Social Integration and Health: Community Involvement, Stigmatized Identities, and Sexual Risk in Latino Sexual Minorities

Jesus Ramirez-Valles; Lisa M Kuhns; Richard T Campbell; Rafael M Diaz

doi:10.1177/0022146509361176

. Author manuscript; available in PMC: 2013 Jun 6.

Published in final edited form as: J Health Soc Behav. 2010 Mar;51(1):30–47. doi: 10.1177/0022146509361176

Social Integration and Health: Community Involvement, Stigmatized Identities, and Sexual Risk in Latino Sexual Minorities

Jesus Ramirez-Valles ¹, Lisa M Kuhns ², Richard T Campbell ¹, Rafael M Diaz ³

PMCID: PMC3674853 NIHMSID: NIHMS464207 PMID: 20420293

Abstract

The purpose of this study is to contribute to the conceptual understanding and practical application of social integration theory to health behaviors. We test whether community involvement in AIDS and GLBT organizations moderates the relationship of racial and homosexual stigmata to sexual risk behavior among gay and bisexual men and transgender persons of Latin American origin or descent. We use structural equation modeling to analyze data from a sample of 643 individuals recruited via respondent-driven sampling. Among those not involved in community organizations, homosexual and racial stigmata are related to sexual activity under the influence of alcohol and drugs, which is linked to sexual risk behavior. Among the involved group, the stigmata are not linked to sexual activity under the influence of alcohol and drugs, or to sexual risk behavior. The moderating role of community involvement seems to be more salient in those currently involved than those ever involved.

Keywords: stigma, gay men, HIV/AIDS, Latinos, social integration

A major tenet of social integration theory is that involvement in public life helps fulfill our lives and achieve well-being (Bellah et al. 1996). Getting involved as a volunteer or activist may help develop a positive sense of oneself by providing social support and coping resources (Piliavin and Siegl 2007). For sexual and ethnic minorities, community involvement, particularly with peers and on issues relevant to their social status, may be relevant because of their exclusion from mainstream forms of involvement. Community involvement may guard against stigmatization, assist in fighting societal discrimination, and transform loneliness and shame into pride and solidarity (Britt and Heise 2000). Participation in the AIDS movement provides a good yet poorly documented example. Anecdotal data suggest that, through their involvement, gay activists found support and self-efficacy to deal with their own health (Omoto and Crain 1995).

The goal of this study is to contribute to the conceptual understanding and the practical applications of social integration theory to health behaviors. We test whether community involvement (e.g., volunteerism and activism) moderates the positive association between racial and homosexual stigma and sexual risk in gay and bisexual men and transgender persons (GBT) of Latin American origin or descent. Latino GBT people have been severely affected by the HIV/AIDS epidemic. Latinos’ rate of HIV/AIDS is three times higher than that of whites (CDC 2008). While a growing body of research strongly indicates that involvement in the form of volunteerism positively affects health (Rietschlin 1998; Thoits and Hewitt 2001), that research has been restricted to white and heterosexual populations. Likewise, in the case of studies on participation in the AIDS movement, the evidence regarding its positive effects is mostly anecdotal, with only a few exceptions (Ramirez-Valles et al. 2005a), and evidence is nonexistent on its association with sexual risk behaviors. Moreover, no study, to our knowledge, has investigated community involvement in the context of the stress created by both racial and homosexual stigma.

THEORETICAL FRAMEWORK

We draw on three interrelated frameworks (see Figure 1): social integration theory (Durkheim [1897] 1951), the stress process (Pearlin et al. 1981), and social movements (McAdam 1989). Social integration theory posits that involvement in formal and informal organizations supply social support and peers, which foster a positive sense of the self (Bellah et al. 1996). Similarly, attachment to organizations works as a social control (Hirschi 1969). Involvement in AIDS organizations, for example, may increase the costs of engaging in unprotected sex.

Theoretical Model of the Moderating Effects of Community Involvement on the Association between Homosexual and Racial Stigmatization and Sexual Risk behavior

A basic premise of the stress process is that circumstances which make demands exceeding individuals’ resources may become a threat to well-being (Ensel and Lin 1991). Some individuals use substances to cope with stress, which may lead to sexual risk behaviors (Diaz, Ayala, and Bein 2004), while others draw on their social support. The latter is likely to prevent the stressor from leading to a negative health outcome.

Theories on identity process in social movements argue that movement participants undergo a positive transformation of the self through their involvement (McAdam 1989). Participants may change from thinking of themselves as victims to activists, or from deviant and immoral to proud and openly gay or transgender (Kiecolt 2000). They also may increase their self-efficacy, so that they become, for instance, assertive Latino gay men. These changes take place as participants interact with peers, find role models, take action on behalf of an organization, and internalize their agendas, e.g., prevent HIV.

We propose that stigmata based on homosexuality (or, more generally, gender nonconformity)¹ and race may work as stressors increasing the likelihood of sexual risk behavior via the use of alcohol and other substances (Meyer 1995; Williams, Lavizzo-Mourey, and Warren 1994). Stigma means a labeling of individuals or groups that discredits them (Goffman 1963). Labeling comes with social distance and discriminatory practices toward those labeled (Link and Phelan 2001). Stigma may lead to negative health outcomes when it is internalized (Meyer 1995). The use of substances and the practice of sexual risk behavior may function as mala-daptive coping strategies in response to that stress (McKirnan, Ostrow, and Hope 1996). This causal path is also proposed by strain theorists, who offer that problem behavior helps cope with stressful circumstances (Agnew 2001; Simons et al. 2003). Individuals may engage in substance abuse and sexual risk acts to compensate for feelings of devaluation, shame, and rejection (Ayala and Diaz 2001). These behaviors, in turn, may exacerbate feelings of devaluation and shame as individuals may feel they lack self-control. Thus, we hypothesize that experiences of stigma are positively associated with sexual behavior under the influence of alcohol and substances and, in turn, with unprotected sex, partly through their positive association with internalized stigmata.

Furthermore, we submit that community involvement moderates the link between stigmata and sexual behavior under the influence of alcohol and substances, hence, reducing the likelihood of practicing unprotected sex. Those who are involved as volunteers or activists are less likely to engage in unprotected sex than those who are not involved because experienced and internalized stigmata do not lead to sex under the influence. But we believe this does not happen universally. The positive outcomes of involvement among GBT people are more likely to occur via participation in GLBT and AIDS organizations than through involvement in other causes.

Stigma of Gender Nonconformity

Negative attitudes toward GLBT people have decreased since the 1980s (Hicks and Lee 2006). Still, the majority of GLBT people believe that the larger society does not accept them, and many report discrimination because of their gender-nonconforming actions (Herek 2007). The majority of Latino GBT also report experiences of discrimination based on gender nonconformity (Ramirez-Valles 2007). Even more, the AIDS epidemic has made people more likely to discriminate against gay men. Unfortunately, the existing conceptualization of experiences with homosexual stigma is very limiting, other than thinking of them as stressors. Researchers have relied on the term homophobia without locating this phenomenon within the larger concept of stigma, failing to look at other dimensions of stigma, such as shame and blame (Fife and Wright 2000).

There is solid evidence linking experienced stigma based on homosexuality to a host of negative outcomes, including depression, substance use, suicidal tendencies, and sexual risk (Mays and Cochran 2001; Paul et al. 2002). Although research on Latino populations is sparse, the research that does exist points to a similar connection (Bruce, Ramirez-Valles, and Campbell 2008; Diaz et al. 2004).

This study aims to put together two pieces of this puzzle: the dimensions of stigma and successful coping processes or risk-protective factors.

Racial Stigma

Racial stigma, frequently referred to as racism, is an exclusion process based on discourses and practices of inferiorization (Anthias 1990). It is built on socially constructed physical and biological differences that are used to define groups and place them in a social structure of inequality. Racism is primarily a structural factor, but it can have a direct impact on individuals’ well-being. It may affect health by lowering self-esteem and increasing one’s sense of helplessness and substance use (Williams, Neighbors, and Jackson 2003).

The limited research on racial stigma in Latinos shows that experiences of discrimination attributable to skin color, language, or national origin are associated with psychological distress (Perez, Fortuna, and Alegria 2008). Yet those who actively address discrimination and who have a strong sense of themselves as Latinos do not experience negative health outcomes attributable to stigmatization (Edwards and Romero 2008).

The experiences of racial stigma are fairly common among Latino GBT and lead to sexual risk behavior when individuals have internalized society’s negative attitudes (Bruce et al. 2008; Ramirez-Valles 2007). Individuals may feel hopeless and dissatisfied and then abuse substances as a coping mechanism. As a consequence, they lose assertiveness to negotiate safe sex (Diaz et al. 2001).

Community Involvement

Not all members of ethnic and sexual minorities suffer the negative health consequences of discrimination. Some Latino and GBT individuals successfully cope with and confront stigma. Gay, bisexual, and transgender people, including those living with HIV/AIDS, defied stigma through their involvement in the early years of the AIDS movement (Weitz 1991).

Community involvement refers to unpaid work on behalf of others or for a collective good, through formal or semi-formal organizations and social networks (Ramirez-Valles 2002). It encompasses volunteerism, activism, and informal helping behaviors. Ramirez-Valles (2002) has proposed that community involvement, specifically in AIDS and GLBT causes, moderates the potentially negative effects of stigma on the health of sexual minorities, as it provides psychological well-being, supplies peers, and develops a sense of competence and belonging. Latino GBT people who are involved in AIDS and GLBT organizations may have higher self-esteem than those who are not involved because they see themselves as victims of prejudice. They are embedded in an organizational milieu that promotes awareness of stigma and attributes it to society’s negative attitudes toward homosexuality and AIDS, and that encourages intragroup rather than intergroup comparisons (Crocker and Major 1989).

Thus, community involvement may address factors leading to substance use and unprotected sex: low self-esteem, shame, and low self-efficacy toward safe sex (Diaz and Ayala 1999). We hypothesize that community involvement in GLBT or AIDS organizations will moderate the association between racial and homosexual stigmata and sexual risk behavior. Specifically, community involvement will reduce the pathways leading from experienced and internalized racial and homosexual stigmata to sexual behavior under the influence. Involvement in other causes will not make a difference in that association. In addition, we expect that the effects will be stronger for recent or current involvement than for involvement in the past.

METHODS

Sample

The sample is comprised of self-identified Latino gay and bisexual men and transgender persons (male to female) from Chicago and San Francisco, drawn using respondent-driven sampling. Respondent-driven sampling is a social network referral method (Heckathorn 1997, Heckathorn 2002). It was designed specifically for use with “hidden” populations, for which no sampling frames are available. It samples individuals through their friendship networks (Heckathorn 1997, Heckathorn 2002). Thus, it has the potential to reach individuals who might not otherwise participate in studies using other sampling methods (e.g., venue-based; Ramirez-Valles et al. 2005b). The sampling begins by having research staff select the initial participants of the study, referred to as “seeds.” Seeds then initiate the chain referral by recruiting a set number of peers who, in turn, recruit other peers into the study. The process continues until the target sample size is attained. When referral chains are sufficiently long (e.g., 4–5 waves), the composition of the final sample with respect to key characteristics and behaviors is independent of the seeds from which it began (Heckathorn 1997).

Because respondent-driven sampling is a network sampling method, it may over-represent subgroups with larger social networks or networks of persons who are more efficient recruiters. However, it is designed to help assess and control this selection bias, making it possible to derive population estimates. Information gathered during the sampling process (e.g., social network size) provides the means for constructing a post-hoc sampling frame from which inclusion probabilities can be calculated. This, in turn, helps assess potential bias in population estimates, and to estimate the variability of indicators (e.g., standard errors).² The analyses presented here, however, were conducted using unweighted data because the weighting method is only available for univariate statistics.

The sample is not self-weighted, but it assesses the degree to which individuals with given characteristics are over- or under-sampled and adjusts for this bias in the analysis by including relevant variables. Preliminary analyses showed that language spoken, place of birth, age, HIV status, and sexual orientation were related to the likelihood of participating in the study. Winship and Radbill (1994) demonstrate that when sampling is associated with potential independent variables in a multivariate model, those variables must be included, and that it is not necessary to weight observations.

The final sample consisted of 643 individuals (N = 320 in Chicago; N = 323 in San Francisco), aged 18 to 73, all of whom self-identified as Latino and either gay, bisexual, or transgender (male to female). Of 734 individuals who were eligible for the study, 649 participated in the survey. Six of 649 interviews were incomplete or contained systematically invalid data. We cannot calculate a refusal rate because recruitment was conducted by participants, thus, we have no meaningful data on refusals.

Data Collection

Data collection took place in 2004 using computer-assisted self-interviews (CASI). All materials and correspondence associated with data collection were prepared in both Spanish and English. Chicago and San Francisco were chosen because they allow for a comparison of two social and cultural contexts. While both cities have large Latino and GBT populations, the GBT community is more visible in San Francisco, with a longer history of activism and a higher rate of HIV/AIDS (Ramirez-Valles et al. 2008).

Measures

All measures were developed from a review of the literature and qualitative formative research. The questionnaire was then tested in a pilot study of 200 Latino GBT in both cities, when psychometric properties of study measures were assessed and measures were adjusted to improve their reliability and validity.

Sexual risk: Sex under the influence of substances

This construct is similar to Diaz et al.’s (2004) measure of “risky situations,” which is strongly predicted by stigma and poverty. In response to two separate questions, participants reported how often they were involved in sexual activities under the influence of alcohol or drugs in the previous 12 months. Response choices range from never (coded 1) to many times (coded 4). The mean for sex under the influence of alcohol is 1.86 (SD = 1.03, median = 1, mode = 1); the mean for sex under the influence of drugs is 1.53 (SD = .94, median = 1, mode = 1).

Sexual risk: Sexual risk behavior

Respondents were asked to indicate separately how often they had unprotected receptive or insertive anal sex in the previous 12 months. Responses were combined to indicate whether respondents had any unprotected anal sex in the past twelve months (0 = no, 1 = yes). Participants were also asked if they had sex with other men or transgender persons in the last 12 months, and if so with how many. Answers to these questions were used to assess the number of male or transgender sex partners in the previous twelve months (range 0–96, skewness = 4.48). Because the distribution of this variable was skewed, it was divided by approximate quintiles (1 = 0 sex partners; 2 = 1 sex partner; 3 = 2–3 sex partners; 4 = 4–9 sex partners; 5 = 10 or more sex partners).

Homosexual stigmatization

Two general dimensions of homosexual stigma were assessed: experienced and internalized stigma. The items in these variables were worded for male homosexuality only, not for transgender identity because of the technical difficulties and costs involved in changing the wording in CASI based on the respondent’s identity. Yet they were general enough to be applicable to GBT, and the number of transgender participants was relatively small (N = 94, 15%).

Experienced stigmatization was measured by 20 items reflecting events across the life span and across a variety of contexts (e.g., work environment, family) and actions (e.g., verbal and physical abuse, displacement). The response choices ranged from 1 = never to 4 = many times. Maximum likelihood exploratory factor analysis was conducted on this measure to determine the underlying factor structure, and the factors were rotated using the “promax” method to allow the factors to correlate. Appendix A presents all stigma factors, items, Cronbach’s alpha coefficients, and scale means and standard deviations. Four factors emerged: (1) childhood experiences of maltreatment, (2) adult harassment and abuse, (3) social rejection and maltreatment, and (4) family experiences. Intercor-relations among factors ranged from .50 to .60. Items from each factor were averaged to create four sub-scales.

Internalized stigmatization was assessed in a similar fashion. A total of 17 items comprise this measure. Results of factor analysis showed four factors: feelings of shame, blame, wanting to change one’s sexuality, and endorsement of normative masculinity (see Appendix A; factor inter-correlations range from .30 to .65).

Racial stigmatization

We assessed experienced and internalized racial stigma. The former comprised 21 items representing lifetime experiences of stigmatization. The response choices were provided on a frequency scale from never (coded 1) to many times (coded 4). Four factors resulted from factor analysis: work, public discrimination, harassment, and rejection in romantic relationships (see Appendix A). The factor intercorrelations varied from .40 to .70.

Internalized racial stigma included 12 items. The response choices were provided on a four-point Likert-type scale (1 = strongly disagree to 4 = strongly agree). Results of factor analysis specified three factors: blame, shame, and social distance from other Latinos (see Appendix A). The factors correlated at between .30 and .50.

HIV/AIDS and GLBT community involvement

Two variables were used to measure community involvement. First, respondents were asked to indicate whether they had ever done any volunteer work (defined as working in some way to help others without being paid, including activism and informal helping). Participants who responded “yes” to this question were then asked to indicate the causes or organizations for which they volunteered time (total of 20 causes listed, e.g., helping the poor, HIV/AIDS, GLBT, and Latino causes). Those participants who said “yes” to volunteering for either HIV/AIDS or GLBT causes were combined into one variable (1 = yes, 0 = no). Respondents were further asked to indicate whether they had been involved in these causes in the last 12 months. A second variable for community involvement reflects involvement in HIV/AIDS or GLBT causes in the past 12 months (1 = yes, 0 = no). Data were also collected on frequency and length of involvement (details are available from the authors).

Sociodemographic variables

Demographic variables include age, annual income, education, and city (i.e., Chicago, San Francisco); summary statistics for these measures are presented in Table 1.

Table 1.

Demographic Characteristics for the Sample of Latino Gay and Bisexual Men and Transgender Persons from San Francisco and Chicago, 2004 (N = 643)

Characteristics	Chicago (N = 320) N (%)	San Francisco (N = 323) N (%)	Total (N = 643) N (%)
Age
18–29	126 (39)	76 (23)	202 (31)
30–39	113 (35)	127 (39)	240 (37)
40–49	55 (17)	89 (28)	144 (23)
≥50	26 (8)	31 (10)	57 (9)
Education
Less than high school	81 (25)	91 (28)	172 (27)
High School/GED	88 (28)	61 (19)	149 (23)
Some college/Technical/Vocational	106 (33)	111 (34)	217 (34)
College degree	35 (11)	51 (16)	86 (13)
Graduate degree	10 (3)	9 (3)	19 (3)
Employment status^a
Full-time	156 (49)	85 (26)	241 (38)
Part-time/Unemployed/Other	164 (51)	236 (74)	400 (62)
Annual income
<10,000	95 (30)	165 (51)	260 (40)
10,000–19,999	108 (34)	64 (20)	172 (27)
20,000–29,999	70 (22)	50 (15)	120 (19)
30,000–39,999	34 (11)	28 (9)	62 (10)
≥40,000	13 (4)	16 (5)	29 (4)
Place of birth
United States	99 (31)	46 (14)	145 (23)
Mexico	141 (44)	158 (49)	299 (47)
Puerto Rico	27 (8)	7 (2)	34 (5)
Central America	13 (4)	59 (18)	72 (11)
South America	30 (9)	36 (11)	66 (10)
Other	10 (3)	17 (5)	27 (4)
Sexual risk
Unprotected anal sex last 12 months	113 (35)	111 (34)	224 (35)
HIV Status
Positive	57 (18)	113 (35)	170 (26)
Negative	208 (65)	184 (57)	392 (61)
Not tested/Don’t know/Refused	55 (17)	26 (8)	81 (13)
Community involvement^b
General ever	227 (71)	270 (83)	497 (77)
AIDS/GLBT ever	124 (39)	185 (57)	309 (48)
AIDS/GLBT last 12 months	98 (31)	159 (50)	257 (40)

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Two cases were deleted due to conflicting employment information.

Frequency of HIV/AIDS, GLBT involvement last 12 months: Chicago: About once a year, 11%; a few times a year,12%; once a month, 5%; a few times a month, 5%; once a week, 3%; a few times a week, 1%

San Francisco: About once a year, 9%; a few times a year, 20%; once a month, 6%; a few times a month, 7%; once a week, 3%; a few times a week, 2%; daily, 2%.

HIV status

A dummy variable was created to reflect HIV status, with HIV-negative/untested as the reference group (0 = HIV-negative/untested, 1 = HIV-positive).³

Acculturation to the United States

We use three variables to measure acculturation to the United States: place of birth, time in the United States, and a composite measure of language acculturation. To measure place of birth, respondents were asked to indicate the country in which they were born (0 = U.S.-born, 1 = non U.S.-born).

To assess language acculturation, a modified version (three items) of the acculturation scale for Hispanics, developed by Marin and colleagues (1987), was used. Example items include, “What language(s) do you usually speak with your friends?” and, “Generally, in what language are the music and TV programs you enjoy?” Responses ranged from, “in Spanish only” (coded 1) to “in English only” (coded 5). A scale was created with the average score on these items (range 1–5, mean = 2.85, SD = .96, Cronbach’s alpha = .83).

We also assessed the number of years in the United States. Because this variable was severely skewed, responses were divided by quintiles for analysis (1 = less than a year to 4 years, 2 = 5–11 years, 3 = 12–19 years, 4 = 20–72 years, 5 = born in the United States).

Data Analysis

We estimated measurement and structural equation models using Mplus Version 4.2 (Muthén and Muthén 2006). Because we used both continuous and categorical variables in our analysis, we computed weighted least squares mean and variance adjusted (WLSMV) estimators (Muthén, du Toit, and Spisic 1997).

We performed modeling in three phases. First, we evaluated the measurement model by conducting a confirmatory factor analysis of six latent variables: experienced and internalized homosexual and racial stigma, sex under the influence, and sexual risk behavior. Then we evaluated the overall measurement model (i.e., all factors together). In the second phase, we assessed the overall fit of the structural model and the hypothesized structural relationships controlling for sociodemographic variables, HIV status, and acculturation. We assessed model fit for the measurement and structural models using conventional thresholds of minimally acceptable fit on the comparative fit index (CFI ≥ .90), Tucker-Lewis index (TLI ≥ .90), and root mean-squared error of approximation (RMSEA ≤ .08; Bentler 1990; Hu and Bentler 1999).

In the third phase, we tested moderation by means of a multiple groups analysis comparing key structural paths (e.g., from internalized homosexual stigma to sex under the influence) among those involved in HIV/AIDS or GLBT organizations in the previous 12 months and those not involved. We also compared groups defined by those ever involved and those never involved. The goal was to determine if the structural paths between stigmatization and sexual risk differed in these two groups, that is, if community involvement reduces these associations. Our hypothesis was that these paths would be positive and significant in the noninvolved group, but not significant in the involved group. Specifically, we ran a model in which all parameters were free in each group (factor loadings were held equal to reflect measurement invariance). We examined the structural coefficients in each group for evidence of differences between the two groups. Then, we constrained the key structural paths to equality in the two groups and compared the fit of the constrained model to that of the free model. A statistically significant chi-square difference for the two models (i.e., free and constrained) was taken to indicate a significant difference in structural paths between the two groups. For the multiple groups analysis, the “DIFFTEST” option in MPlus was used to obtain a correct chi-square difference test for the WLSMV estimators (the difference in chi-square values for two nested models using the WLSMV chi-square values is not distributed as chi-square). The corrected chi-square difference test was used to compare models with the same structural form, but with different constraints on parameters (Bollen 1989). The correct chi-square difference test criterion was set at χ² ≤ .05. Note that although the theoretical model and the analytical strategy imply causality, our cross-sectional data do not permit testing causal paths.

RESULTS

Confirmatory Factor Analysis and Measurement Model

Table 1 presents the distribution of the main study variables, by city.

Confirmatory factor analyses were run for each latent construct. This analysis identified a two-factor model for sexual behavior under the influence and sexual risk behavior (i.e., with two correlated factors, each measured by two indicators: CFI = 1, TLI = 1, RMSEA = .00). The stigmatization factors all showed reasonable model fit (CFI = .99, TLI = .97–.98, RMSEA = .07–.08).⁴

The initial measurement model did not fit the data well (CFI = .82, TLI = .91, RMSEA = .07), with high correlation residuals between several indicators of different factors, indicating that they may measure multiple factors. To improve model fit, the model was re-specified, eliminating the following indicators: social rejection/maltreatment (experienced homosexual stigma); endorsement of normative masculinity and blame (internalized homosexual stigma); romantic rejection (experienced racial stigma); and blame (internalized racial stigma). The re-specified model showed reasonable fit (CFI = .93, TLI = .95, RMSEA = .05; χ² = 87.06, df = 32, p < .001). The final composition of the latent factors is as shown in Figure 2, and the bivariate correlations between exogenous and sexual risk are presented in Table 2.

Final Model and Standardized Coefficients of the Association between Homosexual and Racial Stigmatization on Sexual Risk Behavior (all significant paths at p ≤ .05)^a

^aCorrelations among exogenous variables not shown.

Table 2.

Unstandardized Parameters Estimates (and Standard Errors), Fit Indices for Structural Model, and Bivariate Correlations between Stigma and Sex under the Influence and Sexual Risk

Parameter	Estimates	SE
Sex under influence → Sexual risk behavior	.513	.070
Experienced racial stigma → Sex under the influence	.175	.067
Internalized homosexual stigma → Sex under the influence	.179	.078
Experienced racial stigma → Internalized racial stigma	.230	.037
Experienced homosexual stigma → Internalized homosexual stigma	.290	.060
Education → Sexual risk behavior	.084	.032
Language acculturation → Sex under the influence	.165	.053
Education → Experienced racial stigma	−.060	.029
Time in → Experienced racial stigma	.058	.023
Chicago → Experienced racial stigma	−.158	.059
Income → Experienced homosexual stigma	−.057	.025
Chicago → Experienced homosexual stigma	−.259	.058
Model Fit Indices
CFI	.91
FLI	.93
RMSEA	.05
Chi-square	138.72; df = 56; p < .001
Bivariate Correlations
	Sex under the influence	Sexual risk behavior
Experienced racial stigma	.18^*	.05
Internalized racial stigma	.15^*	.18^*
Experienced homosexual stigma	.06	.04
Internalized homosexual stigma	.16^*	.04

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p < .05.

Test of the Structural Model

Figure 2 depicts the model (with standardized coefficients) that best fitted the data. Structural paths not shown were not significant, and thus we fixed them to 0. Table 2 shows the unstandardized coefficients, standard errors, and fit indices. Experiences of stigmatization are associated with internalized stigma. Stigmatization, however, is associated with sexual risk differently than originally hypothesized. Experienced homosexual stigma is not directly associated with sex under the influence of alcohol or drugs; rather, it is indirectly linked through internalized stigma. In contrast, experienced racial stigma is directly associated with sex under the influence of alcohol and drugs, while internalized racial stigma is not. As expected, sex under the influence is significantly associated with sexual risk behavior (we tested direct paths from stigma variables to sexual risk behavior and found them not to be significant).

Test of Moderation

We defined two groups: those who were involved in HIV/AIDS or GLBT causes in the past 12 months, and those who were not. It is noteworthy that we found no main effects of community involvement on sex under the influence or sexual risk behavior.

We estimated a model in which all structural parameters were free in each group, and we examined parameter estimates for qualitative evidence of modification. Structural path coefficients appeared qualitatively different in the two groups. Based on this result, we tested a model with all structural paths constrained to equality in the two groups, and we compared these to those in the free model. The corrected chi-square test of difference between the two models indicated a significantly worse fit for the constrained model (χ² = 9.51, df = 4, p = .05), providing evidence that at least one of the five paths is significantly different in the two groups. To assess which of these paths was different, we first compared estimates from a model in which the paths from experienced to internalized homosexual stigma and from experienced to internalized racial stigma were free in each group to the estimates from a model in which they were constrained to equality. The test for difference was not significant (χ² = 1.95, df = 2, p > .05). Second, we contrasted estimates from a model constraining the paths from internalized homosexual stigma and experienced racial stigma to sexual behavior under the influence in each group against estimates from a model freeing these two paths. The test for difference was significant (χ² = 8.33, df = 2, p < .05), indicating that these two paths are different in the involved and the not involved groups. Last, following the same procedure, we evaluated the path from sexual behavior under the influence to sexual risk behavior. We found no difference between the constrained and the free models (χ² = 2.98, df = 1, p > .05).⁵

We ran an additional two-group analysis expanding the definition of involvement to lifetime. One group consisted of those who had ever been involved in HIV/AIDS or GLBT organizations, and the other consisted of those who had never been involved in these organizations. This provides a sense of the “dose response” of being involved. We found that the corrected chi-square difference between the free and constrained models was significant when two paths were constrained to equality: the path from internalized homosexual stigma to sexual behavior under the influence, and the path from experienced race stigma to sexual behavior under the influence (χ² = 6.74, df = 2, p < .05). The difference between these paths, however, was qualitatively smaller than in the models comparing involvement in the last 12 months.

To probe those findings, we ran the model simultaneously in each group, defined as involved and not involved in the previous 12 months, using the grouping function in MPlus. Table 3 presents the results of this analysis. For both groups, the direct size effects of experiences of stigmatization on internalization are positive and significant, although smaller for the involved group.

Table 3.

Total Effects (standardized coefficients) for the Association between Stigma and Sexual Risk among Latino Gay and Bisexual Men and Transgender People by Community Involvement (N = 643)

Dependent Variables	City Chicago	Education	Income	Language acculturation	Time in U.S.	Experienced homosexual stigma	Internalized homosexual stigma	Experienced racial stigma	Sex under the influence
Non-involved in HIV/AIDS or GLBT organizations in the past 12 months
Experienced homosexual stigma	−.137^*		−.161^*
Internalized homosexual stigma	−.052^*		−.061^*			.380^*
Experienced racial stigma	−.108^*	−.201^*			.1 16
Internalized race stigma	−.037	−.069^*			.040			.343^*
Sex under the influence	−.029	−.035^*	−.012	.214^*	.020	.074^*	.196^*	.175^*
Sexual risk behavior	−.020	.168^*	−.008	.148^*	.014	.051^*	.136^*	.121^*	.691^*
Involved in HIV/AIDS or GLBT organizations in the past 12 months
Experienced homosexual Stigma	−.279^*		−.075
Internalized homosexual stigma	−.073^*		−.020			.263^*
Experienced racial stigma	−.097	.008			.095
Internalized racial stigma	−.028	.002			.028			.292^*
Sex under the influence	−.001	.000	.000	.132	.002	−.001	−.005	.018
Sexual risk behavior	−.001	.096	.000	.119	.002	−.001	−.005	.017	.899^*

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p ≥.05.

Stigma is related to sexual risk behavior only in the noninvolved group. For this group, the total effect of experienced homosexual stigma (via the factors of internalization and sexual behavior under the influence) on sexual risk behavior is modest but significant (β = .051, p < .05). Moreover, internalized homosexual stigma is associated with sexual risk behavior (β = .136, p < .05) through sex under the influence (β = .196, p < .05). Likewise, having experienced racial stigma is related to sexual risk behavior (total effect, β = .121, p < .05), via sexual behavior under the influence (β = .175, p < .05). These paths are not statistically significant in the involved group. Yet the path from sexual behavior under the influence to sexual risk behavior is positive and significant in both groups.

In separate analysis (not shown), we explored a variety of measures of community involvement, including any type of community involvement (not restricted to HIV/AIDS and GLBT) and frequency and length of involvement in HIV/AIDS or GLBT organizations. The indices for these models indicated a poor fit to the data (i.e., CFI < .90, TLI < .90, RMSEA > .08). In addition, we tested whether community involvement mediated the association between stigma and sexual risk (i.e., stigma leads to involvement, which in turn leads to reduced sexual risk). The structural model did not fit the data.

DISCUSSION

The findings of this study, while supporting the postulates of social integration, advance our understanding of how integration might lead to health, and they provide insights into ways to improve efforts to reduce sexual risk behavior. The results indicate that involvement shields individuals from maladaptive coping mechanisms created by stigmatization attributed to homosexuality and race. They also suggest that the types of causes individuals are involved in do matter. For Latino GBT, involvement in HIV/AIDS or GLBT organizations reduces the association between stigma and sexual risk behavior; involvement in just any type of organization does not. Moreover, being recently involved in HIV/AIDS or GLBT organizations seems to be slightly better than being involved ever.

The hypothesized paths linking stigma and sexual risk behavior were generally supported, with one exception: the one from internalized racial stigma to sexual behavior under the influence. We posited that the association between experienced stigma, both homosexual and racial, and sexual behavior under the influence would be partially mediated by internalized stigma. The findings show that for both stigmata, experience is associated with internalization. However, in the case of homosexual stigma, experience is not directly associated with sexual behavior under the influence. In the case of racial stigma, only experience was linked to sexual behavior under the influence. The results imply that racial stigma might lead to sexual behavior under the influence not through damaging the self-concept as a Latino, but through factors such as peer influence and the high prevalence of alcohol drinking in Latinos (Bruce et al. 2008; Fendrich et al. 2003). Unlike what has been observed in heterosexual Latino populations, GBT who have a solid self-identity as Latinos may be more likely to recognize experiences of stigma and attribute them to racial prejudice than those Latino GBT for whom the ethnic identity is not as salient (Sellers and Shelton 2003). In turn, they are more likely to socialize with other Latinos, including Latino GBT. This, in the context of elevated internalized homosexual stigma, may lead to sexual activity under the influence of alcohol. Another explanation is that experiences of racial stigma create a need to escape, and some Latino GBT use alcohol to satisfy this need.

Furthermore, the assessment of these stigmata revealed relevant theoretical dimensions. Experienced homosexual stigma is primarily comprised of childhood maltreatment, family experiences, and adult harassment. Internalized stigma is composed of two aspects: shame and wanting to change one’s sexuality. Experienced racial stigma includes workplace and general harassment and discrimination. Notably, rejection in romantic relations, which has been identified among Latino gay men (Ayala and Diaz 2001), did not hold within our final model. Last, internalized racial stigma is comprised of shame and social distancing from one’s own ethnic group. This is fairly consistent with research among African Americans (Branscombe, Schmitt, and Harvey 1999). Shame is the only dimension previously identified in research with other populations and conditions (Fife and Wright 2000). Importantly, our model did not include perceptions of stigma, because research has not found them to be related to substance use or sexual risk (Bruce at al. 2008).

What is it about community involvement in AIDS or GLBT organizations that helps Latino GBT? We propose, based on theories of volunteerism and social movements, that this type of involvement enhances self-esteem, fosters peer norms and self-efficacy regarding safe sex, and provides social support. There is a need for empirical evidence to also assess what takes place “inside” AIDS and GLBT organizations. This would include the form and content of interactions and activities in which members take part. We believe that a process of “identity consolidation” (Snow and McAdam 2000) might also be at work. The HIV/AIDS and GLBT organizations reported by individuals in this sample tend to cater to Latinos. In these organizations two seemingly conflicting identities, Latino and GBT, are being combined. That is, these GBTs are getting involved not because of a collective identity as a GBT, but as Latino GBT. Unfortunately, we do not have the data to probe this.⁶ Moreover, another mediating factor may be the use of substances. Involvement may deter alcohol and drug use, hence reducing the likelihood of engaging in sex under the influence.

While there is a significant variation in the assessment of community involvement (Wilson and Musick 1997), we feel confident in our results because we explored several dimensions of involvement, including length, frequency, type of cause, and time period. We conclude that the type of cause does make a difference and that current involvement might be slightly better than ever having been involved. Frequency and length of involvement, however, did not contribute to either measure of involvement, or to its moderating effects.⁷ Furthermore, involvement as effective coping strategy informs other approaches to understand stigma, such as Modified Labeling Theory (Link et al. 1989). The latter proposes that withdrawal, as a coping strategy, may actually be harmful. Conversely, we suggest that active involvement with peers may be beneficial.

These conclusions must be qualified by several limitations. One is the effects of self-selection and temporal order. It is plausible that those who do not engage in substance use and sexual risk are more likely to get involved than those who do not. Although we cannot probe this bias, studies on volunteering have shown that its effects on psychological well-being are independent from self-selection and mastery (Rietschlin 1998; Thoits and Hewitt 2001). One study, however, shows that depression may deter volunteering in middle-age populations (Li and Ferraro 2006). Likewise, our model does not account for psychological aspects, such as self-control and impulsivity (Bancroft and Vukadinovic 2004). Individuals with limited self-control may be more likely to engage in sexual risk acts and less likely to get involved than those with high self-control. The literature, though, does not provide solid support to the connection between self-control and sexual risk behavior (O’Leary et al. 2003). Another shortcoming is the likelihood of social desirability. The lack of association between stigma and sexual behavior under the influence among those involved could be attributed to social desirability. However, the use of CASI for data collection lessens this concern somewhat (Tourangeau and Smith 1996). Likewise, the relative lower statistical power in the involved group could have affected our ability to find significant associations between stigma and sexual behavior under the influence. Moreover, our sampling process did not allow us to assess refusal rates, although anecdotal data from recruiters suggest refusals were minimal. Last, because of the purpose of the study, women were not included; thus, it is unclear to what extent these results would generalize to women’s experience.

This study offers alternatives to improve HIV prevention efforts among GBT communities. Involving participants as volunteers or activists, not only as passive members, in AIDS or GLBT organizations may effectively address substance use and sexual risk. Community involvement may be thought of as naturally occurring intervention. Thus, it could be less expensive, more appealing to the target population, and more sustainable over time than new interventions created from the ground up.

Acknowledgments

FUNDING

This research was supported by National Institutes of Mental Health grant R01MH62937-01 to the first author.

Biography

Jesus Ramirez-Valles is a scholar, filmmaker, and an advocate of Latino and GLBT health. He just completed a documentary, Tal Como Somos (“Just As We Are”), on the lives of Latino gay men, transgender persons, and people living with HIV/AIDS. He is working on a book manuscript titled, “Compañeros: Activism, Race, and Sexuality in the Times of AIDS.” He is a professor of public health at the University of Illinois-Chicago.

Lisa M. Kuhns is a senior research associate at Howard Brown Health Center and an adjunct associate professor in the School of Public Health at the University of Illinois at Chicago. Her research focuses on the role of social marginalization on the health of sexual and gender minorities. She has published in the area of research participation, tracking, and retention among ethnic and sexual minorities.

Richard T. Campbell is a sociologist and statistician. His methodological interests focus on structural equation models and longitudinal data analysis. Substantively, his work focuses on health disparities, particularly with regard to cancer diagnosis and treatment. He is a professor in the University of Illinois-Chicago School of Public Health.

Rafael Diaz is a social worker and a developmental psychologist. He is currently professor of ethnic studies and senior research scholar at the Cesar E. Chavez Institute, San Francisco State University. Diaz has been principal investigator of several funded research projects on the impact of social discrimination and social oppression on the risk for HIV among Latino gay men.

APPENDIX A

Stigma Constructs, Factors, Items, Cronbach’s Alpha Coefficients, and Means (Standard Deviation)

Experienced Racial Stigma^a
Work	Alpha .81; Mean 2.2 (.88)
How often have you …
been treated differently in the workplace because you are Latino?
have you been given more work than others because you are Latino?
have you found it difficult to obtain employment because you are Latino?
Public Discrimination	Alpha .85; Mean 2.1 (.78)
How often have you …
been ignored or treated with less respect than others in public places because you are Latino?
have others looked at you suspiciously because you are Latino?
(as an adult) been treated differently because of your accent or because you do not speak English well?
been treated with less respect than others because you are Latino?
felt that you are not accepted in mainstream U.S. society because you are Latino?
Harassment	Alpha .73; Mean 1.5 (.68)
While growing up, how often were you pushed around or hit for being Latino?
As an adult, how often have you been pushed around or hit for being Latino?
As an adult, how often have you been made fun of or called names for being Latino?
Rejection in Romantic Relationships	Alpha .69; Mean 1.5 (.74)
How often have you had trouble finding romantic relationships because you are Latino?
How often have potential romantic or sexual partners taken more interest in your race than in who you are as a person?
Internalized Racial Stigma^b
Blame	Alpha .64; Mean 1.9 (.88)
Latinos are to blame for high crime rates in the U.S.
Latinos are partially to blame for people’s negative attitudes towards them.
Shame	Alpha .74; Mean 1.5 (.58)
If I were not Latino, I’d probably be happier.
Latinos who are lighter-skinned are usually better people than darker- skinned Latinos.
I sometimes feel ashamed of being Latino.
As a Latino, I sometimes feel undesirable or unattractive.
Social Distance	Alpha .78; Mean 1.6 (.67)
I prefer to date white people rather than Latinos.
I prefer to hang out with white people rather than with Latinos.
As a Latino, I sometimes feel embarrassed by the way my family acts.
Experienced Homosexual Stigma^a
Childhood Maltreatment	Alpha .87; Mean 2.4 (.98)
While growing up, how often …
were you made fun of or called names by your own family, because of the way you behaved?
did other kids make fun of you or call you names because of the way you behaved?
were you pushed around or beaten up because of the way you behaved?
did members of your family tell you to change your behavior because you looked too effeminate?
Family	Alpha .82; Mean 1.9 (.82)
How often …
(as an adult) has your family made fun of you or called you names because of your sexual orientation?
were you rejected by your family because of your sexual orientation?
have you been told to consult a mental health professional because of your sexual orientation?
have you moved away from friends and family because of your sexual orientation?
Social Rejection	Alpha .79; Mean 1.8 (.73)
How often …
has a friend rejected you because of your sexual orientation?
have you been treated unfairly at work because of your sexual orientation?
have you been treated differently in social situations because of your sexual orientation?
have you received poor service because of your sexual orientation?
Harassment	Alpha .71; Mean 1.9 (.86)
As an adult, how often…
have you been made fun of or called names by other people because of your sexual orientation?
have you been pushed around or beaten up because of your sexual orientation?
Internalized Homosexual Stigma^b
Shame	Alpha .83; Mean 1.8 (.68)
I have tried to stop being attracted to men.
I would like to get professional help in order to change my sexual orientation.
Sometimes I wish I could become more sexually attracted to women.
I feel that being gay is a personal shortcoming for me.
Sometimes I feel ashamed of my sexual orientation.
I am afraid my family and friends will find out about my sexual orientation.
Change Sexuality	Alpha .80; Mean 2.1 (.88 )
Sometimes I wish I were not gay.
Sometimes I think that if I were straight, I would probably be happier.
If there were a pill to make me straight I would take it.
Endorsement Normative Masculinity	Alpha .68; Mean 2.3 (.85)
Men who look or act too effeminate make me feel uncomfortable.
It is important for men to look and behave in a masculine way.
Blame	Alpha .55; Mean 2.0 (.73)
Gay people are promiscuous.
Gay people are to blame for society’s attitudes toward us.

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Responses range from never (coded 1) to many times (4).

Responses range from strongly disagree (coded 1) to strongly agree (4).

Footnotes

We use gender nonconformity to refer to identities and behaviors that do not fit dominant gender expectations.

Sampling weights are calculated using the statistical theory upon which respondent-driven sampling is based—a mathematical model of the recruitment process derived from Markov chain theory and biased network theory (Heckathorn 1997). Population inferences are based on information on the proportional recruitment across groups and the estimated mean network size for each group. For a two category system with groups A and B, where S_ab is the proportion of Bs selected for recruitment by As, S_ba is the proportion of As selected for recruitment by Bs, and N_a and N_b are the network sizes for groups A and B, the estimated proportion of As, P_a, in the system is:

P_{a} = \frac{S_{b a} N_{b}}{S_{b a} N_{b} + S_{a b} N_{a}}

The respondent-driven sampling population estimator is the ratio of two Hansen-Hurwitz estimators—a statistical estimator known to be unbiased. The ratio of these estimators is asymptotically unbiased, which means that bias is only on the order of 1 divided by the sample size. Hence, bias is trivial in larger samples. See Ramirez-Valles et al. (2005b) for a detailed explanation. This expression also controls for differences in recruitment effectiveness.

We found no significant differences in sexual risk behavior by categories of HIV status/testing. We did, however, find that those who are HIV-positive are more likely to report experiences of stigmatization than all others (ANOVA, F = 2.8, df = 4, p < .05; post-hoc Scheffé tests for mean difference, p < .05). No significant differences were found for other measures of stigma. For this reason, we dichotomized HIV status with HIV-positive participants in one category vs. all others.

⁴

We examined whether racial and homosexual stigma constituted a higher order stigma factor and found no support for this hypothesis.

⁵

We ran additional analyses eliminating transgender participants. We found essentially the same trends, except that the path from internalized homosexual stigma to sexual behavior under the influence was borderline significant (z = 1.94, p = .05). In the “DIFF Test” (or test of moderation) we found similar trends, but the test did not reach significance.

⁶

About 41 percent of the sample reported involvement in Latino issues. But the overlap between HIV/AIDS and Latino or GLBT and Latino organizations is unknown. Involvement in Latino issues (or any other non-HIV/AIDS or GLBT issues) did not have any effect on the associations between stigma and sexual behavior under the influence or sexual risk.

⁷

The fact that San Francisco has a higher HIV prevalence and community involvement than Chicago does not contradict our conclusions. This city has a more extensive and older epidemic. Yet we are not predicting prevalence, but sexual risk behavior, and although they are related, they are not the same, and both are affected by many factors, one of which is stigma. San Francisco, having a higher HIV prevalence, also has a higher probability of transmission than Chicago. Moreover, HIV-positive status (and the overall higher HIV prevalence) may lead to community involvement, which in turn, may increase awareness of both homosexual and racial stigmata. This could also explain the higher reporting of experiences of racial and homosexual stigma in San Francisco compared to Chicago.

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[R1] Agnew Robert. “Building on the Foundation of General Strain Theory: Specifying the Types of Strain more Likely to Lead to Crime and Delinquency”. Journal of Research in Crime and Delinquency. 2001;38:319–361. [Google Scholar]

[R2] Anthias Floya. “Race and Class Revisited— Conceptualizing Race and Racisms”. Sociological Review. 1990;38:19–42. [Google Scholar]

[R3] Ayala George, Diaz Rafael. “Racism, Poverty and other Truths about Sex: Race, Class and HIV Risk among Latino Gay Men”. Interamerican Journal of Psychology. 2001;35:59–77. [Google Scholar]

[R4] Bancroft John, Vukadinovic Zoran. “Sexual Addiction, Sexual Compulsivity, Sexual Impulsivity, or What? Toward a Theoretical Model”. Journal of Sex Research. 2004;41:225–234. doi: 10.1080/00224490409552230. [DOI] [PubMed] [Google Scholar]

[R5] Bellah Robert N, Madsen Richard, Sullivan William M, Swidler Ann, Tipton Steven M. Habits of the Heart: Individualism and Commitment in American Life. Berkeley: University of California Press; 1996. [Google Scholar]

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PERMALINK

Social Integration and Health: Community Involvement, Stigmatized Identities, and Sexual Risk in Latino Sexual Minorities

Jesus Ramirez-Valles

Lisa M Kuhns

Richard T Campbell

Rafael M Diaz

Abstract

THEORETICAL FRAMEWORK

Figure 1.

Stigma of Gender Nonconformity

Racial Stigma

Community Involvement

METHODS

Sample

Data Collection

Measures

Sexual risk: Sex under the influence of substances

Sexual risk: Sexual risk behavior

Homosexual stigmatization

Racial stigmatization

HIV/AIDS and GLBT community involvement

Sociodemographic variables

Table 1.

HIV status

Acculturation to the United States

Data Analysis

RESULTS

Confirmatory Factor Analysis and Measurement Model

Figure 2.

Table 2.

Test of the Structural Model

Test of Moderation

Table 3.

DISCUSSION

Acknowledgments

Biography

APPENDIX A

Footnotes

REFERENCES

ACTIONS

PERMALINK

RESOURCES

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