = .245, p = .003].
JOURNAL OF HOMOSEXUALITY 9
Dierences between those who face family pressure to get married and those
who do not
An independent samples t-test showed that those who reported family pres-
sure to have a heterosexual marriage exhibited higher internalized sexual
orientation stigma (M = 21.66, SD = 8.10) compared to those who reported
no such family pressure (M = 15.50, SD = 6.64) [t(196) = 5.40, p < .001;
Cohen’s d = .83; 95% CIs (3.898, 8.417)]. Similarly, those who reported family
pressure to have a heterosexual marriage exhibited lower outness to family
(M = 9.20, SD = 6.63) compared to those who reported no such pressure (M =
14.95, SD = 7.29) [t(160) = −4.70, p < .001; Cohen’s d = .82; 95% CIs (−8.156,
−3.331)]; lower outness to world (M = 7.00, SD = 5.15) compared to M = 14.15,
SD = 7.22 [t(31.34) = −4.77, p <.001; Cohen’s d = 1.14; 95% CIs (−10.211,
−4.096)] and lower outness in one’s religious institution (M = 2.56, SD = 2.13)
compared to M = 4.67, SD = 3.51 [t(36.15) = −3.19, p <.01; Cohen’s d = .72;
95% CIs (−3.454, −.769)].
Correlations between key variables of interest
The results indicated negative correlations between internalized sexual orien-
tation stigma and outness to family; religiosity and depression; religiosity and
outness to family. Outness to the world and outness in one’s religious institu-
tion did not correlate with any variable.
There were negative correlations between age and depression; age and
psychological distress; frequency of attending one’s place of worship and
depression; and frequency of attending places of worship and psychological
distress. There was a positive correlation between depression and psychologi-
cal distress; and religiosity and internalized sexual orientation stigma.
Table 4 provides a full overview of the correlations between continuous
variables in this study.
Multiple regression model predicting internalized sexual orientation stigma
A multiple linear regression was conducted to examine which variables pre-
dicted the variance of internalized sexual orientation stigma. The continuous
variables of outness to family, religiosity and frequency of attending one’s
Table 3. Descriptive statistics for religious differences for key variables of interest.
Christians Muslims No religion
F df p η
2
N M SD N M SD N M SD
Overall outness 93 23.42 13.79 62 21.42 15.20 42 29.29 12.79 4.094 2, 194 .01 0.28
Outness to one’s family 78 9.58 6.59 48 10.00 7.48 36 14.08 7.39 4.094 2, 194 . 01 0.20
Depression 91 20.23 4.94 61 22.13 6.03 39 23.25 6.25 4.650 2, 188 .01 0.16
Psychological distress 93 31.94 11.34 62 37.45 16.07 42 38.10 16.08 4.186 2, 194 0.01 0.24
10 I. MAATOUK AND R. JASPAL
place of worship, as well as the categorical variables of sexual orientation (gay
vs. bisexual) and family pressure to have a heterosexual marriage were inserted
as predictors; and internalized sexual orientation stigma was inserted as the
dependent variable.
Religiosity was entered into Step 1 and explained 16.3% of the variance in
internalized sexual orientation stigma. At step 2, religiosity and sexual orien-
tation explained 28.7% of the variance in internalized sexual orientation
stigma. R-square change was 0.127 and F-change was 27.598 (p <.001). At
step 3, religiosity, sexual orientation and family pressure to have a heterosexual
marriage explained 34.4% of the variance in internalized sexual orientation
stigma. R-square change was 0.061 and F-change was 14.381 (p <.001). At step
4, religiosity, sexual orientation, family pressure to have a heterosexual mar-
riage and outness to family explained 36.5% of the variance in internalized
sexual orientation stigma. R-square change was 0.025 and F-change was 6.115
(p = .01).
The regression model was statistically significant for internalized sexual
orientation stigma [F(4, 155) = 23.298, p <.001; R
2
= .365]. Of the 5 predictors,
religiosity with a β = .310 S.E. = .101, 95% CIs (.268,.666) (t = 4.641, p <.001)
was the most powerful followed by sexual orientation with a β = −.308 S.E. =
1.096, 95% CIs (−7.334, −3.003) (t = −4.715, p <.001), family pressure to have
a heterosexual marriage with a β = −.199 S.E. = 1.285, 95% CIs (−6.282,
−1.203) (t = −2.912, p = .004); and outness to family with a β = −.176 S.E. =
.082, 95% CIs (−.363, −.041) (t = −2.473, p = .015) all had significant effects on
the variance of internalized sexual orientation stigma. The variable of fre-
quency of attending a place of worship was excluded from the model in the
first step.
These results suggest that religiosity, being bisexual and family expecta-
tion to have a heterosexual marriage were positively associated with inter-
nalized sexual orientation stigma whereas outness to one’s family was
negatively associated with internalized sexual orientation stigma in our
sample.
Table 4. Correlations between the key variables.
123456789
1. Age .101 .083 −.149* −.174* .094 .060 .064 .080
2. Internalized sexual
orientation stigma
.101 .395** .060 .041 −.397** −.158 −.155 .243**
3. Religiosity .083 .395** −.151* −.134 −.286** −.010 .118 .670**
4. Depression −.149* .060 −.151* .749** .044 −.046 −.110 −.280**
5. Psychological distress −.174* .041 −.134 .749** .081 −.006 −.062 −.246**
6. Outness to family −.094 −.397** −.286** .044 .081 .508** .411** −.270**
7. Outness to world .060 −.158 −.010 −.046 −.006 .508** .665** −.008
8. Outness in one’s
religious institution
.064 −.155 .118 −.110 −.062 .411** .665** .128
9. Frequency of attending
a place of worship
.080 .243** .670** −.280** −.246** −.270** −.008 .128
*p < .050; **p < .005
JOURNAL OF HOMOSEXUALITY 11
Multiple regression model predicting depression
A multiple linear regression was conducted to examine which variables pre-
dicted the variance of depression. The categorical variable of religion
(Christian vs Muslim vs no religion) was recoded (dummy coding), generating
three new dichotomous variables and the continuous variables of age, religi-
osity and frequency of attending one’s place of worship were inserted as
predictors, and depression was inserted as the dependent variable.
Frequency of attending one’s place of worship was entered into Step 1 and
explained 7.3% of the variance in depression. At step 2, frequency of attending
one’s place of worship and age explained 8.2% of the variance in depression.
R-square change was 0.082 and F-change was 3.133 (p = .01).
The regression model was statistically significant for depression [F(1, 185) =
15.599, p <.001; R
2
= .073]. Of the 4 predictors, frequency of attending one’s
place of worship with a β = −.279 S.E. = .391, 95% CIs (−2.318, −.774) (t =
−3.950, p <.001) was the only significant predictor of depression. The variables
of religion and religiosity were excluded from the model in the first step. These
results suggest that frequent attendance of places of worship was associated
with decreased likelihood of depression in our sample.
Multiple regression model predicting psychological distress
A multiple linear regression was conducted to examine which variables pre-
dicted the variance of psychological distress. The categorical variable of religion
(Christian vs Muslim vs no religion) was recoded (dummy coding), generating
three new dichotomous variables and the continuous variables of age, religiosity
and frequency of attending one’s place of worship were inserted as predictors,
and psychological distress was inserted as the dependent variable.
Frequency of attending a place of worship was entered into Step 1 and
explained 5.1% of the variance in psychological distress. At step 2, frequency of
attending a place of worship and age explained 6.7% of the variance in
psychological distress. R-square change was 0.021 and F-change was 4.269
(p = .040).
The regression model was statistically significant for psychological distress
[F(2, 192) = 7.878, p = .001; R
2
= .067]. Of the 4 predictors, frequency of
attending one’s place of worship with a β = −.226 S.E. = .971, 95% CIs (−5.056,
−1.228) (t = −3.237, p = .001) was the most powerful followed by age with a β =
−.144 S.E. = .158, 95% CIs (−.636, −.015) (t = −2.066, p = .04) which had
significant effects on the variance of psychological distress. The variables of
religion and religiosity were excluded from the model in the first step. These
results suggest that frequent attendance of places of worship and higher age
were both associated with decreased likelihood of psychological distress in our
sample.
12 I. MAATOUK AND R. JASPAL
Discussion
All four of our hypotheses were supported by the data. There were observable
differences between gay and bisexual men and religious groups on several key
variables. Moreover, multiple regression analyses indicated that bisexuality,
religiosity and family pressure to enter into a heterosexual marriage were
positively associated with internalized sexual orientation stigma while outness
was a negative correlate. Additional analyses indicated that frequency of
attending a place of religious worship was negatively associated with both
psychological distress and depression, suggesting a possible protective role of
engagement with institutionalized religion. There appears to be a paradoxical
relationship with religion—on the one hand, religion constitutes a source of
negative social representations of one’s sexual orientation and, on the other
hand, it appears to be an important coping resource in Lebanese society.
Sexual orientation
Our data indicate that bisexual men appear to exhibit higher internalized
stigma and less outness and that they are more likely to face family pressure
to enter into a heterosexual marriage than gay men. Bisexual men in Lebanon
and in other Middle Eastern societies occupy a dual space where they adhere to
the patriarchal cultural and religious norm of heterosexuality, on the one
hand, while also engaging in stigmatized same-sex relationships, on the
other hand (Hunter, 2007; Maatouk & Jaspal, 2019). This may lead some
bisexual men to evaluate their same-sex relationships negatively, thereby
increasing the risk of internalized sexual orientation stigma, as evidenced in
our findings.
Internalized sexual orientation stigma is likely to be further reinforced
by the decreased level of outness that bisexual men report in our sample
(compared to gay men) (see also Brewster, Moradi, DeBlaere, & Velez,
2013; Feinstein et al., 2019; Feldman, 2012). They may have limited
opportunity for exposure to positive social representations of their sexual
orientation. Furthermore, given that bisexuals are also more likely to face
family pressure to enter into a heterosexual marriage, their same-sex
attraction may be impeding their desire or ability to adhere to this
norm, thereby leading them to append and maintain negative value in
relation to their sexual orientation. Building on recent work on interna-
lized sexual orientation stigma in Lebanon (Michli & El Jamil, 2020), our
study suggests that the stressors of decreased outness and family pressure
may be sustaining this form of identity evaluation in bisexual men in our
sample. From the perspective of identity process theory, our findings shed
light on the evaluation process of identity in relation to sexuality—religi-
osity and the family may constitute sources of negative social
JOURNAL OF HOMOSEXUALITY 13
representations of one’s sexuality, stimulating internalized sexual orienta-
tion stigma, while greater outness may constitute a strategy for coping and
thus reduce the likelihood of internalized sexual orientation stigma (see
Jaspal & Breakwell, 2021).
The role of religion
The results indicate that Lebanese gay and bisexual men who report no
religious affiliation report higher outness, less parental pressure to enter
into a heterosexual marriage but also higher psychological distress and
depression than those who identify as Christian or Muslim (Jones &
Alexander, 2020; Meladze & Brown, 2015). It is clear that, as in other
societies, religion is a key source of negative social representations con-
cerning homosexuality in Lebanon (Barnes & Meyer, 2012; Heiden-Rootes,
Wiegand, & Bono, 2019; Shilo & Savaya, 2012). Indeed, in our study,
religiosity was positively associated with internalized sexual orientation
stigma. There appear to be two possible explanations: on the one hand,
due to prevalent social representations of homosexuality and bisexuality in
one’s religious group, religiosity may be engendering and sustaining
a negative evaluation of homosexuality; and on the other hand, internalized
sexual orientation stigma may be leading some people to turn to religion,
possibly as a means of distancing themselves from their sexual orientation
(see Jaspal & Cinnirella, 2010). The direction of this relationship will need
to be ascertained in future research using a longitudinal design.
It is unsurprising that those gay and bisexual men who had distanced
themselves from their respective religious groups (and rejected a religious
affiliation in the survey) reported higher outness and were less likely to face
family pressure to enter into a heterosexual marriage than those who
identified as Muslim or Christian. Gay and bisexual men of no religious
affiliation are not subject to the same social norms associated with religion
as those who wish to identify, and to be recognized as, Muslims and
Christians. They may therefore express less trepidation about disclosing
their sexuality to others and less pressure from their family members to
enter into a heterosexual marriage, as our data indicate. The ‘exit option’ in
psychology refers to departure from those groups which pose threats to
one’s identity (e.g., Ellemers, Spears, & Doosje, 1997). Some gay and bisex-
ual men may elect this strategy of disidentifying with their religious group in
order to maintain psychological coherence in identity. Essentially, gay and
bisexual men who perceive a conflict in relation to their religion and
sexuality (Jaspal & Cinnirella, 2010) may simply relinquish their religion
which enables them to assimilate and accommodate their sexual orientation
in identity while obviating the need to evaluate this identity element
negatively.
14 I. MAATOUK AND R. JASPAL
Yet, there is evidence that religion constitutes a significant social group
membership in Lebanese society, that many social and political institutions in
Lebanon are organized in accordance with religious affiliation, and that reli-
gion also constitutes a key dimension of coping in Lebanese society (Afifi et al.,
2020; Harb et al., 2021). Notwithstanding the contribution of religiosity to
predicting internalized sexual orientation stigma in our sample, it is possible
that religion functions as a coping mechanism for this population too and,
thus, those with no religious affiliation may be less well equipped (than
Muslims and Christians) to cope with the various social psychological stres-
sors that are afflicting the Lebanese population. In short, while the ‘exit option’
in relation to religion may enhance the assimilation-accommodation and
evaluation of sexuality in identity, reducing the risk of internalized sexual
orientation stigma, this strategy appears to be dealing with only one dimension
of a complex identity structure characterized by multiple elements. Due to the
lack of religious identification, some gay and bisexual men who elect this
strategy may find themselves less able to cope with other social psychological
stressors in their lives. This could explain why gay and bisexual men of no
religious affiliation reported poorer mental health than those who identified as
Muslim or Christian.
Although religiosity was entered into the models predicting psychological
distress and depression, this variable did not emerge as significant predictor—
in both models, frequency of attending a religious place of worship was in fact
the most powerful significant predictor of mental health (and, in the case of
depression, the only predictor). It is noteworthy that the scale used to measure
religiosity focused mainly on individual religious conviction and spirituality
and, thus, the fact that religiosity was non-significant may mean that religious
conviction and spirituality per se are not protective against poor mental
health. Conversely, it appears that participation in institutionalized religion
—specifically by frequenting one’s place of religious worship and the activities
that this would normally include, such as engaging with other members of the
congregation and participating in religious rituals—is negatively associated
with both psychological distress and depression (Barnes & Meyer, 2012;
Wilkerson, Smolenski, Brady, & Rosser, 2012). This is consistent with the
social cure perspective (Jetten, Haslam, & Haslam, 2012), which suggests that
engagement with relevant and meaningful social groups, such as religion, is an
important determinant of effective coping.
Limitations
This study has several limitations which should be addressed in future
research. First, given that this is a cross-sectional survey, it is not possible to
ascertain the direction of the relationships between religiosity and internalized
sexual orientation stigma and religiosity and mental health outcomes. The
JOURNAL OF HOMOSEXUALITY 15
hypotheses proposed in this article that there is a reciprocal relationship
between religiosity and internalized sexual orientation stigma and
a protective role of religiosity in mental health should be tested using experi-
mental and longitudinal methods. Second, in this study, strength of sexual
identification was not measured. Therefore, it was not possible to determine
the extent to which identification as gay or bisexual was associated with
internalized sexual orientation stigma and particular mental health outcomes.
This should be considered in future research. Third, our study focuses on data
from a convenience sample of gay and bisexual men visiting a sexual health
clinic in Lebanon and does not differentiate between many significant sub-
groups of gay and bisexual men, such as those who are more vulnerable to
poor wellbeing outcomes (e.g., refugees and migrants), those who live in rural
areas, or those who do not have access to healthcare services. Future research
should replicate these findings using additional samples of gay and bisexual
men and, also, other sexual minority groups, such as lesbian and bisexual
women. It is noteworthy that sexual minority women remain under-
researched in Lebanon. Moreover, some variables in our study, such as
perceived family expectation of a heterosexual marriage, are single-item mea-
sures and more sophisticated continuous measures would be valuable in future
research. Future studies should also include other social, demographic and
psychological variables that might influence internalized sexual orientation
stigma, as our studied factors explained only 36.5% of the variance of inter-
nalized sexual orientation stigma. For instance, Jaspal and Breakwell (2021)
found identity resilience (i.e., higher baseline combined levels of self-esteem,
self-efficacy, continuity and positive distinctiveness) to be protective against
internalized sexual orientation stigma in an ethnically diverse sample of gay
men in the UK. This hypothesis should also be tested in a Lebanese sample.
Conclusions
Drawing on identity process theory, this study sheds light primarily on the
evaluation process of identity in relation to sexuality in a sample of gay and
bisexual men in Lebanon. While bisexual men appear to be more prone to
sexuality concealment, family pressure and a negative evaluation of their
sexuality (internalized sexual orientation stigma) than gay men, individuals
of no religious affiliation appear to be at greater risk of psychological distress
and depression than those of religious faith. Some individuals are clearly
rejecting religion but are also reporting poorer mental health. Conversely,
although religion constitutes a source of negative social representations of
their sexual orientation, gay and bisexual men in Lebanon may be developing
ways of maintaining identification with their sexuality while retaining access
to their religion. This possible strategy might also explain why there was no
correlation between internalized sexual orientation stigma and the mental
16 I. MAATOUK AND R. JASPAL
health variables (cf. Newcomb & Mustanski, 2010). Drawing on identity
process theory, it could be hypothesized that compartmentalization (keeping
elements separate in one’s identity) may enable gay and bisexual men of
religious faith to protect sexual identity from threat, on the one hand, and to
retain the functionality of religion as a potential strategy for coping with social
psychological stressors in the Lebanese context. This will need to be investi-
gated further.
In societies characterized by long-standing economic and political instability,
such as that of Lebanon, individuals are exposed to multiple social psychological
stressors—many unrelated to their sexual orientation. It is therefore necessary to
take into consideration the multiplicity of identity, which includes but is not
restricted to sexuality. People in Lebanon are striving to cope not only with the
social psychological stressors associated with their sexual orientation but also
with those related to other aspects of their identity. Interventions that seek to
reduce internalized sexual orientation stigma and to enhance mental health
outcomes in gay and bisexual men in Lebanon would benefit from acknowl-
edging that the hierarchy and salience of identity elements (i.e., sexuality,
religion) change in accordance with social context and personal circumstances.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The author(s) reported there is no funding associated with the work featured in this article.
ORCID
Rusi Jaspal http://orcid.org/0000-0002-8463-9519
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20 I. MAATOUK AND R. JASPAL
