Saalim et al. BMC Public Health          (2023) 23:166 BMC Public Health
https://doi.org/10.1186/s12889-023-15087-y
R E S E A R C H Open Access
Multi-level manifestations of sexual stigma 
among men with same-gender sexual 
experience in Ghana
Khalida Saalim1*, Prince Amu-Adu2, Richard Panix Amoh-Otu3, Ransford Akrong4, Gamji Rabiu Abu-Ba’are5,  
Melissa A. Stockton6,7, Richard Vormawor4, Kwasi Torpey8, Laura Nyblade1 and LaRon E. Nelson9,10,11,12
Abstract
Sexual stigma and discrimination toward men who have same-gender sexual experiences are present across 
the globe. In Ghana, same-gender sexual desires and relationships are stigmatized, and the stigma is sanctioned 
through both social and legal processes. Such stigma negatively influences health and other material and social 
aspects of daily life for men who have sex with men (MSM). However, there is evidence that stigma at the 
interpersonal level can intersect with stigma that may be operating simultaneously at other levels. Few studies 
provide a comprehensive qualitative assessment of the multi-level sexual stigma derived from the direct narratives 
of men with same-gender sexual experience. To help fill this gap on sexual stigma, we qualitatively investigated 
[1] what was the range of sexual stigma manifestations, and [2] how sexual stigma manifestations were distributed 
across socioecological levels in a sample of Ghanaian MSM. From March to September 2020, we conducted eight 
focus group discussions (FGDs) with MSM about their experiences with stigma from Accra and Kumasi, Ghana. 
Data from the FGDs were subjected to qualitative content analysis. We identified a range of eight manifestations 
of sexual stigma: (1) gossiping and outing; (2) verbal abuse and intrusive questioning; (3) non-verbal judgmental 
gestures; (4) societal, cultural, and religious blaming and shaming; (5) physical abuse; (6) poor-quality services; 
(7) living in constant fear and stigma avoidance; and (8) internal ambivalence and guilt about sexual behavior. 
Sexual stigma manifestations were unevenly distributed across socioecological levels. Our findings are consistent 
with those of existing literature documenting that, across Africa, and particularly in Ghana, national laws and 
religious institutions continue to drive stigma against MSM. Fundamental anti-homosexual sentiments along with 
beliefs associating homosexuality with foreign cultures and immorality drive the stigmatization of MSM. Stigma 
experienced at all socioecological levels has been shown to impact both the mental and sexual health of MSM. 
Deeper analysis is needed to understand more of the lived stigma experiences of MSM to develop appropriate 
stigma-reduction interventions. Additionally, more community-level stigma research and interventions are needed 
that focus on the role of family and peers in stigma toward MSM in Ghana.
Keywords Men who have sex with men, MSM, Anticipated stigma, Perceived stigma, Enacted stigma, Internalized 
stigma, Ghana, West Africa, Sexual stigma, Same-gender sexuality
*Correspondence:
Khalida Saalim
ksaalim@rti.org
Full list of author information is available at the end of the article
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Saalim et al. BMC Public Health          (2023) 23:166 Page 2 of 13
Background sexual identity while seeking care at a health care facility 
Sexual stigma and discrimination toward men who have (HCF) and, instead, preferred not to seek care to avoid 
same-gender sexual experiences are present across the the discomfort [6]. Although the avoidance of HCFs is 
globe [1–4]. In Ghana, it is estimated that approximately a protective behavioral strategy used by MSM to avoid 
55,000 men participate in same-gender sexual activi- exposure to sexual stigma [6], it can have indirect resid-
ties [5]. In Ghana, same-gender sexual desires, relation- ual impacts on their health through either the lack of 
ships, and practices are stigmatized, and the stigma is detection or delayed detection and treatment of chronic 
sanctioned both through social and legal processes [6]. or communicable disease [6, 23].
A recent national population-based survey in Ghana Research describing sexual stigma among men with 
found that an overwhelming majority (90%) of Ghanaians same-gender sexual experiences in Ghana is limited and 
believed that same-gender sexualities were inconsistent has focused primarily on occurrences at the interper-
with Ghanaian cultural norms, undermined the basic sonal level [6, 24–26]. However; there is evidence that 
social structure of Ghanaian society, and were there- stigma at the interpersonal level can intersect with stigma 
fore unacceptable [7]. It is well established that stigma that may be operating simultaneously at structural and 
is a social determinant that negatively influences health organizational levels [27]. The interactions among these 
and other material and social aspects of daily life in the multiple levels of sexual stigma are important to iden-
populations subjected to it [8–11]. In Ghana, the nearly tify and understand because they may undermine the 
ubiquitous presence of stigma and discrimination toward development of positive self-concept and maintenance of 
men with same-gender sexual experiences has the poten- psychological well-being among the men [28–30]. More-
tial to limit the opportunities for these men to achieve over, understanding multi-level sexual stigma within the 
and maintain equity in health, well-being, socio-emo- Ghanaian sociocultural context can provide evidence to 
tional development, and economic progress [12, 13]. inform the development, testing, and implementation of 
Sexual stigma is the social status devaluation of sexuali- socioculturally responsive stigma-reduction intervention 
ties (e.g., desires, behaviors, identities, relationships, and strategies. Nonetheless, few studies provide a compre-
communities) that are perceived and treated as abnormal hensive qualitative assessment of the multi-level sexual 
because they are not heterosexual [14–16]. Sexual stigma stigma derived from the direct narratives of Ghanaian 
in Ghana, as in many other countries around the world, men with same-gender sexual experience. To help fill this 
is influenced by social policies and practices that prefer- gap in the state of the science on sexual stigma, our aim 
entially treat heterosexuality as the “natural” or “normal” was to qualitatively investigate the following research 
sexuality [12]. Sexual stigma is activated to socially rel- questions: (1) what was the range of sexual stigma mani-
egate and regulate same-gender sexual practices among festations, and (2) how sexual stigma manifestations were 
men because of those practices’ perceived incongruence distributed across structural, interpersonal, and intraper-
with legal, cultural, and religious norms of masculinity sonal ecological levels in a sample of Ghanaian MSM.
[17, 18]. For example, a Ghanaian legal statute criminal-
izes “unnatural” sexual activities, which serves as a de Specifying terminology and positionality
facto legal premise that justifies stigma against same- A variety of terms have been used to describe men 
gender sex because such sex is characterized as unnatural who have a range of same-gender experiences, includ-
and unlawful, and thus socially dishonorable [6, 19]. Data ing same-gender sex, desires, relationships, and iden-
on sexual stigma toward men who have sex with men tities [31]. These terms, such as ‘gay’, ‘bisexual’, ‘queer’, 
(MSM) in Ghana align with data from research in other and ‘same-gender loving’ have specific sociopolitical 
African contexts that suggest sexual stigma is grounded and cultural meanings for the groups that identify with 
in religious and cultural perceptions around same-gender them [32, 33]. Since the onset of the HIV pandemic, 
sexual behavior [20]. Moreover, in some African con- the term men who have sex with men (MSM) has been 
texts, stigma towards MSM can be more pronounced broadly applied to men across the range of same-gender 
among men who have gender non-conforming behaviors, sexual experiences. MSM is an epidemiological term 
or rather, act more feminine [21].Sexual stigma can be used in public health surveillance in the taxonomy of 
harmful to both physical and mental health, as evidenced HIV exposure categories, such as perinatal or injection 
by research conducted across the African continent that drug use exposures [34]. The term MSM does not refer 
shows that stigma is in part responsible for lower rates of to sexuality and can include, for example, a heterosexual 
testing for HIV and higher levels of depression for MSM man who was exposed to HIV through a non-consen-
[2, 22]. Sexual stigma also influences health care seek- sual sexual encounter with another man. Over time, the 
ing behavior by influencing MSM to either delay or forgo use of “MSM” has crept beyond its original intention 
needed health care services [6]. In a seminal study, MSM and is now popularly used as a convenient blunt short-
in Ghana reported they felt they could not share their hand reference to “gay” or “bisexual” [35]. The continued 
Saalim et al. BMC Public Health          (2023) 23:166 Page 3 of 13
consolidation of men with diverse same-gender sexual Initial participants were recruited by trained staff who 
experiences into a single yet epidemiologically precise had shared lived experiences as well as who had previous 
term such as ‘MSM” erases important lived social reali- work experience conducting lesbian, gay, bisexual, and 
ties of the men who are taxonomized into one group transgender (LGBT) community outreach. Individuals 
[35–37]. As a multicultural (Ghanaian, Korean, Ameri- initially contacted were encouraged to invite others from 
can) team led by Americans who are conducting U.S. their networks who might be interested. We obtained 
Government-sponsored research in Ghana, we also written informed consent from all participants. Inclusion 
acknowledge the settler colonial history of taxonomizing criteria included being at least 18 years old, self-identi-
humans (in Africa, Asia, the Americas, and elsewhere) fying as a cisgender man at time of enrollment, and self-
into groups in order to render them and their sociocul- reporting having had a sexual experience with another 
tural practices more interpretable and manageable to man (cis and transgender inclusive) within six months 
individuals viewing and administering them through prior to enrollment. All participants received 100 cedis 
a Western intellectual lens [38, 39]. Except when mak- each for their participation in the study.
ing references to specific sexual identity groups, we use 
‘MSM’ in this paper to refer to the men in the qualitative Data collection
sample who were recruited in a larger HIV-prevention We conducted eight FGDs from March 2020 to Septem-
trial based solely on their self-reported potential HIV risk ber 2020, with six to eight participants in each group. 
exposure category classification, not on their sexualities FGDs were co-facilitated by pairs of trained research 
[40]. We offer this clarification here as an act of resis- assistants. The FGDs were primarily conducted in Eng-
tance to common practices that uncritically reduce men lish; however, each co-facilitator pair was multi-lingual in 
into behaviors as “MSM”, a dehumanizing practice that order to allow the participants to spontaneously commu-
is entrenched in HIV-prevention literature [41] and one nicate in the main indigenous Ghanaian languages (i.e., 
which is admittedly observable in our previous publica- Twi, Ga). The FGDs were conducted in secure conference 
tions [24, 42–44]. rooms of local LGBT community-centered non-govern-
mental organizations. The discussions lasted between 90 
Methods and 120 min and were recorded as digital audio for tran-
Design scription. All participants were asked to use pseudonyms.
We used qualitative description as the overall design Semi-structured guides were used to standardize the 
for the study. Qualitative description is a low-inference content and sequence of questions across FGDs[52, 53]. 
method that is well-suited for providing a summary of FGDs explored three main topics: (1) community norms, 
perspectives that remain anchored in the everyday lan- attitudes, and experience of life in their community; (2) 
guage of the informants [45–47]. Our team has used experiences seeking or obtaining health care; (3) experi-
qualitative description in previous studies [48], including ences of stigma in health care facilities. Sample questions 
research with MSM in Ghana [49, 50]. We also incorpo- and their associated prompts within each topic were used 
rated a community-based participatory approach by co- to encourage in-depth exploration, presented in Table 1. 
designing this qualitative sub-study with Ghanaian MSM Although questions regarding family and peers were not 
community members and Ghanaian research assistants, formally included in the discussion guides, mentions 
including collaboratively identifying the research ques- of experiences of stigma among these social ecological 
tions, analyzing the data, and writing this manuscript. groups also arose in the conversation and were probed 
Data were generated using focus group discussions and explored as they emerged [53, 54].
(FGDs) that were conducted during the formative phase Research assistants transcribed all FGD audio record-
of a larger cluster randomized-controlled trial of a multi- ings verbatim, with translations to English (including 
level intersectional stigma-reduction intervention [40]. back translations) conducted as necessary. All identifying 
All study personnel were trained on the study protocol information was removed during transcription. All tran-
and ethics of research with human participants[51]. scripts were cross-verified for completeness and accuracy 
to correct any errors or misrepresentations that may have 
Setting, sample and recruitment been made during transcription.
The study was conducted in Accra, which is Ghana’s 
administrative capital, commercial center, and larg- Data analysis
est city, and in Kumasi, Ghana’s second largest city. We conducted qualitative content analysis on data gen-
Both areas are characterized by ethnic and religious erated from FGDs. In qualitative content analysis, data 
diversity, including immigration from other regions of are categorized and reviewed iteratively to determine 
Ghana and neighboring countries. A convenience sam- findings based on both the written text and the unwrit-
ple (n = 61) was recruited using the snowball technique. ten subtexts [55, 56]. Data were managed, coded and 
Saalim et al. BMC Public Health          (2023) 23:166 Page 4 of 13
Table 1 Discussion topics, questions, and sample prompts from Table 2 Distribution of sexual stigma manifestation occurrences 
focus groups across socioecological levels
Topic Question Sample Prompts Sexual Stigma Socioecological Levels
Domain Manifestations Community Institutions Peers Fam- Self
Community How would you de- • What has it been like for you ily
norms, at- scribe the community as a man who has sex with Social, cultural, and X X X X X
titudes, and where you live? men? religious blaming 
experiences • What have been your most and shaming
of life meaningful experiences in Verbal abuse X X X X X
this community? and intrusive 
Tell us about any times • Where do you think these questioning
that you felt guilty or negative feelings come from? Gossiping and X X X X
ashamed for having sex • How do these feeling affect outing
with other men? your life?
Physical abuse X X X
• What do you do to feel bet-
ter about yourself and your Internal conflict X X X
sexuality? and guilt about 
sexual behavior
Experiences Who do you go see • What do you like about the 
seeking/ when you have a sexual provider that you visit? Non-verbal judg- X X
obtaining health issue? • What don’t you like about mental gestures
healthcare the experience? Living in constant X X
• Do you feel like you have a fear and stigma 
say in what happens to you avoidance
there? Poor-quality X
Do you think that your • Why do you think so? services
health care provider • Why don’t you think so?
cares about what hap-
pens to you? is the sexual stigma occurring?” After all of the reports 
When you leave the • Do you want to do what were coded, the study team then met to consolidate the 
health care office, how they advise? Why? Why not? codes that had substantive conceptual overlap, remov-
capable do you feel to • What keeps you from ing those that were superficial and creating clusters of 
follow the provider’s following through with the codes that were closely aligned but represented distinct 
instructions? treatment plan?
Experiences When you go for a • Do you experience welcom- sexual stigma experiences. Through an iterative process 
of stigma in health visit, what hap- ing and positive reactions? of re-immersion in the data, discussion, and code refine-
health care pens once the staff find • Have you experienced ment the team reached consensus on the key manifesta-
facilities out that you are MSM? negative reactions? tions of stigma and the levels at which they were present. 
Tell us about a time that Our final step was the creation of a data matrix display 
you decided not to go (Table 2) to describe the distribution of sexual manifesta-
to a health care facility 
because you were wor- tions across type and socioecological level [56].
ried that you would be Note: Empty cells do not indicate a finding of the 
treated badly for being absence of stigma at these levels. Instead, participants 
MSM? did not explicitly mention sexual stigma manifestations 
occurring at that level.
analyzed using Dedoose 8.3. Open coding was used to 
draft a thematic codebook. Open coding is a process in Results
which codes are developed and applied in-real time dur- Range and distribution of sexual stigma manifestations
ing the process of reviewing transcripts. A team of five We identified a range of eight manifestations of sexual 
coders individually applied the codebook to the same stigma. These manifestations were:(1) gossiping and 
four transcripts, meeting after each transcript to review outing; (2) verbal abuse and intrusive questioning; (3) 
the line-by-line coding, discuss discrepancies, update the non-verbal judgmental gestures; (4) societal, cultural, 
codebook, and ensure consistency in coding. Remaining and religious blaming and shaming; (5) physical abuse; 
transcripts were coded using the final codebook. Code (6) poor-quality services; (7) living in constant fear and 
reports were produced by querying the qualitative data- stigma avoidance; and (8) internal ambivalence and guilt 
base in Dedoose to retrieve all selected text associated about sexual behavior. We also found that sexual stigma 
with the codes that were related to sexual stigma. Four manifestations were unevenly distributed across multiple 
study authors open-coded the reports to identify text socioecological levels (Table 3). Seven of the eight mani-
that was relevant to the questions, “How is sexual stigma festations of sexual stigma occurred at the community 
manifested in this text/subtext?” and “At what level(s) level, with the exception of poor-quality services, which 
Saalim et al. BMC Public Health          (2023) 23:166 Page 5 of 13
Table 3 Sexual stigma manifestations arranged by form of quote below illustrates how gossip that originated at one 
stigma and distribution across multiple socioecological levels socioecological level penetrated across levels through 
Forms Socioecological Levels the constant spread of information. One study partici-
Community Institution Peers Family Self pant narrated his experience of being outed in a situation 
Perceived GO GO, NV, VA, -- -- -- between his friends and family:
BS, PQ
Enacted BS, GO, NV, BS, GO, NV, GO, BS, GO, -- “I’ve had an experience, and it happened in a store 
PA, VA PQ BS, VA VA, PA at our junction. Two girls who happens to be my 
Internalized IC, CF CF IC -- BS, friend outed me to my sister and mom when they 
IC, met at the salon that I am gay. My family confronted 
VA
Anticipated CF, GO, PA, VA CF, GO, NV, CF -- -- me, but I denied to what they asked me.” (Accra, 
PQ, VA FGD 2, participant 1).
Note: Empty cells do not indicate a finding of the absence of stigma at 
these levels. Instead, participants did not explicitly mention sexual stigma 
manifestations occurring at that level. In the example, the gossip and outing manifested at both 
Note BS = social, cultural and religious blaming and shaming. CF = living in the institutional level (“at the salon”) and the community 
constant fear and stigma avoidance. GO = gossiping and outing. IC = internal level (“at our junction”). It was first enacted by two of his 
conflict and guilt about sexual behavior. NV = non-verbal judgmental gestures. 
PA = physical abuse. PQ = poor-quality services. VA = verbal abuse and intrusive friends who transmitted the sexual stigma at the level 
questioning. of the participant’s family, where it was then re-enacted 
upon him through direct confrontation by the mother 
only occurred at the institutional level. There were no and sister. This process of reverberating gossip and out-
reports of physical abuse or internal conflict at the insti- ing can lead to rumination among MSM regarding the 
tutional level. Enacted sexual stigma was experienced fear that gossip about them will continue to spread and 
across all levels, except the individual level (Table  3). negatively affect other aspects of their daily lives, includ-
Gossiping and outing was the most prevalent (n = 8) sex- ing alienation by peers who may avoid social contact with 
ual stigma manifestation, experienced in the perceived, them in order to avoid being the target of gossip and out-
enacted, and anticipated forms and occurring across ing by association.
community, institutional, friends, and family levels. 
Additionally, sexual stigma manifested most frequently Verbal abuse and intrusive questioning
in the enacted (n = 6) and anticipated (n = 6) forms. How- Participants provided numerous examples of how sex-
ever, four of the manifestations (i.e., gossiping and outing, ual stigma manifested as verbal abuse. These examples 
verbal abuse and intrusive questioning, non-verbal judg- include insulting, mocking, name calling, expression 
mental gestures, and poor-quality services) were common of disapproving thoughts, and verbal threats of harm 
between the enacted and anticipated forms. (physical and social). Enacted verbal abuse occurred at 
the community, family, and friends levels. Derogatory 
Gossiping and outing epithets, such as ‘girl-boy’, ‘Sodom and Gomorrah’, and 
Gossiping was defined as spreading information, either ‘drenches of Armageddon’ characterized the types of lan-
true or false, about a person’s sexuality without their guage imbued with references to gender oddity, sexual 
consent. MSM experienced anticipated, perceived, and deviance, and religious damnation that were used to stig-
enacted gossip and outing in their day-to-day lives. These matize the men’s sexualities.
experiences included gossip due to others’ perceptions In addition to outright verbal abuse, participants 
of their mannerisms, for example, in the ‘feminine’ way described being intrusively questioned about their sexu-
they spoke, walked, and dressed, which was viewed in the ality. This manifestation occurred across community, 
community as a proxy-indicator that a man engaged in institutional, family, friends, and individual levels. Intru-
same-gender sexual practices. Community members also sive questioning goes beyond collegial inquiries that 
spread gossip related to participants’ social networks, are grounded in genuine curiosity about an individual; 
including inuendo regarding the relative infrequency of it is an interrogation pattern of questions designed to 
the participants being observed with women compared “expose” sexual identity or behavior with the goal of com-
to the time they were seen to spend in the company of municating to the men that their secret is not safe. This 
other men. sexual stigma is still experienced even when the men pro-
Gossiping can include directly outing an individual’s vide answers to evade the questions or to conceal their 
sexuality in a situation and within a specific context, but sexuality. Enacted sexual stigma is manifested through 
it can also lead to outing in other contexts of the partici- the process of the intrusive questioning itself, regardless 
pants’ lives as the gossip cascades and transmits the sex- of whether or not the men confirm any details about their 
ual stigma into other socioecological levels. The sample same-gender sexualities. This is evidenced in the previous 
Saalim et al. BMC Public Health          (2023) 23:166 Page 6 of 13
quote, where the participant denied that he was gay in his stigma because his femininity will be construed as evi-
self-defense against intrusive questioning from his fam- dence of his same-gender sexuality, which will be a basis 
ily members. Another common example of this sexual for neither warmly receiving his patronage nor providing 
stigma manifestation of intrusive questioning described service in a manner that conveys that he is welcome.
by participants was when community and family mem-
bers frequently interrogated the men on their marital sta- “It wouldn’t be friendly [because] they will find him 
tus. Phrases such as, “Are you married?”, “Where is your weird, like how can a guy look feminine, dress femi-
wife?”, “Why aren’t you married?”, “But do you have a girl- nine, that kind of stuff.” (Accra, FGD4, participant 
friend?”, and “Don’t you want children?” seem benign on 3).
the surface (at the level of the literal text). However, the 
men reported that there are important cultural and reli- This quote reinforces that participants’ experiences of 
gious subtexts that underlie these questions about mari- sexual stigma can be compounded in situations where 
tal interests. In the subtext of these questions is a search the sufficiency of their masculinity (or their performance 
to uncover the real story, which is premised on the ques- of masculinity) is also scrutinized.
tioner’s skepticism about a man’s heterosexuality, their 
awareness of the socially devalued status of a suspected Societal, cultural, and religious blaming and shaming
MSM and the corresponding awareness of the tacit social Participants revealed that they were blamed and shamed 
power it affords them to subject a suspected MSM to for unraveling traditional Ghanaian cultural values by, for 
questioning and expect their cooperation. example, converting other men to homosexuality. They 
were also blamed as being responsible for driving the epi-
Non-verbal judgmental gestures demic spread of HIV in Ghanaian communities. Blaming 
Non-verbal judgmental gestures were described as body and shaming occurred across community, institutional, 
movements that conveyed disapproval of same-gender family, and peer levels. Blaming and shaming were most 
sexuality, including acts of staring, tooth sucking, and frequently reported as enacted sexual stigma.
pointing fingers. Participants reported these non-verbal Cultural and religious alienation was a dominant mode 
gestures occurring at the community and institutional through which this blaming and shaming was enacted 
levels. The men reported that enduring long stares made and internalized by MSM. The enactment of alienation 
them uncomfortable, and the often perceived such acts as and estrangement led to the belief that due to their sex-
judgmental, regardless of the starers’ intention. This dis- uality, they were not a legitimate member of Ghanaian 
comfort was particularly acute when it occurred in the society, religions, and cultures. One participant spoke 
context of trying to seek services at an organization (e.g., about being disowned by family members and banned 
register for educational classes, apply for a job, attend a from using the family name because the family consid-
medical appointment). The example below highlights the ered same-gender sexual activity sinful. Another par-
internal tension of being subjected to staring without a ticipant explained that his family ridiculed him for his 
corresponding verbal narrative to corroborate the MSM’s sexuality, claiming that MSM behaviors are against their 
perception that he is being judged negatively. In the fol- culture:
lowing quote, the participant acknowledges that there 
is non-verbal nuance (subtext) present that makes it “They would say how can an Akan man do this, do 
clear that he is being socially examined. In response to a that? At that moment, I felt so bad. Then I started 
prompt asking the FGD participants to elaborate on why to ask myself questions like, how come I got into this 
they feel that someone looking at them is a manifestation kind of act?” (Accra, FGD 4, participant 4).
of sexual stigma, one participant said:
“Yes, I think it’s mostly people just seeing you and The risk of cultural and religious alienation also affected 
then making assumptions about who you can be and their sexual partners, who sometimes also internalized 
then they don’t say anything but the kind of look they that their same-gender sexual desires and identities could 
give you….” (Accra, FGD 3, participant 2). not co-exist with their cultural and religious identities. In the quote below, another participant recounted a scene 
that unfolded after a sexual encounter in which the sexual 
The participants also considered staring to be intrusive partner began to experience conflict between the sexual 
and an invasion of their privacy. Those who self-identi- intercourse that occurred and his experience of him-
fied as being ‘feminine’ anticipated receiving non-verbal self as the son of a clergy leader. The partner attempted 
judgmental gestures whenever they were seeking to to reconcile his conflict by blaming the participant for 
obtain a service in a public venue. In the respondent’s inducing him into forbidden sexual temptation.
view below, a feminine man will be subjected to sexual 
Saalim et al. BMC Public Health          (2023) 23:166 Page 7 of 13
“I just remembered the experience I had with a guy. their sexuality or getting married. Moreover, these efforts 
We met in a tailoring shop and then there was this to ‘convert’ them and change their behaviors were iden-
shirt I needed to sew. I wanted it. So he was also tified as major sources of psychological distress and 
interested in what I chose and he was all over me. diminished social and physical well-being for the study 
You know every time I say something he is there and participants and the MSM in their social networks.
all that, so we ended up exchanging numbers, and 
one day he just came around and things happened. Physical abuse
But at the end of it, he then turned around and said Physical abuse was defined as the intention, attempt, or 
he was a pastor‘s son and then was blaming me for act of inflicting physical harm on MSM. Participants pri-
making him sin. That made me feel so bad. In fact, marily described that physical abuse of MSM occurs via 
I felt so guilty I thought I was the worst person on being struck by or pelted with objects or being slapped. 
Earth to have done that to him. But he did enjoy it, Physical abuse occurred at the institutional, commu-
he never said stop until the end and then he turned nity, and family levels. Physical abuse can be manifested 
round and blamed me for it. So, that made me feel directly by an assailant or indirectly by a provocateur. For 
really bad.” (Accra, FGD 2, participant 5). example, participants described provocations by pastors 
who preach inflammatory rhetoric to community mem-
Religious lecturing was also utilized to alienate MSM bers that MSM are abominations and that their persecu-
and reinforced to them that same-gender sexual behav- tion is sanctioned by God, inciting abuse of MSM. In the 
ior was incompatible with Christianity and Islam, the two sample excerpt from an FGD, the participant describes 
most-practiced religions in Ghana. MSM described being abuse he experienced at the hands of family members of 
forced to go to religious services by family members and his sexual partner:
taken to the pastor or imam to be ‘monitored’, or ‘prayed 
for’. Participants also described ‘deliverance rituals’, “I once met someone on social media. We chatted 
including visits to fetish priests who are local indigenous for a while and later decided to visit him. When I 
spiritual practitioners who mediate between deceased visited, he offered me a seat outside and we started 
tribal ancestors and the living world. chatting. All of a sudden, I received a slap and the 
In addition to religion-based strategies, participants slapping continued from other family members. 
described being subjected to secular tactics. One par- They also seized my phone and accused me of lead-
ticipant described his friend’s experience with his family’s ing their son astray. They later allowed me to leave. 
attempts to change him and the powerful effects of the This experience really taught me to be careful with 
shame that resulted: people I meet online and also in life.” (Kumasi, FGD 4, participant 7).
“Couple of times his dad’s call comes always after 
he is done with sex, and then the dad will call and 
would want to talk to him about [this topic] that This quote illustrates how sexual stigma manifests as 
we have been talking about. ‘Are you changing? Are physical violence and the ways in which it traverses lev-
you getting married?’ and it’s a bit tough for him. els (and intersects with other manifestations, e.g., blam-
Like, the dad has advised him to ‘Get married so ing and shaming). It also illustrates that these acts are 
that when you are hard in the night, you won’t go grounded in the socially inferior status assigned to MSM 
and chase men, your wife is by you.’ And coinciden- and the socially sanctioned power that allows civilians to 
tally the call always comes after he is done with sex enact property seizure (“they seized my phone”), detain 
or sometimes when the person is there and they are (“they later allowed me to leave”), and physically pun-
about to have sex. So it puts a lot of guilt on him. ish (e.g., slapping) MSM without reasonable recourse. 
Actually, he has tried to commit suicide a couple of Physical abuse and social sanctions harmed MSM both 
times simply because of that.” (Accra, FGD 3, par- physically and emotionally. MSM described feeling ‘less’ 
ticipant 6). in their community, fearing social interactions, and ulti-mately self-isolating in anticipation of this type of stigma 
(see living in constant fear and stigma avoidance).
The tactics outlined in the above-mentioned quote were 
presented by the father as a pragmatic “solution” to the Poor-quality services
participant’s same-gender sexual attraction “dilemma,” There were other non-physical social consequences 
which the father (not the participant) concluded required imposed on MSM that deprived them of their rights, 
behavioral self-regulation. The participants experienced privileges, and societal benefits. These manifested in 
these tactics as controlling and pressure on them to con- the diminished quality of the services that they received 
form to expected cultural norms, including changing in commercial sectors. For example, MSM described 
Saalim et al. BMC Public Health          (2023) 23:166 Page 8 of 13
being refused goods by merchants at marketplaces and “I will also put on baggy jeans and a (big sized) shirt 
denied due process when they register a complaint, have to look like a man. You need to force yourself to be 
a grievance, or are the subject of allegations. Below is an [a] man. We do that for just some few minutes and 
example from the housing sector in which a participant when we come back home, we continue being MSM.” 
discusses experiencing forced eviction by his landlord (Accra, FGD 4, participant 4)
based on suspicion of his sexuality.
“My landlord called me one day and told me there is In response to the constant fear of being exposed to 
going to be a renovation in my room so I have to leave sexual stigma, participants described a strategy whereby 
the house. On the day he gave me my balance to leave, they seek services later in the night to avoid stigma from 
he made me aware he was actually ejecting me because other patrons who may recognize them if they visited 
I am MSM” (Kumasi, FGD 4, participant 8). Participants during the daytime. Participants also described practic-
expressed that, even in the health care sector, the qual- ing a strategy that involved limiting the number of male 
ity of the services they received is compromised. Par- friends surrounding them to evade ‘suspicions’ in the 
ticipants described instances in which they were refused community. Still, others described isolating themselves 
medical attention because health providers had personal from heterosexual-identified people to avoid the risk of 
moral objections to providing care to MSM. In one exam- being ‘outed’.
ple, the potentially fatal consequences of sexual stigma 
when it manifests as poor-quality services in a health care “My take on this is that we should choose who we 
context is underscored. The participant in the following call friends wisely to avoid any confrontation from 
quote shared a story of an MSM whose death he attri- our neighbors. Most MSM always want to have new 
butes to sexual stigma in a hospital: friends, and I think is not the best thing to do. We should also limit the number of friends we invite into 
“A friend who was on admission in one of the facili- our homes to avoid suspicions.” (Kumasi, FGD 3, 
ties died because the aunt who also works in the participant 10).
facility told her colleagues in the department he 
was admitted to that he is an MSM, and he is dying 
because of that… so the nurses and doctors should The quote above also illustrates the way in which some 
not attend to. The nurses and doctors also aban- of the external forms of sexual stigma can subtly become 
doned my friend and he died. So, because of that I internalized, such that MSM begin to self-police their 
don’t want to ever go to that facility because of how behaviors, their expressions, and their social interac-
they stigmatized my friend.” (Kumasi, FGD 4, par- tions with other men who have same-gender sexual 
ticipant 9). experiences.
Internal conflict and guilt about sexual behavior
The scene depicted in this quote illustrates, once again, Statements from MSM demonstrated internal doubt or 
how various manifestations of sexual stigma can be con- confusion about their sexuality and sexual behaviors. 
nected. In the quote, sexual stigma first manifested as The men periodically questioned themselves, wished 
gossip and outing, then evolved into blaming and sham- they were not MSM, or entertained the idea of marrying 
ing, before finally manifesting as poor-quality services. women because of societal pressure.
Furthermore, this quote also illustrates how sexual The internal conflict is described as being most acute 
stigma can traverse multiple socioecological levels (e.g., in proximity to sex activity, wherein the men report that 
originating at the family level and then being transmitted intrusive moral thoughts interrupt the encounter. An 
to the institutional level). example of this is in the quote below where the partici-
pant’s sexual desires appear to collide with his belief that 
Living in constant fear and stigma avoidance sex is not an appropriate activity within same-gender 
MSM anticipated and feared stigmatization and emo- relations.
tional or physical harm because of their sexual identity. 
To avoid these dangers, MSM took precautionary mea- “Yesterday when I was having sex with my guy, I sud-
sures to protect themselves. They expressed the need to denly stopped kissing him and started asking him 
self-regulate or hide their identity to conform to societal why we were doing that. Because we are both guys. I 
gender norms, using practices such as dressing up to felt so bad. I sometimes do think about it, especially 
appear ‘less feminine’. These practices were commonly when I am alone.” (Kumasi, FGD 2, participant 11).
deployed when the men needed to seek services in public 
spaces. One participant explained this process: MSM also expressed internalized guilt, defined as feelings 
of remorse, regret, and self-disapproval of same-gender 
Saalim et al. BMC Public Health          (2023) 23:166 Page 9 of 13
sexual behavior. Guilt specifically occurred when engag- the wholesale rejection of religion may trigger alien-
ing in sexual acts with persons who identified as either ation from other spiritual and religious ritual aspects of 
heterosexual or religious, as MSM felt they were ‘convert- community life that are still important for sociocultural 
ing’ others. identity.
“I feel guilty sometimes, but the moment I felt very 
guilty was when I slept with the school chaplain. I Discussion
felt I have sinned, and that God won’t forgive me; I The purpose of this qualitative study was to describe the 
will go to hell. But as time went on, and he kept on range in manifestations of sexual stigma toward MSM in 
requesting for it, I became okay and I felt it was okay Ghana and to describe the distribution of sexual stigma 
to move on because, he made me feel special at that manifestations across multiple socioecological levels. 
moment. So that was when I felt very guilty, that Consistent with previous literature, our findings show 
one. I remember I prayed that evening for forgiveness that MSM face various forms of sexual stigma across all 
still, but the next day he came again so I felt he also socioecological levels of Ghanaian society, which nega-
knew Satan.” (Accra, FGD 2, participant 1). tively impact their behavior and health outcomes [6, 24–26, 57, 58]. In particular, MSM mentioned eight forms of 
stigma enacted by others: (1) gossiping and outing; (2) 
As shown in other manifestations, the sexual stigma verbal abuse and intrusive questioning; (3) non-verbal 
emanating from across the socioecological spectrum can judgmental gestures; (4) societal, cultural, and religious 
become internalized by MSM, causing them to question blaming and shaming; (5) physical abuse; (6) poor-qual-
their identity and their roles in communities, social insti- ity services; (7) living in constant fear and stigma avoid-
tutions, families, and peer networks. Chronic feelings of ance; and (8) internal ambivalence and guilt about sexual 
guilt and internal conflict have negative impacts on the behavior.
well-being of MSM. One participant summarized the Our study found that a major form of stigma toward 
negative toll that these guilt feelings and internal conflict MSM is societal, cultural, and religious blaming and 
take across multiple spheres of his social reality: shaming. Literature shows that across Africa, and par-
“It affected my self-esteem, it pushed me away from ticularly in Ghana, national laws, policies, and religious 
making male friends. I felt like if I make male friends institutions continue to drive stigma against MSM. 
I will get attracted to them and it might tempt me Ghana has an enshrined stand against non-heteronor-
from having sexual relations with them so I dropped mative sexual behaviors, sanctioned by the country’s laws 
out from my study group, which was an all-male and religious institutions and reflected in sexual norms 
study group. That affected my academics, my grades and expectations among Ghanaians [6, 25, 26, 57–60]. 
were dropping and everything but fast forward Homosexuality is broadly seen as a sin by the major reli-
somewhere in level 300 [third year at university], I gions in Ghana, Christianity and Islam, that define the 
think I picked myself up, and I said you cannot beat perspectives of the majority of Ghanaians around appro-
yourself forever.” (Accra, FGD 4, participant 12). priate ways to engage in sex and procreation [61–64].Fundamental anti-homosexual or pro-heterosexual 
sentiments along with beliefs associating homosexuality 
Despite what can sometimes be years of internalizing with foreign culture and immorality drive stigmatization 
stigma, participants also discussed the development of of MSM. Along with religion, other studies also found 
coping mechanisms and learned self-acceptance. Cop- that being MSM is considered non-Ghanaian, which 
ing mechanisms included letting go of negative thoughts, often contributes to experienced and internalized stigma 
embracing meditative practices, and adopting personal- of MSM [65–67]. Indeed, homosexuality is often falsely 
ized theologies in which their same-gender sexuality falls reflected in media and political opinions as adopted from 
within the normal range of diverse human experiences. Western countries and a non-African practice [68], while 
“It doesn’t affect me in any way. Because I know historians and anthropologists have indicated that tradi-
[it] is the will of God, and if he thinks is not good, tional African societies and religions demonstrated more 
he should find a way to change it.” (Kumasi, FGD 2, acceptance of non-heteronormative self-expression than 
participant 13). post-colonial African societies [69]. In African nations and communities, this externalization of same-gender 
sexual behaviors as a foreign value facilitates the creation 
The quote above highlights the salience of religion in of a platform to advocate against homosexuality [70].
Ghanaian life, including the lives of Ghanaian MSM. The With our participants, societal, cultural, and religious 
practice of reconciling one’s religious identity with one’s views against same-sex sexual behavior manifested in 
sexual identity is identified as a preferred goal, whereas labeling MSM as individuals who have diverged from 
Saalim et al. BMC Public Health          (2023) 23:166 Page 10 of 13
Ghanaian societal norms and in shaming them for dis- violence indicates a high potential for development of 
obeying Ghanaian tradition. These forms of stigma clinical symptoms of post-traumatic stress. Interven-
appeared at the community level as well as in institu- tions that also incorporate clinical and psychotherapeutic 
tional settings. Within their communities, some MSM modalities that can be used in conjunction with stigma-
also faced harsh sanctions, such as eviction from homes, reduction interventions are important targets for future 
or were refused basic privileges, such as the ability to research. Additionally, our findings may suggest the spe-
buy food from the market, because they were MSM. At cific need for more stigma research among health facility 
the institutional level, consistent with previous litera- staff, assessing their beliefs and enacted stigma towards 
ture from Ghana and other African countries, our par- MSM. With the findings from this research, targeted 
ticipants recounted several instances of enacted stigma stigma-reduction trainings should be implemented at the 
at the HCF, such as being preached at or being denied health facility level to decrease stigmatizing beliefs and 
treatment [24, 26, 59, 60, 71–73]. Participants also shared behaviors among health workers and promote safe and 
instances of enacted stigma at other institutions, includ- supportive environments for MSM to receive care.
ing places of worship. These findings provide further 
evidence for the importance of implementing culturally Limitations
relevant interventions to address various forms of stigma While our study is one of the few to conduct FGD 
experienced by MSM at the community level and in insti- directly with MSM about their experiences with stigma 
tutional settings, including health facilities [6, 57–59, 74]. in the community and in HCFs, our study also had some 
Additionally, more research is needed on stigma toward limitations. First, it is possible that included MSM may 
MSM at other institutions, like prisons, in Ghana. not experience the most severe stigma, as all partici-
Values defined by families, community members, pants were connected in some way with advocacy orga-
religious institutions, and national laws influence indi- nizations, therefore, findings may not be generalizable to 
viduals’ self-perception and how they act. These stigma all MSM across Ghana. Furthermore, with a small FGD 
manifestations forced MSM to feel guilty about their sex- sample size and lacking detailed sociodemographic infor-
ual behavior and feel pressured to assimilate into norma- mation about participants, it becomes more difficult to 
tive Ghanaian traditional beliefs. Our participants often generalize these results to all Ghanaian MSM. Lastly, 
questioned their sexual behavior and shared feelings of questions proposed in the interviews addressed sensitive 
regret for having sex with men. These occurrences align issues, and it is plausible that participants were reluctant 
with findings from other studies on stigma toward MSM, to be forthcoming in their responses. In anticipation of 
which shows the negative consequences of family and this concern, our team endeavored to provide MSM 
peer stigma on the general health and mental well-being with a welcoming and confidential space to share their 
of MSM [75]. One study reported that MSM who face experiences.
rejection by their community have an increased risk of 
substance use, depression, suicidal attempts, and sexual Conclusion
health conditions [75]. Additionally, previous literature Stigma experienced at all social ecological levels has been 
shows that experiencing and anticipating stigma from the shown to impact both mental health and sexual health 
public can evoke stigma avoidance tendencies, which can of MSM. Findings from this study highlight the need to 
harm health-seeking behaviors and reduce utilization of understand more of the lived stigma experiences of MSM 
health services, especially HIV testing and care services to develop appropriate stigma-reduction interventions. 
[76, 77]. Our respondents spoke about fearing being Additionally, this study reflects the extent of stigma man-
outed, mistreated, or shamed by members of society, and ifestations and the importance of considering wider scale 
particularly at an HCF when receiving services, and in stigma-reduction interventions that address institutional-
response, adjusting their mannerisms and appearances level stigma beyond the HCF, but target religious and 
to conceal their identity as MSM. However, other studies legal institutions as well. In the broader sense, although 
report that in instances where families and communities our study did not intentionally focus on family and peer 
accept and support MSM, there is an observed increase enactment of stigma, MSM frequently cited these groups 
in acceptance and lowered stigma as well as reduced as perpetrators. Therefore, more community-level stigma 
negative health outcomes such as depression [78, 79]. research and interventions are needed with a focus on 
More research is needed on stigma enacted by communi- the role of family and peers in stigma toward MSM in 
ties and families as well as research on how these groups Ghana.
can assume supporting roles to counteract the effects of 
stigma among MSM in Ghana. Our findings of chronic AcknowledgementsThis study would not have been possible without the generosity of the study 
experience of psychological distress from exposure to participants and their willingness to share their knowledge and experiences 
various forms of physical, emotional, and structural with us, and the expertise of our partner organizations and their staff: Priorities 
Saalim et al. BMC Public Health          (2023) 23:166 Page 11 of 13
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