Health of Immigrant LGBTI +s: The Case of Ankara/Turkey Volume 50- Issue 1

Mehmet Arif Sokmen¹ and Aytul Kasapoglu²*

• ¹Ph D Student of Baskent University Institute of Social Sciences, Turkey
• ²Professor of Sociology, Baskent University Department of sociology, Turkey

Received: March 23, 2023;   Published: May 02, 2023

*Corresponding author: Aytul Kasapoglu, Professor of Sociology, Baskent University Department of sociology, Turkey

DOI: 10.26717/BJSTR.2023.50.007905

Abstract PDF

Purpose: While all immigrants generally have more health problems than the Turkish local population, LGBTI+ immigrants have more vital risks arising from a special situation that we can call layered stigma. The main purpose of this study is to reveal the factors that affect the psychological, social and physical wellbeing of immigrant LGBTI+s.
Methods: In this study, face-to-face interviews were conducted with 50 self-identified LGBTI+ immigrants living in Ankara who migrated from different countries. LGBTI+ people, who were reached through various internet networks, were first asked factual questions. Finally, risky behaviors and some health information were collected and analyzed with advanced statistical techniques.
Results: In Turkey, where LGBTI + locals are also discriminated against, LGBTI + immigrants are disadvantaged in terms of both residence permit and social security, and they continue their lives mostly in the status of trans person and sex worker. Immigrant LGBTIs in the sample are not homogeneous in terms of both gender and sexual orientation, and they came from different countries. They have intersectionally different health statuses. Although they do not engage in very risky behaviors regarding their health, the fact that many of them have a sexually transmitted disease such as HIV are some signs that their health is limited.
Conclusion: Immigrant LGBTI+s in the research sample are subject to layered stigma depending on whether they are both outsiders and LGBTI+. The most important predictor of their psychological and social well-being and general health is emotional labor, namely commercialization of feelings.

According to official statistics in the last 12 years, there are Syrians from the Middle East, Afghans from Asia, Africans from Somalia and irregular migration from other countries in Turkey [1]. Unlike many illegal immigrants in Turkey, Syrian refugees who migrated to Anatolia due to the civil war are in the status of conditional and temporary refugees according to our laws. This policy minimizes Turkey’s obligations. However, in accordance with international agreements, some basic services such as health and education are provided to Syrian adults and children. In fact, according to the latest official data, there is a Syrian population in Turkey who came with the forced migration in 2011, reaching a total of five million [2]. Only 8% of the Syrian immigrants, whose records are kept more systematic and many services are provided to them, live in shelters. The vast majority are scattered throughout the country. Immigrants mostly work by finding jobs in big metropolises such as Istanbul and Izmir. They also live in provinces close to the Syrian border. Seasonal work permits are only granted to them in agriculture. Unfortunately, they are often forced to work for precarious and low wages, which, despite being illegal, are tolerated [3].

According to the current literature, the population coming to Turkey with forced migration has to cope with many problems such as language, economic, health, education, identity and exclusion [4-8]. According to the estimations, the immigrants who come to Turkey will not return even though they live in poverty by working in temporary jobs with low wages and insecure. Some studies show that middle- class immigrants in the informal sector of business also become workers and become victims [8]. Despite all the tolerance of the Anatolian people, who were also immigrants in the past, hate speech is increasing. Because immigrants are seen as the cause of unemployment and attacks on their workplaces can be encountered. The basic concept of this research on immigrant LFBTI+s in Turkey is stigma. This concept is not new and its roots go back to Ancient Greece. It is an application for marking slaves by burning or cutting. Today, limiting membership in a group is a hidden/invisible sign of disapproval and condemnation. According to Goffman, who popularized this concept in sociology, there are three types of stigma [9]. The first of these is related to bodily deformations and is the traces left on the body by some diseases such as “abominations of body” or external deformities such as leprosy. The second is blemishes of individual character, which is used to highlight individual flaws such as a drunkard, murderer or thief. The third is the tribal stigma, which is used to describe subcultural groups such as black and gypsy [10]. Sometimes the concept of layered stigma is used, which is the labeling of people by using more than one accusation together. For example, it is as if she ran away from house and entered premarital sexual intercourse unprotected. The participants of this study are also exposed to layered stigma because they are both refugees and LGBTI+ [11]. Although there is no article prohibiting or penalizing homosexuality in Turkish laws, there is a widespread homophobia and cultural prejudices in the society. Local and central administrators also develop an open hate speech, depending on some sacraments related to the family in daily life as well as in traditional culture [4].

An example of this is that the government, which signed the Istanbul Convention in 2013, left this contract in order to recruit conservative votes. Undoubtedly, a society that hates its native LGBTIs cannot be expected to show sympathy for LGBTI+s, who are a minority among immigrants [5]. The “instrumental” and “symbolic” stigmas defined by Herek are also important for our study. Because the society, especially the health personnel, is afraid or uneasy about LGBTI+s, which they see as carriers of a deadly and contagious disease [12]. For example, physicians and nurses wear double gloves or examine them with a stick in their hands without touching them. Neighbors do not eat or ignore what they give (instrumental stigma). Symbolic stigma, on the other hand, is used to express the attitudes that the disease is caused by a social group or lifestyle. Here, homosexuals are accused according to the Attribution Theory in psychology [13]. It is necessary to know that the reactions to stigma also differ. One of them is reactive, that is, acceptance, while the other is proactive, that is, reacting. The high level of identification in our research can be interpreted as a sign that the majority are proactive.It is possible to talk about two inhibitory factors in the fight against stigma [12]. Both of these are important in our research.

a) Macro-structural: Underdevelopment, migration, poverty and gender.
b) Micro-individual behavioral. Hiding identity so as not to be exposed, not being treated. Obtaining information from the internet and friends instead of doctor.

Data and Sample

In this study, data were collected through face-to-face interviews with 51 LGBTI+ immigrants from different countries living in Ankara. The universe of the study is 500 LGBTI+ people living in Ankara and using the HORNET and TINDER networks. The research started at the end of 2022 after the approval of Başkent University Rectorate Ethics Committee (Protocol Number: 17162298.600-284) and is still continuing.

Measures

In the interviews made with LGBTI+s who are reached through social networks, besides factual questions such as age, gender, education, occupation, residence permit and social security, sexual disease, various measurement tools are used to measure the participants’ data on job satisfaction, alienation, emotional labor, risky behaviors, and information about their health was collected. The data were then analyzed using SPSS 25 with parametric and non-parametric significance tests. Satisfaction with Life scale (SWLS): The sentences of this frequently used scale represent subjective thoughts such as “loving the job very much”; “thinking that it is rewarded”; “the job is a source of pride” [14,15]. The answers are in the form of a five-point Likert scale (strongly disagree with one point and completely agree with five points (Cronbach alpha= .966).

Alienation

For this purpose, the following sentences are used: “I want my daily work to end as soon as possible.”; “If I could not work, I would not work”. “If I had the opportunity to change my job, I would do it.” [16,17]. The answers are in the form of a five-point Likert scale (strongly disagree with one point and completely agree with five points (Cronbach alpha = 819).

Emotional Labor

In this study, dimensions of emotional labor or organizational climate, Emotive Dissonance (“I act differently instead of showing my true feelings”), Emotive Effort (“I make emotional effort to exhibit behaviors suitable for my job”), Emotional Attachment (“I try to be what my customers want)”) was measured (Cronbach alpha: 917) [18]. Then, as antecedent items, Quality Orientation (“Quality is more important than quantity in the work I do; customer satisfaction is more important than quantity in my work.”), Display Training (“I received training on the work I did before I started, I learned how to behave”) Display Latitude (“With the customer” I can talk as I want in my relationships”) and Customer Affect (My customers can easily express their feelings such as anger, boredom, boredom”.) The emotional labor analysis was further deepened. The answers are in the form of a five-point Likert scale (strongly disagree with one point and completely agree with five points (Cronbach Alpha =.531). Organizational Support: It was evaluated with the sentence of revealing the identity (“Everyone at my workplace knows my LGBTI+ identity”) [19-24]. Responses are in the form of five Likert scales and strongly disagree with one point while totally agree gets five points.

Physical Violence

Measured by “My boss has physically assaulted immigrant LGBTI+s” and “Being physically assaulted” (Cronbach alpha = .836) [21,25]. Responses are on a five-point Likert scale (strongly disagree with one point and completely agree with five points). Symbolic violence (invisible stigma): Measured by “My boss makes psychological and verbal insults that humiliate immigrant LGBTI+s”; “I am psychologically abused”; “I suffer social exclusion”; “I experience perceived discrimination, name-calling, etc.”; “We are asked to work for less wages because we are immigrants.” [26,27]. The answers were in the form of a five-point Likert scale (strongly disagree with one point and completely agree with five points (Cronbach alpha = .656).Interpersonal relations (support): Measured by “Indigenous non-LGBTI+ employees in my workplace engage in acts that demean immigrant LGBTI+s.” [20,21,25]. Responses are in the form of a five-point Likert scale ( strongly disagree with one point and completely agree with five points).Perceived discrimination : Measured by “My perception of being an immigrant LGBTI+ forces me to accept injustice at work.” [26]. The answers are in the form of a five-point Likert 20.21, (strongly disagree with one point while completely agree gets five points).

Interpersonal Relations (Support)

Measured by “Indigenous non-LGBTI+ employees in my workplace engage in acts that demean immigrant LGBTI+s.” [20,21,25]. Responses are in the form of a five-point Likert scale (strongly disagree with one point, completely agree with five points). Health risk Behaviors: These are listed as cigarette smoking, alcohol use, drug abuse, substance use [27,28]. The answers are in the form of a five-point Likert (Never received one point and while maximum of five points). Health complaints: Sleepless, lack of appetite, overeating, depression, tiredness, anxiety, sexual dissatisfaction were investigated [29,30]. The answers are in the form of a five-point Likert scale (Never with one point, but very five points).

Health

“How is your psychological, social and physical well-being as an immigrant LGBT+?” was asked separately. The answers are in the form of a five-point Likert scale (very bad one point and five very good).

Analysis

The findings were first presented as marginal tables containing the mean and standard deviations of all variables. After accepting various well-being and general health as the dependent variables, the effects of independent variables that had a significant effect on them were marked by staring according to the regression analysis. In addition, in the regression analysis, categorical variables such as gender, occupation, etc. were first converted into dummy variables and statistical calculations were made. The findings of the variables that showed significant differences in the regression analysis were discussed using Chi-square non-parametric tests.

Findings

Demographic characteristics of the research participants are given in Table 1. The age distribution of the sample in the study is between 19 and 48, with an average age of 30.63. The group with a very high standard deviation is heterogeneous (7.3). The median age of the sample is 30 and the mode is 26. The majority of the sample (70.6%) defines themselves as female and transgender (52.9%). Gays and lesbians in the group are at the same rate (11.8%). In the sample consisting of mostly Syrians (47%), Iranians took the second place (17.6%), while the other participants were Moroccan (2), Kuweit (1), Algerian (2), Sudanese (1), Nigerian (3), Georgian (2), Azerbaijani. (3), Russian (1), Iraqi (3). In other words, there are immigrant LGBTI+s from the Middle East, Africa and Asia. In the sample, the rate of working in jobs with social security is not high (31%). The residence permit rate is still similarly low (33.1%). In terms of education, the majority of the group had only primary education (45%). However, there are also those with higher education (17.6%). As expected in terms of occupations, the majority of them are sex workers (66%). Apart from the salesman and baristas, there is one hairdresser, mechanic, pastry chef, insurance agent, waiter, daily cleaner and painter.

Table 1. Participant Demographics.

Table 2. Work and employment conditions.

Work and employment data is presented in Table 2. Emotional dissonance, emotional effort, and emotional attachment averages all high. While display training and display attitudes are low in Antecedent items, quality orientation and customer affect are high. While the job satisfaction average of the sample is 5.25, its standard deviation is quite high. Therefore, there is a heterogeneous group. The average alienation of the group is quite high. On the other hand, the mean of physical violence is lower than the symbolic violence score. The rate of disclosure, which is a positive feature in large-scale organizations within the scope of organizational support, is high in this study. In addition, negative interpersonal relations and perceived discrimination in the working environment of individuals are also high.For this reason, their first recommendation for the solution of the problems is to organize (86%), while the second is to seek their rights by learning the laws of Turkey. Health data are presented in Tables 3 & 4. When the sample is evaluated in terms of risk behavior, it is understood that more cigarettes and alcohol are consumed. Substance use and drug abuse averages are lower. It is understood that the sample is very sensitive in terms of unprotected sexual intercourse, and the unprotected average is low. Health Complaints: It is observed that the sample has serious health complaints. However, although they do not overeat and lack of appetite problems, it is observed that they suffer mainly from insomnia, depression and tiredness. In addition, sexual dissatisfaction is also quite high. Sexually transmitted diseases are quite high in the sample (58.8%). In addition, there is a high rate of HIV+ in the sample (78.1%).

Table 3. Risk behaviors.

Table 4. Health complaints.

The factors affecting health are shown in Table 5 by calculating the regression analysis. Emotional labor is the only predictor that affects psychological, social, physical and general health. In addition, perceived discrimination and organizational support variables are found to be effective on psychological health. Having a sexually transmitted disease is also effective on physical and general health. Health Complaints: It is observed that the sample has serious health complaints. However, although they do not have overeating and lack of appetite problems, it is observed that they suffer mainly from insomnia, depression and tiredness. In addition, sexual dissatisfaction is also quite high. Sexually transmitted diseases are quite high in the sample (58.8%). In addition, there is a high rate of HIV+ in the sample (78.1%). The factors affecting health are shown in Table 5 by calculating the regression analysis. Emotional labor is the only predictor that affects psychological, social, physical and general health. In addition, perceived discrimination and organizational support variables are found to be effective on psychological health. Having a sexually transmitted disease is also effective on physical and general health. In Table 6, the interaction of health risk factors with psychological, social, physical well-being and general health has been examined by arranging the Regression Analysis table. Having a sexual disease is only correlated with unprotected sex. In addition, general health and social well-being have the highest correlation (.921). Substance use and drug abuse variables are also associated with all health and risk factors.

Table 5. Regression analysis of independent variables on health (I).

Note: Standardized coefficients B are presented with p< .05*; p<.01**; p<.000***

Table 6. Regression analysis of independent variables on health (2).

Note: Standardized coefficients B are presented with p< .05*; p<.01**; p<.000***.

Immigrant LGBT+s are trying to survive by working in jobs that do not have social security, as they cannot obtain a residence permit to a significant extent in Ankara, the capital city of Turkey. Ankara is not an important industrial city, but it is a city of middle- and lower- income civil servants, most of whom work in government offices. In this city, the entertainment and service sector has not developed much. The areas where both local and immigrant LGBTI + people can be employed are very limited [4,8]. As a matter of fact, the majority of those in the sample seem to have had to work as sex workers. Because of the lack of employment opportunities in large-scale organizations, significant relationships among factors that affect health have been observed more in conjunction with commercialization of human feelings (emotional labor) [18]. In this context, the rate of stating that their problems in working life can be solved by organizing is extremely high (86.3%). Since none of the independent variables such as antecedent items, job satisfaction, physical emotional violence, and physical emotional violence had an effect on various well-being and health in the further statistical analyzes of the study, it was not necessary to discuss these variables in detail. On the other hand, all other independent variables affecting well-being and health, especially emotional labor, were discussed according to the results of the chi-square non-parametric statistical significance test. Since negative correlation was observed in the Regression analysis in Table 5, a statistically significant relationship was found between psychological well-being and emotional labor (Chi-square = 33,509 sd: 4; P<.000).

Findings that the psychological well-being of LGBT people who score high in terms of emotional dissonance, emotional effort, and emotional effort is the worst, shows us that the group, which is predominantly sex workers, is dissatisfied with their jobs. It is clear that their excessive effort to hide their true feelings, try to be what the customer wants, and behave appropriately for the job makes them psychologically ill [12]. The social and physical well-being of LGBTI+s in the sample is also similar. It was determined that those with low emotional labor scores had better physical, social and general health, and there was a statistically significant difference. These findings are similar and consistent with previous studies [31]. According to the regression analysis in Table 5, there is a negative relationship between discrimination at work and psychological well-being. The psychological well-being of those who suffer the most discrimination is the worst. It can be said that the findings are in the expected direction (Chi-square= 36,773; Sd: 6; p<.000). The fact that they think that they are subjected to many discriminations, especially being forced to accept injustices in their profession, which is performed under difficult conditions, naturally impairs their psychological well-being.

When the regression analysis in Table 5 is examined, there is a negative relationship between psychological well-being and disclosure. When looked in more detail, the rate of psychological well-being of being very bad was found to be higher among those who did not hide their identity (Chi-square= 65,513 sd: 6 ;p<.000). In this situation, it can be said that immigrants [32] who are already marginalized in society and seen as “outsiders” by Becker, experience much more intense psychological destruction when they reveal their LGBTI identities, in parallel with their double or layered stigma [12,33]. It is understood from the regression analysis in Table 5 that having a sexually transmitted disease is effective on bodily well-being and general health. When looked at in more detail, there is no statistically significant relationship between physical well-being and general health and having a sexually transmitted disease. However, it is observed that those who do not have a sexually transmitted disease have better general health and physical well-being. The results are in the expected direction.

The regression analyzes in Table 6 show that the only variable that is important on social, psychological well-being and general health is alcohol use, but the relationship is negative. In addition, those who consume low levels of alcohol have better psychological, social and general health [34]. However, it should be emphasized that there was no non-alcoholic in the sample. As expected, those who consume a lot of alcohol have worse psychological health (Chi-square= 32.553; sd: p<.000). However, it can be said that the general health of those who consume moderate levels of alcohol is not too bad (Chi-square= 15.783; sd 4; p<.000). The prevalence of alcohol use is in the expected direction due to the environment and occupation of LGBTI+s [35-37]. Likewise, similar comments can be made for the relationship between substance use and social well-being. In fact, substance use was not as common in the sample as alcohol. Very common users (65.5%) stated that their social well-being was better (Chi-square =:37.319 sd: 8; p<.000). It is possible to evaluate all these data as escapes from the dissatisfied lifestyle.

According to the regression analysis in Table 6, depression, insomnia and sexual dissatisfaction factors are effective on psychological and social well-being. As expected, depression (chi-square =:51.00 sd: 4 p<.000) and insomnia (Chi-square = :24.373 sd: 6; p<.000) and psychological well-being are significantly but negatively related. On the other hand, there is a positive relationship between social well-being and insomnia. This may be due to the fact that LGBTI+ people have more night lives. Also, a significant relationship was determined in detailed analyzes (Chi-square = 23.316 sd: 6; p<.000) As a matter of fact, those who stay awake at night have higher social well-being. On the other hand, there is a negative relationship between social well-being and depression. It can be thought that those with high sociability are less depressed. However, no correlation was found in the nonparametric significance test (Chi-square = 7.650 sd: 4 p>.105).

Finally, the regression analyzes in Table 7 show that the variable of sexual dissatisfaction has an effect on both psychological well-being and general health. When examined in more detail, it is understood that the general health of those with high sexual dissatisfaction is better (Chi-square = 35,653 sd: 12; p<.000). In this case, it can be said that those who take care of their health take less risks and prefer not to be satisfied. On the other hand, sexual dissatisfaction was higher for those who stated their gender as female (77.1%) (Chi-square= 20.778 sd: 6; p<.000). In this case, it is expected that the general health of those who state that they are women and those with high sexual dissatisfaction are also good. In addition, when the high level of sexual dissatisfaction of trans individuals (77.8%) and the finding that gays experience a high level of sexual satisfaction (83.4%) are evaluated together, it is revealed that trans people in a liminal position are in a more disadvantaged position [38-41].

Table 7. Regression analysis of independent variables on health (2).

Note: p< .05* ; p<.01**; p<.000***

LGBTI+s, who are sociologically a minority group and examined in this study, are marginalized as “outsiders” in the Howard Becker terminology because they are immigrants in Turkey. In addition to their immigrant identities, they are subject to double or layered stigma, as Herek underlines, because they are LGBTI+. The main finding of the research is that the most common occupation among the participants is sex worker, and this situation is related to emotional labor. In addition, it is a positive situation that the researched minority group does not engage in risky behaviors other than smoking and alcohol consumption. Although there is no statistically significant difference, their exposure to symbolic violence affects their psychological well-being negatively. In addition, working without social security and living illegally without an official residence permit have negative effects on their health. Because although they are HIV+ to a significant extent, getting treatment based on what they learned from the internet or from their friends puts their health at more risk. In terms of health, it is possible to say that they are “absent presence” in Derridas’s words. In fact, it is possible to say that their health, both as immigrants and LGBTI+ in Turkey, is in liminal status in many respects, as Turner stated. The important thing is to reject dualities and essentialism from a relational perspective, to understand immigrant LGBTI+s like other minority groups without stigmatizing and marginalizing them and to make their lives easier. It is clear that we can only support their desire to solve their problems by organizing.

1. (2022) UNHRC. Midyear trends-2022.
2. (2022) UNHRC-Refugee statistics-2022.
3. Kasapoglu A (2021) Subaltern migrant children’s tactics to leak through cracks in everyday life:An example of a neighbourhood in Ankara. International Journal of Arts, Humanities and Social Sciences 2(09): 2693-2555.
4. Engin C (2015b) LGBT in Turkey: policies and experiences. Social Sciences 4(3): 838-858.
5. Ercan SN, Aslan F, Emiroglu ON (2019) Health status, health behaviors, and healthcare access of lesbian, gay, bisexual, and transgender populations in Turkey. Scandinavian Journal of Caring Sciences 34(1): 239-246.
6. Guldal AD, Bozdağ S (2019) Healthcare services experiences of LGBTI individuals: a qualitative research. The Journal of Turkish Family Physician (4): 195-204.
7. Uysal TA (2018) Health care utilization, barriers to care among lesbian, gay, bisexual and transgender persons in Turkey. International Journal of Caring Sciences 11(2): 1204-2013.
8. (2020) KAOSGL.Turkey’s Challenge with LGBTI Refugees. Ayrinti.
9. Ellis A L, Riggle ED (1996) The relation of job satisfaction and degree of openness about one's sexual orientation for lesbians and gay men. Journal of Homosexuality 3: 75-85.
10. Makowski AC, von dem Knesebeck O (2017) Depression and stigma and migration: results of a survey from Germany. BMC Psychiatry.
11. Deepa Rao, Ahmed Elshafei, Minh Nguyen, Mark L Hatzenbuehler, Sarah Frey, et al. (2019) A Systematic review of mult-level stigma interventions: State of science and future directions. BMC Medicine 17(41): 1-11.
12. Herek GM, Garnets LD (2007) Sexual orientation and mental health. Annual Review of Clinical Psychology 3: 353-375.
13. Heider F (1958) The psychology of interpersonal relationships,1958; John Wiley & Sons, Inc., New York.
14. Adler S, Skow RB, Salvemini NJ (1985) Job characteristics and job satisfaction: when cause becomes consequence. Organizational Behaviour and Human Decision Processes 35: 266-278.
15. Alrawadieh DD, Dincer MZ (2021) Emotional labour, quality of work life, and life satisfaction of tour guides: The mediating role of burnout . Journal of Tourism, Leisure and Hospitality 2(3): 118-128.
16. Nair N, Vohra N (2010) An exploration of factors predicting work alienation of knowledge workers”. Management Decision 48(4): 600-615.
17. Mottaz CJ (1981) Some determinants of work Alienation, The Sociological Quarterly 22(1): 515-529.
18. Hochschild A The managed hearth: commercialization of human feeling. UCLA Press.
19. Morris JA, Feldman DC (1996) The dimensions, antecedents and consequences of emotional Labour, Academy of Management Review 21(4): 986-1010.
20. Eisenberger R, Huntington R, Hutchison,S, Ivan Laars Sucharski, Justin Aselage (1986) Perceived organizational support. Journal of Applied Psychology 71: 500-507.
21. Eisenberger R, Stinglhamber F, Vandenberghe C, Ivan Laars Sucharski, Linda Rhoades (2022) Perceived supervisor support: Contributions to perceived organizational support and employee retention. Journal of Applied Psychology 87: 565-573.
22. Griffith KH, Hebl MR (2022) The disclosure dilemma for gay men and lesbians: “Coming out” at work. Journal of Applied Psychology 87: 1191-1199.
23. Caplan RD, Cobb S, French JRP, et al. (1975) Job demands and worker health: Main effects and occupational differences. 1975 . U.S. Department of Health, Education and Welfare: Washington.
24. WebsterJR, Maranto M (2017) Workplace contextual supports for LGBT employees: A review, meta-analysis, and agenda for future research. Human Resource Management.
25. McFadden C (2015) Lesbian, gay, bisexual, and transgender careers and human resource development: a systematic literature review. Hum Resource Dev Rev 14: 125-162.
26. Bourdieu P (1977) Outline of a theory of practice. Stanford University Press.
27. White JC, Dull VT (1997) Health risk factors and health seeking behaviour in lesbians, Journal of Women’s Health 6(1): 103-112.
28. Michele D Kipke, Katrina Kubicek, George Weiss, Carolyn Wong, Donna Lopez, et al. (2007) The health and health behaviours of young men who have sex with men. The Journal of Adolescent Health 40(4): 342-350.

29. David J McKirnan, Steve N Du Bois, Lisa M Alvy, Kyle Jones (2013) Health care access and health behaviours among men who have sex with men: the cost of health disparities, Health Education & Behaviour 40(1): 32-41.
30. Lombardi E (2001) Enhancing transgender health care, American Journal of Public Health 91(6): 869-872.
31. Button SB (2001) Organizational efforts to affirm sexual diversity: A cross-level examination. Journal of Applied Psychology 86: 17.
32. Becker HS (1966) Outsiders: Studies in the sociology of deviance. The Free Press.
33. Goffman E (1963) Stigma: Notes on the Management of Spoiled Identity, Prentice Hall: Englewood Cliffs, NJ.
34. Richard S Henry, Paul B Perrin, Ashlee Sawyer, Mickeal Pugh (2020) Health conditions, access to care, mental health, and wellness behaviours in lesbian, gay, bisexual,and transgender adults. International Journal of Chronic Diseases.
35. Mereish EH, Fish JN, Watson RJ (2023) Intersectional minority stress and alcohol, tobacco, and cannabis use among sexual and gender minority adolescents of color: Moderating role of family support. LGBT Health 10(1).
36. Kruml SM, Geddes D (2000) Exploring the dimensions of emotional labor. Management and Communication Quarterly 14(1): 8-49
37. Lovro Markovic, Daniel Schönherr, Martina Zandonella, Alejandro Gil-Salmeron, Lee Smith, et al. (2022) Associations between workplace characteristics and outness in LGBTI workers in Austria. Occup Environ Med 79: 10-16.
38. Grant J M, Mottet L A, Tanis J Jody L Herman, Jack Harrison, et al. (2010) National transgender discrimination survey report on health and health care. National Center for Transgender Equality and the National Gay and Lesbian Task Force.
39. Turner VW (!174) Dramas, fields and metaphors: symbolic action in human society. Ithaca UP.
40. Kasapoğlu A, Kus E (2008) Responses to stigma and discrimination: A Case Study for PLWHIV in Turkey. Journal of Gender Studies 17: 359-368.
41. Kasapoğlu A, Kus E , Kaya NC Feryal Turan (2011) AIDS Related Stigma in Social Relations: A Qualitative Study in Turkey. Journal of Qualitative Report 16: 6-26.