Childhood Sexual Abuse and the Sociocultural Context of Sexual Risk Among Adult Latino Gay and Bisexual Men

Abstract

Objectives. We sought to examine the relationships among childhood sexual abuse, social discrimination, psychological distress, and HIV-risk among Latino gay and bisexual men in the United States.

Methods. Data were from a probability sample of 912 men from Miami, FL; Los Angeles, CA; and New York, NY. We used logistic regression and path analyses to examine direct and indirect effects of childhood sexual abuse on psychological distress and sexual risk behavior.

Results. We found a 15.8% (95% confidence interval = 12.3%, 19.2%) prevalence of childhood sexual abuse. Not having sex before age 16 years and having consensual sex before age 16 years did not differ from each other in predicting any of the outcomes of interest. Forced sex was associated with a significantly increased risk for all outcomes. A path analyses yielded direct effects of childhood sexual abuse and exposure to homophobia during childhood and during adulthood on psychological distress and indirect effects on risky sexual behavior.

Conclusions. HIV-risk patterns among Latino gay and bisexual men are related to childhood sexual abuse and a social context of discrimination, which combined lead to symptoms of psychological distress and participation in risky sexual situations that increase risky sexual behaviors associated with HIV acquisition.

Latino gay and bisexual men comprise one of the most vulnerable groups in the United States for HIV infection. Although White men who have sex with men (MSM, of whom most self-identify as gay or bisexual) continue to have the highest absolute numbers of HIV infections, Latino MSM have higher prevalence and incidence rates of HIV.^1–4 In 2004, estimated HIV/AIDS rates among Latinos (29.5 per 100 000) were 3.3 times higher than those among Whites (9.0 per 100 000).^4,5

Despite intentions to practice safe sex and high levels of knowledge about HIV and safe sex, Latino gay and bisexual men engage in some of the highest levels of risky sexual behavior.^6,7 Investigators attempting to explain these findings have examined possible determinants of increased risky sexual behavior and found that childhood sexual abuse increases HIV risk^8,9; however, we know very little about the mechanisms that explain this association.

Prevalence of childhood sexual abuse varies across studies, likely because of discrepant operationalizations: some studies deem all childhood sexual experiences with someone older as abusive, whereas others incorporate the subjective experience of coercion as a criterion. Recent research indicates that MSM who do not have sex before age 18 years or have consensual sex before age 18 years do not differ from each other in psychological outcomes, whereas those who experience forced sex have significantly more psychological distress.¹⁰ Nevertheless, independent of measurement criteria, trends in prevalence estimates of childhood sexual abuse remain consistent. Although childhood sexual abuse is likely underreported among boys, its prevalence, especially at earlier ages and in severe cases, approaches that of girls.^11,12 Furthermore, prevalence of childhood sexual abuse is higher among gay and bisexual men compared with heterosexual men.^13–15

As high as childhood sexual abuse prevalence is among gay and bisexual men (17%–39%),^8,9,16,17 it is even higher among Latino gay and bisexual men.⁸ In a national probability survey of adult MSM, a significantly higher proportion of Latino MSM reported sexual abuse before age 13 years (22%) than did non-Latino MSM (11%).¹⁸ Additionally, compared with non-Latinos, Latino boys are more likely to have experienced sexual abuse by an extended family member, more genital fondling, exposure to more sexually abusive behaviors, and more anal abuse.^19,20 Given the prevalence and severity of childhood sexual abuse among Latino gay and bisexual men and its association with HIV infection, it is essential that we examine the mediators of these associations in the context of Latino gay and bisexual men's lives.

Studies show that childhood sexual abuse significantly predicts negative health outcomes including HIV-risk and mental health issues such as depression, suicidal ideation, and substance abuse among adults.^{16,17,21–23} In a study with a probability sample of Latino gay and bisexual men, a high prevalence of psychological distress during the 6 months before the interview, including, anxiety, depression, and suicidal ideation was found. Furthermore, experiences of homophobia strongly predicted psychological distress.²⁴ These findings were specific to Latino gay and bisexual men, illustrating the importance of examining the impact of contextual factors, such as experiences with homophobia, on individually focused outcomes, such as psychological distress. They also provide a foundation for examining the psychological and contextual factors that may explain the relationship between childhood sexual abuse and HIV risk among Latino gay and bisexual men.

We used path analysis to test a model containing hypothesized relationships among self-reported childhood sexual abuse, experiences of homophobia, symptoms of psychological distress, and risk for HIV among Latino gay and bisexual men in the United States. Based on previous studies, we hypothesized that (1) not having sex before age 16 years and having consensual sex before age 16 years would not differ from each other in predicting any of the outcomes of interest; (2) experiences of homophobia would be associated with significantly increased risk for negative psychological, situational, and behavioral outcomes; and (3) experiences of forced sex would be associated with significantly increased risk for negative psychological, situational, and behavioral outcomes.

METHODS

Details of the procedures for this study have been described elsewhere.²⁴ In summary, the sampling, recruitment, and interviewing procedures for this study occurred between October 1998 and March 1999 as part of a multisite study of self-identified Latino gay and bisexual men in the United States. A probability sample of 912 men was drawn from men entering social venues (e.g., bars, clubs, and weeknight events primarily attended by Latinos and gay men) in the cities of New York City, New York (n = 309); Miami, Florida (n = 302); and Los Angeles, California (n = 301).

Measures

All measures were based on responses to closed-ended surveys individually administered face to face.

Childhood sexual experiences.

Consistent with previous findings, we subdivided childhood sexual experiences into 3 discrete categories: none, consensual, and forced sex.¹⁸ Participants were asked if they had had a sexual experience before age 16 years with someone 5 or more years older. If the participant answered no, he was categorized as not having sex; if he answered yes, he was asked if the sex was against his will. Those who answered no to the latter question were categorized as having consensual sex; those who answered yes were categorized as having forced sex. For this study, childhood sexual abuse was defined as forced sex (“against your will”) before age 16 years with someone 5 or more years older.

Homophobia.

Consistent with previous measures,²⁴ 5 items measured respondents’ exposure to homophobia during childhood (e.g., “As you were growing up, how often did you feel that your homosexuality hurt and embarrassed your family?”); 2 of these items focused on experiences of verbal harassment and physical assaults in relation to both perceived sexual orientation and gender nonconformity (e.g., “As you were growing up, how often were you hit or beaten up for being homosexual or effeminate?”). Ratings for items were made on a 4-point scale ranging from never (0) to many times (4). The items showed satisfactory internal consistency (Cronbach α = 0.65). Six items measured respondents’ exposure to homophobia during adulthood (e.g., “As an adult, how often have you had to pretend that you are straight to be accepted?”); 2 of these items focused on experiences of verbal harassment and physical assaults in relation to both perceived sexual orientation and gender nonconformity (e.g., “As an adult, how often were you hit or beaten up for being homosexual or effeminate?”). The internal consistency was marginally acceptable (Cronbach α = 0.59).

Symptoms of psychological distress.

This variable was assessed through a 4-item measure; items were rated on a 4-point Likert scale ranging from never (0) to many times (4).³ Scale items measured symptoms of anxiety, depression, and suicidality during the previous 6 months (e.g., “In the last 6 months, how often have you thought of taking your own life?”), with higher scores indicating more psychological distress. Consistent with previous findings,²⁴ reliability analyses showed the scale had good internal consistency (Cronbach α = 0.73).

Risky sexual situations.

Consistent with previous research,²⁵ this variable was made up of 5 items, including having sex while under the influence of drugs or alcohol, having sex to escape negative emotions, having sex within interpersonal relations of unequal power, situational experiences of sexual dysfunction, and having sex with partners who resist condom use (e.g., “In the last 12 months, how often have you been lonely and depressed and had sex in order to feel good?”). Items were assessed on a 4-point frequency scale ranging from never (0) to many times (4).³ Analysis of the scale's internal consistency yielded Cronbach α at 0.70.

Risky sexual behavior.

Risky sexual behavior was a categorical variable defined as those who reported having engaged in 1 or more acts of unprotected insertive or receptive anal intercourse with more than 1 male partner in the last year (1 = engaged in 1 or more acts; 0 = did not engage in any such acts).

Statistical Analyses

Demographic characteristics were assessed via proportions and stratified by childhood sexual experience (no sex, consensual sex, or forced sex). Proportions of respondents who experienced any versus no psychological distress or risky sexual situations were computed for each childhood sexual experience group. Additionally, unadjusted odds ratios (ORs) comparing childhood sexual abuse with groups experiencing nonforced sex were generated. Proportions and ORs were generated using Stata version 9 for Windows (StataCorp LP, College Station, TX).

To examine indirect effects of childhood sexual experience and experiences of homophobia on sexual risk behavior by way of psychological distress and risky sexual situations, we used path analysis. Path analysis is a method of simultaneous estimation of multiple regression equations.²⁶ The simultaneous estimation of more than 1 regression equation enables the computation of direct effects of each exposure variable on mediating and outcome variables. As well, for models that incorporate mediating variables, the analysis can compute the indirect effects of an exposure variable on an outcome variable by way of 1 or more mediating variables.

Based on prior population-based research findings,^{10,18,24–28} we specified a saturated path analyses model in which forced childhood sex, experiences of homophobia during childhood, and homophobia during adulthood influence the likelihood of subsequent sexual-risk behaviors directly and indirectly via intermediary psychological distress and risky sexual situations variables (Figure 1). All direct and indirect effects were estimated via weighted least-squares with a mean and variance adjustment using Mplus 5.1 (Muthén and Muthén, Los Angeles, CA). To reflect the probability-based sampling method used to recruit participants, all analyses incorporated case weights, city as a stratification variable, and recruitment venue as a cluster variable. Nativity (born in the United States = 1; not born in the United States = 2), age in years, and HIV status (0 = negative or unknown; 1 = positive) were included as covariates. For each effect, we report the unstandardized parameter estimate (b); its standard error; a z statistic, which tests the null hypothesis that the parameter estimate is zero; and the standardized regression weight (B).

FIGURE 1.

Standardized parameter estimates of direct and indirect effects of predictors of risky sexual behavior: Miami, FL; Los Angeles, CA; and New York, NY; October 1998–March 1999.

Note. Results based on 880 respondents. Solid lines represent statistically significant direct effects of the regression of each mediator (i.e., psychological distress, risky sexual situations) on childhood sexual abuse, experiences of homophobia during childhood, and experiences of homophobia during adulthood. Dashed lines represent statistically significant indirect effects, which are the regressions of risky sexual behavior on childhood sexual abuse, experiences of homophobia during childhood, and experiences of homophobia during adulthood through (1) psychological distress, (2) risky sexual situations, or (3) psychological distress and risky sexual situations. Dashed lines that cross an intermediary variable (i.e., psychological distress, risky sexual situations) include that variable as a mediator. Results for control variables (i.e., nativity, age, and HIV serostatus) are included in the analysis but are not shown in the figure to preserve clarity. *P = .05; **P = .01; ***P = .001.

RESULTS

The prevalence of childhood sexual abuse among Latino gay and bisexual men was 15.8% (95% confidence interval [CI] = 12.3%, 19.2%). The prevalence of consensual sex before age 16 years was 34.8% (95% CI = 29.5%, 40.1%); the prevalence of not having sex before age 16 years was 49.4% (95% CI = 44.6%, 54.2%). The sample was primarily Spanish speaking, born outside of the United States, young (i.e., < 31 years), and of modest socioeconomic status (less than a college degree and $100–$500 weekly income). Childhood sexual experiences did not vary by any of the demographics.

Childhood Sexual Abuse, Risky Sex, and HIV Risk

We found no differences in psychological distress outcomes between those who reported not having sex before age 16 years compared with those who reported having consensual sex before age 16 years. Accordingly, we pooled both groups into a no childhood sexual abuse group and compared them with a childhood sexual abuse group composed of individuals who had experienced forced sex in childhood. The childhood sexual abuse group reported significantly more anxiety, depression, and suicidality than did the no childhood sexual abuse group (Table 1).

TABLE 1.

Proportions of Psychological Distress, by Level of Childhood Sexual Experience Before Age 16 Years: Miami, FL; Los Angeles, CA; and New York, NY; October 1998–March 1999

		Childhood Sexual Experience
Psychological Distress Variable	Sample, No.	No Sex, %	Consensual Sex, %	Forced Sex, %	P a
Anxiety	881	42	39	65	<.001
Depression
Sleeping	880	58	60	72	.008
Sad	880	77	77	94	<.001
Suicidality	880	14	17	28	.022

^aFor forced vs consensual sex.

We found no differences between those who reported not having sex before age 16 years compared with those who reported having consensual sex before age 16 years. However, compared with the no childhood sexual abuse group, those who reported childhood sexual abuse were significantly more likely to report (1) sexual situations involving drug and or alcohol use, (2) having sex to escape from loneliness or depression, (3) having a nonmonogamous partner, and (4) difficulty maintaining an erection (Table 2).

TABLE 2.

Proportions of Risky Sexual Situations as an Adult, by Level of Childhood Sexual Experience Before Age 16 Years: Miami, FL; Los Angeles, CA; and New York, NY; October 1998–March 1999

		Childhood Sexual Experience
Risky Sexual Situation Variable	Total, No.	No Sex, %	Consensual Sex, %	Forced Sex, %	P a
Partner refuses to use condom	877	48	48	66	<.001
Lonely or depressed	878	35	32	50	<.001
Has sex while drunk	877	48	46	57	.05
Has sex while high on drugs	875	26	24	37	.004
Afraid of losing partner	877	43	42	52	.041
Difficulty maintaining erection	877	34	31	51	<.001

^aFor forced vs consensual sex.

Childhood sexual abuse (OR = 2.0; 95% CI = 1.1, 3.8) significantly predicted increased adult risky sexual behavior in unadjusted logistic regression analyses. As previously reported,²⁵ we found that psychological distress (OR = 1.7; 95% CI = 1.1, 2.5), exposure to homophobia during childhood (OR = 1.6; 95% CI = 1.3, 2.0), and risky sexual situations (OR = 3.0; 95% CI = 2.0, 4.3) significantly predicted increased adult risky sexual behavior in unadjusted logistic regression analyses.

Path Analysis

Direct effects linking childhood sexual abuse, experiences of homophobia during childhood, and experiences of homophobia during adulthood to psychological distress, risky sexual situations, and sexual risk behavior are shown in Table 3. Childhood sexual abuse, exposure to homophobia during childhood, and exposure to homophobia during adulthood were positively associated with psychological distress. However, those who did not have sex before age 16 years and those who had consensual sex before age 16 years did not differ from each other in levels of psychological distress. Psychological distress, exposure to homophobia during childhood, and exposure to homophobia during adulthood were positively associated with participating in risky sexual situations.

TABLE 3.

Direct Effects From Hypothesized Path Model: Miami, FL; Los Angeles, CA; and New York, NY; October 1998–March 1999

Explanatory	b (SE)	z	B	P
Psychological distress
Childhood homophobia	0.150 (0.054)	2.78	0.144	.005
Adult homophobia	0.360 (0.079)	4.54	0.252	<.001
Forced sex	0.346 (0.115)	3.01	0.169	.003
Consensual sex	0.033 (0.073)	0.45	0.021	.652
Nativity	−0.053 (0.069)	−0.77	−0.034	.442
Age	−0.007 (0.004)	−1.87	−0.078	.061
HIV positive	0.328 (0.079)	4.12	0.184	<.001
Risky sexual situation
Psychological distress	1.365 (0.289)	4.37	0.203	<.001
Childhood homophobia	0.796 (0.317)	2.51	0.114	.012
Adult homophobia	1.754 (0.359)	4.89	0.183	<.001
Forced sex	0.268 (0.529)	0.51	0.020	.612
Consensual sex	0.622 (0.439)	1.42	0.060	.157
Nativity	−0.821 (0.451)	−1.82	−0.078	.069
Age	−0.056 (0.024)	−2.40	−0.093	.017
HIV positive	0.764 (0.540)	1.41	0.064	.157
Sexual risk behavior
Risky sexual situations	0.097 (0.010)	9.37	0.453	<.001
Psychological distress	0.022 (0.109)	−0.20	0.015	.841
Childhood homophobia	0.104 (0.089)	1.17	0.069	.241
Adult homophobia	0.031 (0.107)	0.29	0.015	.769
Forced sex	0.250 (0.229)	1.09	0.085	.275
Consensual sex	−0.032 (0.156)	−0.20	−0.014	.84

Experiencing risky sexual situations was the only variable directly linked with risky sexual behavior. This finding was qualified by the presence of several statistically significant indirect effects of exposures and mediators on risky sexual behavior. Childhood sexual abuse (b = 0.043; SE = 0.023; z = 2.02; B = 0.016), experiences of homophobia during childhood (b = 0.020; SE = 0.008; z = 2.35; B = 0.013), and experiences of homophobia during adulthood (b = 0.048; SE = 0.014; z = 3.48; B = 0.023) were positively related to risky sexual behavior through psychological distress and risky sexual situations. By contrast, respondents who had experienced consensual sex before age 16 years were not significantly different from those not having sex before age 16 years in this indirect effect (b = 0.004; SE = 0.010; z = 0.45; B = 0.002). Men with higher levels of psychological distress were more likely to engage in risky sexual situations, which in turn led to an increased risk of risky sexual behavior (b = 0.133; SE = 0.034; z = 3.95; B = 0.092).

A similar set of findings emerged for indirect effects linking childhood sexual abuse and homophobia with risky sexual situations by way of psychological distress. Childhood sexual abuse (b = 0.473; SE = 0.212; z = 2.23; B = 0.034), experiences of homophobia during childhood (b = 0.205; SE = 0.081; z = 2.55; B = 0.029), and experiences of homophobia during adulthood (b = 0.491; SE = 0.139; z = 3.53; B = 0.051) were positively associated with participating in risky sexual situations, whereas having consensual childhood sexual experiences was not (b = 0.045; SE = 0.101; z = 0.45; B = 0.004).

DISCUSSION

Our findings indicated that HIV-risk patterns among Latino gay and bisexual men in the United States were related to childhood sexual abuse and a social context of discrimination resulting in psychological distress and risky sexual situations that increase risky sexual behaviors associated with HIV acquisition. The high prevalence of childhood sexual abuse among Latino gay and bisexual men in our study is consistent with previous findings that found Latino MSM (22% of them) were twice as likely as non-Latino MSM to have childhood sexual abuse histories.¹⁸

Using a probability sample from 3 large US cities, we found further support for the use of both subjective and objective considerations in the definition of childhood sexual abuse.¹⁰ There were no differences between Latino gay and bisexual men who reported not having sex before age 16 years and those who reported consensual sex before age 16 years with someone 5 or more years older for any of the outcomes, underscoring the importance of examining both subjective and objective experiences of childhood sexuality. Consistent with previous findings,¹⁰ Latino gay and bisexual men who initiated sex consensually before age 16 years appeared to be at no greater risk for psychological distress, risky sexual situations, or risky sexual behaviors than were those who initiated sex at later ages. By contrast, having experienced childhood sexual abuse was associated with greater risk for psychological distress, risky sexual situations, and risky sexual behaviors.

Path analysis also indicated no differential direct or indirect effects between not having sex before age 16 years and consensual sex before age 16 years. Nevertheless, childhood sexual abuse was directly associated with increased risk for psychological distress and indirectly associated with increased risk for risky sexual situations and risky sexual behaviors. Psychological distress had a direct effect on risky sexual situations, which had a direct effect on risky sexual behaviors. These results suggest that the relationship between childhood sexual abuse and risk for HIV may be mediated by increased psychological distress and risky sexual situations. It may be that for Latino gay and bisexual men, placing themselves in risky sexual situations that increase risk for risky sexual behavior is an immediately gratifying strategy for coping with the psychological distress that comes with having experienced childhood sexual abuse. As Diaz has suggested, when the need for connectedness, affirmation, or self-worth is so great and deeply felt, individuals’ usual concern for sexual safety and health seems to be overpowered.²⁹

Not surprisingly, childhood and experiences of homophobia during adulthood were directly associated with increased psychological distress and directly and indirectly associated with risky sexual situations. Whereas the actual occurrence of childhood sexual abuse ends in childhood, homophobic environments that continue into adulthood can result in ongoing psychological distress that result in maladaptive coping strategies in which Latino gay and bisexual men seek out risky sexual situations to distract themselves from these feelings. Although using sex as a coping mechanism may be beneficial for reducing unwanted feelings associated with early forced sexual experiences and a pernicious homophobic environment in the absence of meaningful relationships, these very coping strategies may lead to a greater sense of isolation and distress in a cycle that increases risky sexual situations.

Our findings reveal a strong relationship between childhood sexual experiences and patterns of adulthood sexual experiences among Latino gay and bisexual men. Although behavioral interventions to reduce risk behavior may be effective as a way of increasing awareness and reducing risky sexual behaviors among some men, it is becoming increasingly clear that we must develop interventions that address the contextual and psychological factors that influence Latino gay and bisexual men's sexual lives. Many schools and workplaces feature antidiscrimination workshops and classes. These activities encourage children and employees to be mindful of antidiscrimination laws and promote respectful communication among peers. Sexual orientation should be added to such training.

Strengths and Limitations

Although the use of a probability sample of Latino gay and bisexual men in 3 US cities is a strength of this study, it has limitations. The findings may not generalize to other cities in the United States, and the model assumes equal correlation structure across the 3 childhood sexual abuse classification groups. Further, our measurement of HIV risk behavior encompassed a 1-year timeframe including both insertive and receptive partners, whereas a shorter timeframe that differentiated positioning could have captured risk more accurately. The model posited relationships among contemporaneously measured variables, making causal ordering among variables impossible to determine in this cross-sectional sample.

Future studies should measure constructs such as exposure to homophobia during childhood in samples of youths with the aim of determining whether such experiences can be prospectively linked with subsequent sexual risk behavior in adulthood. Because of ethical concerns, it is likely that retrospective investigations such as ours will remain representative of childhood sexual abuse research in the immediate future. Additionally, all responses consisted of self-reports. Although previous research has found good reliability and validity for retrospective reports of childhood sexual abuse³⁰ and sexual risk behavior,^31,32 interpretations of temporal or causal relationships are limited by the retrospective and cross-sectional nature of the data.

The field still grapples with 2 unresolved theoretical and methodological issues: the possibility of objectively describing a sexual act as consensual and the validity of asking participants about the level of consensuality of their experiences. Miscategorization of childhood sexual experiences is always possible. Those who were coerced into sexual activity in childhood, but who do not see themselves as having been forced, may have been miscategorized into the consensual sex group. However, as noted in previous research differentiating forced from consensual sex in childhood,¹⁰ one would expect miscategorization to have resulted in an underreporting of forced sex and inflated the risk outcomes for the consensual sex group. Nonetheless, individual cases of childhood sexual experiences are not populations. We must pay attention to individuals’ circumstances when determining whether there was abuse and how to best intervene to improve a sense of worth and safety for Latino gay and bisexual men.

Conclusions

Based on our findings, we believe that future research should focus on individual and contextual resiliency factors that may be protective, other sociocultural indicators of both increased and decreased risk outcomes, and uncovering underlying mechanisms that maintain the relationship between childhood sexual abuse and later risk-taking behaviors.

Researchers studying women have found a strong relationship between childhood sexual abuse and dissociation in cases in which the childhood sexual abuse was severe.^33–37 Dissociation is a psychological state or condition in which certain thoughts, emotions, sensations, or memories are separated from the rest of the psyche. Pierre Janet coined the term, emphasizing its role as a defensive mechanism in response to psychological trauma.³⁸ It may be that the ability to dissociate during childhood sexual abuse is adaptive, especially when there is no control over the situation, such as is the case when a child is forced into a sexual behavior. However, to the degree that dissociation is generalized to nonthreatening situations (such as consensual sexual encounters in adulthood), the ability to make conscious choices about behavior in nonthreatening contexts may be dramatically limited.

The extent to which childhood sexual abuse is associated with dissociation among Latino gay and bisexual men is unknown. Given the findings among women, dissociation may be one of the mechanisms accounting for the link between childhood sexual abuse and risky sexual behaviors in adulthood. Future research should examine the role of dissociation among Latino gay and bisexual men.

Finally, we must examine childhood sexual experiences to differentiate age-appropriate and adaptive sexual development from that which is abusive or coercive. Our findings highlight the need to promote socially contextualized ways to reduce childhood sexual abuse and its sequelae, including increasing awareness through open discourse and education concurrent with laws and policies that make it more difficult to perpetrate sexual abuse of children. For those who have been sexually abused in childhood, interventions must also focus on reducing the psychological distress that appears to override Latino gay and bisexual men's intentions to practice safer sex. For instance, a young Latino gay man who feels unworthy as a result of physical (e.g., forced sex) and contextual maltreatment (e.g., homophobia) may not believe that he deserves to be taken seriously and consequently may not be able to garner the resources (psychological and environmental) needed to enact safe sex behaviors consistently. Research must be directed toward interventions that will reduce psychological distress associated with these factors, increase self-worth, and create an environment or context that supports and welcomes Latino gay and bisexual men's full engagement in society.