Latinx Sexual Minority Adolescent Substance Use: State of the Science and Call for Intersectional Minority Stressors and Protective Factors

Abstract

Purpose of review:

Latinx sexual minority adolescents (LSMA) are at an intersection of ethnic and sexual minority (SM) status and may experience heighten risk of substance use and related problems. These youth may also hold unique protective factors that help mitigate the effects of minority stress and curb substance use. Little is known, however, about the intersectional minority stressors (i.e., due to ethnicity and SM status) and protective factors related to substance use among this population.

Recent Findings:

According to the minority stress model, there are unique minority stressors and resiliency factors that can help explain differences in behavioral health rates between white SM and SM of color. Research supports the notion that minority stressors (e.g., stigma/risk, homophobic bullying, and family rejection of SM status) confer risk for substance use among LSMA. In terms of resilience, less is known, but there may be some protective factors that have not been measured that could explain lower rates in some substances (i.e., club drugs and methamphetamine).

Summary:

Little is known about how the intersections of ethnicity and SM status are associated with substance use in adolescence. Future research should assess the temporal relationship of multilevel (i.e., intrapersonal, relational, and system), intersectional (i.e., ethnicity and SM status) minority stressors and protective factors unique to LSMA on substance use. We propose that the findings from these future studies will help to create socioculturally appropriate behavioral health treatments that consider the intersectional risks and strengths within the LSMA population.

Introduction

The onset and escalation of alcohol and other drug use often begins during adolescence. It is well established that adolescent substance use is associated with myriad adverse consequences, including acute harms (e.g., academic difficulties, family conflict, legal involvement, etc.) and longer-term struggles with addiction. Numerous factors contribute to substance use and related problems during this critical developmental period, such as peer and family influences, neurocognitive changes, and mental health issues. Although the emergence of substance-related problems is complex and governed by many influences, mounting evidence indicates that individuals from minoritized groups experience unique risk factors that heighten liability for host of adverse health outcomes, including substance use and related problems. This review focuses on the state of the science regarding risk and resilience factors for alcohol use among Latinx sexual minority adolescents (LSMA) and provides a roadmap for future research in this area. Understanding risk and protective factors associated with drinking alcohol and using other drugs during adolescence is essential for advancing prevention and intervention efforts and curbing the harmful effects of teenage substance use.

Who are Latinx sexual minority adolescents?

Latinx refers to people of any gender born or descendants of Latin America, including South America, Central America, and the Caribbean. Although “Latinx” has received criticism for categorizing Latinx people as a single homogeneous group, it allows for consideration and measurement of often common experiences, like ethnic discrimination, and going beyond the gender binary. The Pew Research Center showed that only 3% of all Latinx people in the U.S. use the term “Latinx”,[1] however it is possible that Latinx is used more often within sexual and gender minority group because of its gender inclusivity. SM status is defined based on one’s sexual identity, behavior, and attraction [2]. This multidimensional characterization encompasses people who may not identify as sexual minorities but who engage in behaviors or experience attractions that diverge from exclusively heterosexual individuals. Assessing SM status using identity, behavior, and attraction may be particularly useful during adolescence, a period of identity exploration and development that is typically defined as the second decade of life.

Adolescents who identify as sexual minorities are more likely to drink alcohol and use other drugs than heterosexual youth. Not only do SMA report higher rates of substance use than their heterosexual counterparts [3], they also engage in substance use earlier than heterosexual adolescents and these disparities are widening [4, 5]. Minority stress theory posits that this heightened risk among SMA results from discrimination-related emotional stress associated with their sexual minority (SM) status [6]. This distress can be difficult for SM individuals, especially when developing their identities and dealing with their sense of belongingness in adolescence [7].

LSMA are more likely to report substance-related problems than non-Latinx white SMA [8], although not all studies found this disparity [9]. LSMA may be at greater risk of substance use due to intersectional forms of minority stress related to both their ethnic and sexual identities and acculturation within the mainstream white United States (U.S.) culture and SM spaces. They may also face heteronormative ideals within Latinx spaces. Indeed, LSMA experience greater discrimination and general bullying than their non-Latinx white counterparts [10, 11]. On balance, however, LSMA also may experience unique protective factors at multiple levels (e.g., intrapersonal, relational, and community). Careful consideration of the protective and risk factors for alcohol and other drug use in this vulnerable population is central to mitigating these disparities.

LSMA and Substance Use: State of the Science

We conducted a literature search of studies that assessed LSMA substance use using the Google Scholar search engine between November 2022 and February 2023. Our search terms included variations for ethnicity (i.e., Latin* OR Hispanic), sexual minority status (i.e., sexual minority OR LGB OR gay OR lesbian OR bisexual OR pansexual), age (i.e., adolescent OR adolescence OR youth OR teenagers), and substance use (substance OR substance use OR Alcohol OR Cigarettes OR Tobacco OR Vaping OR Marijuana OR Cannabis). The review was not limited to a certain timepoint. We included manuscripts if they presented substance use findings specifically for LSMA between 11-20 years old or in middle or high school at baseline. Research that pooled Latinx with the rest of the sample were excluded unless they delineated findings specific for LSMA. Table 1 summarizes the 12 studies we found on substance use among LSMA.

Table 1.

Summary of research on Latinx substance use

Reference	Study design	Analytic method	Sample	Protect/risk factors	Outcome for LSMA
Ocasio et al. [8]	Baseline data from five completed trials of a family-based intervention	Cross-sectional	Population: General adolescents Ethnicity: Latinx adolescents=1,632; LSMA=195 (12%) Age: 12-18 years of age Substance use eligibility: None	Protective factors: None Risk factors: None	Greater drug use (cigarettes, alcohol, illicit drugs) than heterosexual LSMA.
Dunbar et al. [29]	Five waves of a longitudinal comfort study of Hispanic, Asian, and White emerging adults	Trajectory analysis of alcohol and cannabis use using latent growth modeling	Population: General adolescents Ethnicity (baseline): Latinx=188 (52.4%); White=107; Asian=64 Age: M=18-23 years of age throughout waves Substance use eligibility: None	Protective factors:None Risk factors: None	Lower alcohol use at baseline and follow up assessments for LSMA compared to white SMA.
Halkitis et al. [21]	Four waves of a prospective cohort study	Trajectory analysis of alcohol, cannabis, inhalant nitrates, and other drug use using latent growth modeling	Population: SM young men Ethnicity (baseline): Latinx=229 38.3%); White=173; Black=89 Age: 18-19 years of age at baseline Substance use eligibility: None	Protective factors: None Risk factors: None	Higher levels of cannabis consumption at 18 months and steeper change over time than other racial/ethnic SMA.
Rosales et al. [20]	Cross-sectional analyses of 2015-2017 Youth Risk Behavior Survey (YRBS)	Cross-sectional regressions and moderation analyses to test alcohol use	Population: SM youth in high school Ethnicity: Latinx=728 (31%); Black=497; White=1,116 Age: M=17 years of age Substance use eligibility: None	Protective factors: None Risk factors: School-based victimization	School-based victimization was associated with greater current alcohol use than for white SMA.
Newcomb et al. [28]	Cross-sectional analyses of a longitudinal study	Cross-sectional regressions and latent class analysis to test substance use and user categories	Population: Young men who have sex with men (YMSM) Ethnicity: Latinx=90 (20%); Black/African American=240; White=81; Other=39 Age: 16-20 years of age Substance use eligibility: None	Protective factors: None Risk factors: None	Lower alcohol, cannabis, and club drug use when compared with White YMSM.
De Pedro et al. [9]	Cross-sectional analysis of the California Healthy Kids Survey (CHKS)	Cross-sectional regressions on substance use	Population: LGB adolescents Ethnicity: Latinx=50%; Black=4.5%; White=23.4%; Asian/Pacific Islander=9.4%; Multiracial=12.6% Age: 7-11th grade Substance use eligibility: None	Protective factors: None Risk factors: None	Less likely to smoke cigarettes than white LGB adolescents.
Newcomb et al. [27]	Cross-sectional analyses of the 2005-2007 YRBS	Cross-sectional regressions on substance use with interactions between gender and race/ethnicity	Population: High school students from 8 jurisdictions throughout the US Ethnicity: Unknown Age: Unknown Substance use eligibility: None	Protective factors: None Risk factors: None	Lower odds of methamphetamine use than white SMY, which was substantially larger among bisexual participants.
Pollitt et al. [24]	Cross-sectional analyses of the 2015 YRBS	Cross-sectional path analysis with mediation on alcohol use	Population: High school students from seven states Ethnicity: Latinx=4950 (21%); Black=4174; White=11,620 Age: 9-12th grade Substance use eligibility: None	Protective factors: None Risk factors: Homophobic bullying	Bisexual Latinos reported higher drinking than heterosexual Latinos. Bisexual and unsure Latinas reported higher drinking frequency and heavy episodic drinking than heterosexual Latinas. All LSMA who reported homophobic bullying had higher drinking frequency and heavy episodic drinking than their heterosexual counterparts. All Latina SMA who reported homophobic bullying had higher drinking frequency and heavy episodic drinking than their heterosexual counterparts. All Latino SMA who reported homophobic bullying had higher drinking frequency and heavy episodic drinking than their heterosexual counterparts.
Baams et al.[26]	Cross-sectional analyses of the 2013-2015 CHKS and the Gender and Sexuality Alliance Network	Cross-sectional regressions	Population: Middle and High school students Ethnicity: Latinx=51.3%; Black/African American=5.4%; Asian=13.4%; Native Hawaiian or Pacific Islander=2.4%; American Indian or Alaska Native=4.7%; Mixed race=42%;White=24.1% Age: 6-12th grade Substance use eligibility: None	Protective factors: None Risk factors: None	The presence of gay-straight alliances had a weaker association on lifetime cigarette smoking for Latinx students (SM status not measured in this analysis).
Mata et al. [22]	Qualitative	Reflexive thematic analysis	Population: Bi+ male youth Ethnicity: Latinx=33%; Black/African American=19%; White=39%; Different race=9% Age: 14-17 years of age Substance use eligibility: None	Protective factors: bad taste, fear of negative consequences Risk factors: academic stress, to have fun, peer pressure	Latinx Bi+ male youth said they did not use substance because they don’t like the taste of alcohol and they feared they would have negative consequences. Latinx Bi+ male youth said they used substances to cope with academic stress, to have fun, and because they were pressured by friends.
Gattamorta et al. [92]	Cross-sectional analyses of the 2015 YRBS	Cross-sectional chi-square analyses and regressions	Population: High school students Ethnicity: Latinx=4,871 (37%); Black/African American=1,422; White=6,690 Age: 14-17 years of age Substance use eligibility: None	Protective factors: None Risk factors: None	LSMA were more likely to be current alcohol users and to use alcohol/drugs during sex compared to white heterosexuals.
Watson et al. [25]	Cross-sectional analyses of the LGBTQ National Teen Survey	Cross-sectional regressions with latent variables	Population: High school students Ethnicity: Latinx=1,149 (10%); Black/African American=516; Asian or Pacific Islander= 433; White=7,576; Biracial/multiracial= 1,515 Age: 13-17 years of age; M=15.53 Substance use eligibility: None	Protective factors: Teacher social-emotional support Risk factors: None	Teacher social-emotional support moderated the relationship between victimization and alcohol use for LSMA when compared with white SMA. At lower teacher social-emotional support levels, the association between victimization and alcohol use was stronger for LSMA when compared with white SMA. At higher teacher social-emotional support levels, the association between victimization and alcohol use was stronger for LSMA when compared with white SMA.

Notes. Black=Non-Latinx Black; Asian=non-Latinx Asian; white=non-Latinx white; M=Mean

In terms of study design, only 1 of these studies (8%) used qualitative methodology. Additionally, 7 (58%) used national (Youth Risk Behavior Survey [33%] or LGBTQ National Teen Survey [8%]) or state (California Health Kids Survey [17%]) samples, 2 manuscripts used baseline or multiple waves of data from longitudinal community samples (17%), 1 manuscript (8%) used longitudinal data collected from adolescents in the California middle school system, and 1 (8%) used baseline data from an intervention study of adolescents from the Miami-Dade County Public School system. The manuscripts were published from 2014 to 2022, with the majority being published in 2014 (3 [25%]) and 2022 (3 [25%]). The following section provides an overview of our findings related to the predictors associated with LSMA substance use, focusing on minority stress and resiliency.

Minority Stress Theory

SMA experience a host of unique stressors associated with their SM status, such as bullying and victimization [12], which increase their risk for mental health issues [6] and substance use and related disorders [13-15]. According to the minority stress model, these SM stressors can be proximal (e.g., the expectation of rejection, concealment, and internalized homophobia) and distal (e.g., discrimination, victimization, and violence) and occur at environmental, familial, and individual levels [6].

To advance research with SM people of color, Meyer (2010) expanded the minority stress model to include a double jeopardy hypothesis — SM people who identify as racial and ethnic minorities may use substances because of the excessive stress they experience from being marginalized for their sexual and ethno-racial minority statuses [16]. In line with this hypothesis, Latinx sexual minorities experience greater childhood physical and sexual abuse than white sexual minorities [17]. In one study, almost all the Latinx SM participants (91%) reported hearing that “gays are not normal” while growing up, a form of heterosexist discrimination [18]. Research also shows that SMA experience greater racism than heterosexual youth of color [19]. This intersection of heterosexism and racism can significantly strain coping abilities of LSMA, possibly leading some youth to turn to substances to manage stress. Indeed, LSMA are more likely to drink alcohol, engage in heavy episodic drinking, use inhalants, and use cannabis in school than white SMA [9, 20]. Their trajectory of some substance use, such as cannabis, also increases at a quicker rate than other racial/ethnic SMA [21]. The following quote from a LSMA participating in a qualitative study exemplifies how some LSMA may drink to cope with stress, “I'm very, very susceptible to drinking whenever I feel upset” [22].

Which minority stressors have been examined in substance use research with LSMA?

LSMA experience ethnicity-based minority stressors faced by the general population of Latinx youth in similar and unique ways. For instance, although stronger familistic ties are linked to positive health and academic outcomes for the general Latinx adolescent population, familism may also confer risks due to fear of rejection from their caregivers if they find out about their SM status. Indeed, qualitative research shows LSMA use substances to cope with family conflict related to their SM status [23]. Family rejection of their SM status may be particularly stressful for LSMA due to the importance of family ties in Latinx culture.

Social and academic pressures and homophobic bullying in schools may also be important risk factors for LSMA substance use. Qualitative research shows that some LSMA use substances because of peer pressure from friends and to cope with academic stress [22]. Male bisexual LSMA report more frequent alcohol use and female bisexual and unsure LSMA report more frequent drinking and heavy episodic drinking than their heterosexual counterparts, and homophobic bullying is associated with increased use [24]. Similarly, Rosales and colleagues (2022) found that being victimized at school was associated with an almost three times greater risk of current alcohol use [20]. Watson and colleagues (2021) found that the LSMA drank alcohol more if they were victimized and had lower teacher social-emotional support than white SMA [25].

Where adolescents use substances can also be an important risk factor; there may be greater consequences for using substances in public versus private places. Certain locations may be associated with greater discrimination (e.g., workplace, school). LSMA are more likely to use alcohol and marijuana in school than white SMA [9]. Baams and Russell (2021) found that school-based gay-straight alliances served as stronger protection against substance use for non-Latinx compared to LSMA, highlighting the need for school-based support specific to LSMA experience [26].

Resiliency

The minority stress model postulates factors that help relieve the effects of SM stressors on behavioral health [6]. Meyer (2010) proposed the resiliency hypothesis, which states that people of color who are also sexual minorities may hold unique forms of resilience that helps them deal with minority-related stressors [16]. Lower rates of some substance use may point to this resilience. For instance, research shows that some LSMA use club drugs and methamphetamine less than white SMA [27, 28]. Ameliorating factors at the individual level – including coping with stigma, acceptance of sexual identity, and group resources – may help to explain these lower rates of some substances. For example, exposure to racism might increase resilience to homophobia among LSMA more than white SMA. The following section provides an overview of the current literature on resiliency among LSMA.

Which resiliency factors have been measured in substance use research with LSMA?

Little is known about the resiliency that LSMAs hold that could help them deal with minority stressors in healthy and adaptive ways. A recent qualitative study from Mata and colleagues (2022) found that LSMA said they stopped using substances because they worried about the dangers involved with how often they drank by themselves [22]. Although this qualitative work presents quotes from LSMAs about how they have abstained or halted their alcohol use, more information is needed about the unique reasons that help explain these decisions and how these factors can serve as resiliency.

Another study found that LSMA were less likely to use drugs other than cigarettes, alcohol, or cannabis in school than their white counterparts [9]. School connectedness and support were associated with decreased substance use among SMA in general but whether these factors are associated with LSMA’s substance use in particular was not tested.

Call for Intersectional Minority Stressors and Protective Factors

We agree with the call for greater attention to discrimination and resilience of substance use among SMA of color [29]. Mounting evidence suggests that LSMA face unique risk and protective experiences associated with substance use that warrant further empirical attention. Therefore, our first call to action is to focus more on the intersectional measurement of minority stress that may be unique to LSMA. Our second call is for a strengths-based approach to substance use research with this population that considers the resiliency that LSMA may hold. We go beyond individual resilience, however, and call for multilevel protective factors at the relational, and systems levels. Davis and colleagues (2021) proposed a strengths-based model to help explain social inequities and health disparities among Latinx youth [30]. The model proposes a multilevel process of risk and protective factors that help to explain the effects of discrimination, including intrapersonal characteristics and relational systems. As other research with Latinx youth has proposed, we add to this model the resources that systems (e.g., communities) can provide as a level of resilience or risk [31].

In the following section, we provide a roadmap of potential avenues for the field to better understand why some LSMA may engage in substance use and progress to develop substance-related problems. Table 2 also lists these potential factors and examples that researchers may study in the future. Since research has shown that mental health issues (specifically mood and anxiety disorders) are a risk factor for substance use,[32] factors shown to be associated with mental health have the potential to be associated with substance use in LSMA. Therefore, we also present findings from the mental health field that may help to move this field forward.

Table 2.

Examples of multilevel risk and protective factors and their association with LSMA substance use

Multilevel factors	Potential significant factors	Example
Intrapersonal
	Identity salience	Risk: Ethnic identity salience and certain cultural norms may be connected to riskier health decisions [113]. LSMA boys who are high on machismo, a Latinx cultural norm, may drink because of expectations about males being able to tolerate heavy drinking [114]. Protective: LSMA with higher self-acceptance and identity centrality may drink less alcohol because they experience less minority stress and feel well-adjusted [80].
	Sexual orientation	Risk: Having a strong connection to the Latinx community may be a risk factor in using substances to cope with sexual orientation minority stress [41]. Protective: Having a strong sexual orientation identity was associated with higher levels of self-esteem for plurisexual LSMA [82]. This high self-esteem may mean that plurisexual LSMA may not need to turn to substances, like marijuana, to cope with stress.
	Acculturation	Risk: Low levels of acculturation, having a strong Hispanic/Latinx orientation, has been linked to higher rates of alcohol use and positive health behaviors (e.g., lower rates of HIV testing) [40, 113]. Among LSMA in the US, lower acculturation may be an indicator of marginalization by peers, which could lead to drinking alone. Protective: Higher levels of acculturation, U.S. cultural orientation, has been linked to positive health behaviors for Latinxs [40]. For LSMA, higher levels of acculturation may indicate that LSMA feel connected to SM populations, which may be predominantly, and have higher resources to seek help when they experience minority stressors.
Relational
	Familismo	Risk: Having low connectedness with one’s family may contribute to discrimination, minority stressors, stigma, & can become barriers to acceptance and support from their family members [58]. Low levels of parental acceptance is associated with depressive symptoms within LSMA [95]. It is possible that the deterioration of familistic values in later generation LSMA may lower the ability to receive support from parents when they are experiencing minority stress. Lower connection with parents may also mean that parents are not able to monitor their child’s substance use. Protective: Having high connectedness with the family has the potential to reduce substance use (e.g., cannabis use) among Latinx youth [90]. Higher levels of parental acceptance is protective at low levels of intersectional forms of discrimination for Latinx sexual and gender minority adolescents [95]. LSMA who experience parental acceptance may feel more connected to their parents, which means that the parents may be able to provide more support and monitor their substance use.
	Colorism	Risk: Dark-skinned LSMA youth may experience rejection and othering in White Latinx SM and non-SM spaces [66], which could lead to greater need for coping through substance use. Protective: N/A
Systems
	Religious institutions	Risk: Latinxs, during adolescence, may be exposed to heterosexist norms and socialization within family and religious spaces [75]. Heterosexist norms may make feel LSMA feel unwelcomed in religious institutions, an important aspect of Latinx culture. Not feeling welcome at religious institutions could mean that LSMA may turn to socially unacceptable behaviors to find a community and connection, such as through partying and substance use with peers. Protective: Latinxs may feel community connectedness, in religious spaces with shared culture (e.g., language, familismo and personalismo) [73].
	Community connection	Risk: Without social support and self-care, high levels of activism may expose LSMA with fatigue and burnout [102, 103]. Protective: Advocating for immigrant and SM rights within community and participating in social, cultural, and political event [100, 101].
	Policy	Risk: Policies that discriminate again SM populations may negatively affect LSMA making them feel disenfranchised [78]. These feelings could lead to the use of substances to deal with feelings of sadness and fear. Protective: Policies that target decreasing minority stress, especially among sexual and gender minority populations, could help decrease substance use [114].

Multi-levels of Intersectional Minority Stress

Intrapersonal Level Risks

Individual Intersectional Minority Stressors.

There is a lack of research assessing how LSMA maneuver through the complex intersections of race, ethnicity, and SM status and the associated systems of oppression (e.g., racism and heterosexism). LSMA deal with multiple forms of oppression, even within one interaction or space, that go beyond SM stressors experienced by their white SMA counterparts. The literature on Latinx SM adults and the general Latinx youth population provides insight into such intersectional minority stressors.

One example of the measurement of intersectional minority stressors from the literature using the LGBT People of Color Microaggressions Scale (LGBT-PCMS)[17] and its association with substance use. The LGBT-PCMS contains three subscales: 1) racism within the SM community, 2) heterosexism within communities of color, and 3) racism within close relationships and dating. Research consistently shows that experiencing rejection of SM status (i.e., heterosexism within one’s community of color) from one’s community tends to be particularly harmful and stressful [17, 33]. However, the measure has not assessed the effects of microaggression on substance use among LSMA and may have inappropriate questions for adolescents [34]. Specific stressors may be pivotal parts of LSMA’s experiences with oppression, such as minority stress from colorism within SM and Latinx spaces.

Acculturation.

Acculturation is the continual psychological and behavioral changes that happens when people of differing cultures interact [35]. For Latinx people living in the U.S., acculturation refers to the psychological and behavioral changes due to their exposure to the predominantly white mainstream culture and traditional Latinx culturation values. The literature regarding Latinx SM adults on the relationship between acculturation and substance use remains scarce and even more so for LSMA. Most acculturation research for Latinx sexual and gender minorities has focused on substance use and sexual risky behavior [36]. Zelaya and colleagues (2023) found that Latinx SM men with a higher Hispanic cultural orientation reported higher levels of intersectional minority stressors associated with hazardous alcohol use [37]. Another analogous study found that acculturation influenced discrimination and substance use among Latina SM women [38]. People with HIV have a high prevalence of substance use and significantly lower treatment adherence than the general population.[39] Thus, it is important to note that acculturation has also been linked to structural barriers to receiving HIV care for Latinx individuals [40].

In one sample of LSMA, Anhalt and colleagues (2020) found that various forms of minority stressors (e.g., Latinx discrimination, sexual and gender minority discrimination, and internalized heterosexism) were significantly associated with higher levels of depressive symptoms and lower self-esteem [41]. The authors examined the buffering effects of acculturation and enculturation; they found that higher levels of acculturation were related to increased depressive symptoms and decreased self-esteem within. Finally, enculturation, the sense of belonging to one’s own cultural group (i.e., Latinx culture), was related to lower levels of self-esteem within the context of sexual and gender minority discrimination and internalized heterosexism. These findings suggest that having a strong connection with one’s Latinx community may be a risk factor in coping with sexual orientation related to minority stress. LSMA who have exhausted their coping maneuvers may turn to substance to help deal with the stress discrimination and acculturation imposes on their mental health. This is consistent with Balsam and colleagues' (2010) studies, where facing rejection from one’s community was particularly stressful for individuals [42]. One plausible reason the authors propose is that Latinx communities may be less accepting of SM identities.

Research also shows that almost all the Latinx SM report hearing that heteronormative discrimination at home and the negative views towards SM people in Latin American countries[18, 43] Thus, there may be an acculturation gap related to SM views between US-born LSMA who may be more accepting of their sexuality and their immigrant parents who have grown up in countries with negative views towards people who are not heterosexual. Further, there is evidence to suggest LSMA may tend to assimilate more than their caregivers [44], the caregiver-adolescent gap and relationship literature further suggests that these caregiver-youth acculturation gaps are also linked to changes in alcohol use via caregiver-adolescent conflict [45]. On the other hand, Pew Research Center data studies suggest that Latinx communities are just as accepting of sexual minorities as their white counterparts [46]. Future research may assess how the acculturation gap related to views towards SM people is associated with substance use among LSMA.

These findings point to the possibility that the process of acculturating to the U.S. puts substantial stress on immigrant LSMA that put them at a higher need for coping. However, the lack of resources available to immigrants in the U.S. may mean that LSMA have to turn to maladaptive ways of coping, such as misusing substances.

Adversities experienced by LSMA.

The general SMA population experiences alarmingly high rates of childhood adversities. However, LSMA may have higher rates of specific adversities, which may be associated with LSMAs’ substance use. For instance, LSMA have a higher rate of being disciplined in school (44%) compared to their non-Latinx white counterparts (36%) [47]. School discipline may include arresting, suspending, or experiencing the detention facility as a juvenile or an adult.[48] LSMA are also overrepresented in the child welfare system [49, 50]. Latinx adolescents also have a higher chance of experiencing discrimination and bias-based peer victimization than white adolescents, often attributed to racial-ethnic biases [51, 52]. This is problematic as research shows discrimination and bias-based peer victimization are strongly associated with mental health issues and ultimately substance use.[53-55] It is possible that these adversities specific to LSMA put a strain that depletes their coping maneuvers and decreases their mental health, which leaves LSMA to use substance as the only way of coping. [56]

Relational Level Risks

Familismo.

Familism, or familismo, is a key Latinx cultural value that emphasizes social support, attachment, loyalty, the obligation to the family, honor, and familial harmony [57]. It is also possible that familismo contributes to discrimination, minority stressors, and stigma and becomes a barrier to acceptance and support from family members [58]. Familial rejection, which goes against the cultural value of familismo, of SM status is associated with psychological symptoms, including increased suicide attempts, substance use, and depression among LSMA [59]. Familismo may also contribute to LSMAs hiding their sexual orientation out of fear or concern that their family may feel disrespected, distressed, or embarrassed [18, 60]. Parnes and colleagues (2022) used ecological momentary assessment data to show that parental heterosexism increased the odds of SMA reporting cannabis and alcohol cravings [61]. Due to the central role of the family in the Latinx population, parental heterosexism may have an even greater effect on LSMA’s substance use. More research is needed to explore whether familismo buffers or worsens the relationship between experienced discrimination and its association with substance use among LSMA.

Colorism in SM spaces.

Skin color also matters in the lives and mental health of Latinxs [62-64]. According to Centering Racial Ethnic Identity for Latinx Framework (C-REIL), skin color shapes how heterosexism impacts Latinxs [64, 65]. Although little research has been conducted on colorism in SM spaces, available evidence suggests that having darker skin is associated with SM Latinxs experiencing more racism within SM communities. In a study specifically examining the racism experiences of gay and bisexual Latino men (n=911) in the U.S., researchers found “lighter skinned” gay Latino men reported fewer instances of feeling uncomfortable in a white gay club and being turned down for sex than "darker skinned” gay Latino men [66]. A more recent article that describes a psychotherapy case study with a young immigrant adult who is Queer and Afro-Colombian, highlights this client discussing being racialized in ways he does not see himself racially and feeling ignored in clubs, and experiencing isolation [67]. These studies point to how the intersection of colorism and heterosexism can result in skin color disadvantages for Queer dark-skinned/Afro-Latinxs and advantages that their light-skinned/white peers. Although no study has directly examined the mental health effects of colorism within SM spaces among dark-skinned and Afro-Latinxs in the U.S., the negative mental health effects (e.g., psychological distress) of microaggressions uniquely experienced by SM people of color are well documented [33, 68]. Future research should assess the risk factors of colorism among LSMA (e.g., Queer Afro-Latinx youth) when navigating non-Latinx white and Latinx non-SM and SM spaces and how they may put this population at risk for substance use.

Systems Level Risks

Religious Institutions.

Although religiosity is generally associated with less substance use [69, 70] due to increased religious/social support [71], meaning-making and decision processes that serve as buffers [72], and religious morals/norms being protective against risky behaviors [73], there are contextual factors that may negatively affect LSMA substance use when they interact with religiosity. For example, Latinx youth who report high church attendance (as a behavior) but lower religious importance (as an identity) reported more risk of using alcohol and nicotine [74]. Among LSMA, given that many Latinxs grew up with heterosexist norms and socialization that interact among Latinx and religious cultures [75], the degree of religious views has played a key role in risk factors. Those identifying as Christians with high religious guidance had the greatest risk, and those with low religious guidance had the least risk associated with mental health [76]. Therefore, interactions between religion and other contextual factors may serve as risk factors for substance use. This is especially true for LSMA who may be navigating conflict with their parents around how their religion may disapprove of their SM status.

Policy.

Diversity in state level anti-immigrant policies negatively affect Latinx living in politically conservative states, deterring families from using social and health services. Latinx youth have been particularly overrepresented in healthcare appointment cancellation and no-show rates [77]. Anti-immigrant policies, such as Arizona’s SB 1070, Georgia’s HB 87, and Alabama’s HB 56 increase negative mental health outcomes for immigrant families (e.g., depression and anxiety) (Perreira & Pedroza, 2019; Philbin et al., 2018). In addition, there are anti-SM (e.g., “Don’t Say Gay Act”) and racist (e.g., “Stop Woke Act”) policies that may interact to make LSMA feel especially uninvited in their schools and negatively affect their behavioral health [78]. These feelings could lead to the use of substances to deal with feelings of sadness and fear.

Multi-levels of Intersectional Resilience

Although little has been written about the protective factors within Latinx communities that could help buffer SMA from using substances, researchers have proposed that connection with racial/ethnic communities and coping strategies developed from experiencing racial/ethnic discrimination may help ameliorate the effects of minority stress on substance use [79]. The emphasis on a strengths-based approach to Latinx behavioral health has been proposed with general Latinx youth populations [30]. The following section provides multilevel protective factors that should be assessed in LSMA substance use research.

Intrapersonal Level Protective Factors

Identity salience.

A recent study examined profiles of LSMA in an effort to understand the role of identity salience and centrality in its association to intersectional minority stressors (e.g., perceived discrimination), adjustment, and demographic variables [80]. LSMA with low stress and higher levels of identity centrality were higher on self-esteem; however, LSMA with low identity centrality had higher levels of intersectional minority stressors and maladjustment. Therefore, it could be that interventions targeted toward increasing self-acceptance and identity centrality can help promote health and well-being and serve as a buffer against LSMA substance use problems.

Increasingly new research is delving into the diversity of sexual orientation for LSMA. It is important to consider the heterogeneity within the broader Latinx diaspora, which holds when considering the intersecting identity of sexual orientation for LSMA. As newer research emerges, scholars should center the experiences of diverse LSMA given the unique challenges they may face. For instance, the literature has extensively documented that plurisexual (i.e., attraction to people of multiple genders) and bisexual (i.e., attraction to men and women) individuals encounter higher forms of discrimination and oppression (e.g., biphobia) from the heterosexual and LGBQ+ community [81]. Hainsworth and colleagues (2023) examined the identity development of plurisexual and monosexual LSMA and found that plurisexual LSMA had higher levels of sexual identity affirmation, exploration, and resolution, and these were associated with higher self-esteem [82]. Furthermore, monosexual LSMA higher on affirmation had lower depressive symptoms, but the same pattern of results did not hold for plurisexual LSMA. The authors argue that these identities are distinct and should be examined separately in research. Future research should also examine the experiences of Latinx gender-diverse youth. Emerging research suggests that Latinx gender-diverse youth encounter more intersectional stressors than their cisgender counterparts [83]. Future research could assess how plurisexuality and bisexuality may be protective against LSMA’s substance use.

Relational Level Protective Factors

Research indicates that individuals with high levels of social support are buffered from the effects of stress compared to those with less social support [84]. SMA can form supportive relationships across multiple levels of support, including their families, friends, and communities. Social support from these sources is linked to numerous benefits for SMA. For instance, SMA who obtain social support from their caregivers have stronger caregiver-child attachment [85]. Deficits in the parent-child relationship have mediated the association between adolescent same-sex attraction and later alcohol abuse during young adulthood [86].

Low social support is associated with greater depression, alcohol and drug use, and anxiety among the general SM youth population [87]. Receiving social support from parents, friends, and teachers prospectively weakens the link between racial discrimination and relational aggression among Latinx youth [88]. It is therefore possible that social support can buffer the relationship between discrimination and substance use among LSMA. More research is needed, however, to directly test these hypotheses.

Familismo.

When Latinx youth acculturate to the U.S. white mainstream culture, there is that Latinx youth may have a higher risk for substance use because of lower family ties [89]. By contrast, greater familismo is associated with reduced marijuana use among the general Latinx youth population [90]. In the context of discrimination influences on psychosocial functioning among Mexican-origin adolescents, familism appears to serve a protective function when youth experience low levels of discrimination [91]. It is possible that familismo can be a protective factor when considering the relationship between discrimination and substance use among LSMA.

Parental acceptance of LSMA may be a protective or risk factor for mental health and substance use problems. Scholars have suggested that Latinx cultural values may influence parental acceptance, such as gender norms, religiosity, and traditional familial norms [92]. Further, LSMA must navigate Latinx cultural factors and their sexual orientation, which may impact their decision to “come out” and possible parental acceptance or rejection [92]. However, few studies have examined the role of parental acceptance and its associations with behavioral health among Latinx sexual and gender minority youth [83], and findings are mixed.

Latinx parents (i.e., Cuban and Puerto Rican) of sexual and gender minorities reported that cultural values such as familismo, caballerismo (cultural value that Latinx males must be loyal, socially responsible, and connected to their family), machismo (cultural value that Latinx males must avoid feminine behaviors and homosexuality), and marianismo (cultural value that Latinx females must be selfless and self-sacrificing for the family) impacted the degree of acceptance toward their child [93]. A recent study by Abreu and colleagues (2022) found that Latinx sexual and gender minority youth reported low levels of parental acceptance, which was associated with symptoms of depression and bullying in person (e.g., at school) and online [83]. Research also suggests that parents of Latinx SM young adults may become more accepting over time [92]. Lozano and colleagues (2021) interviewed Latinx SMA and their parents and found that parents believed their acceptance might change over time; they shared being aware of possible mental health concerns and noted loving their child unconditionally [94]. Finally, in a large sample of Latinx SM youth Abreu and colleagues (2023) found that parental acceptance was associated with lower depressive symptoms [95].

The research supports a nuanced perspective on the parental acceptance of LSMA’s identity and further highlights the importance of not examining the Latinx diaspora as a monolith.

Community Level Protective Factors

Community influences play a crucial role in adolescent substance use [96, 97]. Ecological frameworks argue the importance of understanding individuals within the environments that shape their experience and overall health [98]. For LSMA, school supports, community climates, and connectivity may all play a critical role in substance use [26, 99]. Regardless of risk type, however, when youth are connected and involved within their community, these connections may confer serve protective effects when it comes to substance use and other health outcomes. For example, SM community connectedness mediates the relationship between sociopolitical involvement (participating in social, cultural, and political events) and well-being [100]. Further, Gray and colleagues (2015), in a qualitative study among 13 first- or second-generation immigrant gay Latino men, found the importance of shared language and Latino culture on community connectedness, suggesting that immigrant Latino gay men feel more connected to a community that aligns with their culture [101].

Community connections also protect against possible anti-Latinx and anti-SM rhetoric and sentiments in the community. Although high levels of activism without social support and selfcare may lead to fatigue and burnout [102, 103], collective action (acting on behalf of one’s group to improve the group’s conditions [104]) and sociopolitical involvement are protective factors for the well-being of SM people of color when their communities and identities are being threatened [100, 105]. Therefore, community connectedness is associated with community and individual-level resilience strategies, such as advocating for immigrant rights and SM rights in their community [101].

Another community-level support in Latinx communities is the role of religious institutions within community spaces. As noted earlier, religiosity within Latinx communities is associated with less substance use [69, 70], especially when connected to community-level factors (e.g., religious institutions and churches). At these levels, LSMA may have increased religious/social support [71], meaning-making and decision processes that are shaped in these community-level spaces [72], including religious morals/norms protecting against risky behaviors [73]. Most importantly, these community-level spaces may also align with their Latinx cultural values of collectivism (the prioritizing of groups, interdependence and social relationships) [106], familismo (strong ties to one’s family and their well-being) [107, 108], and personalismo (getting along with others and having caring interactions) [109, 110].

Community-level factors also play a critical role in LSMA substance use. However, community connectedness may assist in building more community support, resilience, and empowerment when these community spaces align with Latinx cultural factors (e.g., language, values, practices, beliefs). Community level protective factors should receive more attention in the future, since policies could target these protective factors to prevent LSMA substance use.

Conclusion

Our review illustrates how little is known about the risk and protective factors related to substance use among LSMA. As a subset of the larger population of SMA, LSMA are often underrepresented in research [111]. Existing theoretical frameworks, including the minority stress theory and the resulting double jeopardy and resilience hypothesis, highlight intersectional minority stressors and protective factors to explain substance use among SM people of color [6, 16]. However, we found a lack of research measuring these factors among LSMA. Such factors should go beyond intrapersonal/individual factors and include how relational and community-level factors could explain these relationships. As other SM researchers have done [14], research with LSMA should move from cross-sectional analyses to studying whether there is a temporal relationship between these constructs.

We propose that a greater focus on the intersectional minority stressors and protective factors of substance use among LSMA across their diverse profiles (e.g., gender, nationality, geography, skin color) could help to decrease disparities in substance use between this population and other groups of interest (e.g., white SMA and Latinx adolescents). Since behavioral health providers may not be prepared to work with this population [112], findings from research with LSMA could help develop a culturally and structurally responsive treatment specifically addressing the factors related to their substance use.