|Year : 2020 | Volume
| Issue : 4 | Page : 344-350
An online survey of education, knowledge and attitude toward homosexuality in adults
T Siva Ilango, S Karthikeyan, S Sumithra Devi, S Arumuganathan, S Usaid, V Sethumadhavan
Department of Psychiatry, Karpaga Vinayaga Institute of Medical Sciences, Maduranthakam, Tamil Nadu, India
|Date of Submission||14-Mar-2020|
|Date of Decision||26-May-2020|
|Date of Acceptance||11-Jun-2020|
|Date of Web Publication||31-Dec-2020|
Dr. S Arumuganathan
Department of Psychiatry, Karpaga Vinayaga Institute of Medical Sciences, Maduranthakam, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: People across cultures have negative stereotypes, prejudice, and discrimination toward homosexuality for many years. The concept is changing, and recently in India, the Supreme Court has decriminalized homosexuality and recognized it as natural, with people having no control over it. This study aims to find out if there is any change in knowledge and attitude toward homosexuality in the Indian adult population after the landmark judgment. Methods: The study was designed as an online survey using snowball sampling incorporating the questions from Sex Education, Knowledge about homosexuality questionnaire (SEKHQ), Attitudes toward Homosexuality Questionnaire (AHQ) and relevant sociodemographic details and the data were collected using google form for 3 months. Results: Six hundred and forty-three people over the age of 18 years participated in the study. The mean age of the study participants was 29.12 years. The mean score on SEKHQ was 16.18 ± 4.71, with a median score of 16. The mean score on the “Attitudes toward Homosexuals” questionnaire (AHQ) was 54.04 ± 8.43. On Pearson's correlation test, age of the participants is positively correlated with SEKHQ score (r = 0.014; P = 0.71 at 95% confidence interval and AHQ score (r = 0.151; P ≤ 0.001 at 95% CI) while SEKHQ score is negatively correlated with AHQ score (r = −0.20; P ≤ 0.001 at 95% CI). Conclusion: The participants had better knowledge and positive attitudes towards homosexuality, especially being single, student and from a medical background. The study showed that higher knowledge on SEKHQ scores did not reflect the positive attitudinal change with increasing age. Generation gap exists and explains the open and diverse attitude of the younger generation toward this marginalized population. More large scale studies in the community setting are needed not only to evaluate but also to educate and improve the attitudes of people toward homosexuality.
Keywords: Attitudes, discrimination, homosexuality, knowledge
|How to cite this article:|
Siva Ilango T, Karthikeyan S, Sumithra Devi S, Arumuganathan S, Usaid S, Sethumadhavan V. An online survey of education, knowledge and attitude toward homosexuality in adults. Indian J Soc Psychiatry 2020;36:344-50
|How to cite this URL:|
Siva Ilango T, Karthikeyan S, Sumithra Devi S, Arumuganathan S, Usaid S, Sethumadhavan V. An online survey of education, knowledge and attitude toward homosexuality in adults. Indian J Soc Psychiatry [serial online] 2020 [cited 2021 Jan 17];36:344-50. Available from: https://www.indjsp.org/text.asp?2020/36/4/344/305950
| Introduction|| |
Homosexuality refers to sexual attraction or sexual behavior between individuals of the same sex. The homosexual population often suffers negative stereotypes, prejudices, and discrimination that has stood ages; even Old Testament condemns homosexuality and India being a nation of cultural conservatism is not different in these practices., The prejudice and discrimination toward lesbian, gay, bisexual, transgender (LGBT) community are often termed as homophobia, which is prevalent across the society, including health-care settings.,,
Homosexuality has been condemned across many cultures and countries; however, the concept is changing, and many countries have taken a more positive and acceptable stance recently. In 2009, the Delhi High Court revoked Section 377 of the Indian Penal Code, which criminalized consensual acts of same-sex adults and held that it violated the fundamental right of life and liberty and the right to equality as guaranteed in the Constitution. However, this verdict was overturned by the Supreme Court of India in December 2013. Later, in a historic judgment, the Supreme Court ruled that consensual adult gay sex is not a crime saying sexual orientation is natural, and people have no control on it, and from September 6, 2018, gay sex stands decriminalized. Chief Justice Dipak Mishra stated “Criminalising carnal intercourse is irrational, arbitrary and manifestly unconstitutional” and Justice Indu Malhotra stated history owes an apology to these people and their families. Homosexuality got legal approval and recognition. Even the established classificatory systems for mental illnesses-International Classification of Diseases (ICD-10) and Diagnostic Statistical Manual 5 (DSM-5) have already declassified homosexuality as a disorder.
While media from India and across the world hail this historic judgment, still some religious movements say homosexuality is against nature though they agree its not a crime. The legal hurdles were crossed, but whether homosexuality has society's approval remains to be seen.
The stance against homosexuality has been propagated by religious and spiritual organizations and it can have a significant impact on the attitudes of people in the community. This negative attitude, when present among the health-care professionals, can lead to unconscious bias in the treatment of LGBT patients despite having an adequate medical education. Evidence has shown that the LGBT population has unique physical and mental health care needs. Yet the associated stigma prevents them for accessing their health care needs.
Attitude is defined as the sum of feelings, prejudices, ideas, fears, or beliefs that an individual has about a specific issue. Its expression is the opinion of acceptance or rejection by an individual about a particular condition. Attitude may be also considered a set of beliefs, feelings, and tendencies that include three components: cognitive, affective, and behavioral. Education and knowledge about a particular concept do influence the attitude of individuals toward it and homosexuality is not an exception.
Since knowledge, attitude, and practices of the general population decides the successful incorporation of any rights and laws pertaining to the marginalized population undertaking of this study becomes essential.
The objectives of this study were to (1) estimate the knowledge and attitude towards homosexuality in the Indian adult population, (2) determine any differences in sociodemographic factors on knowledge and attitudes towards homosexuality.
| Methods|| |
This study was designed as an online cross-sectional survey.
Participants >18 years, with access to the Internet and can read English were included in the present study.
The snowball sampling technique was adopted as the questionnaire was circulated among different WhatsApp groups initiated by one of the authors with the request to share the link with their acquaintance.
The responses were collected in as much number of participants for 3 months between March and May 2019.
The authors created a Google Form for the present survey consisting of four sections. Section I provided information about the principal investigator, the objectives of the study and a statement requesting consent to participate. Section II collected information on baseline demographic information obtained included age, gender, occupation, marital status, and income. Section III collected information on knowledge on homosexuality incorporating the questions from The Sex Education and Knowledge about Homosexuality Questionnaire (SEKHQ), and Section IV incorporated The Attitudes toward Homosexuals Questionnaire (AHQ). The questionnaire had a total of 57 questions.
The Sex Education and Knowledge about Homosexuality Questionnaire
Participants were required to express their opinion on the validity of 32 statements as true, false, or don't know. The score on this scale ranged from 0 to 32, where 32 represented the score with all correct answers. Wrong answers or answers with the response don't know were scored 0. The instrument was found to have a Cronbach's alpha of 0.724. The questionnaire has been used previously by Dunjić-Kostić et al. and was created by a compilation of statements used in the three previous studies.,,
The Attitudes toward Homosexuals Questionnaire (AHQ)
It contains 20 statements regarding homosexuals, their lifestyle, and their social position and is scored by the participants on a 5-grade Likert type scale ranging from 1 (”Strongly agree”) to 5 (”Strongly disagree”). Some items require an inverse scoring. The score range on this scale was 20–100, with a higher score indicating a more negative attitude towards homosexuals. The instrument was found to have a Cronbach's alpha of 0.810. This instrument is also a compilation of items used in three previous studies,,, and was used by Dunjić-Kostić et al. for their work.
The authors developed the questionnaires to a Google Form, and on obtaining ethical clearance, one of the authors shared the link for the online survey form in the WhatsApp group with an advertisement describing principal investigators' information and the objectives of the study. The survey took approximately 20–30 min to complete. The participants were requested to circulate the link of the survey to other friend groups on completion of the survey. The completed responses were recorded in the Google spreadsheet automatically and later were transferred to the excel database. Reminder to complete the questionnaire was sent once in 2 weeks.
Informed consent was made mandatory before answering the questionnaire from all the participants. This study was approved by the Institutional ethics committee. Participation was completely voluntary, and no incentives were provided for participation. Participants were ensured anonymity and confidentiality of data collected.
The data were analyzed using SPSS software version 20.0 (IBM SPSS Statistics for Windows, Version 20.0, Armonk, New York, USA). Descriptive statistics used include mean and standard deviation for continuous variables, frequency, and percentage for categorical variables. Independent samples t-test was used to compare the parametric data while Mann–Whitney U-test was used for nonparametric ordinal data. Pearson's correlation was employed to find the correlation between age, knowledge, and attitude questionnaire scores. Stepwise multiple linear regressions were done to analyze the predictive models for knowledge and attitude. Significance was set at P < 0.05 (two-tailed).
| Results|| |
A total of 643 participants over the age of 18 years consented and completed the questionnaire included in the study. The mean age of the study participants was 29.12 years. Males were slightly older than female participants and had higher representation in the sample. One participant declared as the third gender. More than sixty percent were professionals, and half of the participants were earning more than Rs. 30K per month [Table 1].
The mean score on SEKHQ was 16.18 ± 4.71with a median score of 16. More than seventy percent of participants responded correctly to four questions, while <20% responded correctly to two questions [Figure 1]. The highest percentage of correct response (89.6%) was for the question, “The homosexuals usually disclose their sexual identity to a friend before they tell a parent.” The lowest percentage of correct response (13.2%) was for the question “almost every culture has evidenced widespread intolerance towards homosexuals, viewing them as “sick” or as “sinners.”
|Figure 1: Percentage of correct responses to individual questions on sex education, knowledge about homosexuality questionnaire|
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On comparing the responses to individual questions on SEKHQ, significant differences based on gender were noted on 12 questions with females having high mean rank score on eight questions and males on four questions. The mean rank score of the student category scored high on six questions while the professional scored high on three questions [Table 2].
|Table 2: Comparing individual questions on sex education, knowledge about homosexuality questionnaire based on gender and occupation using Mann-Whitney U-test|
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The mean score on the “Attitudes towards Homosexuals” questionnaire (AHQ) was 54.04 ± 8.43. The study participants had mean score of more than 3 for five questions while a score of <2 on only one question [Figure 2].
|Figure 2: Mean scores of individual questions on attitudes toward homosexuality questionnaire|
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The maximum negative attitudes in AHQ were expressed in the following statements “Homosexuals are sick” (mean = 3.75 ± 1.2), “Many gay men use their sexual orientation so that they can obtain special privileges” (mean = 3.59 ± 1.0) and “Homosexuals should not be allowed to work with children” (mean = 3.37 ± 1.4). The most positive attitude in AHQ was for the statement “the homosexuals should have an equal opportunity of employment” (mean = 1.88 ± 0.98).
On comparing the responses to individual questions on AHQ, significant differences based on gender were noted on nine questions with males having a high mean rank score on six questions, and females on three questions. The mean rank score of the student category scored high on only one question while professionals scored high on eight questions [Table 3].
|Table 3: Comparing individual questions on attitudes toward homosexuality questionnaire based on gender and occupation using the Mann-Whitney U-test|
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On comparing the mean scores of SEKHQ and AHQ among different demographic variables, significant differences were noted in marital status, education, and occupation [Table 4].
|Table 4: Comparison of mean scores of sex education, knowledge about homosexuality questionnaire and Attitudes toward Homosexuality questionnaire across demographic variables using Independent t-test|
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On Pearson's correlation test, age of the participants is positively correlated with AHQ score suggesting higher the score poorer the attitude (r = 0.151; P ≤ 0.001 at 95% confidence interval [CI]) but not with SEKHQ score (r = 0.014; P = 0.71 at 95% CI) and while SEKHQ score is negatively correlated with AHQ score (r = −0.20; P ≤ 0.001 at 95% CI).
A stepwise multiple linear regression analysis was carried out with two predictive models. The first predictive model included knowledge, age, income, and occupation. The analyzed model was statistically significant, and all the proposed factors together accounted for 8.3% of the variance of the attitudes toward homosexuals. The second predictive model included attitude, education, and income. The analyzed model was statistically significant, and all the proposed factors together accounted for 6.8% of the variance of the knowledge of homosexuality [Table 5].
|Table 5: Effect estimates of predictive variables on knowledge and attitude towards homosexuality|
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| Discussion|| |
The study period lasted for 3 months, but more than ninety percent of responses were obtained within the 1st month. Although the author started this study with an intention to collect data from a heterogeneous population using an online survey, more than 78% of the respondents were from the medical field. This skewed representation could possibly be due to the author's acquaintance being mostly from the medical field, the topic being considered a taboo, unimportant, or difficulty in comprehending the questions.
The mean scores on SEKHQ and AHQ in this study suggest that the participants had better knowledge and more positive attitudes than the findings from Banwari et al. in 2015.
The individual responses recorded in SEKHQ showed that >80% of the people still believe that “In the past 25 years, there has been an increase in homosexuality” and “Historically, almost every culture has evidenced widespread intolerance towards homosexuals, viewing them as sick or as sinners.” These negative knowledge statements are in contrast to what the recordings from the ancient literature documents that homosexuality was in existence thousands of years ago and even worshiped as God.
Respondents showed more positive attitudes with respect to employment opportunities and social equality. At the same time, significant negative attitudes were evident by considering them as sick, use their orientation to obtain special privileges and by not willing to allow them to work with children. These findings are similar to the study done by Felmlee et al., 2010.
Female participants had better knowledge and positive attitudes toward homosexuality than male counterparts, but the difference was not statistically significant. Being single or committed, student and from medical background had significantly more positive attitudes towards homosexuality. We believe all the above findings may possibly be explained by the lesser homophobia among the younger generation.
Studies on attitudes usually show that increase in knowledge is often associated with positive attitudes. However, our study showed that higher knowledge on SEKHQ scores did not reflect in positive attitudinal change with increasing age. This difference was consistent among the professionals and a student population of medical background. This further substantiates the author's presumption that generation plays a major role in the attitudinal change where older generations are more homophobic despite an increase in knowledge.
The absence of civil rights before the landmark judgment resulted in significant discrimination and stigmatization, leading to abuse of sexual minorities as well increased risk of adverse mental and physical health. Furthermore, the lack of societal acceptance had led to concealment of sexual orientation from different walks of life.,, While imparting knowledge alone might not result in attitudinal changes, it requires alternate strategies like self-reflection on one's own beliefs and attitudes toward homosexuality using clinical cases, lectures, personal interaction, and instilling human ethical values as part of curriculum development. This study highlights positive changes in attitude towards homosexuality among the younger generation, but more work has to be done in improving the knowledge and attitudes among the wider population. An outcome of all these might be the development of a more inclusive society for all to live in harmony, and decriminalization of homosexuality was the first prominent step.
Strengths and limitations
There have been very few studies done in India in the LGBT population, and even those studies were done a few years ago before Supreme Court verdict of decriminalizing homosexuality. This study has a good number of participants with more professionals than students from all walks of life. Inherent to the study design, causal association could not be established for poor knowledge and attitude toward homosexuality. Since the survey was conducted online, we could not give in-person explanations to participants, on the flip side, this would have helped them to participate without being socially pressurized to participate or guided to answer in a particular way. It is also possible social desirability, and mental fatigue could have had some impact in the participant's response. With the convenience sampling and mode of data collection, the results might not be generalizable to whole population and hence warranted replication of the study in a face to face community surveyor prospective study design.
| Conclusion|| |
This study highlights that the knowledge and attitudes towards homosexuality have become better over the years, especially among the younger generation instilling hope and brighter prospects of future. Although the Supreme Court of India has decriminalized homosexuality, it would not by itself bring any change in the attitudes of the society at large and the prejudices and stigmatization of this marginalized group persist. As Justice Dhanajaya Y Chandrachud quote, “It is difficult to right a wrong by history. However, we can set the course for future. This case involves much more than decriminalizing homosexuality. It is about people wanting to live with dignity.” Further large scale studies in the community setting are needed not just to evaluate but to educate and improve the attitudes of people towards homosexuality.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Álvarez H. Social perception of homosexuality. J Med Sci La Habana 2015;21:75-83.
Torales J, Barrios I, Torres A, Dunjo N, Benitez MG, Villalba J, Ventriglio A, et al
. Attitude of medical students in Paraguay towards homosexuality. East Asian Arch Psychiatry 2018;28:101-3.
Gato J, Carneiro NS, Fontaine AM. Contribution to a historical and critical review of prejudice against non-heterosexual individuals. Crítica Soc Rev Culturapolítica 2011;1:139-67.
Röndahl G, Innala S, Carlsson M. Nurses' attitudes towards lesbians and gay men. J Adv Nurs 2004;47:386-92.
Eliason MJ. Does “don't ask don't tell” apply to health care? Lesbian, gay, and bisexual people's disclosure to health care providers. J Gay Lesbian Med Assoc 2001;5:125-34.
Beagan B, Fredericks E, Bryson M. Family physician perceptions of working with LGBTQ patients: Physician training needs. Can Med Educ J 2015;6:e14-22.
Sathyanarayana Rao TS, Jacob KS. The reversal on Gay Rights in India. Indian J Psychiatry 2014;56:1-2.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th
ed.. Arlington: American Psychiatric Association; 2013.
Banerjee A. Social Change & The Marginalized- the Case of the Queer Community. Social Change & The Marginalized: The Case of the Queer Community” in N.K.Bhargava et al,
eds: Agrarian Structure and Social Transformation Udaipur, New Delhi; 2020. p. 39-65.
Drescher J, Byne WM. Homosexuality, gay and lesbian identities and homosexual behaviour. In: Sadock BJ, Sadock VA, Ruiz P, editors. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9th
ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 2060-89.
Narrain A, Chandran V. Medicalisation of Sexual Orientation and Gender Identity: A Human Rights Resource Book. New Delhi: Yoda Press; 2012.
Kalra G, Gupta S, Bhugra D. Sexual variation in India: A view from the west. Indian J Psychiatry 2010;52:S264-8.
Dunjić-Kostić B, Pantović M, Vuković V, Randjelović D, Totić-Poznanović S, Damjanović A, et al
. Knowledge: A possible tool in shaping medical professionals' attitudes towards homosexuality. Psychiatr Danub 2012;24:143-51.
Harris MB, Nightengale J, Owen N. Health care professionals' experience, knowledge, and attitudes concerning homosexuality. J Gay Lesbian Soc Serv 1995;2:91-107.
Alderson KG, Orzeck TL, McEwen SC. Alberta high school counselors' knowledge of homosexuality and their attitudes toward gay males. Canadian J Educ 2009;32:87-117.
Wells JW, Franken ML. University students' knowledge about and attitudes toward homosexuality. J Humanist Educ Dev 1987;26:81-95.
Smith DM, Mathews WC. Physicians' attitudes toward homosexuality and HIV: Survey of a California Medical Society- revisited (PATHH-II). J Homosex 2007;52:1-9.
Morrison MA, Morrison TG. Development and validation of a scale measuring modern prejudice toward gay men and lesbian women. J Homosex 2002;43:15-37.
Herek G. Heterosexuals' attitudes toward lesbian and gay men: Correlates and gender differences. J Sex Res 1988;25:451-77.
Banwari G, Mistry K, Soni A, Parikh N, Gandhi H. Medical students and interns' knowledge about and attitude towards homosexuality. J Postgrad Med 2015;61:95-100.
] [Full text]
Somasundaram O, Tejus Murthy AG. Homosexuality – Leaves from antiquity: Lesbian, gay, bisexual, and transgender population: A Tamil perspective. Indian J Psychiatry 2016;58:336-8.
] [Full text]
Felmlee D, Orzechowicz D, Fortes C. Fairy tales: Attraction and stereotypes in same-gender relationships. Sex Roles 2010;62:226-40.
Lopes L, Gato J, Esteves M. Portuguese medical students' knowledge and attitudes towards homosexuality. Acta Med Port 2016;29:684-93.
Hollenbach A, Eckstrand K, Dreger A. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals who are LGBT, Gender Nonconforming, or Born with DSD. Washington: Association of American Medical Colleges; 2014.
Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003;129:674-97.
Frost DM, Lehavot K, Meyer IH. Minority stress and physical health among sexual minority individuals. J Behav Med 2015;38:1-8.
Garofalo R, Wolf RC, Wissow LS, Woods ER, Goodman E. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med 1999;153:487-93.<
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]