MENTAL HEALTH SERVICES AND SEXUAL/GENDER MINORITY CLIENTS IN BANGKOK, THAILAND: VIEWS BY SERVICE USERS AND SERVICE PROVIDERS TIMO OJANEN A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCE IN COUNSELING PSYCHOLOGY Graduate School of Psychology ASSUMPTION UNIVERSITY THAILAND October 2010 ii MENTAL HEALTH SERVICES AND SEXUAL/GENDER MINORITY CLIENTS IN BANGKOK, THAILAND: VIEWS BY SERVICE USERS AND SERVICE PROVIDERS TIMO OJANEN Pages: 277 October 2010 The purpose of this qualitative study was to explore how professional Thai mental health practitioners and sexual/gender minority clients view sexual/gender minorities and the provision of mental health services for them. APPROVED: ______________________________________ VORAPOT RUCKTHUM, Ph.D. Chairperson ______________________________________ ASSOC. PROF. ARCHANYA RATANA-UBOL, Ed.D External Examiner ______________________________________ HOLLY DUGAN, Ph.D. Advisor ______________________________________ ASSOC. PROF ROBERT HO, Ph. D. Member ______________________________________ BEN WEINSTEIN, Ph. D. Member iii MENTAL HEALTH SERVICES AND SEXUAL/GENDER MINORITY CLIENTS IN BANGKOK, THAILAND: VIEWS BY SERVICE USERS AND SERVICE PROVIDERS TIMO OJANEN ABSTRACT This qualitative study explored how Thai psychologists, psychiatrists and their sexual/gender minority clients view these minorities and professional mental health services in Bangkok, Thailand. 16 Bangkok-based Thai nationals were interviewed (3 gay clients, 3 transgendered client, 1 other client, 5 psychologists, and 4 psychiatrists). Neither clients nor practitioners openly viewed homosexuality as abnormal; views on transgenderism were more diverse. Only 1 psychologist viewed either as changeable, and added that only he offers therapy aimed at sexual orientation change in Thailand. Services openly based on a pathologizing model of homosexuality thus seem rare in the context. Many practitioners viewed service provision to sexual/gender minority clients as little or no different from other service provision, but also expressed views about distinct characteristics of such clients or issues that need to be considered when providing services to them. Parental pressure, sexual/relationship issues, depression, and SRS readiness evaluation were some key issues among these client groups. Key problems in service provision include lack of personnel resources on the public sector (allowing few opportunities for counseling); stigmatization of service use, and low level of practitioner knowledge, especially on community resources. Sufficient budgeting, training, and online/hotline services are ways to address these problems. iv ACKNOWLEDGEMENTS The author is most indebted to all the participants for daring to reveal their personal or professional experiences and views on sensitive and sometimes controversial matters. Thanks also to the employing organizations of practitioner participants for permitting their employees to participate. At the Graduate School of Psychology, thanks go to the author’s thesis advisor Holly Dugan, who believed in the author’s vision for the research; Ben Weinstein and Christine Bierdrager, who provided comments on research plans and wordings used; various office staff and the Dean, Vorapot Ruckthum, for all those official letters to request permission for interviews. Ramil Ampa, Sari Castrén, and Sirintip Poovaratanakul, friends and fellow GSP students, helped the author to identify and contact participants and academic articles referred to in the study. Peter Jackson at the Australian National University and Sam Winter at the University of Hong Kong provided background materials and comments on certain sections. Sulaiporn Chonwilai, who previously interviewed some practitioners on similar issues, provided an early discussion on what to cover. Rainbow Sky Association of Thailand (RSAT) let the author use their meeting room for interviews without charge and recruit participants through their activities. Klairung Sonklin of the Women’s Health Advocacy Foundation provided information on lesbian matters. Isnai Kraisem provided plentiful practical help and much appreciated moral support through the various stages of the research process. Some sections of this thesis correspond to certain parts in the author’s earlier article (Ojanen, 2009) in Sexuality Research and Social Policy, now published by Springer. Thanks for the valuable input of the journal’s editor, Ingrid Wynden. v TABLE OF CONTENTS Page TITLE PAGE i APPROVAL PAGE ii ABSTRACT iii ACKNOWLEDGEMENTS iv TABLE OF CONTENTS v NOTE ON TRANSCRIPTION METHOD xvi I INTRODUCTION 1 Statement of the Problem 10 Purpose of the Study 10 Significance of the Study 11 Questions Guiding the Study 11 Basic Assumptions 12 Limitations 13 Delimitations 14 Definition of Terms 14 II REVIEW OF RELATED LITERATURE 16 Scope of the Review 16 Western Psychological Perspectives on Homosexuality and Bisexuality in Counseling 17 International Psychological Perspectives on Transgenderism 22 Comparing the Thai and Western Sexual/Gender Systems 29 vi Prevalence of Sexual/Gender Minority Groups in Thailand and Abroad 36 Sexual/Gender Minorities and Mental Health Services in Thailand 38 Conclusion on Existing Information 44 III METHOD 45 Type of Research 45 Research Design 48 Participants and Sampling 50 Instrumentation 57 Data Collection and Compilation 58 Data Analysis 59 Ethical Considerations 61 IV RESULTS 64 Reporting Conventions Used in This Chapter 64 Treatment of Sexual/Gender Minority People in Thailand 65 Actions by Parents 65 Taking One’s Child to a Psycho-Scientist 65 Violence against One’s Child 66 Forbidding a Type of Gender Identity or Expression 66 Expression of Denial 67 Control 67 Acting Out 67 Giving Consent for SRS 67 Actions by Employers 68 vii Controlling Employees’ Gender Expression 68 Sacking an Employee For Being Gay 68 Actions by Partners 68 Violence Between Partners 69 Abandonment 69 Staying Married for Appearances 69 Actions by Healthcare Staff 69 Actions by Schoolmates 70 Actions by Staff in Educational Institutions 70 Actions by Others 71 Treated as Abnormal 71 Sexual Violence 71 Malicious Gossip 72 Other Relatives’ Reactions 72 Discrimination by Social Workers 72 The Legal Context 72 Acceptance of Sexual/Gender Minorities in Thailand 73 Views by Client Participants 73 General Views by Gay Participants 73 General Views by TG participants 74 Client Views on Parental Acceptance 74 Views by Practitioner Participants 75 Acceptance within Society at Large 75 Parental Acceptance 76 Acceptance within Religions 77 viii Acceptance by Other Named Groups 77 Women and Men 77 Teachers 78 Friends 78 Hospital Staff and Patients 78 Government 78 Characteristics of Sexual/Gender Minority Individuals and Communities 78 Views and Experiences by Client Participants 79 Experiences Related to Identity Development 79 Lack of Awareness of One’s Phêet 79 Embarrassment, Hiding One’s Phêet 79 Coming To Terms with One’s Phêet 79 Identity Confidence 79 Client Views on Etiology of Homosexuality and Transgenderism 80 Gay Participants’ Views and Experiences 80 Sexual and Relationship Problems 80 Specificity of Gay People 80 Involvement in Gay Specific Groups and a Need for a sense of Belonging 81 Drug use 81 Reactions to Problems 82 TG Participants’ Views and Experiences 83 Sexual Diversity and Fluidity 83 Medical versus Social Model of Transgenderism 83 ix Transitioning 84 Reactions to Social Pressure 85 Reactions to Other Problems 85 Specific Demands, Recommendations to Society by Sexual/Gender Minority Groups 86 Views and Experiences by Practitioner Participants 86 Etiology of Homosexuality/Transgenderism 86 Normality of Sexual/Gender Minorities 87 Non-Specificity of Sexual/Gender Minority People 88 Specificity of Sexual/Gender Minority People 89 Creativity of Sexual/Gender Minority Individuals 89 Specific Relationship and Sexual Characteristics and Problems of Sexual/Gender Minority People 89 Gay Social Life 91 Closeted vs. Out Sexual/Gender Minority People 91 Reactions to Societal Pressure 92 STIs and HIV 93 Gay Social Influence 93 Practitioner Views Specifically on TGs 94 SRS and Psychological Adjustment 94 Reactions to Harassment 95 Relationship Issues 95 Involvement in Sex Work 95 Beauty 95 In-Between Beings 95 x Likeness with God 95 Practitioner Views and Experiences on Lesbians 95 Practitioner Views on What Sexual/Gender Minority People Should Do 96 Ordain 96 Work 96 Stick to Society’s Frame 97 Create Good Publicity 97 Find a Way to be Happy 97 Dare to be Yourself 97 Understand Relationship Realities 97 Clients’ Experiences and Views on Mental Health Services 98 Clinical Roles of Various Kinds of Practitioners 98 Psychiatrists 98 Psychologists 99 Other Clinical Staff 99 Confusion of Roles and Lack of Professionalism 100 Helping Processes Other than Counseling 100 Psychological Testing 100 Diagnosis & Certificate Writing 102 Advice 103 Medication 104 Referrals 104 Practitioner Stance toward Sexuality and Gender Issues 105 Positively and Negatively Perceived Practitioners and Practices 107 xi Negatively Perceived Practitioners and Practices 107 Psychiatrists 107 Lack of Confidentiality 107 Lack of Responsiveness and Respect toward the Client 108 Lack of Diagnostic and Counseling Skills 108 Too Narrowly Focused or Inappropriate Advice 108 Insincerity 108 Something Missing 109 Lack of Knowledge about Sexuality Matters 109 Positively Perceived Practitioners and Practices 109 Establishing Therapeutic Relationship 109 Listening 109 Analyzing 110 Influencing