Individual Well-being

Relational Well-being

Given the oppressive socio-political climate in Nigeria in which homosexuality is criminalized, it is important to operationalize the term “romantic relationship” in this context. In Nigeria, romantic relationships refer to mutual, voluntary, and active, but mostly covert interactions between two (or more) SMGD persons. A romantic relationship can be between someone who identifies as SMGD and a person (or persons) who identifies as heterosexual, characterized by expressions of intimacy and shared affection. The oppressive climate in Nigeria that derecognizes SMGD romantic relationships/marriages (Human Rights Watch, 2016) invariably compels SMGD individuals to “pass,” that is, where SMGD persons settle into heterosexual romantic relationships of convenience for the purpose of heterosexual normative acceptance/approval (Olaseni et al., Reference Olaseni, Oguntayo and Nel2024). This may shed light on why so many SMGD persons in relationships report prevailing experiences of minority stress.

Another type of romance evident among SMGD persons in Nigeria is transactional romance. Transactional romance is defined as a romantic relationship between two parties that began with mutual understandings and an agreement of having romantic interplay in exchange for material things or objects, such as cash/money, the provision of shelter, food, or any other valuable items (McMillan et al., Reference McMillan, Worth and Rawstorne2018). Transactional romance or any form of romantic relationships among SMGD persons living in Nigeria implicitly comes with the burden of minority stress.

Although there is limited research on SMGD populations in Nigeria, available findings suggest SMGD persons and communities are at higher risk of social, psychological, and healthcare discrimination (Makanjuola et al., Reference Makanjuola, Folayan and Oginni2018). Such an understanding informs our recommendations for future directions in the field.

Research

More research on SMGD people living in Nigeria will improve our knowledge of their lived experiences. In general, there is a paucity of research on SMGD populations in Nigeria. Especially little is known about a wide range of factors associated with individual or relational well-being of the SM and GD persons and communities in Nigeria. Thus, we make recommendations for future research in several areas.

Advocacy/Education and Awareness

We recommend promoting education and awareness of the challenges of SMGD persons and communities in Nigeria, including information about minority stress that affects individual and/or relational well-being. This can help reduce prejudice and increase understanding, fostering a more inclusive and supportive climate/environment. Advocating for and supporting the implementation of anti-discrimination policies in schools, workplaces, healthcare settings, and other institutions is recommended. Doing so could protect SMGD individuals from discrimination based on their sexual orientation, gender identity, and/or expression.

Mental Health Services

Specialists in Nigeria should ensure that mental health services are inclusive and accessible to SMGD individuals. Providing training to mental health professionals on the unique challenges faced by these communities, by experts experienced in working with SMGD persons on a global scale, and creating a safe and supportive environment for therapy and counseling, are essential. Even in the face of the anti-homosexuality law in Nigeria, the codes and ethics of practice encourage allegiance to the well-being of all clients/service users (American Psychological Association, 2016). Clinicians working with SMGD persons in romantic relationships could also be educated on how individuals could cope with experiences of minority stress. The activities and practices of health services in Nigeria are solely guided by the policies of the Nigerian Ministry of Health. Therefore, policymakers are encouraged to critically consider the identified psychosocial variables that influence minority stress among SMGD persons and change policies that harm SMGD people living in Nigeria.

Community Engagement and Supportive Relationships

Encouragement of community engagement would help SMGD persons find a sense of belonging, empowerment, and solidarity to buffer the current oppressive Nigerian climate for SMGD people. Despite the socio-political context that criminalizes and forbids support for SMGD persons and communities, there are some designated non-governmental organizations that provide health-related support to SMGD persons and communities. Supportive relationships between SMGD individuals and their friends, families, and colleagues could also play a crucial role in creating inclusive environments and reducing minority stress by challenging discrimination and providing support.

In closing, it is essential to reflect on the needs and experiences of SMGD persons and communities and work toward creating a more inclusive and supportive society for all in Nigeria.

SMGD-Related Legal Developments

Moreno et al. (Reference Moreno, Ardila, Zervoulis, Nel and Chamberland2020) mapped out important SMGD-related legal developments, specifically in South African family law. Regarding SM people, these prohibitions on employment discrimination on grounds of sexual orientation were set in place in 1995 (Barker, Reference Barker2011); allowance of same-sex partners to be registered as dependents through the Medical Schemes Act in 1998; the prohibition on unfair discrimination in relation to gender, sex, and sexual orientation through the Promotion of Equality and Prevention of Unfair Discrimination Act in 2000; and legalization of adoption by same-sex couples in 2002 (Adeagbo, Reference Adeagbo2016; Breshears & Lubbe-De Beer, Reference Breshears and Lubbe-De Beer2016). The only specific law related to GD people living in Africa was the Sex Description and Sex Status Act that went into effect in 2004, that allowed for gender marker and name change only after surgical or medical gender affirming treatment (Tomson et al., Reference Tomson, McLachlan, Wattrus, Adams, Addinall and Bothma2021). Also, South Africa became the fifth country worldwide, and the first in Africa, to legally recognize same-sex marriages through the introduction of the Civil Union Act of 2006 (De Vos, Reference De Vos2007; Judge et al., Reference Judge, Manion and De Waal2008).

Social Attitudes toward SMGD Persons

The radical political advances and law reforms brought about by the South African Constitution do not match the prevailing social attitudes of society toward SMGD persons. Despite depathologization, decriminalization, and equality (at least on paper), many of the oppressive heterosexist, hetero-cis-normative, and entrenched patriarchal social attitudes characteristic of South Africa’s past persist (Breshears & Lubbe-De Beer, Reference Breshears and Lubbe-De Beer2016). “Both murder and marriage signpost queer life in post-apartheid” (Judge, Reference Judge2018, p. 14).

Prejudice and discrimination that remain(ed) embedded in society are evident in several high-profile cases. First, Jacob Zuma, prior to his inauguration as President of South Africa, publicly commented that same-sex marriages were a “disgrace to the nation and to God” and that, when he was younger, he would beat up gay men. Second, in 2008, anti-apartheid veteran and high-profile journalist Jon Qwelane published a blatantly homophobic article in which he demeaned and debased same-sex relationships as being against “the natural order of things” and compared same-sex sexuality with bestiality (Judge & Nel, Reference Judge and Nel2018). Qwelane called for the Constitution to be amended to outlaw same-sex marriage (Judge & Nel, Reference Judge and Nel2018). Notably, it took a protracted legal battle of more than 10 years before the Constitutional Court in 2021 finally found Qwelane’s article to constitute homophobic hate speech, ushering in greater clarity as to the limits of freedom of expression and the definition of hate speech (Qwelane v South African Human Rights Commission [SAHRC] and Another, 2021; van Wyk & Nel, Reference van Wyk and Nel2023). Third, the recent Woolworths “Be an Ally” campaign in celebration of Pride Month was met with bigotry and social media backlash from the public against the retail store, with calls to boycott Woolworths flooding social media platforms (Carolin & Fourie, Reference Carolin and Fourie2023).

Survey studies have also demonstrated that negative attitudes toward SMGD people in South Africa persist. Results of several SMGD-related attitude surveys conducted 20 years and more since the dawn of democracy in 1994 suggest that, while there have been some positive, progressive changes, a significant proportion of the population in South Africa still hold largely conservative SMGD-related opinions (Pillay et al., Reference Pillay, Nel, McLachlan and Victor2019). For example, a survey conducted by the Other Foundation (2016) found that 51% of respondents believe that gay people should have the same human rights as all other South African citizens, yet 72% of respondents felt that same-sex sexual activity was “morally wrong.” Pillay et al. (Reference Pillay, Nel, McLachlan and Victor2019) purport that contributing to social attitudes lagging behind legal changes are “the politically expedient myth that being gay is un-African, that is, foreign to African cultural norms” (p. 960).

Notably, in a 30-country global survey (Ipsos, 2023), an online sample of more urban-based, educated, and affluent respondents than the general population in South Africa, indicates significant visibility of SMGD persons, with the respondents reporting that they have a family member, friend, or work colleague who is lesbian/gay (59%), bisexual (38%), transgender (13%), and/or nonbinary/nonconforming/gender fluid (17%). Support for same-sex marriage is at 57% (compared to a global average of 56%), showing a 2% decline since 2021, when it was at 59%. Views on same-sex parenting are more positive than for same-sex marriage, with 70% (up from 69% in 2021) strongly agreeing that same-sex couples should have the same rights to adopt children as heterosexual couples do. As many as 70% of respondents (compared to a global average of 67%) are of the opinion that GD people experience a great deal or a fair amount of discrimination while 82% (compared to a global average of 76%) are of the opinion that related protections in employment, housing, and access to public facilities are required (Ipsos, 2023).

While South Africa’s progressive constitutional and legal frameworks may in some way contribute to a better life for all its citizens, it is evident that entrenched conservative social attitudes may call for sustained psychosocial interventions to truly attain this ideal.

Affirmative Stances toward SMGD Persons

Responding to, and advancing understanding of SMGD experiences of discrimination, hate victimization, and minority stress toward improved well-being are not only the responsibility of government and civil society agencies. Following Glassgold and Drescher (Reference Glassgold and Drescher2007), others have called on organized psychology to increasingly be part of the solution by embracing social justice and human rights approaches in their interventions (Pillay et al. Reference Pillay, Nel, McLachlan and Victor2019; van Wyk & Nel, Reference van Wyk and Nel2023) and to “work against and beyond hate in increasingly tangible ways” (Judge & Nel, Reference Judge and Nel2018, p. 19). In their 2015 policy recommendations, the Academy of Science of South Africa (ASSAf) called on African health professionals and their associations to adopt affirmative stances toward SMGD persons. Within psychology, the first (and still only) such professional association on the African continent to do so is the Psychological Society of South Africa (PsySSA) (McLachlan et al., Reference McLachlan, Nel, Pillay and Victor2019).

PsySSA released a position statement in 2013 that provided a framework for understanding the associated challenges that SMGD people face in a hetero-cis-normative society, including minority stress and associated poor mental health outcomes. This was followed in 2017 by more extensive affirmative practice guidelines for working with SMGD persons that, among others, aim to assist health professionals to mitigate symptoms of minority stress in their client populations, to become aware of their own biases, conscientize themselves of the best practices in the field by continued professional development, and to utilize the guidelines as a resource in their related work (McLachlan et al., Reference McLachlan, Nel, Pillay and Victor2019). The PsySSA guidelines most pertinently addressing minority stress and its correlates with individual and/or relational well-being, including the role of perceived social support and coping, are Guideline 1: Nondiscrimination; Guideline 5: Intersecting discriminations; Guideline 6: Counteracting stigma and violence; and Guideline 8: Nonconforming family structures and relationships (McLachlan et al., Reference McLachlan, Nel, Pillay and Victor2019; Psychological Society of South Africa, 2017; Wilks et al., Reference Wilks, Papakyriakou and Nel2022).

Experiences of Prejudice Events

Successfully negotiating the inclusion of sexual orientation as a protected aspect of identity in South Africa’s Constitution hinged on presenting SMGD-related oppression and discrimination as being similar to other forms of oppression and discrimination associated with the struggle against apartheid, such as racism and the unequal distribution of resources (De Vos, Reference De Vos2007). Unsurprisingly, such heightened awareness has brought about a significant body of SMGD-related South African research on the injustice and deleterious effects of experiences of prejudice events (for examples, see Arndt & Hewat, Reference Arndt and Hewat2009; ASSAf, 2015; Graziano, Reference Graziano2004; Müller & Daskilewicz, Reference Müller and Daskilewicz2019; Nel & Judge, Reference Nel and Judge2008; Nel & Mitchell, Reference Nel, Mitchell and Peacock2019; Padmanabhanunni & Edwards, Reference Padmanabhanunni and Edwards2013; Tshisa & van der Walt, Reference Tshisa and van der Walt2021). As will be outlined next, such prejudice events may entail stigma and/or anticipated stigma, marginalization, exclusion, discrimination, and/or (hate) victimization on the basis of SMGD identification.

Experiences of Stigma or Anticipated Stigma

Experiences of stigma or anticipated stigma, often at the hands of criminal justice officials and other service providers who share societal prejudices, are commonly reported among SMGD people living in South Africa (Arndt & Hewat, Reference Arndt and Hewat2009; Müller & Daskilewicz, Reference Müller and Daskilewicz2019; Nel & Judge, Reference Nel and Judge2008); people who remain haunted by a not-so-distant history of officially being labelled as “criminal,” “sick,” and “sinners.” Notably, microaggressions (i.e., enduring incidents of hate, such as daily provocations, persistent bullying, conflict between people known to each other, and/or negative gossip) are often normalized in communities because of specific identities and/or behaviors, such as that of SMGD persons being deemed offensive, inappropriate, or socially unacceptable (Nel & Mitchell, Reference Nel, Mitchell and Peacock2019). These experiences of stigma and microaggressions faced by SMGD individuals in South Africa have extensive consequences that not only shape the daily interactions of SMGD individuals but also influence their mental and emotional well-being, highlighting the urgent need for societal awareness and systemic change to cultivate a more inclusive environment.

Experiences of Hate Speech and Hate Crimes

Disconcertingly, homo-, bi-, and trans-phobia are sometimes violently asserted in the forms of intentional unfair discrimination, hate speech, and even murderous hate crime (Judge, Reference Judge2018; Nel & Judge, Reference Nel and Judge2008). Since the mid-2000s, (inter)national attention and community mobilization have focused on the often-murderous targeting of SMGD black Africans and lesbians in particular (Judge, Reference Judge2018; Nel & Judge, Reference Nel and Judge2008; Nel & Mitchell, Reference Nel, Mitchell and Peacock2019; Padmanabhanunni & Edwards, Reference Padmanabhanunni and Edwards2013). This has pressured government to finally take related experiences of SMGD people and hate victimization, in general, seriously and to initiate urgently required measures (albeit with limited success to date) (Breen et al., Reference Breen, Lynch, Nel, Matthews, Schweppe and Walters2016; Nel & Mitchell, Reference Nel, Mitchell and Peacock2019; van Wyk & Nel, Reference van Wyk and Nel2023). In their exploration of homophobic hate victimization in Gauteng, South Africa, Nel and Judge (Reference Nel and Judge2008) presented self-reported data from 487 SM persons that highlighted the high prevalence of homophobic discrimination in Gauteng.

Graziano (Reference Graziano2004) qualitatively examined seven black South African SM participants from four Gauteng townships, five participants (four lesbians and one gay male) reported having been sexually and physically assaulted for their SM identity. Additionally, the qualitative study of Arndt and Hewat (Reference Arndt and Hewat2009) found that the 10 black African lesbian participants experienced significant stress and trauma from socio-cultural marginalization, with several emerging themes indicating that their sexuality was at the center of their experiences of stress and trauma. Moreover, Padmanabhanunni and Edwards (Reference Padmanabhanunni and Edwards2013) highlight how lesbian-identified women have been the targets of rape to “correct” their SM identity.

A ground-breaking longitudinal study was conducted in five of South Africa’s provinces between 2013 and 2017 by Mitchell and Nel (Reference Mitchell and Nel2017). Data from 945 participants found that SMGD persons were the second most targeted group, following non-nationals, with others targeted for religion and race (Mitchell & Nel, Reference Mitchell and Nel2017; Nel & Mitchell, Reference Nel, Mitchell and Peacock2019). Hate studies, or studies that focus on hate incidents or victimization, have established that one of the reasons for significant under-reporting of incidents is the sense of shame victims experience because it is the victim’s identity, including their race and/or SMGD status that is specifically targeted in the attack (Breen et al., Reference Breen, Lynch, Nel, Matthews, Schweppe and Walters2016; Nel & Mitchell, Reference Nel, Mitchell and Peacock2019). In a study conducted by the Hate Crimes Working Group, that is a civil society network lobbying for hate crimes legislation in South Africa, victims not only reported anger, hopelessness, and distrust but it was indicative of internalized oppression, shame, and a loss of their dignity and worth (Mitchell & Nel, Reference Mitchell and Nel2017; Nel & Mitchell, Reference Nel, Mitchell and Peacock2019).

The empirical studies indicate that SMGD persons are subjected to high levels of verbal assault and that physical harm is often accompanied by hate speech in South Africa (Nel & Judge, Reference Nel and Judge2008; Nel & Mitchell, Reference Nel, Mitchell and Peacock2019). Furthermore, as expert evidence provided by PsySSA in the earlier-mentioned Qwelane equality and constitutional court case (Qwelane v SAHRC and Another, 2021) illustrates homophobic hate speech does considerable psychological harm (Judge & Nel, Reference Judge and Nel2018). Indeed, a large-scale quantitative study with 385 South African SM participants indicated that frequent experiences of hate speech was a significant predictor of vulnerability to depression (Polders et al., Reference Polders, Nel, Kruger and Wells2008).

Experiences of Oppression and Depressive Symptoms

McAdams-Mahmoud et al. (Reference McAdams-Mahmoud, Stephenson, Rentsch, Cooper, Arriola and Jobson2014) conducted a mixed methods study with 22 men who have sex with men (MSM) in Cape Town and found that most participants experienced minority stress that negatively affected their sexual relationships and coping strategies. McAdams-Mahmoud et al. (Reference McAdams-Mahmoud, Stephenson, Rentsch, Cooper, Arriola and Jobson2014) found that 86% of respondents experienced direct or indirect stress, oppression related to their SM status, and prejudice events, such as hate speech, violence, and exclusion. Most of the participants experienced depressive symptoms and had suicidal ideation due to the discrimination (McAdams-Mahmoud et al., Reference McAdams-Mahmoud, Stephenson, Rentsch, Cooper, Arriola and Jobson2014). Relatedly, a recent study of 300 partnered MSM in South Africa reported a significant association between minority stress and depressive symptomology (Metheny et al., Reference Metheny, Stephenson, Darbes, Chavanduka, Essack and van Rooyen2022).

At present, GD and intersex people do not fully enjoy the freedoms promised by South Africa’s progressive constitution. A vast array of barriers, discrimination, and hate victimization are their daily reality (Müller & Daskilewicz, Reference Müller and Daskilewicz2019). Indeed, GD persons experience a disproportionately high level of violence (Müller & Daskilewicz, Reference Müller and Daskilewicz2019; Tomson et al., Reference Tomson, McLachlan, Wattrus, Adams, Addinall and Bothma2021). In their community-led study on the realities of violence, mental health, and access to healthcare for SMGD persons in South Africa (n = 832), Müller and Daskilewicz (Reference Müller and Daskilewicz2019) found that almost half of the 232 GD participants consume alcohol at hazardous, harmful, or dependent levels and this misuse of alcohol can be associated with a lifetime experience of physical or sexual violence. Alcohol, tobacco, and recreational drugs may also be used as coping mechanisms in the face of adversity (Tomson et al., Reference Tomson, McLachlan, Wattrus, Adams, Addinall and Bothma2021).

Experiences of Perceived Rejection

Given the bleak picture that emerges from the literature, it is clear that fear of discrimination and/or victimization is inevitably part of the lived experiences of a majority of SMGD persons in South Africa. Notably, SM women and GD persons in informal settlements/squatter camps and economically disadvantaged communities are particularly at risk (Müller & Daskilewicz, Reference Müller and Daskilewicz2019). Compelling evidence of a direct link between the expectations of rejection and the minority stress experienced by SMGD individuals in South Africa highlight the need for increased support to curb these challenges. In their longitudinal study on the potential contribution of therapy groups to SM well-being with 15 SM participants (n = 14 males and n = 1 female), Nel et al. (Reference Nel, Rich and Joubert2007) reported that participants in the group were prone to experiencing perceived rejection by society, self-devaluation, identity confusion, hiddenness and isolation, excessive self-reliance, lack of trust, and difficulties in familial interactions.

Concealment of SMGD Identity

Hiding and concealing one’s identity is often the result of anticipated rejection, but also experiences of internalized oppression. In the earlier-mentioned Cape Town-based MSM study by McAdams-Mahmoud et al. (Reference McAdams-Mahmoud, Stephenson, Rentsch, Cooper, Arriola and Jobson2014), trauma and internalized oppression were related to the 22 participants’ levels of comfort with others knowing their sexual orientation, the level of mental stress they associated with their sexual orientation, their coming-out process, and whether they chose to conceal their sexual identity and/or behaviors. Results demonstrate that the diverse South African MSM included in this study had concealment behaviors, associated with race, religion, SES, and geographical location (McAdams-Mahmoud et al., Reference McAdams-Mahmoud, Stephenson, Rentsch, Cooper, Arriola and Jobson2014), indicating the complexity of minority stress factors in South Africa and the need for intersectional understanding.

Contemplating choices of living authentically, rather than concealment of SMGD identities in work settings, Tshisa and van der Walt (Reference Tshisa and van der Walt2021) studied discrimination challenges and the psychological well-being of black African queer employees. In their qualitative study with nine participants, Tshisa and van der Walt (Reference Tshisa and van der Walt2021) found issues such as derogatory remarks, casual transphobia, absence of queer policies, and hostile work environments, despite participants’ not directly reporting discrimination. Wolson (Reference Wolson2023) researched the lived experiences of gay men in their achievement of leadership in South African organizations. Wolson’s (Reference Wolson2023) findings suggest significant barriers encountered by the 11 participants, including in relation to the continual process of coming out to colleagues and implications for their authenticity, that impeded their professional development and growth into senior leadership positions.

Experiences of Discrimination in Healthcare Settings

Historically, mental health professionals colluded in pathologizing and institutionally oppressing SMGD persons. For those in minority groups, healthcare and therapy spaces often are the last safe haven away from persistent societal prejudices and discrimination (McLachlan et al., Reference McLachlan, Nel, Pillay and Victor2019; Psychological Society of South Africa, 2017; Victor & Nel, Reference Victor and Nel2016). However, the related minority stress experienced in the face of social discrimination is exacerbated when SMGD clients encounter healthcare providers who share societal prejudices and/or lack competence in working with such client populations (McLachlan et al., Reference McLachlan, Nel, Pillay and Victor2019; Psychological Society of South Africa, 2017; Victor & Nel, Reference Victor and Nel2016). The lack of training of mental healthcare professionals in dealing with SMGD individuals, and limited understanding of differing identities can contribute to secondary victimization and poor healthcare experiences of SMGD individuals. Victor and Nel (Reference Victor and Nel2016) found negative or poor-quality psychological services included aspects such as a client’s sexual orientation being viewed as abnormal, lack of acknowledgement of the difference in challenges experienced by SMGD individuals compared to their heterosexual counterparts, and heterosexism and negative myths within the therapy space.

Relational Well-being

Some initial work exists specific to the association between minority stress and relational well-being for SMGD individuals living in South Africa. The importance of social support in facilitating adjustment to stress and mediating SMGD well-being is well-established (Diamond & Alley, Reference Diamond and Alley2022; Wilks et al. Reference Wilks, Papakyriakou and Nel2022). In a study by Müller and Daskilewicz (Reference Müller and Daskilewicz2019), exploring physical and sexual violence, depression, anxiety, suicidality, and substance use, as well as experiences of discrimination when accessing healthcare among LGBTQ+ communities, 832 South African participants reported having the most social support from friends (75%), followed by family members (45%), and then only current romantic partners (44%). GD people were more likely to report being out to SMGD civil society organizations (CSOs), often also described as non-governmental organizations (57%) and using such organizations for social support (24%), suggesting SMGD organizations are a particularly important resource for GD people in South Africa. Further, GD participants were more likely to report support from healthcare providers (20% versus 13% of cisgender participants), that may reflect use of gender affirming treatment facilities and resulting open communication about gender identity (Müller & Daskilewicz, Reference Müller and Daskilewicz2019).

Limited expressions of SM intimacy of couples in contexts requiring identity concealment to avoid negative experiences in the face of societal prejudice may suggest these marginalized individuals’ resilience in navigating hostile situations (Lesch et al., Reference Lesch, Brits and Naidoo2017). Also, Breshears and Lubbe-De Beer (Reference Breshears and Lubbe-De Beer2016) found that the same-sex parented families who participated in their study negotiated their SM social identity status in daily living in particular ways. These families ignored negative SMGD-related social attitudes, created safe spaces, and similarly altered behavior while in public.

Research indicates that Intimate Partner Violence (IPV), abuse, and aggression toward a partner in a romantic relationship are major and serious public health problems affecting the lives of some SMGD persons and communities in South Africa (Edwards et al., Reference Edwards, Sylaska and Neal2015; Metheny et al., Reference Metheny, Stephenson, Darbes, Chavanduka, Essack and van Rooyen2022; Stephenson et al., Reference Stephenson, Darbes, Chavanduka, Essack and van Rooyen2022; Tallis et al., Reference Tallis, Jean-Pierre and Madi2020). In one study, the SM women participants indicated relationship dissatisfaction, with their partners having anger issues and being jealous or intimidated by them, and that it was difficult to report or speak out about the abuse because of the shame and division it would bring to LGBTQ+ communities (Tallis et al., Reference Tallis, Jean-Pierre and Madi2020). Stephenson et al. (Reference Stephenson, Darbes, Chavanduka, Essack and van Rooyen2022), in a one-time cross-sectional study with 220 male couples from South Africa and another Southern African country, posited that SM men who reported experiences of minority stress were similarly more likely to report IPV and bi-directional IPV. Important to note is that participants who reported having experiences of internalized homophobia and discrimination were more likely to report IPV and bi-directional IPV (Stephenson et al., Reference Stephenson, Darbes, Chavanduka, Essack and van Rooyen2022).

Interestingly, some research findings also exist on intimate relationship experiences of cisgender female partners of masculine-identifying transgender persons. Faced with the persistent fear of being confronted with assumptions and exclusionary behaviors, appropriate support is not easy to find in South Africa as they constitute such a minority (Theron & Collier, Reference Theron and Collier2013). Findings in this subsection are suggestive of the association between minority stress and relational well-being. In addition, these findings also emphasize the need for comprehensive interventions to strengthen support mechanisms, in general, and address both physical consequences and the psychological toll experienced by those affected by IPV, in particular.

Summary

The literature reviewed in this section spanning 20 years examined the association between minority stress and the well-being of SMGD living in South Africa. While there is some literature on the well-being of SM individuals, research on GD individuals is notably limited. Despite the inclusion of sexual orientation, gender, and gender identity as protected grounds in South Africa’s Constitution, prejudice, and oppression toward SMGD people still occurs. The lived experiences of SMGD people in South Africa highlight how critical it is to raise public awareness of these issues, implement systemic/structural changes, and provide more support.

Being Mindful of Intersectionality

An intersectional understanding calls for attention to “the vexed dynamics of difference and the solidarities of sameness in the context of antidiscrimination and social movement politics” (Cho et al., Reference Cho, Crenshaw and McCall2013, p. 787). South Africa is inherently diverse and so too are SMGD persons in South Africa “differently queered and marginalized by factors such as race, class, nationality, geography, and bodily violence” (Wilks et al., Reference Wilks, Papakyriakou and Nel2022, p. 352). In contemplating SMGD-related minority stress in post-apartheid South Africa (1994–present), an intersectional understanding is vital as related experiences constitute race, class, sexual and gender identities, among others, simultaneously (Judge, Reference Judge2018; Nel & Judge, Reference Nel and Judge2008).

In conducting further research with and designing interventions for SMGD individuals, we are reminded that a “one size fits all” approach is inappropriate. Instead, “there is a need to acknowledge how the various positionalities, marginalities, inequalities, and intersectionalities” (Wilks et al., Reference Wilks, Papakyriakou and Nel2022, p. 352) of SMGD persons in South Africa can be theorized and understood also with regard to relational well-being theory and concepts. Factoring in the intersecting discriminations experienced by SMGD people (Psychological Society of South Africa, 2017) is essential so that the complex systems and strategies for enhancing overall well-being can optimally be applied to South Africa.

Resilience Studies

Reid (Reference Reid2013), in his acclaimed study into what it means to be “the other” in contexts of risk, exclusion, and inclusion in rural, small, South African towns, established the remarkable capacity of gay men to imagine and create life-worlds in a harsh environment. Wilks et al. (Reference Wilks, Papakyriakou and Nel2022), too, acknowledge the resilience of SMGD individuals and their problem-solving capabilities and solution focused behaviors, while lamenting that, in contrast to adversity research, resilience studies are woefully absent in the South African landscape. Knowledge of the psychological and social factors of resilience remains sparse, and strategies to build resilience need to be prioritized. We are thus directed to see the importance of research studies that are more focused on resilience behaviors and abilities, and ultimately looking to SMGD communities for solutions, rather than only recognizing adversity.

According to Wilks et al. (Reference Wilks, Papakyriakou and Nel2022), current understandings within resilience enquiry suggest that multiple socio-ecological systems interact with individuals in adversity. “How traumatized individuals perceive their own skill sets, strengths, cognitive abilities, and emergent resilience empowers them to navigate adversity on multiple levels effectively” (p. 352). Wilks et al. (Reference Wilks, Papakyriakou and Nel2022) thus call for a shift of focus in SMGD resilience studies, from individually focused accounts to multi-systemic ones in which systems co-facilitate a person’s resilience. Moving forward, this calls for an overall strengths-based, rather than deficit-based, approach in scholarly work that explores the lived experiences of SMGD people within their unique contexts and relationships. Specific studies could prioritize increased knowledge of the psychological and social factors of resilience and strategies to build resilience. Resilience-building interventions may also require alterations to accommodate stigma-related challenges, while resilience can be advanced through training.

Support and Social Safety

Graziano (Reference Graziano2004) indicated that, amidst oppression and despair, the offering of social support contributes to restored faith and staying positive about selves and futures. Notably, in support of the constitutional project that aims at establishing a functional democracy, post-apartheid South Africa boasts robust CSOs. The focus of too many of these CSOs, however, tends to be on advocacy of individual rights (and responsibilities), while the establishment of much-needed psychosocial support mechanisms may generally be lacking (Nel & Mitchell, Reference Nel, Mitchell and Peacock2019; van Wyk & Nel, Reference van Wyk and Nel2023).

Diamond and Alley (Reference Diamond and Alley2022) argue that insufficient social safety is a primary cause of stigma-related health disparities and a key target for intervention. The lack of social safety has health consequences for stigmatized individuals compounding the impact of minority stress. This is because the persistent threat awareness resulting from inadequate safety measures adversely affects cognitive, emotional, and immunological functioning over the long term, even in situations where exposure to minority stress is minimal (Diamond & Alley, Reference Diamond and Alley2022, p. 1). Diamond and Alley define social safety as reliable social connection, social recognition, social inclusion, and social protection that could be argued as core human needs across all life stages. They consider the power of disconnection, isolation, and rejection to impair health and well-being over time, but also the power of social support and social connectedness to foster psychological and physical well-being in the forms of social safety in the family, at school, in the community, and social safety provided by laws and policies.

Thus, we recommend an exploration of the dynamics of social support networks among SMGD people in South Africa, looking at the quality and nature of support received from friends, family, partners, and healthcare providers. This investigation can also look at the role of social support from various sources (e.g., friends and one’s romantic partner) in mitigating depression, anxiety, suicidality, and substance use. Future studies could also evaluate the suitability of current CSOs to offer their SMGD client base psychosocial support, given the skew in their endeavors toward promoting individual rights. Future research can explore the connection between social safety and health disparities in SMGD communities, building on the notion of social safety proposed by Diamond and Alley (Reference Diamond and Alley2022). Researchers could monitor changes in well-being, social safety, and social support over time by carrying out longitudinal studies, allowing them to capture the dynamic nature of these factors. Exploring how intersecting identities, such as race, gender, and socio-economic status, influence the availability and effectiveness of social support for SMGD individuals may be an important area of research in a diverse context such as South Africa.

In the South African context, beyond legal protections for SMGD individuals, Diamond and Alley’s (Reference Diamond and Alley2022) concept of social safety is of significant relevance due to the absence of adequate social safety networks that exacerbates the challenges faced by individuals dealing with minority stress. Therefore, interventions and policies aimed at enhancing social safety, fostering social connection, recognition, and inclusion, also within romantic relationships, can be pivotal in improving the psychological well-being of SMGD individuals living in South Africa.

Relational Well-being

South African literature on SMGD relational well-being, in general, is almost nonexistent, “despite a recent shift to affirmative, systemic, interpersonal, and contextual stances” (Wilks et al., Reference Wilks, Papakyriakou and Nel2022, p. 351). In suggesting the expansion of a “well-being” frame beyond the individual to the relational, this chapter may serve as an important intervention in the overarching ways in which South African scholars and psychology professionals theorize and conduct research; to inform therapeutic and other psychological services to SMGD persons and provide an important counterweight to the more general focus in South African SMGD scholarship and psychological practice on the individual (Wilks et al., Reference Wilks, Papakyriakou and Nel2022).

SMGD people’s sexual and romantic relationships, whether short-lived or enduring, that were once excluded from the scope of traditional family life have now been legally accepted as another form of family in post-apartheid South Africa (Adeagbo, Reference Adeagbo2016; Breshears & Lubbe-De Beer, Reference Breshears and Lubbe-De Beer2016). This shift in the definition of family has influenced SMGD persons’ sense of belonging as individuals and as partners who can form enduring romantic relationships (Adeagbo, Reference Adeagbo2016). While this acknowledgment is an important stride toward inclusivity, it also prompts the need for comprehensive research to explore the long-term impacts on the well-being of SMGD individuals in South Africa. Future research should delve into the dynamics of these family structures, examining factors such as social support, mental health outcomes, and societal perceptions; importantly, also exploring how romantic partners navigate this inclusivity and societal perceptions together. This will contribute to a more holistic understanding of the evolving landscape of family structures for SMGD individuals, guiding inclusive policies and support systems.

In South Africa, emerging findings underscore the mediating and/or the moderating associations of psychological or social variables/constructs that may intervene in the association between minority stress and relational well-being. Dyadic coping, referring to the strategies employed by individuals within a relationship to manage stress collectively (Bodenmann et al., Reference Bodenmann, Randall, Falconier, Falconier, Randall and Bodenmann2016), is particularly significant for SMGD people in South Africa. Considering the unique challenges and minority stressors faced by SMGD communities, an understanding of how couples navigate and cope with stress together is crucial. Investigating dyadic coping in the context of SMGD relationships can provide valuable insights into the shared experiences, resilience, and support mechanisms within these partnerships. Noting that there is no literature about dyadic coping and SMGD people in South Africa indicates a dire need for this to be investigated further.

Psychosocial Interventions

The documented deleterious effects of experiences of discrimination in healthcare settings serve to motivate the urgent need for training in SMGD affirmative practices. Extensive revision of the PsySSA affirmative practice guidelines (McLachlan et al., Reference McLachlan, Nel, Pillay and Victor2019; Psychological Society of South Africa, 2017) are currently underway and present an ideal opportunity toward linking individual experiences with more relational ones (Wilks et al., Reference Wilks, Papakyriakou and Nel2022). Such revisions provide an opportunity for healthcare providers working with SMGD populations to develop much needed evidence-informed understandings of the contribution to be made by dyadic coping strategies. Studies that focus on understanding coping strategies employed by SMGD persons within romantic relationships, delving into different aspects of the relationships such as gender identity, relationship status, and how they perceive their partner’s ability to show them support emotionally, are urgently needed.

Research is needed on how healthcare providers can (and should) intervene to improve or promote dyadic coping and overall well-being of SMGD persons individually and within romantic relationships. The research studies should be centered around investigating the current understanding of healthcare workers on the diverse sexual orientations and gender identities and minority stress experienced by SMGD persons. This should be followed by studies on SMGD persons with the intention of understanding how they experience healthcare facilities and what would improve their experience at these facilities, like the study of Victor and Nel (Reference Victor and Nel2016). Findings from such research can be included in training and workshops to prepare healthcare workers and mental health professionals to appropriately work with SMGD populations from an evidenced-based perspective.

Cultural and Legal Contexts

Relationships do not occur in a vacuum. Instead, the cultural and political contexts in which SMGD individuals manage their relationships play a crucial role in their relational experiences and well-being. As the preceding chapters highlighted, the levels of cultural and legal acceptance of SMGD individuals and relationships vary widely across countries. In countries such as Austria (Chapter 2), Portugal (Chapter 8), Switzerland (Chapter 9), and the United States (Chapter 11) there is growing societal acceptance of SMGD people and same-sex couples have the right to legally marry. In contrast, other countries like India (Chapter 4), Italy (Chapter 6), and Türkiye (Chapter 10) have decriminalized homosexuality but lack legal protections for SMGD individuals or their relationships. In other countries, such as Indonesia (Chapter 5), Malaysia (Chapter 7), and Nigeria (Chapter 12), there is no legal recognition of same-sex relationships and SMGD people can be prosecuted and imprisoned or corporally punished for nonheterosexual sex acts.

The variability in socio-political climates across nations offers opportunities to explore how factors at higher levels of the social ecology influence the individual and relational well-being of SMGD individuals. For example, in one 28-nation study, country-level structural stigma explained 60% of country-level variation in life satisfaction and more than 70% of country-level variation in sexual orientation concealment (Pachankis & Bränström, Reference Pachankis and Bränström2018). Future multi-nation studies could examine if structural factors such as nondiscrimination and marriage equality laws, as well as cultural factors such as predominant religious views about homosexuality (see Chapter 6, Italy), account for between-nation differences in SMGD minority stress experiences, mental health, and relationship outcomes. Further, such studies may allow us to identify universal versus culture-specific factors that affect SMGD relationships. For example, future research could compare the experiences of SMGD individuals in individualistic cultures that emphasize autonomy (e.g., Austria, Chapter 2) versus collectivistic cultures that prioritize group harmony (e.g., Indonesia, Chapter 5). How do cultural dimensions like individualism–collectivism moderate the effects of stigma on relationship functioning for SMGD individuals? By answering these questions, multi-nation study findings can inform actionable policy recommendations that cater to different cultural contexts, consistent with the United Nations’ Sustainable Development Goals to promote mental and physical health among SMGD individuals (Goal 3: Good Health and Well-being), improved gender quality and inclusivity (Goal 5: Gender Equality), and reduced inequalities faced by SMGD couples (Goal 10: Reduced Inequalities).

Emerging research from various international contexts also illuminates the considerable influence of changes in laws and public policies on the relational experiences of SMGD individuals, couples, and families. Within the United States (Chapter 11), prior empirical studies have offered nuanced perspectives on topics such as the effects of legalized same-sex marriage on relational understanding among SMGD couples (Lannutti, Reference Lannutti2005, Reference Lannutti2008) and the influence of the 2016 presidential election on their marriage decisions (Lannutti, Reference Lannutti2018). In Austria (Chapter 2) and Switzerland (Chapter 9), while family laws protect equality in parenting for same-gender couples, the current policies also limit the possibilities of forming families and giving birth for many GD individuals (see Graupner, Reference Graupner2021). Future research should continue to investigate the potentially profound influence of legal changes, policies, and rights of SMGD individuals and couples over time. For example, how have marriage equality laws in Western countries and those of the Global North affected the relational well-being of SMGD couples? While these legislative milestones are generally viewed as progressive, it is essential to consider potential unintended consequences, such as whether increased visibility and legal recognition inadvertently contribute to heightened levels of discrimination or stigmatization.

Moreover, future research should extend its scope to include nations that lack legal protections for SMGD individuals or even criminalize same-sex relations and/or diverse gender expression, as exemplified by Indonesia (Chapter 5) and Malaysia (Chapter 7). Rather than merely cataloging instances of discrimination, studies should assess the psychological and relational toll that discriminatory legislation and punitive laws exact on SMGD individuals and couples. For instance, Chapter 7 illustrated that the lack of legal protection in Malaysia has resulted in greater minority stress among SMGD individuals, such as increased workplace discrimination and heightened internalized sexual stigma, that in turn reduce SMGD individuals’ intentions to pursue and maintain a long-term, seriously committed romantic relationship. Research examining the individual and relational effects of discriminatory laws would be valuable for informing and refining policy decisions, as well as for shaping advocacy efforts aimed at the rights and well-being of SMGD individuals on a global scale. Moreover, studies assessing the underlying mechanisms accounting for how hostile legal climates affect SMGD individual and relational health (e.g., via reduced social support or increased use of maladaptive coping strategies) could inform the development of interventions to promote mental health and adaptive coping strategies, such as social support and dyadic coping.

Another direction is to explore cultural and legal influences on SMGD relationships from a historical perspective. For instance, in countries with a colonial history that criminalized homosexuality, such as Brazil (Chapter 2), India (Chapter 4), and Nigeria (Chapter 12), the legacy of such laws may still influence societal attitudes toward SMGD individuals and their experiences of stigma. It would also be valuable to investigate the dynamic nature of cultural norms and their evolution over time, examining how these shifts affect both societal perceptions and the lived experiences of SMGD individuals. For instance, in the context of a history marked by harmonious coexistence between heterosexual and SMGD communities, colonizers in Nigeria altered prevailing attitudes and perceptions of homosexuality using religious and cultural means (see Chapter 12). How does colonialism affect Nigerian SMGD individuals’ lived experiences? Similarly, in China where gay relationships were socially accepted in ancient times but largely stigmatized in the modern era (Huang & Lu, Reference Huang and Lu2013), how do these contrasting norms influence the self-perception and relationships of gay people and other SMGD individuals in present-day China? Such knowledge could be instrumental in developing culturally sensitive interventions tailored to the values and historical contexts of different cultural and political settings.

Minority Stress and Well-being

The concept of minority stress has been a recurring theme throughout this volume. For example, the chapters on Brazil (Chapter 3) and the United States (Chapter 11) describe associations between minority stress and poorer mental health and relationship quality among SMGD individuals. Together with evidence from longitudinal studies that both distal minority stress (experiences of stigma enacted by others) and proximal minority stress (psychological experiences, such as internalized stigma against one’s own sexual or gender identity) prospectively predict worsening mental health within SMGD individuals (Birkett et al., Reference Birkett, Newcomb and Mustanski2015; Dyar et al., Reference Dyar, Sarno, Newcomb and Whitton2020; Pachankis et al., Reference Pachankis, Sullivan, Feinstein and Newcomb2018), the preceding chapters make a strong case for universal adverse effects of minority stress on SMGD well-being. However, emerging evidence suggests that different domains of minority stressors may predict personal and relational outcomes differently. For example, Weeks et al. (Reference Weeks, Renshaw and Vinal2023) found that distal stressors, but not proximal stressors, predicted individual mental health (i.e., substance misuse, suicidality, and psychological inflexibility) among sexual minority adolescents. In contrast, meta-analyses showed that proximal minority stress has stronger influences on SMGD individuals’ romantic relationship functioning and relational well-being than do distal minority stressors (Cao et al., Reference Cao, Zhou, Fine, Liang, Li and Mills-Koonce2017; Doyle & Molix, Reference Doyle and Molix2015). Thus, future studies should compare the distinct functions of various minority stressors and examine how they may affect SMGD individuals and their relationships differently. In addition, scholars still know little about the specific pathways through which minority stress affects personal and relational outcomes across cultures. Thus, we encourage more global research on the psychological, interpersonal, and biological mechanisms of minority stress effects on SMGD relationships and individual well-being, that can serve as intervention targets in future efforts to reduce inequities.

This volume serves as a starting point to examine the role of minority stress in non-Western and Global South contexts, specifically Brazil (Chapter 3), India (Chapter 4), Indonesia (Chapter 5), Malaysia (Chapter 7), and Türkiye (Chapter 10). Additional studies are needed to understand how minority stress affects SMGD individuals’ relationships and well-being across various cultural contexts, as demonstrated in Chapters 12 (Nigeria) and 13 (South Africa). Few studies to date have compared the connections between minority stress and health across cultures. For instance, Baiocco et al. (Reference Baiocco, Scandurra, Rosati, Pistella, Ioverno and Bochicchio2023) examined the role of internalized sexual stigma and rumination as mediators between discrimination and health in groups of Italian and Taiwanese LGB+ individuals. Baiocco et al. (Reference Baiocco, Scandurra, Rosati, Pistella, Ioverno and Bochicchio2023) found that Italian participants reported higher discrimination, but lower internalized sexual stigma, rumination, and health problems than their Taiwanese counterparts. Further, though discrimination was associated with health problems in both groups, this effect was accounted for by heightened international sexual stigma and rumination in the Italian sample only (Baiocco et al., Reference Baiocco, Scandurra, Rosati, Pistella, Ioverno and Bochicchio2023). By indicating that the mechanisms underlying the impacts of minority stress on SMGD health differ across cultures, these findings raise the important possibility of cultural differences in all of the proposed pathways within the individual and couple-level minority stress models (LeBlanc et al., Reference LeBlanc, Frost and Wight2015). We suggest more multi-national studies to examine cultural differences in these pathways, including the potential stress-buffering effects of individual and community social support, with emphasis on couple-level outcomes.

Moreover, minority stress research has been criticized for focusing primarily on individual-level stressors, neglecting stressors at other levels of the social ecology, such as institutional and structural stigma (Hatzenbuehler, Reference Hatzenbuehler2016). These forms of stigma can manifest in various ways, such as unequal access to healthcare, housing, education, and employment. The variation in institutional and structural stigma across different nations provides a unique opportunity to examine the effects of these stressors on SMGD individuals and relationships. As demonstrated in previous chapters, some countries, such as Austria (Chapter 2) and Portugal (Chapter 8), have made progress in reducing structural stigma through protective laws and policies, while others, like India (Chapter 4) and Malaysia (Chapter 7), maintain discriminatory, criminalized practices. By comparing the experiences of SMGD individuals in different countries, researchers can identify the specific impacts of institutional and structural stigma on individual and relational well-being. In addition, future studies could compare the mechanisms connecting institutional and structural stressors to SMGD individuals’ outcomes across cultures. In short, broadening the investigation of minority stress beyond individual experiences to include institutional and structural factors is crucial for a comprehensive understanding of the challenges faced by SMGD individuals globally.

SMGD Strengths and Resiliency Factors

Existing theories and research on SMGD health have predominantly focused on challenges and risk factors, overlooking SMGD strengths, protective factors, and processes that promote resilience in the face of societal stigma and other obstacles (see Chapter 1 for a review). Additional research examining these strengths and resilience factors, that reduce or counteract the adverse effects of stigma on SMGD individuals and couples, would greatly inform efforts to enhance their well-being. Emerging research has explored strengths such as having a positive LGB identity (Rostosky et al., Reference Rostosky, Cardom, Hammer and Riggle2018), as well as resilience and coping mechanisms among SMGD individuals and couples. Yet, these studies have generally been restricted to samples in the United States (e.g., Asakura, Reference Asakura2016; Schmitz & Tyler, Reference Schmitz and Tyler2019) and the focus has been disproportionately on young gay men and white individuals (Robinson & Schmitz, Reference Robinson and Schmitz2021). In a notable exception, Siegel and colleagues (Reference Siegel, Randall, Lannutti, Fischer, Gandhi and Lukas2022) explored associations between a positive LGB identity and relationship quality in three European nations (Austria, Germany, and Switzerland). Relationship quality was higher among participants who perceived that a sexual minority identity enhances the potential for romantic intimacy, suggesting that this aspect of a positive minority identity may promote relational health among SMGD Europeans. Yet, the literature still lacks a comprehensive understanding of the types of resilience processes and coping strategies that are effective in different cultural and social contexts. We echo the chapters on Brazil (Chapter 3) and South Africa (Chapter 13) by advocating for additional investigations of individual resilience processes in culturally diverse contexts. We ask, are there indigenous forms of resilience and coping that have not yet been identified in the literature? How do the cultural and historical contexts affect the effectiveness of different resilience processes across cultures?

Another future direction is relational resilience, the process in which a couple performs relationship behaviors that assist each party in adapting and maintaining well-being during stressful life situations. Haas and Lannutti (Reference Haas and Lannutti2022) found that relational resilience is a crucial mechanism linking the enactment of relationship maintenance to positive relational quality outcomes. Moreover, when coping with minority stress, SMGD individuals in the United States are less reliant on LGBTQ-specific social supportive environments, but more dependent on romantic partners, underscoring the centrality of partner social support (Haas & Lannutti, Reference Haas and Lannutti2021). In nations such as Türkiye (Chapter 10), where SMGD individuals are subject to both societal and institutional discrimination, understanding the role of relational resilience becomes even more crucial. Thus, future research should aim to explore the types of relational resilience that are effective in such hostile environments. In sum, there is a need for additional studies on how SMGD individuals cultivate individual and relational resilience across various cultural and relational contexts.

Intersectionality

Intersectionality examines how multiple social identities, such as race, gender, sexual orientation, and social class, interact to produce complex experiences of privilege and oppression (Crenshaw, Reference Crenshaw1991). Rather than viewing these identities in isolation, intersectionality emphasizes that the interplay between different identity facets is synergistic, creating unique challenges and opportunities not reducible to any one identity. For example, the experiences of a black lesbian woman cannot be fully understood by separately examining the effects of race, gender, and sexual orientation. Instead, these identities intersect in complex ways, generating distinct experiences (Bowleg, Reference Bowleg2008). Intersectionality is particularly relevant when considering the experiences of SMGD individuals. However, much existing literature tends to prioritize singular or dual identity facets, such as gender and sexual orientation, with limited research on individuals with multiple marginalized identities (see Randall & Curran, Reference Randall and Curran2023 for a literature synthesis). Thus, additional studies are needed to investigate how different combinations of intersecting identities create unique experiences for SMGD individuals.

A growing number of studies have examined intersectionality in Western contexts like the United States (Chapter 11), where race and socio-economic status frequently intersect with sexual orientation and gender identities (e.g., Swann et al., Reference Swann, Dyar, Baidoo, Crosby, Newcomb and Whitton2022; Reference Swann, Crosby, Newcomb and Whitton2024). However, there is also a need for more nuanced research that explores how these intersections manifest in different cultural contexts. For example, in countries like India (Chapter 4), where the caste system still holds significant social influence, how does one’s caste intersect with their SMGD identity to shape their experiences in romantic relationships? How do SMGD individuals navigate the complexities of caste or religious differences within their romantic relationships in India? Systematic mapping of identity combinations will enable deeper theoretical insights and better-targeted interventions and policy planning. Therefore, future research should aim to incorporate culturally tailored variables, such as caste and religion, to provide a more comprehensive understanding of the intersectional experiences of SMGD people globally.

Family and Family Planning

The experiences of SMGD youth and families represent a critical yet underexplored area of research. While the chapter on Indonesia (Chapter 5) indicated that family social support is associated with lower minority stress and better mental health, as noted in Chapter 2 (Austria) and Chapter 11 (US), there remains a need for more comprehensive studies that explore the impact of family dynamics on SMGD individuals’ psychological well-being, self-esteem, and relational competence. For example, future research may scrutinize how varying familial structures, such as single-parent versus two-parent households, households with stepparents versus biological parents, and adopted families versus nuclear families, exert differentiated effects on SMGD youth. Beyond parental influences, the role of siblings in shaping the experiences of SMGD youth remains an underexplored avenue: How do the experiences of SMGD youth who are only children differ from those who grow up with siblings? This could include an investigation into whether sibling relationships serve as sources of support or, conversely, contribute to minority stress.

Another significant yet underexplored topic is the experiences of SMGD individuals who choose to become parents. Researchers could examine the diverse paths to parenthood among SMGD individuals, such as biological parenting, adoption, and surrogacy. Such work could illuminate the unique benefits and challenges associated with each pathway, from navigating legal systems to managing societal prejudice. Additionally, future research could delve into how the transition to parenthood shapes SMGD individuals’ identities, well-being, and relationships. Future studies documenting the outcomes of children raised by SMGD parents will be very important for efforts to address discriminatory laws and policies that prevent these individuals from adopting or being recognized as the legal parents of their children.

A growing body of research from the United States and Western Europe, such as Italy, the Netherlands, and the United Kingdom, has revealed that children raised by same-sex couples fare equally well in terms of psychological and social functioning (Anderssen et al., Reference Anderssen, Amlie and Ytterøy2002; Miller et al., Reference Miller, Kors and Macfie2017; Yun et al., Reference Yun, Haimei, Min, Jiawen, Sumin and Weiyi2023). However, more studies on this topic are needed in non-Western countries, particularly in regions where SMGD relationships are illegal and/or largely stigmatized. Costa and Shenkman (Reference Costa, Shenkman, Goldberg and Allen2020) noted that existing studies in non-Western contexts are primarily in languages other than English and generally comprise small-scale qualitative studies. Moreover, the legal landscape also presents a paradoxical challenge. For example, in Taiwan, while the legalization of same-sex marriage has provided some legal protections for SMGD couples, it has also created new forms of stigma toward SMGD adoption and other family-building options (Friedman & Chen, Reference Friedman and Chen2023). Thus, future work should examine how cultural norms and legal frameworks intersect to shape the family planning experiences of SMGD individuals.

Intimate Partner Violence

One aspect of SMGD relational health that deserves more attention is intimate partner violence (IPV). High rates of IPV victimization have been documented among SMGD populations across numerous countries, including Australia, Brazil, Canada, India, Kenya, Nigeria, South Africa, the United Kingdom, and the United States (Kar et al., Reference Kar, Das, Broadway-Horner and Kumar2023). Recent literature reviews show higher rates of lifetime and past-year IPV among sexual minority compared to heterosexual individuals (Porsch et al., Reference Porsch, Xu, Veldhuis, Bochicchio, Zollweg and Hughes2023) as well as among gender minority compared to cisgender individuals (Peitzmeier et al., Reference Peitzmeier, Malik, Kattari, Marrow, Stephenson, Agénor and Reisner2020). Examining how IPV manifests and is addressed among SMGD individuals cross-culturally can identify important similarities and differences across diverse contexts. In addition, minority stress processes, including anti-SGM victimization and microaggressions, contribute to IPV vulnerability and risk in SMGD relationships (Kar et al., Reference Kar, Das, Broadway-Horner and Kumar2023; Sarno et al., Reference Sarno, Newcomb and Whitton2023). Additional cross-cultural research could help elucidate how these minority stress processes may operate in specific cultural settings to influence IPV in SMGD relationships.

Moreover, future research could explore how cultural norms shape IPV experiences and dynamics within SMGD relationships. For example, some cultures do not acknowledge that IPV occurs in SMGD relationships at all. Other cultures have a “double closeting” stigma where both SMGD identities and IPV experiences are deeply stigmatized and hidden (Kar et al., Reference Kar, Das, Broadway-Horner and Kumar2023). Legal frameworks and social policies that protect and support SMGD IPV survivors also vary dramatically worldwide. Only few countries currently have legal protections specifically for SMGD IPV victims and survivors (Kar et al., Reference Kar, Das, Broadway-Horner and Kumar2023). These differences in cultural norms and legal contexts surrounding IPV may necessitate that SMGD individuals and couples develop different coping mechanisms and strategies. Comparative research examining IPV across diverse cultural settings can lead to a better understanding of these critical cultural and legal influences. Such research can ultimately inform the development of culturally sensitive IPV prevention efforts, intervention programs, and supports that are tailored to meet the unique needs of SMGD people across the world.

Summary

Despite growing visibility, global research on SMGD individuals and their relationships remains limited and knowledge gaps persist regarding the basic demographic characteristics and lived experiences of SMGD populations in many countries. Existing studies largely concentrate on individual factors and outcomes, overlooking couple-level outcomes and how relational, cultural, and political factors shape SMGD individuals’ personal and relational well-being. In addition, research rarely examines relationships beyond monogamous couples, excluding polyamorous relationships and arrangements with more than two partners. Future studies should be more inclusive of other types of SMGD relationships. In short, this section intends to catalyze a more expansive dialogue on potential research topics that could deepen our understanding of the experiences of SMGD individuals. By focusing on these key areas, we can develop a more comprehensive and nuanced understanding of the unique and diverse experiences faced by SMGD individuals and couples.

Developing Measures with Cross-Cultural Reliability and Validity

As noted in Chapter 2 and demonstrated in other chapters, a major obstacle to conducting multi-nation studies is a lack of data regarding the cross-cultural reliability and validity of measures. Many of the theoretical frameworks and measurement instruments have been developed within Western contexts, primarily by researchers in English-speaking countries (Guillemin et al., Reference Guillemin, Bombardier and Beaton1993). Consequently, these variables and instruments necessitate rigorous cross-cultural conceptualization and adaptation before they can be suitably deployed in diverse linguistic and cultural settings (see Maneesriwongul & Dixon, Reference Maneesriwongul and Dixon2004 for a methods review of the instrument translation process). The multi-nation study that is the root of many chapters in this book is a good example of a study that has done this type of cross-cultural methodological work, but more studies employing such methods are needed.

First, the process of adaptation should extend beyond mere linguistic translation to encompass nuanced cultural and contextual relevancy. In doing so, researchers should aim not only to produce a version of the questionnaire that is linguistically equivalent to the original but also to modify it so that it resonates with the cultural norms and lived experiences of the target population. For example, while the English statement “I pray to God to be straight” can be translatable into Chinese with linguistic accuracy, it may not be relevant or meaningful to many Chinese participants.

Additionally, the applicability of Western-centric theoretical constructs may be limited in non-Western settings. For instance, the construct of “coming out,” that is rooted in Western individualism, may not have a direct equivalent in collectivistic societies such as Malaysia (Chapter 7) and Portugal (Chapter 8), where collectivistic values prevail over individualistic ones. In Western models, revealing one’s minority sexual orientation and gender identity to others is often posited as a critical milestone in identity development and a path to self-authenticity. Conversely, in societies where homosexuality is highly stigmatized and/or criminalized, many SMGD individuals do not perceive the need to declare their identities, as they are content with being invisible and private (Cheah & Singaravelu, Reference Cheah and Singaravelu2017). Therefore, cross-cultural studies should ensure that the instruments measure the same construct in all sampled groups. Future research should prioritize the development and validation of culturally sensitive measures through collaborations with local experts and community members.

Dyadic Research

The dynamics of interpersonal relationships are complicated and multi-faceted, underscoring the importance of dyadic research that can capture these nuances (Kenny et al., Reference Kenny, Kashy and Cook2006). In romantic dyads, members are interdependent and interconnected with one another. That is, a dyad member’s action is likely to affect not only their own behaviors and outcomes (i.e., actor effects) but also their partner’s experiences (i.e., partner effects) over time. The Actor–Partner Interdependence Model (APIM) offers a useful framework for capturing dyadic patterns in quantitative research by simultaneously estimating actor and partner effects while accounting for the covariation between partners (Kenny et al., Reference Kenny, Kashy and Cook2006). Recent research using the APIM approach has revealed interesting patterns of actor and partner effects of minority stress on relationship functioning that may differ by gender. For example, only actor effects of internalized stigma and anti-SMGD microaggressions on relationship quality were observed in a US sample of male same-gender couples (Feinstein et al., Reference Feinstein, McConnell, Dyar, Mustanski and Newcomb2018), whereas both actor and partner effects of internalized stigma and discrimination on relationship quality were observed among female same-gender couples in the United States (Scott et al., Reference Scott, Parsons, Do, Knopp and Rhoades2023). Future studies can employ APIM to better understand which particular minority stress experiences affect not only the individual but also their partner, for which types of couples in which particular contexts. This approach could also be particularly enlightening in contrasting societal contexts, such as Nigeria (Chapter 12) and Austria (Chapter 2), where the levels of social acceptance of minority identities vary significantly. Such cross-nation studies could help build understanding of how cultural factors may moderate actor and partner effects identified within the APIM framework.

In addition to quantitative dyadic research, various scholars also advocate qualitative dyadic research, in which both members of a dyad are interviewed, either together or separately, and responses from both parties are analyzed to understand the dynamics of the dyads (see Manning & Kunkel, Reference Manning and Kunkel2015). Dyadic analysis in qualitative research allows researchers to comprehend and compare the similarities and differences between members of the couple, especially when they have been interviewed separately. Consequently, this approach enables researchers to gain insights that go beyond individual viewpoints, offering a deeper understanding of how these individuals perceive their shared experiences as a dyadic unit (Manning & Kunkel, Reference Manning and Kunkel2015). Based on the Framework method, Collaço and colleagues (Reference Collaço, Wagland, Alexis, Gavin, Glaser and Watson2021) have outlined detailed procedures to conduct qualitative dyadic analysis. Regardless of quantitative or qualitative research, we suggest researchers collect and analyze dyadic data when feasible.

Longitudinal Designs

While cross-sectional studies offer valuable insights into SMGD individuals’ experiences, they are inherently limited in their ability to establish causality and track changes over time (Bolger & Laurenceau, Reference Bolger and Laurenceau2013). Longitudinal designs offer a solution to these limitations, allowing researchers to observe how experiences and outcomes evolve over time (Bolger & Laurenceau, Reference Bolger and Laurenceau2013; Caruana et al., Reference Caruana, Roman, Hernández-Sánchez and Solli2015). Specifically, researchers can utilize panel studies that follow the same participants over an extended period and collect data at multiple time points to observe changes or developments within the same group of individuals (Caruana et al., Reference Caruana, Roman, Hernández-Sánchez and Solli2015). For instance, future multi-nation studies can form cohorts of SMGD individuals in different countries and follow these cohorts over several years to track changes in minority stressors, relationship dynamics, and mental health outcomes within each cohort and across nations. However, in countries where SMGD individuals face legal and social adverse consequences for disclosing their sexual orientation or gender identity, participating in a long-term study can be risky. To minimize participation risk, other forms of longitudinal design, such as repeated cross-sectional studies and retrospective studies, can be particularly valuable.

In repeated cross-sectional studies, data is collected from different participants or samples at multiple points in time (Caruana et al., Reference Caruana, Roman, Hernández-Sánchez and Solli2015). As the stigma and legal landscape surrounding SMGD issues can shift rapidly, repeated cross-sectional studies can capture these evolving contexts while reducing individual participation risks, such that participants may feel more comfortable knowing that their participation is less likely to be identified or tracked over time. In retrospective studies, researchers collect data retrospectively, examining past experiences within a defined cohort (Caruana et al., Reference Caruana, Roman, Hernández-Sánchez and Solli2015). In nations lacking SMGD research, a retrospective design can analyze historical events, legal records, policy changes, and their effects on the SMGD community. Participants may also be more willing to share historical data that does not jeopardize their current safety or privacy. Thus, future studies should utilize various forms of longitudinal designs to elucidate the direction of effects, developmental trajectories, contextual variations, and historical insights while minimizing participation risks.

Notably, the feasibility of implementing longitudinal designs should be carefully evaluated. Longitudinal studies often require substantial resources, including financial support for participant compensation, research tools, and sustained data collection efforts over an extended period (Bolger & Laurenceau, Reference Bolger and Laurenceau2013). Researchers should navigate the challenges of securing funding and ensuring the availability of appropriate research tools to gather comprehensive and reliable data. Moreover, the ethical implications of compensating participants, especially in regions with limited resources or where stigma is pervasive, need to be thoughtfully addressed. Collaborative efforts with local advocacy groups and community organizations are instrumental in overcoming these challenges, fostering community engagement, and enhancing the overall feasibility of the research endeavor. By acknowledging and proactively addressing these practical considerations, researchers can strengthen the robustness and applicability of their longitudinal studies on SMGD individuals and couples.

Community-Based Participatory Research

Several chapters in this volume emphasized the importance of community-based participatory research (CBPR). For example, Chapter 2 (Austria) recommended adopting a CBPR approach throughout the research cycle as community members possess unique knowledge in different stages of the research process. These recommendations echo the broader literature that advocates for such an approach in marginalized communities (Minkler & Wallerstein, Reference Minkler and Wallerstein2011; Wallerstein & Duran, Reference Wallerstein and Duran2010). By involving members as active partners, rather than passive subjects, CBPR places the target community at the center of the research process, integrating community members into various aspects of the research, including study design, data collection, analysis, and dissemination. First, this approach ensures that the research design is culturally sensitive and socially relevant (Minkler & Wallerstein, Reference Minkler and Wallerstein2011). For example, participants from diverse cultural backgrounds may weigh the importance of coming out to family members differently. Without community input, researchers risk focusing on issues less relevant to participants.

Moreover, there is often a negative association between a country’s hostility toward SMGD individuals and the willingness of these individuals to participate in research studies conducted in that country. Such reluctance often results in selection bias, as the individuals who do opt into studies tend to be unrepresentative of the broader SMGD population in that cultural context. CBPR helps address the selection bias, as well as navigate ethical challenges and risks. In some countries, such as Nigeria (Chapter 12), punitive laws and societal discrimination against SMGD individuals pose ethical dilemmas that could expose participants to harm without proper safeguards. By involving the community in the recruitment process, researchers can better assess the potential risks, as well as identify accessible resources and develop feasible strategies to recruit and protect participants (Minkler & Wallerstein, Reference Minkler and Wallerstein2011).

In addition, engaging the local SMGD community ensures that research findings are effectively disseminated and implemented to address the needs of the community (Minkler & Wallerstein, Reference Minkler and Wallerstein2011). By involving community members in the dissemination process, researchers can leverage their insights and experiences to develop strategies for reaching a wider audience and making a more significant impact (Minkler & Wallerstein, Reference Minkler and Wallerstein2011). In short, we recommend future studies engage community members throughout the research process, from developing research questions, to recruiting and protecting participants, and to disseminating research findings. We recommend CBPR, that promotes culturally sensitive and socially impactful research while addressing ethical challenges and reducing participation risks and selection bias. Even when it is not feasible, we still advocate for as much community involvement as possible.

Mixed-Methods Approaches

Given the intricate and diverse nature of SMGD individuals’ experiences of their relationships, utilizing both qualitative and quantitative methods can provide a more comprehensive understanding of these phenomena (Creswell & Plano Clark, Reference Creswell and Plano Clark2017). Quantitative methods can provide generalizability for identifying overarching patterns, while qualitative methods can capture the nuances and complexities that quantitative methods might overlook, especially in culturally diverse settings such as Malaysia (Chapter 7) and the United States (Chapter 11). Thus, future research should employ mixed-methods approaches to leverage the strengths of both methods. For instance, a mixed-methods study could involve quantitative surveys to assess the prevalence and cognitive predictors of certain issues within SMGD relationships, followed by in-depth qualitative interviews to explore the unique contextual factors influencing these dynamics. This integration of methods offers a more comprehensive view of SMGD relationships and well-being.

Summary

This section suggests several strategies for elevating the methodological rigor and social value of research on SMGD individuals and relationships, including developing methods and measures with cross-cultural reliability and validity, dyadic designs, longitudinal studies, community-based participatory research, and mixed-methods approaches. Other methods, such as daily diaries (Gunthert & Wenze, Reference Gunthert, Wenze, Mehl and Conner2012) and naturalistic observations (Angrosino, Reference Angrosino2016), can also provide valuable additions to the literature. Moreover, open science practice addressing the rigor, transparency, and reproducibility of research is also a critical consideration (see Chapter 2). By adopting these methodologies, researchers can not only address the limitations of past studies but also contribute to a more nuanced and comprehensive understanding of SMGD experiences across cultures.

Community Outreach

Community outreach refers to deliberate efforts to engage with, support, and empower SMGD individuals who may not otherwise have access to those resources (Minkler & Wallerstein, Reference Minkler and Wallerstein2011). As exemplified by grassroots organizations in India (Chapter 4), community engagement not only enables data collection but also facilitates the active dissemination of information, policies, and interventions grounded in research findings. Indeed, by actively involving community members in research and outreach efforts, these methods not only empower the SMGD communities but also foster a sense of ownership and responsibility for the outcomes. This inclusive approach ensures that the research findings are not just disseminated but are actively integrated into practical solutions, thereby maximizing their social impact (Minkler & Wallerstein, Reference Minkler and Wallerstein2011).

To disseminate and implement what is learned from research, community outreach could involve holding town hall meetings, focus groups, or workshops to share key findings with community members. Researchers should also establish genuine partnerships and foster a sense of shared responsibility with community leaders and organizations to develop action plans, programs, or policies based on the results. For example, if the research identified a need for more youth programs, the team could work with local nonprofits to create an after-school initiative. Or if systemic inequities were uncovered, advocates could lobby for legislative changes. The key is an ongoing, two-way dialogue where community priorities steer the translation of research into real-world change. This ensures the knowledge gained will address the actual needs and challenges experienced by the SMGD groups. Through continued partnership, researchers and communities can find ways to sustainably put insights into practice.

However, community outreach cannot adopt a one-size-fits-all approach, as unique socio-political contexts demand tailored strategies. For instance, in countries like Indonesia (Chapter 5) and Nigeria (Chapter 12), where SMGD individuals face punitive laws and widespread social discrimination, outreach initiatives should explore “underground” or discreet methods of connecting community members and providing support, such as online forums or encrypted communication channels. These secure platforms can provide SMGD individuals with a safe space for sharing experiences, seeking guidance, and accessing resources free from persecution and stigmatization. Therefore, future studies should also consider how the political and cultural contexts may affect their community outreach efforts. In other words, future outreach endeavors should emphasize flexibility, inclusivity, and contextual relevance.

Interventions and Programs

The need for targeted interventions and applied programs is underscored by the consistent findings across chapters linking minority stress factors to adverse mental health and relational outcomes. Cognitive Behavioral Therapy (CBT) adapted for SMGD individuals has shown promise in reducing anxiety and depression symptoms in Western contexts (Pachankis, Reference Pachankis2014). However, the cultural adaptability and inclusiveness of such interventions need to be considered. Interventions could incorporate elements of local culture and spirituality to enhance their effectiveness. For example, researchers can develop a trauma recovery program for SMGD individuals that integrates traditional healing practices with CBT. In addition, interventions and programs should also focus on relational well-being, incorporating dyadic approaches that involve both partners in a relationship.

The chapters on Brazil (Chapter 3) and the United States (Chapter 11) emphasized the importance of resilience and dyadic coping in mitigating the effects of minority stress. Recent years have witnessed an initial emergence of such programs, including tailored SMGD versions of healthy relationship education (Buzzella et al., Reference Buzzella, Whitton and Tompson2012; Pepping et al., Reference Pepping, Halford, Cronin and Lyons2020; Whitton et al., Reference Whitton, Weitbrecht, Kuryluk and Hutsell2016; Reference Whitton, Scott, Dyar, Weitbrecht, Hutsell and Kuryluk2017), relationship-focused HIV prevention programs (Newcomb et al., Reference Newcomb, Macapagal, Feinstein, Bettin, Swann and Whitton2017; Reference Newcomb, Sarno, Bettin, Carey, Ciolino and Hill2020; Reference Newcomb, Sarno, Bettin, Conway, Carey and Garcia2022), and couple therapy (Pentel et al., Reference Pentel, Baucom, Weber, Wojda and Carrino2021). However, a 2019 systematic review of SMGD relationship interventions highlighted the ongoing underrepresentation of SMGD individuals in couple outcome research (Kousteni & Anagnostopoulos, Reference Kousteni and Anagnostopoulos2020). Future programs could focus on relational resilience-building, dyadic coping, and social support enhancement.

Moreover, interventions and programs should consider the role of intersectionality, as discussed in the chapters on India (Chapter 4) and Italy (Chapter 6). Programs should address the unique challenges faced by SMGD individuals who also belong to other marginalized groups. A 2020 review of 43 mental health interventions for sexual minority people indicated that only 16% of the programs adequately considered the complex effects of intersectionality (Huang et al., Reference Huang, Ma, Craig, Wong and Forth2020). This suggests that there is still a significant need for interventions and programs tailored to the diverse, intersecting identities and experiences of SMGD people. The review also identified community-based participatory research as a useful method to ensure intersectionality (Huang et al., Reference Huang, Ma, Craig, Wong and Forth2020). Therefore, researchers should partner with community organizations to ensure programs are culturally inclusive, feasible, and meet local needs. Furthermore, there is also a need for more rigorous program evaluation at a global level to build the evidence base for SMGD interventions and programs. Currently, all known relationship intervention programs for SMGD couples originate from Australia and the United States (Kousteni & Anagnostopoulos, Reference Kousteni and Anagnostopoulos2020), leaving unanswered questions about the most effective means of delivering interventions to SMGD couples in other countries and cultural contexts. Future research is needed to develop culturally tailored, evidence-based interventions and programs to improve the well-being of SMGD individuals, couples, and families in other areas of the world.

Legal Advocacy and Activism

Legal advocacy in the context of SMGD research refers to the strategic use of empirical findings to advance SMGD rights and well-being through a range of activities, such as legislative lobbying, litigation, public awareness campaigns, and grassroots organizing. For example, research on the mental health disparities faced by transgender youth can inform legal advocacy efforts to limit conversion therapy and ensure access to gender-affirming healthcare. Similarly, studies on the economic hardships experienced by SMGD couples can be used to advocate for marriage equality and anti-discrimination protections. In essence, legal advocacy in the context of SMGD research is the bridge that connects empirical knowledge with tangible changes in law and society, striving to create a more inclusive and equitable future for all.

However, while legal frameworks significantly influence the lives and well-being of SMGD individuals and couples, as evidenced in places like South Africa (Chapter 13) and Taiwan (Friedman & Chen, Reference Friedman and Chen2023), there exists a paradox wherein progressive laws coexist with persistent societal prejudice. In other words, progressive laws alone cannot overcome entrenched societal prejudice. Thus, effective legal advocacy should be coupled with well-crafted public awareness campaigns designed to challenge deeply ingrained stereotypes and prejudices. These campaigns should be grounded in empirical evidence, drawing upon research findings to construct compelling arguments for reform. Collaborating with legal scholars and activists, future studies should strategically blend empirical evidence with persuasive narratives to advance legal advocacy and activism for SMGD individuals by addressing both legislative reforms and societal attitude shifts.

Technology-Enabled Solutions

Although not a central focus in preceding chapters, emerging technologies present significant opportunities to enhance outreach and advocacy for SMGD individuals globally. In restrictive environments where traditional interventions and advocacy pose risks, technology-enabled solutions can provide discreet, accessible support to the SMGD community through digital platforms offering legal guidance, mental healthcare, and safe online forums for experience sharing and mutual support. Beyond facilitating help-seeking and resource access, technology also empowers advocacy through global online campaigns, social media activism, digital storytelling, and crowdfunding for SMGD organizations. Digital tools can further aid future research by serving as data collection points, ensuring interventions adapt to evolving real-world needs.

However, the digital divide of unequal technology access should be considered when leveraging these tools. Given that not all SMGD individuals have access to smartphones or computers, organizations can establish low-tech alternatives, such as SMS-based support services or toll-free hotlines to help those with limited digital access. In addition, by partnering with telecommunications companies or government agencies, advocacy organizations can subsidize smartphones and data plans for marginalized SMGD individuals, making technology more accessible. Moreover, running digital literacy programs that educate SMGD communities on safely and effectively using technology can empower individuals to harness the benefits of the digital age. Thus, technology-enabled solutions are an important future direction and consideration. By leveraging technology for outreach, participant recruitment, and concurrently addressing the digital divide, researchers can ensure that innovative solutions are both inclusive and effective in advancing the rights and well-being of SMGD individuals worldwide.

Summary

This section highlights several pathways for extending SMGD research to have tangible impacts. Through active and respectful engagement with stakeholders, scholars can help develop interventions, programs, legal reforms, educational initiatives, and technology-based solutions to promote social justice worldwide. Importantly, scholars should consider the unique needs and perspectives of diverse SMGD communities when developing solutions, as a one-size-fits-all approach may overlook key factors. Sustained collaboration and open communication with SMGD individuals and groups will help ensure research translates into meaningful progress. In short, by linking science to advocacy and action, researchers can foster a more just world where SMGD can build thriving relationships and live fully as their authentic selves across all cultures.

The Need for SMGD Culturally Responsive Training and Education

Many chapters described the dangers and frequency of sexual orientation change and gender identity change efforts (SOCE/GICE), often referred to as conversion therapy or reparative therapy. These unethical approaches have been reported throughout the world and have been documented in 68 countries (OutRight Action International, 2019; UN Human Rights Council, 2020); it is estimated that 698,000 LGBT adults in the United States have experienced SOCE/GICE during their lifetimes (Mallory et al., Reference Mallory, Brown and Conron2018) and, among a large national sample of transgender individuals (N = 27,716), 13.5% reported lifetime prevalence of GICE (Turban et al., Reference Turban, King, Reisner and Keuroghlian2019). Although lay professionals and religious leaders are often the most common perpetrators of SOCE/GICE, mental health professionals have often engaged in SOGE/GICE through behavioral modification, electroconvulsive therapies and aversive therapy treatments, medication therapy, hypnosis, trauma prevention therapies, and involuntary hospitalization (Independent Forensic Expert Group, 2020). Although several countries have enacted or proposed bans on conversion therapy (e.g., Brazil, Germany, Ecuador, Malta, Taiwan), these practices remain common and are related to increased mental health risks among SMGD people who experience them (Horne & McGinley, Reference Horne, McGinley, Yel and Maroney2022).

As was described in Chapter 7, on Malaysia, SOCE/GICE is common in contexts in which there are strong religious or cultural values that contrast with developing norms and protections of SMGD populations (see Haldeman & Hendricks, Reference Haldeman and Hendricks2022; Horne & McGinley, Reference Horne, McGinley, Haldeman and Hendricks2022). Clinical research findings have consistently found that SOCE/GICE can be harmful, and these conclusions have been supported by international investigations by the Pan American Health Organization (2012), the Academy of Science of South Africa with the Uganda National Academy of Sciences (ASSAf, 2015), and the United Nations Independent Expert on Sexual Orientation Gender Identity violence and discrimination (United Nations Human Rights Council, 2020). In countries where SOCE/GICE is rampant, mental health professionals will need to draw upon multiple resources (e.g., clinical training, research findings, international standards and guidelines) to end these practices and move toward affirmative treatment.

A consistent message throughout the chapters was the emphasis on the need for mental health professionals and health care providers to be appropriately trained and educated on SMGD concerns. Even within countries with a full range of SMGD legal protections (e.g., Austria [Chapter 2], Brazil [Chapter 3]), gaps in SMGD-specific mental health and medical treatment delivery were identified. These deficits included a dearth of providers who are familiar with affirmative care models and have knowledge and experience integrating a minority stress framework into their provision of care; an overall absence of training on SMGD concerns within mental health and medical professions; and a scarcity of clinical outcomes data on interventions that had been adapted or developed to serve SMGD populations.

In countries where the delivery of affirmative care to SMGD populations can fall within criminal behavior (e.g., Indonesia [Chapter 5] and Nigeria [Chapter 12]), protections need to be in place for providers of affirmative practice and for training within the helping professions. For example, professional mental health organizations and professions could commit to an ethics of care even when it conflicts with current legal standings and ground SMGD-related care and mental health needs in culturally appropriate and an empirically supported literature base. The pathologization of SMGD identities persists, rendering the work of affirmative practitioners in high structural stigma contexts fraught with challenges. Taking steps to provide affirmative care may require support from international and inter-regional bodies; for example, mental health professionals can draw from the global standards of the classification of diseases related to SMGD people’s concerns prescribed by the ICD-11 (World Health Organization, 2018), or the Standards of Care for the Health of Transgender and Gender Diverse People (Coleman et al., Reference Coleman, Radix, Bouman, Brown, de Vries and Deutsch2022; World Professional Association for Transgender Health, 2022) to underscore the transnational consensus on appropriate treatment and care.

Vulnerable SMGD Communities: Bisexual and Transgender/Gender Diverse People, Youth, and Asylum Seekers

Risks for poor mental health, internalized stigma, and suicidal ideation and attempts are even higher in two identity groups within the larger SMGD population. For example, in the chapter on Italy (Chapter 6), authors noted that bisexual men and women have been found to report higher rates of depression and anxiety, as well as greater sexual identity concealment in comparison to other SMGD. In Brazil (Chapter 3), transgender people are at the highest risk for violence within SMGD communities, and this country reports the highest homicide rate for transgender and gender diverse people in the world. The chapter on Portugal (Chapter 8) emphasized the need for specific interventions for bisexual cisgender men and women as well as transgender and intersex individuals due to greater mental health risks and lack of services for these groups. In a meta-analytic review, bisexual individuals and transgender people are found to report higher or equivalent mental health concerns in comparison to cisgender gay and lesbian people (Ross et al., Reference Ross, Salway, Tarasoff, MacKay, Hawkins and Fehr2018). Higher rates of suicidality and mental health concerns have been found among transgender people in comparison to cisgender people (e.g., Su et al., Reference Su, Irwin, Fisher, Ramos, Kelley, Mendoza and Coleman2016). Mental health supports and social services for bisexual and transgender individuals lag behind community-based assistance for gay and lesbian people. These chapters exploring SMGD concerns transnationally suggest that the vulnerability of bisexual and transgender people should be given focused attention for clinical interventions and supports.

Many chapters drew attention to the increased risks for mental health concerns for SMGD youth. This developmental period is rife with stressors for those who are often coming into a SMGD identity and, depending on the level of social support, are often navigating this process in isolation (Layland et al., Reference Layland, Bränström, Murchison and Pachankis2023). For example, in the chapter on considerations for those living in Austria (Chapter 2), the authors shared findings that 11% of SMGD youth surveyed reported changing schools, and they called for more outreach to SMGD youth in schools and families. In Switzerland (Chapter 9), documented high rates of suicide among young people led the authors to recommend increased social supports at the community as well as family and friend level. Authors writing about SMGD concerns in Türkiye (Chapter 10) noted the need for family interventions for youth. Indeed, for many countries in which the social fabric is built upon family, ethnic, and community interrelationships and kinship (Henrich, Reference Henrich2020), interventions for SMGD youth, in particular, may benefit from inclusion of family members in intervention and prevention efforts, development of and training for family practitioners, and a family systems approach (Koch et al., Reference Koch, Knutson, Nyamdorg, Nakumura and Logie2020).

Other SMGD groups at heightened risk are refugees and asylum seekers and more mental health supports are needed as global migration increases. Countries included in the book that are experiencing an increase in asylum seekers, such as Italy (Chapter 6), discussed this concern. Asylum seekers are vulnerable to discrimination if they identify as SMGD or are perceived to be SMGD during detention and during the process of asylum, and they are at increased risk of violence if their cases are not accepted and they are involuntarily returned to their home countries where they may not have been identified as SMGD (Briseño, Reference Briseño2024). In general, the process of migration represents an “indistinct boundary” when it comes to identification and disclosure of sexual and gender identity (Feinstein & Rentería, Reference Feinstein and Rentería2023, p. 1917; Pachankis & Jackson, Reference Pachankis and Jackson2023); for asylum seekers and refugees there is often no distinct or progressive pattern of disclosure of SMGD identity or coming out, rather, this process is frequently marked by periods of disclosure of SMGD status to gain consideration as someone of a social group that meets criteria for asylum, and simultaneous concealment of SMGD status due to risk for harm from people from the same country during detention or upon arrival in immigrant neighborhoods in the new country. These vulnerabilities will be greatest in countries high in migration regardless of levels of structural stigma; thus, clinical supports for SMGD asylum seekers and immigrants are critically needed (Briseño, Reference Briseño2024).

Suicide Intervention and Prevention and Emphasis on SMGD Positive Psychological Well-being

Although many mental health risks, including depression and anxiety, were discussed in the chapters, the need for suicide awareness and prevention was underscored across the majority. In countries where suicide research had been conducted with SMGD populations (i.e., Austria [Chapter 2], Malaysia [Chapter 7], Switzerland [Chapter 9], the United States [Chapter 11]), increased rates were reported in comparison to cisgender and heterosexual populations. Chapters called for increased attention to suicide awareness, including campaigns that would target SMGD communities. Although measurement of suicidal ideation varies across contexts, it appears to be a common concern for SMGD individuals. At the same time, it may be beneficial to consider strengths-based approaches that may buffer against psychological distress and suicidality by highlighting positive aspects of SMGD identities (Riggle et al., Reference Riggle, Whitman, Olson, Rostosky and Strong2008; Reference Riggle, Rostosky, McCants and Pascale-Hague2011; Rostosky et al., Reference Rostosky, Riggle, Pascale-Hague and McCants2010) and the strengths of same-gender relationships (Rostosky & Riggle, Reference Rostosky and Riggle2017) and communities (Horne et al., Reference Horne, Levitt, Sweeney, Puckett and Hampton2014). These strengths and resiliencies may inspire hope and possibility for SMGD people: In countries where SMGD sexuality and relationships are not criminalized, raising awareness of resiliency, community-based supports, and SMGD-related pride may offset mental health risks by presenting a positive picture of SMGD experience rather than reinforcing minority stress or damage-centered SMGD narratives (Levitt et al., Reference Levitt, Kehoe and Hand2023).

Contributions of International Human Rights and Professional Standards

The influence of international human rights bodies cannot be underestimated in the development and implementation of global SMGD-related rights and protections. For example, beginning in 2011, the inclusion of sexual orientation and gender identity within United Nations (UN) resolutions has been raising international expectations of SMGD-related human rights (Office of the United Nations High Commissioner for Human Rights, 2011). This step forward by the largest international human rights body was followed by subsequent statements and positions in numerous committees of the UN and evolved into the eventual establishment of an independent expert on sexual orientation and gender identity to serve the UN (United Nations, 2016). Other instrumental interregional bodies that have ushered in expansions of marriage rights and hate crimes protections have been the European Union Human Rights Council and the Inter-American Court of Human Rights, that is a body of 20 Central and South American countries whose membership includes a commitment to endorsing marriage equality. When international human rights bodies endorse SMGD-related standards, these resolutions can initiate passage of marriage equality, adoption rights, and non-discrimination policies. Although Brazil was a frontrunner in establishing broad SMGD-related rights in South America, the Inter-American Court has helped foster a broad expansion of SMGD-related human rights in other countries in South and Central America. As Santos and Natividade (Chapter 3) emphasize, however, these policies have not prevented high rates of SMGD hate crimes. Countries that do not belong to interregional bodies that have declared a commitment to SMGD-related rights may not have the same regional supports to rally for rights (e.g., countries in Africa and Asia).

Other international organizations have provided platforms for the establishment of principles to apply to sexual orientation and gender identity. The Yogyakarta Principles, a collection of 29 principles that support legal standards specific to sexual orientation and gender identity, have been used in international courts to inform legal decisions (International Committee of Jurists, 2007). These principles have been expanded with the addition of 10 more principles (International Service for Human Rights & ARC International, 2017) and are considered to be progressive legal aspirations that are widely applicable.

In psychology, the development of the Statement and Commitment on LGBTI Issues by the International Psychology Network for Lesbian, Gay, Bisexual, Transgender, and Intersex Issues has been endorsed by 46 national and international psychology organizations, and its seven principles have been utilized to advocate for mental health professional standards and supports in many countries (Horne et al., Reference Horne, White, Nakamura and Logie2019; IPsyNet, 2018). These international efforts can help usher in advances in mental health professional values and aims; however, many authors in this volume noted that, despite laws, policies, and protections, ongoing pathologization of sexual and gender identities in mental health professions persists. Several country chapters (e.g., Austria [Chapter 2], Italy [Chapter 6], Portugal [Chapter 8], Türkiye [Chapter 10]) commented upon widespread discrimination in health care and lack of access reported by SMGD as well as intersex individuals despite legal protections. And, in places where rights and policies have been enacted within a relatively short period (e.g., the United States [Chapter 11]) there is pervasive backlash and direct threat to legislation in regions where general attitudes toward SMGD individuals have been slow to change (e.g., rural areas and states with larger evangelical Christian populations) (Pew Research Center, 2014; Thompson, Reference Thompson2023).

The Role of Grassroots Organizations and Professional Organizations

Campaigns to change attitudes are needed alongside policy and legislative action. In particular, authors in this volume stressed the need for greater SMGD family and community visibility. Among the high stigma countries, the authors of the Nigeria chapter (Chapter 12) discussed the need for psychoeducation and SMGD awareness campaigns to challenge current laws and policies that are psychologically damaging and harmful. As part of this charge, the authors discuss the need to include critical histories of SMGD people in Africa including the role of British colonization and the ongoing influence of religious hegemony and doctrine in different regions. Countries that have benefitted from successful partnerships between mental health organizations and grassroots SMGD human rights nonprofit organizations (e.g., Colombia, South Africa, the Philippines) are able to use a full range of community-based resources as well as science and clinical treatment information to expand SMGD representations and resources (see Chapter 13; Horne, Reference Horne2020; Horne et al., Reference Horne, White, Nakamura and Logie2019). Alongside grassroots organizations, mental health professionals can contribute to determining the best paths for making progress on SMGD human rights, for example, prioritizing marriage equality (e.g., Italy [Chapter 6]), workplace nondiscrimination policies (e.g., Austria [Chapter 2]), or the decriminalization of gender identification as another gender than that assigned at birth (e.g., Malaysia [Chapter 7]). These chapters highlight the many policy challenges that countries are experiencing as well as the enduring lag in attitude change toward SMGD individuals and communities even in low structural stigma contexts.