'We are inferior, we have no rights': Statelessness and mental health among ethnic minorities in Northern Thailand.

Research has shown that asylum seekers, refugees, and internally displaced persons, including stateless persons, are at increased risk of poor mental health. Yet, only a few studies explicitly focus on stateless persons. This article examines the association between legal status and mental health among Akha, Lahu and Tai-Yai people in Northern Thailand. A convergent parallel mixed-methods design was adopted and primary data were collected in June 2020 by face-to-face, semi-structured interviews with persons who do not hold a nationality (n = 108). A distinction was made between registered (nationalityless) and unregistered (stateless) persons since only the former have a legal status in Thailand. The correlates of mental health were analyzed using descriptive statistics and logistic regression. Qualitative thematic analysis was employed to gain deeper insights into the relationship between legal status, ethnicity and mental health. The quantitative results weakly suggest that stateless persons are more likely to have poorer mental health than nationalityless persons, who are recognized as habitually resident in Thailand and are recorded in the country's civil registry. The qualitative results, however, show that the legal status afforded to nationalityless persons is considered important as it gives rise to hope and increases livelihood opportunities. Yet, respondents also pointed out that it is not comparable to citizenship. The odds of having poorer mental health are significantly higher for Lahu and Tai-Yai respondents. The importance of ethnicity is confirmed by the qualitative results. These further indicate that citizenship problems and ethnicity are deeply interrelated. Stigma, discrimination, and lack of social support are key risk factors identified by respondents. Disaggregating data to better understand the heterogeneity of persons without nationality could play a key role in accelerating efforts to resolve protracted citizenship problems and close ethnic gaps.

Introduction

The number of stateless persons was reported to have reached 4.2 million globally in 2019 (UNHCR, 2020). Included in this estimate are stateless persons and persons of undetermined nationality. The 1954 Convention relating to the Status of Stateless Persons defines a stateless person as ‘a person who is not considered as a national by any State under the operation of its law’ (UN General Assembly, 1954a, p. 136). Stateless persons defined pursuant to the 1954 Convention are sometimes also referred to as de jure stateless persons. The 1961 Convention on the Reduction of Statelessness, on the other hand, contains a reference to de facto stateless persons, a term that has not been formally defined though (Price, 2017). According to Massey (2010, p. 61), de facto stateless persons are ‘persons outside the country of their nationality who are unable or, for valid reasons, are unwilling to avail themselves of the protection of that country’, that is persons who lack an effective nationality. Yet, definitions vary and have been applied in different ways (Price, 2017; UNHCR, 2010; 2019). A formal definition of a person of undetermined nationality also does not exist. In some countries, these may include, for example, persons at risk of statelessness or persons of unknown nationality (Chen, Nahmias, & Steinmueller, 2019). Due to definitional and other data collection challenges, the world's stateless population is believed to be much larger than reported by the United Nations High Commissioner for Refugees (UNHCR).

Stateless persons are exposed to numerous daily environmental stressors that are specific to their situation. They are excluded and deprived of basic rights, including the right to healthcare and health (Kingston, Cohen, & Morley, 2010).1 Research on stateless Rohingya in Bangladesh, for example, showed that post-migration daily environmental stressors associated with life in refugee camps had a negative impact on mental health (Riley, Varner, Ventevogel, Taimur, & Welton-Mitchell, 2017). Most studies do not explicitly focus on stateless persons though, but examine health outcomes of vulnerable and marginalized groups in a migratory context, which may include persons with and without legal nationality.

Several systematic reviews that focused on vulnerable and marginalized migrant subgroups concluded that asylum seekers, refugees and internally displaced persons tend to have poor mental health outcomes (Blackmore et al., 2020; Bogic, Njoku, & Priebe, 2015; Porter & Haslam, 2005). The diversity across and within these migrant subgroups, however, renders generalizations difficult (Rechel, Mladovsky, Ingleby, Mackenbach, & McKee, 2013). Predictors of mental health outcomes of forced migrants are classified into pre-displacement characteristics, circumstances of travel, and post-migration conditions (Bogic et al., 2015; Miller & Rasmussen, 2017; Porter & Haslam, 2005; Steel et al., 2009). Pre-displacement characteristics comprise standard socio-demographics, conflict exposure and, in studies that include diverse ethnic groups, also region/country of origin or birth and/or self-identified ethnicity (Bayard-Burfield, Sundquist, & Johansson, 2001; Gerritsen et al., 2006; Heeren et al., 2012; Jakobsen, Thoresen, & Johansen, 2011). Ethnicity is a complex ‘umbrella construct’, which comprises attributional and relational characteristics of groups (Ford & Harawa, 2010, p. 252). While the former reflect the unique socio-cultural characteristics of a group, the latter describe the relationship between a group and the society in which it is situated (Ford & Harawa, 2010). Post-migration factors identified in the literature include, for example, income, unemployment, host language proficiency, perceived discrimination, perceived level of acceptance, and social support (Bogic et al., 2012; Dangmann, Solberg, & Andersen, 2021; Ellis, MacDonald, Lincoln, & Cabral, 2008; Gottvall, Sjölund, Arwidson, & Saboonchi, 2020; Priebe et al., 2013). Legal status and the uncertainty surrounding it was identified as another important post-migration risk factor in several studies (Bogic et al., 2012; Castañeda, 2009; Fernandez, 2018; Gerritsen et al., 2006; Heeren et al., 2014; Leiler, Bjärtå, Ekdahl, & Wasteson, 2019).

Statelessness, however, does not only arise in the context of migration. Most stateless persons are, in fact, stateless in situ, that is they consider themselves to be in their own country by reason of birth, long-term residency or other ties (Albarazi & van Waas, 2016). Lubkemann (2008), focusing on war-affected Mozambicans, highlights that displacement can occur without migration given that some people are ‘displaced in place’. To dissociate displacement from migration, he defines displacement as forcible ‘immobilization’ due to an involuntary ‘disruption of the socio-spatial strategies upon which life projects are premised’ (Lubkemann, 2008, p. 471). Drawing on Lubkemann (2008), in situ statelessness can, hence, be seen a form of forced displacement that immobilizes (Belton, 2015). Documents such as passports and identity cards are tools that allow states to make a distinction between nationals and non-nationals, as well as to regulate and control their movement (Torpey, 1999). Their possession, therefore, demarcates the scope of geographic and social mobility (Cheva-Isarakul, 2019). Studies using data from Thailand, for example, demonstrated that legal status (as indicated by the possession of identification cards) affects education and health risk (Koning, Flaim, Baldiga, & Feingold, 2021), access to healthcare (Flaim et al., 2021; Herberholz, 2020), as well as access to land and credit (Flaim, Williams, & Ahlquist, 2019), that is, more generally, the key factors that matter for social ascent. Experiences of in situ stateless populations in Southeast Asia further showed that protracted statelessness results in an intergenerational transmission of immobilization (McAuliffe, 2017). Koning et al. (2021), for example, found that parent citizenship increases the odds of greater adult HIV knowledge, which is partially explained by birth registration, adult citizenship and secondary school completion.

Statelessness and nationalitylessness in Thailand

With about 475,000 recorded persons, Thailand's stateless population ranked fourth worldwide in 2019 (UNHCR, 2020). Reported are persons without nationality who are registered with the national civil registration system. Referred to as nationalityless persons in the Thai context, these are considered habitually resident in Thailand and hold a special identification document (ID) (Boonrach, 2017; Chidchanoknart et al., 2017; Saisoonthorn, 2006). They are permitted to stay in Thailand and granted access to certain rights and benefits such as, for example, coverage by the Health Insurance for People with Citizenship Problems (Suphanchaimat, Kantamaturapoj, Pudpong, Putthasri, & Mills, 2016). Mobility restrictions require them to stay in the province where they were first registered, although permission to change the designated location or travel may be granted on a case-by-case basis (Boonrach, 2017). Nationalityless persons are at risk of statelessness if citizenship is not confirmed by any state (Chidchanoknart et al., 2017). If confirmed by the Thai authorities, Thai citizenship is obtained. The complex and lengthy process of granting citizenship, however, has resulted in protracted nationalitylessness (Flaim, 2017; Tamee, 2015). Persons without nationality who do not enjoy the protection afforded to nationalityless persons, on the other hand, are referred to as stateless persons in the Thai language (Saisoonthorn, 2006). Stateless persons are not recorded in the country's civil registry and are, therefore, without permission to stay in Thailand, which increases the precariousness of their situation. The registration of people classified as non-Thai has been characterized by bureaucratic arbitrariness (Flaim, 2017; Laungaramsri, 2014). Flaim (2017) further showed that the bureaucratic process reproduces statelessness and results in protracted situations. While above categorization of stateless persons does not conform to the international legal definition of statelessness provided in the 1954 Convention,2 it aligns with the concept of effective statelessness and highlights the challenge of operationalizing statelessness in practice. Effective statelessness exists when ‘persons entitled to citizenship cannot prove it, or such proof is disregarded by government officials’ (Price, 2017, p. 28). Persons not legally recognized as stateless, are not protected by international law.

Citizenship problems are particularly widespread among Thailand's ethnic groups, including Akha and Lahu people, who make up about 15% of the country's ‘highland’ population (Ministry of Social Development and Human Security, 2015), as well as the ‘lowland’ Tai-Yai.3 The Tai-Yai only account for about 2% of the ‘lowland’ population, but they are one of the largest ‘lowland’ ethnic groups in Northern Thailand (Ministry of Social Development and Human Security, 2015). Akha and Lahu ethnic groups historically located in remote, high-altitude areas of Laos, Myanmar, Northern Thailand and Yunnan, a province of China (Schrock et al., 1970). The first Akha and Lahu are thought to have migrated into Northern Thailand at the end of the nineteenth century (Schrock et al., 1970), that is before the 1911 Naturalization Act as well as the first Nationality Act in 1913 (Laungaramsri, 2014). The languages of both highland ethnic groups belong to the Tibeto-Burman family of languages (Bhruksasri, 1989). The Tai-Yai, on the other hand, are Tai-speaking people, living in parts of the tri-border area between Laos, Myanmar and Thailand (Boonyawongwiwat, 2018). They are part of the Shan (Schrock et al., 1970), a large ethnic minority group in Myanmar, whose desire for political autonomy has been well documented in the literature (Jirattikorn, 2011; Mong, 2007).4 Out-migration from villages as well as rural areas has been a common livelihood strategy in Thailand, also among ethnic groups who have increasingly settled in lowland urban areas (Flaim et al., 2019; Morton & Baird, 2019). Those who acquired Thai citizenship are free to move since they possess a citizenship ID. Others who hold a special ID, however, also move in spite of mobility restrictions, especially workers in the fisheries sector and seasonal agricultural workers (Suphanchaimat, Kantamaturapoj, et al., 2016). If moving without permission, they are living in fear of arrest and possibly deportation like stateless persons.

Objective and hypotheses

The objective of this mixed-methods study is to explore the correlates of mental health among stateless and nationalityless Akha, Lahu and Tai-Yai persons who are living in Northern Thailand. The contribution of this article is twofold. First, it adds to the scarce body of literature that specifically focuses on persons who experience effective statelessness. Second, it accounts for the heterogeneity of these in terms of legal status and ethnicity. It is hypothesized that stateless persons are more likely to have lower mental health than nationalityless persons and that ethnicity affects mental health due to differences in risk factors for mental health.

Materials and methods

This study uses a convergent parallel mixed-methods research design. Quantitative and qualitative data are analyzed separately and the results are then brought together in the discussion.

Data collection

A two-stage sampling technique was adopted for the data collection as also described in Herberholz (2020), who used the same dataset, but examined serious problems stateless and nationalityless respondents encounter in their daily lives, the focus being on healthcare services, health insurance coverage and mobility. Eight villages were purposively selected from one district in Chiang Mai province, based on existing records of a non-governmental organization (NGO) working with ethnic minorities to support citizenship applications. Chiang Mai is the province where most nationalityless persons are living according to official estimates (Department of Provincial Administration Ministry of Interior, 2020; Suphanchaimat, Prakongsai, Limwattananon, & Mills, 2016).5 Stateless and nationalityless household heads (or their representatives), aged 15 years and above, who are living in Northern Thailand were subsequently identified purposively in each village by the NGO and its key contacts in the communities. Nationalityless persons included in this study hold an ID with a 13-digit identification number that starts with zero, which is used for persons ‘without civil registration records’ (Archavanitkul, 2011, p. 4). The ID card they hold is also referred to as the ‘number zero-card’. It has been issued since the adoption of the 2005 National Strategy on Administration of Legal Status and Rights of Persons to those previously unregistered (Archavanitkul, 2011). The number zero-card is held by about two thirds of nationalityless persons recorded in Thailand, whereas the remaining nationalityless persons, some of whom were granted permanent residence (Archavanitkul, 2011), hold an ID starting with numbers 6 or 7 (Department of Provincial Administration Ministry of Interior, 2020). Persons who reported that they neither hold an ID issued by Thai authorities nor any other ID are presumed to be stateless in this study, even so a legal claim to this status cannot be determined on the basis of the collected data. Several probing questions were asked, including questions about IDs from other countries and the possession of a birth certificate. Possession of an ID is also used as indicator of legal status in recent studies that use the 2010 UNESCO Highland Peoples Survey dataset (Flaim et al., 2019, 2021). The stateless category in Flaim et al. (2019), for example, comprises those who possess an ‘alien’ ID6 and those who do not possess any ID. The sample size (n = 108; 36 from each ethnic group) in this study was determined a priori given resource constraints. Where identification of stateless household heads in a selected village was not possible, these were replaced with nationalityless household heads. The final sample thus included 44 stateless persons, who do not possess any ID, and 64 nationalityless persons who have the special ID starting with number zero.

Cross-sectional quantitative and qualitative data were simultaneously collected in June 2020 using a semi-structured questionnaire. The instrument was translated from Thai into the local languages by the field work team, which was recruited from the three ethnic groups, and discussed until a consensus translation was reached. Interviews were either conducted in the Thai language or bilingually. In case of the latter, answers to open-ended questions given in the language of the ethnic group were consecutively translated into Thai by the interviewers. Audio recordings of interviews conducted bilingually were cross-checked by the field work team at the end of the data collection to ensure translation accuracy. Field notes and responses to open-ended questions were subsequently transcribed and translated into English by professional translators.

Ethical clearance was granted by the Research Ethics Review Committee for Research Involving Human Research Participants, Group 1, Chulalongkorn University on March 5, 2020 (certificate of approval number 114/2020). Informed consent was obtained prior to the interview by asking respondents to sign by fingerprint once they verbally agreed to participate in the study. Interviews were recorded if permission was given. Five Tai-Yai respondents preferred field note recording over audio recording. Respondents received an incentive payment of 100 Thai baht (THB) (about 3.3 US dollars).

Quantitative data analysis

Descriptive statistics were used to examine the quantitative data and the correlates of mental health were further explored using logistic regression analysis.

Outcome variable: mental health

Mental health was measured using the Thai Mental Health Indicators-15 (TMHI-15) Version 2007 (Department of Mental Health Ministry of Public Health, Supplementary file S1). The TMHI-15 consists of twelve positive items and three negative items and covers the domains of mental state, mental capacity, mental quality and social support (Department of Mental Health Ministry of Public Health, Yiengprugsawan, Somboonsook, Seubsman, & Sleigh, 2012). Cronbach's alpha indicated a reasonable internal consistency ( = 0.67). Respondents were also asked how satisfied they are with their life as a whole. Mental state and social support had the strongest correlation with life satisfaction, while the correlations were rather low for the mental capacity and mental quality domains, which confirms the findings in Yiengprugsawan et al. (2012). Given the skewness of the data, the mental health variable was split at the median to create a binary variable.

Explanatory variables

The focal independent variables were binary variables for legal status (stateless = 1) as well as self-identified ethnicity, that is Lahu (Lahu = 1) and Tai-Yai (Tai-Yai = 1). Ethnicity is used to capture attributional (e.g. language, religion) and relational (e.g. discrimination, social isolation) characteristics of the ethnic groups (Ford & Harawa, 2010) that may affect mental health.

Based on previous work, gender (male = 1), marital status (married = 1), middle aged respondent (31–45 years = 1), older respondent (46–61 years = 1), health literacy (average score), and yearly income (THB, log transformed) were used as control variables. Health literacy was assessed using the short version of the European Health Literacy Survey Questionnaire (Finbråten et al., 2018). It had a good internal consistency (Cronbach  = 0.80). The health literacy variable also served as proxy for literacy more generally (Kickbusch, Pelikan, Apfel, & Tsouros, 2013).

Qualitative data analysis

Open-ended questions served to elicit in-depth information about statelessness, nationalitylessness, and ethnicity. The qualitative data were coded using qualitative data analysis software to identify, within the themes legal status and ethnicity, subthemes that allowed a deeper understanding of the ways in which legal status and ethnicity are related with mental health. The thematic analysis, hence, contained deductive and inductive elements and it was used to confirm and enrich the results obtained from the quantitative analysis. Quotations were selected to support the findings, the focus being on a balanced representation of the data by ethnicity. Coupled with the fact that some themes more directly pertained to nationalityless people and the fact that only 41% of respondents were stateless as described in section 2.1, relatively more quotations from nationalityless than stateless persons were selected.

Results

Quantitative analysis

Descriptive statistics

All of the 108 stateless and nationalityless persons agreed to participate in this research, resulting in a response rate of 100%. Of the sample, about 55% were male and the average age of the adult respondents was about 38 years. While most respondents were married (70%), about 18% were single and about 12% widowed, divorced or separated. Only 1/3 of all respondents and 1/6 of respondents aged 31 and above received some formal education. The average yearly income of about THB 76,500 (Akha respondents: THB 75,486, Lahu respondents: THB 53,861; Tai-Yai respondents: THB 100,056) was low compared to an average monthly household income of about THB 20,270 in Northern Thailand and about THB 26,018 countrywide (NSO, 2020). More than 80% of respondents worked as day laborers.

The mental health of respondents was good with an average score of 31.5 (Table 1). This average score compares well with the average score of 31.4 for Thai citizens aged 15 and above, 31.6 for Thai citizens aged 15 and above in Northern Thailand, as well as 32.3 for a large cohort of Thai distance learning adults (NSO, 2016; Yiengprugsawan et al., 2012). The mean score among stateless respondents was 30.8 and lower than that of nationalityless respondents. In the mental capacity domain, scores were relatively low in general compared to other domains. Several respondents explained that while they could handle minor problems, they are unable to deal with large-scale problems, that is mostly those associated with their prolonged and unresolved citizenship status. Higher mean scores were observed for Akha respondents, overall and in the mental state, mental capacity, mental quality and social support domains. Tai-Yai respondents, on the other hand, had lower scores on average overall, as well as in the mental state and social support domains compared to Akha and Lahu respondents.

Table 1

Mean TMHI-15 and domain scores: Full sample and subsamples by legal status and ethnic group.

	Full sample		Akha		Lahu		Tai-Yai		Stateless		Nationalityless
TMHI-15	31.5	(4.2)	33.0	(3.3)	31.5	(4.1)	30.0	(4.6)	30.8	(4.5)	31.9	(4.0)
Mental state	12.7	(2.9)	13.3	(2.2)	12.7	(3.0)	12.0	(3.4)	12.2	(3.0)	13.0	(2.8)
Mental capacity	4.3	(1.7)	4.5	(1.4)	4.3	(2.2)	4.3	(1.4)	4.4	(1.7)	4.3	(1.7)
Mental quality	6.8	(1.3)	7.1	(1.2)	6.7	(1.5)	6.8	(1.3)	6.8	(1.2)	6.9	(1.4)
Social support	7.6	(1.4)	8.1	(1.0)	7.8	(1.1)	6.9	(1.6)	7.5	(1.5)	7.7	(1.3)
Observations	108		36		36		36		44		64

Maximum score for the TMHI-15: 45; standard deviation in parentheses.

Mental health (dichotomized) by respondent attributes is shown in Table 2. There were no statistically significant differences in terms of age, gender, marital status, education, health literacy and yearly income between the high and low mental health groups. None of the respondents perceived their household to be better off relative to other households in the village, but perceptions of being the same or worse off were related with mental health (p < 0.05). Those who perceived that their household is comparable to other households in the same village, mostly nationalityless respondents (70%), were more likely to be in the high mental health group. Reasons for perceiving their household to be worse off relative to other households in the village were mostly related to mobility restrictions and difficulties in finding work, particularly stable and better paying work that would make it easier to get by and be able to pay for the education of children.

Table 2

Mental health (dichotomized) by respondent attributes.

		High mental health		Low mental health		χ2	p
		n	%	n	%
Age group						2.625	0.269
	19–30	12	22.64	18	32.73
	31–45	25	47.17	27	49.09
	46–61	16	30.19	10	18.18
Gender						0.000	0.986
	Male	29	54.72	30	54.55
	Female	24	45.28	25	45.45
Marital status						0.299	0.585
	Married	36	67.92	40	72.73
	Otherwise	17	32.08	15	27.27
Education						2.242	0.134
	Formal education	14	26.42	22	40.00
	None	39	73.58	33	60.00
Relative position						4.631	0.031
	Better off	–	–	–	–
	Same	35	66.04	25	45.45
	Worse off	18	33.96	30	54.55
Legal status						3.237	0.072
	Nationalityless	36	67.92	28	50.91
	Stateless	17	32.08	27	49.09
Ethnic group						9.188	0.010
	Akha	25	47.17	11	20.00
	Lahu	15	28.30	21	38.18
	Tai-Yai	13	24.53	23	41.82
Perception of qualifying for Thai nationality 1/						5.772	0.016
	Yes	43	82.69	34	61.82
	No	9	17.31	21	38.18
		mean	std. err.	mean	std. err.	t	p
Health literacy 1/		2.41	0.09	2.42	0.09	0.065	0.948
Yearly income		78,801.89	8414.28	74,218.18	5962.38	0.447	0.656

TMHI median: 32; 1/107 observations due to one missing observation.

Statelessness was only weakly associated with mental health (p < 0.1). About 61% of stateless respondents compared to about 44% of nationalityless respondents were in the low mental health group. Of the 27 stateless respondents in the low mental health group, about 48% were Tai-Yai, 30% Lahu and 22% Akha respondents, suggesting that stateless Tai-Yai respondents are particularly vulnerable. Self-identified ethnicity was significantly associated with mental health (p = 0.01). Only about 31% of Akha respondents were in the low mental health group, despite the fact that they reported the largest number of serious problems (daily environmental stressors) on average (Herberholz, 2020). In contrast, about 58% of Lahu respondents and 64% of Tai-Yai respondents were categorized in the low mental health group. Respondents who perceived themselves as qualifying for Thai citizenship in terms of their documentary evidence were more likely to be in the high mental health group (p < 0.05). Of the 30 respondents, who believed that their documentary evidence is insufficient to qualify for Thai citizenship, 57% were stateless and 43% nationalityless respondents. A break-down by ethnicity further revealed that about 77% of respondents who believe that they are not eligible for Thai citizenship are Tai-Yai, 20% Lahu and 3% Akha respondents. The main reasons given were lack of birth certificate, as well as lack of knowledge and help in applying. Three Tai-Yai respondents believed that ethnicity was the reason for not qualifying.

Regression analysis

The logistic regression results (Table 3) confirm the weak association between statelessness and mental health controlling for other factors. Ethnic group differences are again striking and the odds of being in the low mental health group are much higher for Tai-Yai and Lahu respondents. Socio-demographic respondent characteristics are mostly not associated with mental health in a statistically significant way. The odds of being in the low mental health group, however, are lower for respondents who are older. As robustness check, interaction terms of ethnicity and statelessness were added. The likelihood ratio test results, however, showed that these are statistically insignificant (results not shown, but available upon request).

Table 3

Logistic regression results.

		Mental health (low group)
		coeff.	(std. err.)	ME	(std. err.)
Gender	male	−0.14	(0.45)	−0.030	(0.09)
	female (ref.)
Marital status	married	0.31	(0.52)	0.065	(0.11)
	other marital status (ref.)
Age group	age (31–45 years)	−0.93	(0.57)	−0.186	(0.10)
	age (46–61)	−1.42**	(0.68)	−0.288**	(0.12)
	age (19–30) (ref.)
Health literacy	health literacy	0.27	(0.39)	0.057	(0.08)
Yearly income	yearly income (ln)	−0.37	(0.46)	−0.077	(0.10)
Legal status	stateless	0.84*	(0.47)	0.181*	(0.10)
	nationalityless (ref.)
Ethnic group	lahu	1.28**	(0.58)	0.261**	(0.10)
	taiyai	1.54***	(0.58)	0.316***	(0.10)
	akha (ref.)
N		107
Pseudo-R2		0.119
Mean variance inflation factor		1.420
Hosmer–Lemeshow goodness-of-fit (p-value)		0.252

*p < 0.10, **p < 0.05, ***p < 0.01; ref.: reference; ME: marginal effects; constant not reported.

Qualitative analysis

Within the major theme legal status, hope and access to rights and benefits were identified as key advantages of the legal recognition afforded to nationalityless persons. Citizenship problems and ethnicity were found to be deeply intertwined. Respondents shared their experiences of being an ethnic minority without nationality in Thailand and described how these experiences affected their mental health. Three sub-themes emerged, (1) perceived stigma, (2) perceived discrimination, and (3) perceived lack of social support. These problems were acknowledged by stateless and nationalityless respondents alike, but differences by legal status and ethnicity emerged.

Legal recognition - hope

Not being officially recognized as a person was associated with feelings of personal stagnation by stateless respondents. The legal recognition given to nationalityless persons was, therefore, considered important and some stateless respondents explained that seeing others receive a 13-digit ID starting with number zero gave them hope that after an impasse of many decades their legal status would eventually change as well.

‘I feel quite depressed actually, but there are people asking for an interview, an inspection of our homes and this gives me hope. We used to have nothing, but now there are state agencies who come and help us, like getting the number zero-card, to begin with. It helps us a lot. However, I do not think I will stop there. I was born in Thailand. I have to get a Thai ID card for my personal use. … It [the number zero-card] is still being processed though. Now, I am trying to get my birth certificate as a proof that I was really born in Thailand.’ (33-year old stateless Akha)

This was echoed by most nationalityless respondents. As a stepping stone, the 13-digit ID starting with number zero raised hope among those who had received it that their citizenship problems would finally be resolved, that they would eventually receive Thai nationality and be recognized as members of Thai society.

‘The biggest change in my life was when I received the number zero-card, which encouraged me to stay hopeful about my life.’ (56 year-old nationalityless Lahu)

‘In the past, when we had nothing, our life was disappointing and depressing. Now, this has changed. We have had more hope since the day we got the number zero-card. Although, it is minor, we still hope that one day we would get the national ID card and a better life. The number zero-card already gave us hope in life. It is a proof that we exist. We want to be seen as part of the Thai community. We are sick of hiding ourselves, of living in fear. We want more paved ways to lead our life. We want to be able to travel freely so we can visit family and friends. We cannot do that as we wish [at present]. However, I hope one day this will change.’ (46-year old nationalityless Akha)

Legal recognition - access to rights and benefits

The recognition of legal identity in the number zero-card, as well as the rights and benefits attached to it, was considered important by respondents. Nevertheless, several respondents emphasized that it does not convey the same rights as those attached to Thai nationality.

‘To have the 13-digit ID card starting with number zero, which changed how we can live our life, was very important, even though we are unable to claim all rights yet.’ (35-year old nationalityless Lahu)

‘The biggest change for me is the number zero-card. It is a big leap from the day where I had nothing. It was quite demotivating and depressing. However, the number zero-card also has its limits, like access to the healthcare system. I hope one day the government would see us in a better way and give us the national ID card.’ (38-year old nationalityless Akha)

‘At the beginning we had nothing, now we at least have the card starting with zero, which more or less helps to improve our life, like around 10%. However, the 13-digit Thai ID card would help us a lot more, like 100%, because after we get that we can choose the way in which our life goes, including improving ourselves, buying land and house, getting better careers and cars.’ (24-year old nationalityless Akha)

Respondents were also asked to reflect on the life of other people in their community and describe what they thought had brought about the biggest change in people's lives and what had helped other people in their community the most. Their assessment of other people's lives reiterated what they believed to be important for their own life, namely legal recognition and access to rights and benefits. Security, mobility and access to employment (although still limited) improved livelihood opportunities and were identified as key benefits of the legal recognition enjoyed by nationalityless persons. Access to healthcare under Thailand's Universal Health Coverage Scheme (UCS) was considered an important benefit of Thai citizenship, in addition to other benefits of citizenship more generally.7

‘Some of them received the number zero-card, which made them really happy. They have never had it before and now they do not have to live in fear of the police or other state officials any longer.’ (47-year old nationalityless Lahu)

‘Some of them have received the 13-digit ID card starting with zero and thus are able to leave their area, to find a job, and to have a better life - unlike myself who hasn’t got the card yet. I can’t leave my area to work elsewhere and I can only work in the garden.’ (35-year-old stateless Tai-Yai)

‘Some of them have already received their national ID card, which enables them to travel freely, choose a job as they wish, and be covered by the Universal Health Coverage Scheme.’ (19-year old nationalityless Tai-Yai)

Citizenship problems and ethnicity were found to be deeply intertwined. Several respondents emphasized that ending statelessness and nationalitylessness is an important issue not only for themselves and their communities, but for their ethnic group as a whole.

‘The [national] ID card is the most important issue that we [Akha people], are facing. … Without one, we are inferior, we have no rights, … ’ (33-year old nationalityless Akha)

‘The national ID card is the biggest problem among the people from our ethnic group …. We are all facing the same problem, which is the ID card.’ (52-year old nationalityless Lahu)

‘For the Tai-Yai people, I think the most serious issue is that we do not have equal rights compared to Thai people because we do not have a [national] ID card. We cannot claim any of our rights … ’ (35-year old nationalityless Tai-Yai)

Perceived stigma and discrimination

Respondents discerned that the lack of recognition as Thai citizens and their ethnicity resulted in stigmatization across multiple dimensions and exposed them to discriminatory experiences, which negatively affected their mental health. Respondents from all three ethnic groups had experienced stigma and disrespect related to their ethnicity and their legal status. Stigma due to language barriers was found to particularly affect Lahu respondents as also discussed in Herberholz (2020).

‘I have been insulted for being a “tribal man”, for not speaking Thai “correctly”, for being “inferior” than those living in the city.’ (23-year old nationalityless Lahu)

‘People call us with the name of our ethnic group – Tai-Yai – instead of our own name.’ (27-year old nationalityless Tai-Yai)

‘I faced stigmatization from primary school throughout high school. Others made remarks on my name, called me names, laughed at me. Sometimes, I was constantly bullied. I would like them to know that doing this can make someone really depressed.’ (19-year old nationalityless Akha)

Discriminatory practices included, for example, harassment, wage discrimination, and discrimination in hiring.8 Employment discrimination was most vocally voiced by Tai-Yai respondents.

‘The card [number zero-card] allows me to work without being afraid of getting caught by the police and to not get taken advantage of by the employer. For example, those who have the card get a wage of 350 baht per day while those without the card get only 250 baht per day doing the same job.’ (24-year old nationalityless Tai-Yai)

‘There is a clear discrimination between Thai people and nationalityless people. At work, Thai people are treated much better than nationalityless people. Nationalityless people work harder, but get paid less. For example, a Thai national may get 500 baht while a nationalityless person gets only 300 baht [per day]. In addition, the police like to take advantage of us - for example, at a check point, they may seize our car keys or driving license and impose a fine of 2,000 or 3,000 baht.’ (27-year old nationalityless Tai-Yai)

‘Without the 13-digit national ID card, we can hardly find a job even when we have the qualifications they need.’ (22-year old nationalityless Tai-Yai)

Stateless and nationalityless respondents associated the lack of nationality with an absence of legal protection, leaving them unable to combat stigma and discrimination. Not being able to take or being afraid of taking legal action, thus, reinforced the negative impact of stigmatization and discrimination.

‘I have been stigmatized and insulted. They call me a “Burmese” and say that I will never thrive because they think I can do nothing about it. They know that I cannot sue or file a complaint against them. I have no access to legal rights, so they are not scared to insult me because they think they are superior.’ (36-year old stateless Akha)

‘The Thai law does not cover us. The Thai law does not cover people with number zero-card. … Some of them are afraid of filing a complaint against their employers even though they are being taken advantage of or not being paid. They are more afraid of the police. Moreover, they do not know much about the law and legal processes.’ (30-year old nationalityless Akha)

Perceived lack of social support

Stigma made it also difficult for respondents to interact with other members in society and to receive social support. Ethnic differences in community support were identified by several respondents belonging to the Lahu ethnic group as additional risk factor. They shared that their villages lacked unity, which further amplified citizenship problems.

‘The lack of support from the community is an important issue for stateless and nationalityless. A kind of jealousy exists. There is no unity among us.’ (32-year old stateless Lahu)

‘The issue is that we do not have love for each other. The Lahu people are not quite knowledgeable and they are not well-united.’ (33-year old nationalityless Lahu)

Discussion

This article examined the correlates of mental health among stateless and nationalityless Akha, Lahu and Tai-Yai persons who are living in Northern Thailand (n = 108). Despite their precarious situation, the mental health status of respondents was good overall and comparable to nationally representative mental health survey data. Although contrary to the literature (Bas-Sarmiento, Saucedo-Moreno, Fernández-Gutiérrez, & Poza-Méndez, 2017; Blitz, Lynch, Lakshman, & Balaton-Chrimes, 2011), one possible explanation is that respondents, all of whom are quite literally living on the margins of society in rather remote villages, are mostly living together with their families and not alone.

No significant association between demographic factors and mental health was found, which is consistent with several studies included in the systematic review by Bogic et al. (2015). Some studies, however, indicated that older age is a risk factor for mental health (Bogic et al., 2015; Riley et al., 2017). In contrast to these, older respondents in this study seemed to have better mental health, possibly because they have lived their life and became somewhat accustomed to their situation.

The quantitative analysis provided only weak evidence that stateless persons were more likely to have poorer mental health than nationalityless persons. This result is not entirely surprising though, since (1) the legal status afforded to nationalityless persons is not comparable to citizenship and (2) the subsequent process of granting citizenship has remained slow despite the adoption of a framework in 2005 to solve citizenship problems (Tamee, 2018). The importance of having a legal identity was, however, reinforced by the qualitative analysis. The legal recognition of nationalityless persons raised hope among nationalityless and stateless respondents alike that their citizenship problems would ultimately be resolved. Hope is an important motivational factor and as such affects mental health (Long et al., 2020). Yet, the number zero-card was recognized by respondents as substantially inferior to that of citizens, given the limited rights and benefits attached to it. Differences in official status have been associated with health and mental health outcomes in the literature (Bogic et al., 2012; Castañeda, 2009; Fernandez, 2018; Gerritsen et al., 2006; Heeren et al., 2014; Leiler et al., 2019). The more secure the residence status, the better the mental health outcome. Respondents associated several rights and benefits with Thai citizenship, including coverage by the UCS. Citizenship was also linked with integration into Thai society. Research, however, has shown that marginalization does not automatically end with the possession of a national ID (Balaton-Chrimes, 2014; Kingston & Stam, 2017; Sing'oei, 2009).

The results of the quantitative and qualitative analyses further revealed pronounced differences in mental health by ethnic group, with Tai-Yai and Lahu respondents more likely to have lower mental health than Akha respondents. The interconnectedness of citizenship problems and ethnicity was recognized by respondents and associated with perceived stigma, discrimination, and lack of social support. Lack of legal protection further reinforced perceived stigmatization and discrimination. Stateless persons were most affected given their relatively more precarious circumstances. Tai-Yai respondents, on the other hand, were most prone to employment discrimination, while Lahu respondents reported language difficulties and a lack of unity in their communities. These ethnic differences can be explained in terms of relational and attributional characteristics of ethnicity (Ford & Harawa, 2010).

With regard to relational characteristics of ethnicity, the three ethnic groups differ in terms of their historical relationship with the Thai state and society more generally, as well as the attention and support received from national and international organizations. Highlander groups have been of strategic interest to the Thai state, given the multitude of problems these were associated with, broadly ranging from communist insurgency, opium production to natural resource conservation (Fujioka, 2002). Framing highlander groups as threat also served to justify the persistence of exclusionary policies and control measures (Flaim et al., 2021). Since the 1950s, the Thai government has implemented programmes to promote the development of highland communities (Bhruksasri, 1989). The problematization of opium production in particular and subsequent drug control efforts, which were largely supported by international aid flows, specifically targeted highlander groups (Gillogly, 2008), and, thereby, influenced agenda-setting. Existing research on statelessness and related problems, hence, also tends to focus on highlander groups (Pesses, 2007; Rijken, Waas, Gramatikov, & Brennan, 2015). In general, there is relatively little research about the ‘lowland’ Tai-Yai in Thailand despite their long history of networks, movements and trade across the Thai-Myanmar border (Grundy-Warr & Wong Siew Yin, 2002; Jirattikorn, 2017; Latt & Roth, 2015; Verma, Su, Chan, & Muennig, 2011). According to Schrock et al. (1970), about 50,000 Shan were already living in Thailand in 1963. Early migrants were able to obtain Thai citizenship, but this was not possible for Shan who migrated to Thailand after the mid-1970s as immigration policies were tightened (Murakami, 2012). The long-lasting civil war in Shan State and intensified forced relocation programmes in the mid-1990s triggered massive refugee flows into Thailand (Grundy-Warr & Wong Siew Yin, 2002). In contrast to other refugees from Myanmar, however, the Shan were not recognized by the Thai government as displaced persons, but instead considered economic migrants (Latt & Roth, 2015; Suwanvanichkij, 2008). Many Shan, therefore, ended up as ‘illegal’ migrants in Thailand, working in the agricultural and construction sectors (Latt & Roth, 2015). Concomitantly, driven by economic hardship in Myanmar and attracted by relatively higher incomes in Thailand, Shan labour migration to Thailand accelerated in the 1990s (Jirattikorn, 2012). Hence, it became increasingly difficult to distinguish Shan in Thailand by duration of stay (recent migrants as opposed to long-term residents) or reason for migration (migration due to conflict and persecution versus economic migration). While the cultural and linguistic proximity facilitated their assimilation into Thai society, the uncertainties surrounding their status made them particularly prone to stigmatization and discrimination, which the findings of this study support. Discrimination and especially employment discrimination was strongly felt by Tai-Yai respondents who participated in this study, most notably in terms of hiring biases as well as unfair wages. Given the lack of legal protection, many were forced to accept these conditions. The results from a livelihood analysis in four countries showed that average income levels for those who recently acquired citizenship were much lower compared to native citizens, especially in cases where the formerly stateless have been marginalized (Blitz et al., 2011). Marginalization of the Shan has also been documented in the few studies that focus on this ethnic group (Howes & Hammett, 2016; Murray, DiStefano, Yang, & Wood, 2016; Suwanvanichkij, 2008). Moreover, Koning (2019), using data from women (mostly Shan) living in Chiang Mai along the border with the Shan State, documented a high prevalence of adverse and threatening life events and circumstances related to work and mobility. Unemployment, discrimination and not feeling accepted are important post-migration factors that were related with mental health or quality of life in several studies (Bogic et al., 2012; Dangmann et al., 2021; Ellis et al., 2008; Priebe et al., 2013).

Attributional characteristics of ethnicity also played a role. Unlike the ‘lowland’ Tai-Yai, the Akha and Lahu are historically situated in remote mountainous areas. The Lahu, however, have experienced higher geographical remoteness than the Akha, given that they are living in higher altitudes (Schrock et al., 1970). All three Lahu villages included in this study were located on remote mountaintops that could only be accessed using precipitous mountain roads. Living standards were generally lower than in other villages as also evidenced in the lower average yearly incomes reported by Lahu respondents. Flaim et al. (2021) reported that in 2010 the proportion of Lahu villages with a functional healthcare centre was lower compared to other villages (including e.g. Akha villages). Furthermore, language barriers, which complicate interactions with persons outside the ethnic group and hinder integration into the larger society, were found to particularly affect Lahu respondents. Several studies demonstrate that economic concerns and difficulties communicating in the host country language affect mental health (Bogic et al., 2012; Dangmann et al., 2021; Priebe et al., 2013). Lack of social support is an additional risk factor that affects overall health (Gottvall et al., 2020). A lack of unity was observed by several Lahu respondents, possibly indicating lower levels of social support within their communities. The data, however, do not permit further investigation of this possibility. Akha respondents seemed to have more awareness of issues related to citizenship problems and were much more confident raising these than respondents from other highlander groups. In fact, ‘a few of the most outspoken leaders in the highland citizenship movement are Akha’ (Flaim, 2017, p. 154). Hence, Akha respondents may have more reason to hope since there are strong Akha activists who argue in support of and draw attention to their cause, resulting in better mental health outcomes. This is supported by the descriptive analysis, since only 3% of those who believe that they will not be eligible for Thai citizenship were Akha respondents.

Limitations

Data collection challenges are an important limitation of this study. The data collection was limited to one of the 25 districts in Chiang Mai province due to COVID-19-related travel restrictions. Language barriers posed another challenge. Despite the safeguards in place, translation errors may have occurred when translating the instrument, field notes and verbatim transcriptions, as well as during interviews that were conducted bilingually. Selection bias is an additional concern given that the records of an NGO that helps ethnic groups resolve their citizenship problems were used to select villages as well as respondents (i.e. purposive sampling). Respondents who participated in this study may have had a deeper understanding of issues related to citizenship problems compared to other stateless and nationalityless persons in Thailand. Besides, the sample is not only geographically very limited, but also relatively small. Hence, the findings of this study have to be understood in this context and cannot be generalized. The experiences of Akha, Lahu and Tai-Yai without IDs in urban areas, for example, are likely to be very different. Moreover, although several questions were asked to confirm the information obtained about respondents’ legal status, distinguishing native (or long-term residents) from other groups, including illegal migrants and refugees, is extremely difficult given their cultural proximity. In addition, the three ethnic groups comprise several subgroups that this research did not take into account, inter alia due to the relatively small sample size.

Conclusion

Focusing on an understudied and hard-to-reach population, this article demonstrates that mental health is affected by legal recognition and ethnicity. Having some form of legal identity as a stepping stone to citizenship matters for the mental health of persons without nationality. Such policies, however, have to be designed very carefully to avoid reinforcing ‘otherness’. The plight associated with experienced statelessness in its various forms, characterized by different degrees of precariousness, as revealed in this article further accentuates the complexity of the phenomenon and underscores the deficiencies in international definitions of statelessness discussed in the literature (Lawrance & Stevens, 2017). Moreover, this article highlights the importance of taking the ethnic heterogeneity of stateless populations into account in future research, as well as promoting data disaggregation more generally.

Although significant progress has been made since 2005 to resolve citizenship problems, stateless and nationalityless persons in Thailand are still deprived of basic rights and access to services.9 In addition, the results with respect to ethnicity suggest that legal documentation alone (including ultimately citizenship), while of utmost importance, ‘does not absolve states of the responsibilities to prevent discrimination and ensure all benefit from their human rights’ (Blitz & Lynch, 2009, p. 101). Efforts to resolve protracted citizenship problems and close ethnic gaps have to be accelerated to ultimately end the intergenerational transmission of immobilization.

Ethical approval

Ethical clearance was granted by the Research Ethics Review Committee for Research Involving Human Research Participants, Group 1. Chulalongkorn University on March 5, 2020 (certificate of approval number 114/2020).

Funding

This work was supported by under grant number CU_GR_62_89_29_01.

Data availability

The dataset cannot be made publicly available due to ethical restrictions. It contains information that could compromise the privacy of respondents.

Consent to participate

Informed consent was obtained prior to the interview by asking respondents to sign by fingerprint once they verbally agreed to participate in the study.

Consent for publication

Informed consent for the publication of de-identified data was also obtained from respondents.

Author statement

Chantal Herberholz: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Supervision; Validation; Visualization; Writing - original draft; Writing - review & editing.

Declaration of competing interest

None.