Microsoft Word - 2. Accepted - Original, Dhesi Ari Astuti, 19-24.docx Cite this article as Astuti DA, Kurniati N. Factors influencing stigma to lesbian, gay, bisexual and transgender (LGBT) among teenagers at Ngaran Village, Gamping, Sleman, Indonesia. Global Health Management Journal. 2018; 2(2): 19-24. Global Health Management Journal www.publications.inschool.id PUBLISHED BY Original Research Article ISSN 2580-9296 (ONLINE) Factors influencing stigma to lesbian, gay, bisexual and transgender (LGBT) among teenagers at Ngaran Village, Gamping, Sleman, Indonesia Dhesi Ari Astuti, Nurul Kurniati Magister Program in Midwifery, Faculty of Health Science, Universitas Aisyiyah Yogyakarta, Yogyakarta, Indonesia. *Corresponding author. Email: dhesi_stikesayo@yahoo.co.id (DAA), nurul.kurniati@yahoo.com (NK) ARTICLE INFO ABSTRACT Article history: Received 6 February 2018 Reviewed 12 February 2018 Received in revised form 16 June 2018 Accepted 27 June 2018 Background: Lesbian, Gay, Bisexual, and Transgender (LGBT) still becomes a social, theological, and psychological problem. Similar to trauma, low self- acceptance, low self-esteem, and anxiety, if it is not handled properly, the condition will be getting worse. Aims: The objective of this study is to increase prevention efforts toward stigma to the LGBT, a growing phenomenon on the teenagers. Methods: This is a quantitative study with one group pretest and posttest design. The work involved forty one (41) teenagers at at Ngaran Village, Balecatur, Gamping, Sleman, Indonesia. A set of questionnaires that has been tested for validity and reliability was given to the respondents to measure knowledge, attitude, perception, service access, and also peer’s attitude to LGBT. Counseling was given once together with material content about LGBT awareness in family. Statistical analysis was employed to process and analyze the data. Results: The result showed the factors correlated to stigma about LGBT on teenagers such as knowledge, attitude, perception, access to any service, and peer’s attitude. The study noticed the knowledge to LGBT (p value < 0.001) and peers’ attitude (p value = 0.02) strongly build stigma among the teenagers. Conclusion: The most influencing factor of the stigma on LGBT is knowledge and peer attitudes. Involving peers in improving teenagers’ knowledge and better understanding to the phenomenon are necessary to suppress discrimination and negative stigma to the LGBT people. Keywords: Teenagers Lesbian, Gay, Bisexual, and Transgender LGBT Stigma Indonesia © 2018 Publications of Yayasan Aliansi Cendekiawan Indonesia Thailand This is an open-access following Creative Commons License Deed – Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) INTRODUCTION A preliminary study was conducted in May 2016 to teenagers of Ngaran Village of Sleman, Indonesia, where a group of lesbian, gay, bisexual and transgender (LGBT) has been seen as a controversy phenomenon. One of the respondents stated that he/she had ever seen a man kissed another man in a food stall in one evening. The other teenagers felt disgusted to hear the story and mocked that the couple were insane, and they had to be wary of them because it was a contagious disease. It may define stigma to the minor group among teenagers at the study site. Factors known influencing stigma are: Predisposing factors (knowledge, education, socio- economic, cultural), enabling factors (facilities and infrastructure (access to health services), media, facilities, government policy), and reinforcing Global Health Management Journal, 2018, Vol. 2, No. 2 20 factors (intervention officers, community leaders, peers, parents). Lack of access to information in health services can cause a person to have a different stigma towards a group, this is because they access information from the internet, peers, mass media so that they can be less relevant information [1]. Non reliable and ambiguous information provided by the media results inconsistence attitudes to the minor group simply because the recent knowledge is inadequate [2]. A research conducted by Mustanski and his team (2010) in the United States also orchestrates how stigma of racial, gender, and sexual affected to the mental disorders among the LGBT teenagers [3] where a third of respondents had 17% mental disorders, 15% severe depression, and 9% post- traumatic stress disorder (Anorexia and bulimia are rare), and 31% committed suicide. A previous study in two cities in Indonesia, Jakarta and Yogyakarta, related to stigma, discrimination and violence to LGBT, shows that 89.3% of LGBT had experienced physical violence, 79.1% experiencing psychological violence, and 45.1% had sexual violence [4]. The Indonesian government made policy to protect citizens which is contained in the Law of 1945 article 28 related the human rights. Article 28 paragraph I states that "Everyone has the right to be free of discriminatory treatment on any basis and entitled to protection against discriminatory treatment". The article is included in the government policy based on the results of identification of stigma, discrimination and violence experienced by the LGBT community. METHODS This research uses a quantitative method with one group pretest-posttest design. This study involved 41 teenagers, recruited by a total sampling method, from Ngaran Village, Balecatur, Gamping, Sleman, Indonesia. Data has been collected using a set of questionnaires and follow up plan form to measure knowledge level on the respondents after and before the given counseling. The counseling includes a one- time meeting with material presentation of LGBT awareness in the family. At a later stage, a follow-up plan for adolescents performed their roles to provide information, especially for the prevention efforts toward stigma to the LGBT, a growing phenomenon on teenagers. Further, the data was processed and analyzed by software using computer. This study used T-test for statistical analysis. RESULTS Respondents’ age, religion, occupation and education were noted and have been presented in the form of frequency distribution table, as Table 1. The respondents were the youth aged from 12 to 25 years old, dominated by the group aged between 17 to 21 years old (56.3%) who had more individuals (11 from 41) having negative stigma to the LGBT people. The study shows that the age has association (p value = 0.03) to the LGBT stigma in adolescents, both through maturity of thinking, the process of interaction with the environment and understanding of information. The majority of respondents in the study are Muslim, and seems the number of Muslim teenagers to having positive and negative stigma are not different. We cannot see the significant difference of stigma between the two group, Islam and Non-Islam, since the distribution of data are not difference (p value = 0.05). More than half of the adolescences had jobs. The data showed that more adolescents had positive stigma if had an occupation (26.8%), compared to the peers who were unemployed (9.8%). Although statistically insignificant (p value = 0.09), a person who became employment allows more access to information than non-employees, it is likely to relate to how the teens stigmatize the LGBT group. Interestingly, the stigma to the LGBT people on the teenagers at different education level is difference (p value = 0.02). Among the respondents who were currently not attending a school, the number of those had positive stigma found higher. While the findings show more teenagers have negative attitude (51.2%) and perception (58,5%) to the LGBT, however, the results shows that teenagers’ attitude and perception has no significant association to their stigma, respectively at p value 0.4 and 0.41. However, interestingly, their peer’s attitude to the phenomenon significantly influence the teenagers’ stigma to the LGBT (p value = 0.02). Out of 41 respondents, more than half described having friends with positive attitude to the LGBT (58.5%), and among them there are 17 teenagers measured having positive stigma. Interestingly, the rest 17 respondents declared having peers with negative attitude toward LGBT, 13 of them noted with negative stigma to this phenomenon. The results showed that peer attitudinal variables on stigma showed that most often were positive peers with positive stigma about LGBT and the least positive peer attitude with negative stigma. Moreover, the results on the access to public service to adolescent stigma about LGBT showed that the most accessible ones had negative stigma of 31.7%. 21 Global Health Management Journal, 2018, Vol. 2, No. 2 Table 1. Respondents’ characteristics and their stigma to LGBT Variable Stigma Total P value Negative Positive f % f % f % Age 12-16 years old 6 14.5% 8 19.5% 14 34.1% 0.03 17-21 years old 11 26.8% 11 26.8% 22 53.6% 22-25 years old 3 7.2% 2 4.8% 5 12.3% Religion Non Islam 1 2.4% 2 4.9% 3 7.3% 0.05 Islam 19 46.3% 19 46.3% 38 92.7% Total 20 48.8% 21 51.2% 41 100% Education No schooling 1 2.4% 3 7.3% 4 9.8% 0.02 Elementary School 6 14.6% 2 4.9% 8 19.5% Junior High School 0 0% 7 17.1% 7 17.1% Senior High School 12 29.3% 8 19.5% 20 48.8% Bachelor Degree 1 2.4% 1 2.4% 2 4.9% Total 20 48.8% 21 51.2% 41 100% Occupation Not yet working 5 12.2% 6 14.6% 11 26.8% 0.09 Unemployment 4 9.8% 4 9.8% 8 19.5% Employment 11 26.8% 11 26.8% 22 53.7% Total 20 48.8% 21 51.2% 41 100% Table 2. Factors Influencing Stigma about LGBT on teenagers Variables Stigma Total P value Negative Positive f % f % f % Attitude 0.4 Negative 11 26.8% 10 24.4% 21 51.2 Positive 9 22% 11 26.8% 20 48.8 Total 20 48.8% 21 51.2% 41 100% Perception Negative 13 31.7% 11 26.8% 24 58.5% Positive 7 17.1% 10 24.4% 17 41.5% 0.41 Total 20 48.8% 21 51.2% 41 100% Peer’s Attitude Negative 13 31.7% 4 9.8% 17 41.7% Positive 7 17.1% 17 41.5% 24 58.5% 0.02 Total 20 48.8% 21 51.2 41% 100% Service Access Negative 7 17.7% 9 22% 16 39% 0.42 Positive 13 31.7% 12 29.3 25 61% Total 20 48.8% 21 51.2 41 100% Global Health Management Journal, 2018, Vol. 2, No. 2 22 Table 3. Correlation between knowledge about LGBT and Stigma LGBT on Teenagers Variables Mean ±SD T test Δ Mean± Std Error Mean P value 95% CI Pre test Post test Stigma 52.7 ±8.1 54.4±8.5 -3.67 2.27±1.23 0.00 50.11-55.21 Table 4. Factor influencing LGBT stigma on the teenagers Independent Variables Dependent Variable P Value Interpretation Knowledge Stigma LGBT on Teenagers 0,00 Related Attitude 0,4 Not related Perception 0,41 Not related Service Access 0,42 Not related Peer’s Attitude 0,02 Related Table 5. Independent multivariable analysis of the observed variables Variables Coefficient SE Wald Df P value OR CI 95% Min Max Attitude 4.468 0.789 0.351 1 0,4 1.59 0.34 7.49 Perception 4.38 0.73 0.359 1 0.55 0.64 0.15 2.70 Access 5.81 0.75 0.6 1 0.04 2.04 0.4 7.82 Peer’s attitude 2.27 0.82 7.68 1 0.006 0.1 0.02 0.51 Constanta 0.7 0.7 1.1 1 0.027 2.1 Service Access 0.5 0.78 0.46 1 0.4 1.7 3.6 7.9 Peer’s attitude 7.5 1 0.02 1.601 Constanta 21.03 0.00 In summary, the bivariable analysis indicates that knowledge and peers’ attitude are the two factors influencing stigma to lesbian, gay, bisexual and transgender (LGBT) among teenagers at Ngaran Village, Gamping, Sleman, Indonesia (see Table 3 and Table 4). Variables that are not related to LGBT stigma in adolescents are attitude, perception, and service access, however, those three variables may influence the peers’ attitude. The OR at Table 5 shows the strength of relationship between the two parameters. From the table it is known that adolescents with far access to services tend to have a negative attitude or negative stigma 1.7 times greater than adolescents with access to services nearby. Teenagers with good peers, potentially 1.6 times more likely to have a good stigma about LGBT. DISCUSSION Roughly, it can be said that among the participated teenagers, we found that only 21 of 41 participants had positive stigma, while the rest 20 persons had negative stigma to the LGBT group. The level of education may generate a difference to one's understanding of something [5]. In this present study, we noticed a significance difference of LGBT stigma among the age group (p value = 0.02). However, it is not clear how education affects the stigma. Though, adolescents with higher education tend to be easier to gain access to information; adolescents will have no trouble in getting information. Teenagers with higher education may have better understanding of information in adolescents, however the result shows the number of the Senior High School students having negative stigma is still high. The attitude shown is more to a negative attitude with a negative view of LGBT so that the stigma that exists from the negative attitude is a stigma of negative tendency. Negative stigma to the LGBT group will be following with the negative attitude among the participants. Although the present study does not show the statistically significant effect on the stigma on LGBT, negative attitudes about LGBT will result in negative stigma, and vice versa. In this case, an individual may have interaction and contact with the other members of her/his social group that might shape the attitudes toward LGBT [6]. 23 Global Health Management Journal, 2018, Vol. 2, No. 2 The perceptions of the stigma about LGBT most commonly indicated negative perceptions with negative stigma of 31.7%, and the least was positive perception with negative stigma of 17.1%. Not only lack of knowledge [7], the negative perception among the participants may be shaped by their environment that present meaning to their organization of thinking and experience [8]. By the socio-cultural factor in the society, a gay man might be seen as a source of sexually transmitted infections among men who have sex with men [9]. Negative perceptions will lead to a negative stigma, further, contributing mental conditions in the Gay group [9]. The general perception doctrine of the majority of society assumes that hetero is the "most correct" sexual orientation and behavior, and the others are wrong and deviant. Man are in the hegemony by the viewing that hetero sexual is normal and natural, while homo is distorted, abnormal perpetrator, having mental and suffering mental illness [10, 11]. The phenomenon of LGBT behavior in the world today is very massive propaganda. In general LGBT behavior have a lot of contradictions to various perspectives, from the perspective of religion, mental health and psychiatric. Acceptance to LGBT becomes the pros and cons in society. Thus, by some groups it is considered as a discriminatory behavior to the minority group, the LGBT people [12]. Religion is one of variables which is considered as factor influencing stigma among the teenagers to the LGBT phenomenon. Muslim is obliged to hold the laws contained in it in order to become a human who is obedient to Allah SWT because every treatment will be accountable in the hereafter. However, the rejection occurred in the community may due to the explanation of the verses of the Qur'an that same-sex relationships are strictly prohibited. The stigma arises usually from an inadequate understanding of religion or even the culture planted in the society [13], however in contrast to the present research, it shows that adolescents from both Islam and non-Muslim faiths cannot determine the stigma of LGBT where there is no relation between Religion and stigma about LGBT. Stigma, not necessarily arises, is explained in history in some classical Islamic history literature which tells that Abu Nuwas, a poet who loves boys and wine, this poetical texts become a mockery of the people to Abu Nuwas but not to the level of slander. Also Al- Ghazali, a mystical religious leader once composed poems for his young (male) lovers. However, Al- Ghazali refuses to be called as homo [14]. Negative stigma and discrimination toward the LGBT group are often seen as lack access to health services [15]. Stigma is illustrated by cynicism, excessive fear and negative perceptions that affect and degrade the quality of life including discrimination in health care. Stigma and discrimination will also create an isolated/marginalized community [16]. The stigma about LGBT remains negative even though adolescents have affordability access to health services. If closer, teenagers will more easily get information about credible sexual diversity. There is a strong relationships between peers’ attitudes and stigma to LGBT among the participated adolescents. It is because peer attitudes and views can affect friends from the process of interaction and daily life. Adolescents will tend to be affected, so peer attitudes will help determine how teens can show positive or negative stigma. However, some studies reveal that bad stigma about LGBT was not only in the general public but occurs among health workers where health care is difficult to obtain information about credible sexual diversity [17]. In the same region, our previous study on 2nd year midwifery students found that despite having access to media and information, they expressed negative attitudes toward LGBT, unwilling to be closer to LGBT and agree to keep way their children from the LGBT people [2]. Stigma in some conditions will cause stress. The stress associated with the stigma is much in the past, because it is clear that negative stigma results adversely to the mental state of the LGBT people [18, 19]. The LGBT group is not well maintained, as most of them have poor health conditions, and marginalization occurs in this sexual minority [20]. Not only in society, even the stigma among health workers makes LGBT groups get discrimination in terms of health services [21]. In this case, culture are the factors of the emergence of stigma, because in Indonesian society, LGBT groups are still regarded as a minority group and still being debated. CONCLUSION This study clearly found that the teenagers’ knowledge and attitudes of their friends to the LGBT are the most influencing factor to the stigma. Involving peers in improving teenagers’ knowledge for better understanding to the phenomenon is necessary to suppress discrimination and negative stigma to the LGBT people. Global Health Management Journal, 2018, Vol. 2, No. 2 24 CONFLICT OF INTERESTS There is no conflict of interests. Nothing to disclosure. REFERENCES 1. Notoatmodjo S. Pendidikan Perilaku Kesehatan Cetakan 1 (Health Behavior Education, First Edition). Yogyakarta: Penerbit Andi Offset (60). 2003. 2. Astuti DA, Hidayat A, Humaira RZ, Widyastari DA, Sinaga DM. 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