Effects of Minority Stress Processes on the Mental Health of Latino Men Who Have Sex with Men and Women: A Qualitative Study

Abstract

Emerging literature on minority stress among sexual minority populations has described the negative consequences that multiple minority statuses may exert on mental health and well-being. This literature has tended to focus on individuals whose self-identifications reflect sexual minority sexual categories, such as gay or bisexual, and has explored the intersection of these definitions with ethnic, racial, and class statuses. Few such studies have explored mental health among men who actively deny a sexual minority sexual identity label while engaging in same-sex sexual behaviors. The present study used ethnographic interview data from 20 non-gay-identified bisexually behaving Dominican and Puerto Rican men in New York City. Participants described discovery of same sex sexual behavior as a threat to their intimate relationships, community affiliation, and counter to expectations of Latino masculinity. Recounting a wide range of information management strategies used to avoid open disclosure about their sexual lives, participants experienced the potential consequences of disclosure as extreme and even life threatening. Men anticipated social isolation, depression, self-injury, and suicidality as possible outcomes from disclosing sexual behavior with other men to their female romantic partners. This analysis provides direction for future research on minority stress processes and mental health service delivery among Latino men who have sex with men and women.

INTRODUCTION

Health literature on lesbian, gay, bisexual, and transgender (LGBT) populations has expanded dramatically, focusing on a range of health issues, including mental health (Mayer et al., 2008). Several studies have documented disparities in mental health and substance use patterns among sexual minority populations when compared to their heterosexual counterparts (Cochran & Mays, 2000; Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007; Cochran, Sullivan, & Mays, 2003; Sandfort, de Graaf, Bijl, & Schnabel, 2001). In a study using the National Epidemiologic Survey on Alcohol and Related Conditions, Bostwick, Boyd, Hughes, and McCabe (2009) found that LGB identity was associated with higher odds of the mood and anxiety disorders they studied, including major depression, dysthymia, phobias, and generalized anxiety disorder. McCabe, Hughes, Bostwick, West, and Boyd (2009) also found that, in general, non-heterosexual orientation was associated with higher rates of both substance use and substance dependence. Suicidality is also a major health concern among LGBT populations (for review, see Haas et al., 2010), with gay and bisexual men four times more likely to attempt suicide as compared to their heterosexual counterparts (King et al., 2008).

The disproportionate mental health burden among LGBT populations has been attributed to the multiple stresses that these individuals experience as a result of their sexual minority status. Minority stress theory (Meyer, 2003; Meyer, Schwartz, & Frost, 2008) suggests that stress is a function of social systems that promote discrimination and stigmatization of sexual minority populations. Accordingly, the processes that contribute to stress among sexual minorities include experiences of prejudice (both structural and individual), anticipation of rejection, concealment of sexual identity, and the extent to which individuals integrate sexual minority identity with other identities. Much of the extant literature assumes that identities are more or less prominent in different situations/contexts, highlighting the fluidity or contingent nature of sexual minority sexual identities. However, little attention has been devoted to individuals or groups who do not espouse a sexual minority sexual identity or who actively seek to conceal their same-sex sexual behavior while espousing a heterosexual public identity. From a public health perspective, this population is of particular importance given research linking men’s desires to minimize social risks (i.e., threats to one’s social status or relationships) and the transmission of HIV within heterosexual relationships (Hirsch et al., 2007) and arguing for greater attention to the cultural underpinnings of sexual communication as a critical component of effective HIV prevention efforts (Carrillo, 2001).

There is some evidence to suggest that the integration of sexual minority identity and the expression of stigmatizing aspects of the self can help maintain physical and mental health whereas repression and inhibition can negatively affect immune function and health outcomes (Pachankis & Goldfried, 2010). For example, Crawford, Allison, Zamboni, and Soto (2002) found that, in a sample of African American gay men, those who identified with a racial minority identity and a gay identity (i.e., integrated identity) had higher levels of self-efficacy, stronger social support networks, greater levels of life satisfaction, and lower levels of psychological distress compared to those whose identities were less well-integrated. This integration may buffer stigma by promoting affiliation (Meyer, 2003); those who identify with a sexual minority sexual identity are more readily able to access LGBT communities and social support from similarly identified others. A more recent study found that greater concealment of same sex sexual behavior was associated with lower levels of mental health, which was fully mediated by internalized homophobia and general emotional support (Schrimshaw, Siegel, Downing, & Parsons, 2013).

Following the logic of these findings, individuals who identify with a heterosexual identity would be likely to exclude themselves from gay-related affiliation experiences, limiting the availability of a resource that may promote well-being. Nevertheless, such a conclusion is complicated by the findings from other studies showing that identification with a gay community may be especially challenging for racial/ethnic minorities (Pathela et al., 2006; Ross, Essien, Williams, & Fernandez-Esquer, 2003), who may be members of culturally distinct immigrant communities or ethnic populations in which sexual minority sexual identities are presumably less acceptable than among their White counterparts (Lewis, 2003). There is some evidence to suggest that the competing needs for affiliation of these individuals can contribute to elevated minority stress. In an early study, Siegel and Epstein (1996) found significantly higher gay-related minority stress among Puerto Rican and African American gay men than among White gay men. Diaz, Ayala, Bein, Henne, and Marin (2001) showed high prevalence rates of psychologic distress in a probability sample of over 900 non-heterosexually identified Latino men during the 6 months prior to the study, including suicidal ideation (17% prevalence), anxiety (44%), and depressed mood (80%). A more recent study including non-heterosexually identified Latino men demonstrated higher rates of psychiatric morbidity in this population compared to their heterosexual counterparts (Cochran et al., 2007).

There are numerous qualitative studies that have examined sexual behavior and disclosure practices among gay and bisexually behaving Latino men (Carballo-Diéguez, Remien, Dolezal, & Wagner, 1997; Diaz, 1998; Finlinson, Colón, Robles, & Soto, 2006; Muñoz-Laboy, 2008). Many of these studies have argued that family and community relations play crucial roles for Latino men who have sex with men and women (MSMW¹), who may fear discrimination and marginalization (Diaz, 1998; Guarnero, 2007; Muñoz-Laboy, 2008). Other studies have focused on the specific social and economic constraints on the disclosure of sexual minority identity and behavior, as well as the culturally available strategies that these men use to express their sexuality while remaining connected to family and community (Carrillo, 2001; Decena, 2011).

Few studies have focused on Latino men who engage regularly in both opposite- and same-sex experiences while actively concealing (or maintaining discretion about) certain aspects of these experiences from their female partners. Because their sexual behavior is inconsistent with the presumptions of normative heterosexuality, these men fall between social and epidemiological categories of sexual orientation and, as a result, they are often neglected in the framing of health research and writing on sexual health and HIV/AIDS. Indeed, these men are often described as “hard-to-reach” because they do not openly identify with a static sexual identity that is concordant with their sexual behavior (Khan & Khan, 2006). The relative neglect of these men in research results in a myopic understanding of the ways that social stigma affects health and well-being for sexual minority sexual identities. Research on the ways that heterosexually identified men who have sex with men manage social stigma within their distinct cultural and ethnic environments may help generate new strategies for prevention that cross-cut traditional “risk groups.”

The degree to which Latino MSMW withhold or alter information about their same-sex sexual practices or use strategies such as ambiguity, subterfuge, silence, or partial disclosure to maintain discretion about their same-sex sexual behaviors may have significant implications for the mental health of these men and, perhaps, the burden of HIV risk in their sexual networks. While ours was a small qualitative study that cannot demonstrate elevated risk of mental health outcomes or HIV infection among the men we studied, we argue that the communication dilemmas and discretionary practices these men utilize are important for understanding how they manage the “social risks” of their extra-relational sexual behaviors (Hirsch et al., 2007). The present study sought to describe the sexual identity and disclosure practices among Latino MSMW and the impact of sexual disclosure dilemmas and strategies for concealment on their mental health and well-being. Our primary aim in this article was to explore the mental health effects of these experiences. This is because we believe the potential mental health consequences faced by the men as a result of concealment may contribute to the HIV risks they or their partners face, as the social stresses begin to impinge upon their overall decision-making and psychological well-being.

Specifically, this analysis focused on: (1) Latino MSMW’s narratives of their sexual identity, understandings of masculinity, and practices of disclosure (or non-disclosure) of same-sex attraction and sexual behavior to primary female partners; (2) how Latino MSMW’s practices of non-disclosure were informed by cultural norms of gender, sexuality, and experiences of stigma and discrimination; and (3) potential consequences of concealment of same sex sexual behavior on Latino MSMW’s mental health and well-being.

METHOD

Participants and Procedure

Data were gathered through semi-structured interviews with MSMW of Puerto Rican or Dominican ancestry living in New York City (N = 20). The selection of these two groups was an attempt to be attentive to the vast cultural diversity of Latino populations by focusing on men whose heritage is linked to a more specific cultural and geographical area, while also increasing the feasibility of recruitment by selecting participants from two Latino sub-populations that are well-represented in New York City. Participants were recruited through flyers posted in a range of community agencies serving Latino communities throughout New York City. These flyers instructed potential participants to call a toll-free number where they were asked a series of screening questions to determine their eligibility in the study. Men were eligible to participate if they indicated that they were of Puerto Rican or Dominican heritage; that their primary sexual partner (married or unmarried) was female; and that they had had sex with at least one man during their relationship with a woman. In order to ensure a wider catchment of eligible participants, the reported same-sex relationship did not have to be concurrent with their opposite-sex relationship at the time of the interview.

Confidential, audio-recorded interviews that lasted approximately 90–120 minutes were conducted in English and/or Spanish depending upon participant preference at community-based agencies in New York City. Following the semi-structured interview, participants were given a brief questionnaire that gathered quantitative demographic and sexual behavior disclosure information. The Institutional Review Boards at Columbia University Medical Center and the University of California, San Francisco approved the research protocol prior to implementation. The Institutional Review Board at the University of California, Los Angeles approved secondary data analysis for the present article.

Measures

Semi-structured interview guides contained a range of questions² related to sexual identity, masculinity, sexual relationships with both male and female partners, and anticipated reactions to or consequences of disclosure of same-sex sexual behavior. For the purpose of this study, three sets of codes were abstracted for formal coding and analysis: (1) codes related to masculinity; (2) codes related to concealment of same sex sexual behavior; and (3) codes related to consequences of disclosure of same sex sexual behavior.

Masculinity

To gain a better understanding of how they understood and constructed ideas regarding gender norms, participants were asked to describe their conceptions of masculinity. They were probed on what it means to be and act “masculine” and were asked to explicitly describe the qualities of men they know who met their criteria of a “masculine” man, including how a “masculine” man behaves sexually. These questions were designed to explore the participant’s notions of masculinity as a gender construct. Participants were also asked to describe what it means to not be masculine and to differentiate between how masculine and non-masculine men are treated by others. Additionally, each participant was asked to describe how he believed masculinity is perceived and treated within his specific culture (Dominican or Puerto Rican), with the goal of better understanding how culture influences one’s perception of gender norms.

Concealment of same-sex sexual behavior

Participants were asked to discuss the extent to which they tried to conceal their sexual relationships with men from others, as well as the methods of concealment or discretion used to manage information about these relationships. They were specifically asked if their female partner(s) were aware of their sexual involvement with men, as well as the degree to which they believed their partner(s) knew about these activities. If a participant indicated that he made a concerted effort to ensure his female partner(s) did not find out about his sexual experiences with men, follow up questions regarding methods of concealment or discretion were asked. This helped to gain a better idea of how participants managed this information and the lengths to which individuals believed they needed to go in order to conceal same-sex sexual behavior from others.

Consequences of disclosure

In addition to questions about concealment efforts, participants were also asked to discuss the consequences they believed they might face if their female partner(s) were to find out about their sexual relationships with men. They were specifically asked if concealment of their sexual relationships with men was an attempt to avert specific consequences and, if so, what they believed the consequences might be should others find out. If a participant believed there would be consequences to others learning about his same-sex relationships, he was asked to describe the impact of these consequences on himself as well as his female partner(s).

Data Analysis

The present analysis focused primarily on the information gathered through semi-structured interviews; however, survey data are presented to provide context for understanding participants’ demographic characteristics and disclosure practices. Qualitative interviews were digitally recorded, transcribed, and coded by bilingual researchers using a methodology of “Coding Consensus, Co-occurrence, and Comparison” outlined by Willms et al. (1990). The research team reviewed an initial sample of interviews to identify key themes via in vivo coding, which formed the basis of a formal codebook. The codebook was discussed and refined after initial coding of a sub-set of interviews (n = 5) and, once finalized, two members of the research team (IWH, MP) were responsible for coding the interviews. Iterative communication between research team members took place during formal coding, for which we used ATLAS.ti (1999) textual analysis software. When inconsistencies between coders was noted, and third member of the research team (VGR) was consulted to discuss and help resolve these inconsistencies. Our analysis here focused in particular on the narratives that directly examined the three thematic areas named above (i.e., masculinity, concealment of same-sex sexual behavior, consequences of disclosure).

Analysis was guided by grounded theory (i.e., theory derived from data and then illustrated by characteristic examples of data) (Glaser & Strauss, 1967); transcripts were reviewed and memos were written to document initial concepts and to define the boundaries of specific concepts (Miles & Huberman, 1994). Field notes and interview transcripts were then independently coded to condense the data into analyzable units. Segments of text ranging from a phrase to several paragraphs were assigned codes based on a priori definitions (i.e., from the interview guide) or emergent themes (also known as open coding) (Strauss & Corbin, 1998). Based on these codes, the computer program ATLAS.ti (1999) was used to generate lists of codes, which were then summarized and entered into data matrices (with the participant on the column and content area on the row) for comparison across participants. Through the process of constant comparison, the codes were further condensed into broad themes (Glaser & Strauss, 1967), which are reported here. Pseudonyms were used in lieu of actual names to maintain confidentiality and protect the identities of participants.

RESULTS

Participants were between the ages of 22- and 46-years old (M = 32; SD = 7). Over two-thirds of participants were Puerto Rican (n = 14; 70 %) and nearly one-third Dominican (n = 6; 30 %). Half of all participants were born in the United States (n = 10; 50 %) and the majority identified themselves as bisexual to the interviewer (n = 14; 70 %). During participants’ relationships with their current female partners, 95 % (n = 19) of men reported having had sex with a man. One fourth of participants reported that their female partner knew anything about their current or past sexual relationships with men and nearly half (n = 9) indicated that discussing relations with men with their female partners was of any importance. The majority of men reported actively trying to conceal their same-sex sexual behavior from their female partners (n = 18; 90 %) and most believed they were (very) “successful” at doing so (n = 15; 75 %). When asked whether it was important for their female partners to know more about their sexual relationships with men, the sample was divided, with 55 % (n = 11) indicating that it was of little or no importance. Additional disclosure data from the brief social survey are shown in Table 1.

Table 1.

Sexual behavior and sexual behavior disclosure to female partners (N = 20)

Variable	N	%
How much discussed sexual relations with men with female partner
Everything	1	5 %
Somewhat	3	15 %
Nothing	16	80 %
How much female partner knows about sexual relations with man
Everything	1	5 %
Somewhat	3	15 %
Very little	1	5 %
Nothing	15	75 %
Importance of discussing relations with men with female partner
Extremely important	3	15 %
Important	5	25 %
More or less important	1	5 %
Of little importance	2	10 %
Not important at all	9	45 %
Importance that female partner know more about relations with man/men
Extremely important	6	30 %
Important	2	10 %
More or less important	1	5 %
Of little importance	2	10 %
Not important at all	9	45 %
Prevents female partner from finding out about relations with men	18	90 %
Success at preventing female partner knowing about relations with men
Very successful	13	72 %
Successful	2	11 %
Somewhat successful	2	11 %
A little successful	1	6 %

Note: Sample sizes vary due to missing data on certain variables

Stress Related to Masculinity Expectations

Participants almost universally described themselves as “masculine” (masculino). When asked to define masculinity, men gave a range of responses related to both physical appearance and personality. Masculine men were defined as “serious,” “show[ing] little emotion,” and “hardworking.” More commonly though, men responded to this question by citing examples of masculinity that were manifest or expressed in behavior. Some thought that a masculine man was “macho,” “a womanizer,” and “a bigshot,” expressing the belief that masculinity was directly related to a man’s demonstrable ability to attract many women. For example, Rocco, a 36-year-old Puerto Rican man from New York, compared a masculine man to James Bond, who “is so articulate and so like perfect with the women and…takes his time picking what he wants.”

Other participants felt masculinity was reflected in an individual’s ability to be reserved in his behavior and dress. Being reserved involved the conscious avoidance of any behavior considered loud or flamboyant. For example, Raul, a first generation 37-year-old Puerto-Rican man from Brooklyn, indicated, “Well, if you have good posture; if you walk without any attitude. If you just walk regular, you know? That’s what we say is masculine.” Inherent in these comments was a logic that being reserved in one’s masculine presentation was counterposed to the presumed lack of restraint of effeminate men, whose conduct was roundly criticized by the participants, often with implicit or explicit derogatory statements about flamboyant men. Michael, a 22-year-old Dominican man from the South Bronx, for example, stated that a masculine man “dress[es] like a man. [He] doesn’t put on skirts or tight leathers or Spandex leotards…[he doesn’t] put on makeup.” Still others described masculinity in relation to a man’s intimate relationships with other men; for example, one participant explicitly stated that masculine men did not allow themselves to be penetrated sexually. Another described masculine men as not “jodiendo con homosexuales” (fooling around with homosexuals) and implied that there was a social cost to doing so. Alejandro, a 34-year-old Puerto Rican born man, painted a pejorative picture of a man who was not masculine: “I would describe him as an effeminate man, who has fragile emotions…a man that cries for any silly things…a man that does not like women, a man that is sensitive, who speaks about feelings is really…really weak.”

Several men described both sexual and emotional attachments to women, but only sexual attachment to men. To describe their attraction to men, participants used phrases like having “gustos differentes” (different tastes) and being “a little weak.” For these men, same-sex sexual behavior was perceived as reducing or endangering their masculinity. Participants’ opinions of themselves were closely tied to the way they felt they would be perceived by others for not upholding standards of masculinity. For example, Juan, a 24-year-old Puerto Rican man from New Jersey, described the vigilance with which he had to monitor his behavior and the mental health consequences of that vigilance:

You know, I play the role pretty good, I think. But maybe I don’t, you know. Sometimes I’m just in the moment, just chilling whatever and I catch myself, you know, with a little feeling…You know what I mean? I can tell when I’m feminine. You can tell from the feminine to masculine. I don’t know. Like I said, it might be just be my paranoia.

Juan remarked on the masculine performance that he had to enact for his female partner and the emotional consequences of being perceived as feminine:

When people start talking about me, oh, faggot this, and, you know, he’s [a] faggot. I was playing the role for her, but inside I felt different…Like, you know, I don’t know…it kind of affects me now when people say faggot. I kind of feel like, huh?

Yet another participant, Antonio, commented on the false masculine self he had to present to the world in order to be well regarded by others:

I don’t let my whole self come out. I just let whatever I want people to view me as out. I’ll talk about my heterosexual experiences, because that makes me look masculine, and it makes me look, in a way, kind of cool. And if…I was to tell them I’m a homosexual, they would look at me [as] weak or feminine, so I leave it alone.

Stress Related to Concealment

Participants agreed that the affairs they had with male partners were very different from affairs they may have had with women. Luis, a 27-year-old Dominican man who emigrated to the U.S. from the Dominican Republic when he was 24 and worked as a stripper in a night club, remarked:

It’s easier for a woman to tolerate [a man having affairs with other women. When] a person is gay…people see it as something bad, that those people are sinning people. Many women know that their husband has other women. But if they know that that man has already… is with another man, those are things that women, it’s very difficult, you know?

The majority of men reported taking measures to prevent their female partners from finding out about their relations with men (n = 18; 90 %). Some participants described incidents in which their female partners suspected them of having relationships with men. Rodrigo, a 38-year-old Puerto Rican man born in Brooklyn who was married and reported having multiple current male and female sexual partners, observed that his female partner was “always checking [his] pockets” and “sometimes smelling [his] underwear” because she suspected him of cheating on her with men. He described an incident when his female partner overheard him talking on the phone to a male partner:

So I told her that I had to go someplace. And she was like, “Oh, you’d rather be with him than me?” And all of a sudden [I had to] make up a lie that he was going to show me his car. And she called like two or three times and all two or three times I had to lie. And she knew something like was fishy, like she suspected. She don’t…she don’t come outright and say that, but I could tell that she suspected it.

Suspicions from female partners prompted some participants to develop elaborate strategies to keep their female partners from finding out about their involvement with men. One man described a code he used for switching the digits of male partners’ phone numbers to prevent his female partner from calling them and discovering his same-sex sexual behavior. Other men reported only having sex with men when their female partners were out of town or traveling to different neighborhoods from those where their female partners lived to have sex with men.

Information management for these men was often difficult, as evidenced by “close calls” where female partners nearly discovered men’s sexual relationships with other men. Luis told a story about a male partner calling his home:

Okay, once she told me that someone that called her, supposedly, a man called that told her that I was…his lover, do you understand? She told me that, but I think that she suspected something, without my being aware, she took the phone, and then she threw it at me, to see if I would say something…[I told her] maybe it was someone trying to pull a prank on her, fucking around, but…things had already cooled off, I noticed, she was pretty cold.

In the survey, most participants reported success at preventing female partners from knowing about sexual relationships with men (n = 18, 90 %). In the qualitative interviews, men spoke explicitly about elaborate methods they used to “cover their tracks.” For example, Alejandro, the 34-year-old Puerto Rican man described above, indicated specific strategies he employed to avoid suspicion of his current girlfriend when he went out with men:

I don’t carry condoms in my wallet. Whenever I leave with my clothes, I come back with the same ones, I try to not change clothes, to not get back with the scent of a cologne that is different to the one I use…no phone numbers, no pictures of them, I don’t come back with the soap from the hotels in my pockets or with the towellettes from the hotels. [I’m] really careful.

Despite this level of care in the practice of discretion, other evidence indicated that men were only partially successful at keeping information about their male partners secret from their female partners. Juan, a 24-year-old Puerto Rican man with a steady girlfriend of two years, acknowledged that “she has a little something in the back of her head [about my relationships with men], but she doesn’t want to admit to herself because she doesn’t want it to be true.” This quote illustrates the unspoken collusion or complicity of both male and female partners in not openly talking about men’s sexual relationships with other men. This was emphasized by Victor, a 25-year-old Puerto Rican man, who, when asked about how he managed information about male partners, replied, “I don’t…that’s why I don’t ask her who she’s fucking and she never asks me. It’s like a fairy tale, you know.”

When strategies men used to conceal their same-sex sexual behavior were not successful, it presented a source of significant stress. For example, despite his attempts to keep his sexual relationship with men secret, Rodrigo, a Puerto Rican man from Manhattan, reported that his female partner was suspicious and asked constant questions about his whereabouts:

So, when it has reached to a point where she’s always getting into these little arguments…I tell her…I can’t live like that. I can’t be like that. I don’t do that to her. I’m not like “Where you at?” “What are you doing?” you know. “You better not to do this.”

Another participant Juan, described above, explained the discomfort he felt around his wife’s friends, who he suspected might know about his relationships with men, “I’m a little paranoid with a couple of her friends. And so that might be part of it, too. But, I don’t know…I can feel it. You know, when you feel something, you feel something.” For other participants, fears about others discovering their relationships with men extended to the ways in which they conducted themselves in public with other men. Antonio, a 38-year-old Puerto Rican man, didn’t touch other men in public, stating, “No, because when you do that, you set yourself up, and, you know, people could use that against you, you know, I don’t want people to…represent me [negatively] …at their convenience.” Renado, a 32-year-old Puerto Rican man from the Bronx, described a deeper emotional connection to his male partner than most other participants and directly commented on the stigma that could result from others knowing about his feelings for his male partner:

I can’t [be affectionate] with him. Not in public. For two reasons. One, because I’m not comfortable being like that with a man in public. And, two, because it’s also frowned upon by society. You know, it’s like, I mean…[I] live in the Bronx. I don’t see myself holding his hand, walking along in the Bronx…I don’t want the people talking. Whether they know me or not, I just don’t want, you know, people like, “Oh, my God! Look.”

For men who felt romantic feelings both toward men and women, the stress of managing not only information but emotion related to these romantic feelings presented another source of stress. Renado, one of the only men who described an emotional connection to a male partner, later described how difficult it was for him to hide his feelings about a male partner from his primary female partner and what it might be like to tell her:

I want to do it before we…get married…because I want her to know everything she’s getting into. Just like I want to know everything I’m getting into. But…I’m not mentally ready for that yet. Because…I’m not sure what I want yet. Maybe if, let’s say by next month I really want to be with him, then I would have that conversation, regardless of what the consequences would be. Because it’s not fair for me to go into a marriage with her, but loving him, but being in love with her, it’s mentally strange.

Stress Related to Perceived Possibilities of Disclosure

For most men, the fear of their female partners finding out about sexual relationships with male partners was significant. Men described responses from female partners ranging from “[she] would deal with it” to “she would kill me.” Renado, described above, who was engaged to a woman with whom he had been in a relationship for 14 years, envisioned what would happen if his fiancé discovered he was sexually active with men:

She’ll cry. She’ll scream. She’ll hate me. And, then, plus, you know, like, my son is also involved and I don’t know how she is going to react. If she doesn’t want me to see my son. I mean, there’s a lot of extras involved.

Other participants used narratives of violence and other serious consequences that would result in their female partners finding out about male partners. Some men felt that their female partners would be so enraged that they would seek retribution by exposing the man’s same-sex sexual behavior to family and friends. Several men felt that disclosure of same-sex sexual behavior to their female partners would mean the end of those relationships. Men also described their female partners’ reactions with words like “disgust,” “shame,” and “rage.” Ramón, a 22-year-old Puerto Rican man from Manhattan, said his female partner was explicit about her response if she were to find out he was with another man: “I’ll fucking kill you.”

Almost all of the men interviewed described negative consequences of disclosure about same-sex relationships to their female partners, with one exception. Carlos, a 31-year-old Dominican man who had recently moved to the U.S., spoke of the benefits of both his male and female partners knowing about one another:

It is more comfortable…because you are constantly fearing that someone is going to see you or someone who is friends with your girlfriend or your friend, or whomever…they might see you with a gay or something… or they might see you at a gay place or they might realize. Because it is easier that they see you with your girlfriend and she knows it can tolerate it more.

Despite the perceived benefits of disclosure about his male sexual partner to his female partner, Carlos still felt the need to conceal and omit information about his relationship with this man. For example, he lied about the frequency of which he saw his male partner and felt comforted by the fact that his male and female partners lived far apart from each other.

Mental Health Consequences

Several men described mental health consequences for themselves that resulted from the stress of concealing same sex sexual behavior or which would stem from disclosure of their sexual relationships with men. These consequences ranged from mild stressors, such as confusion, anxiety, and fear, to more severe mental health issues, which included substance use and suicidality. Rodrigo, described above, spoke of “a state of confusion” about his attraction to men, which was the result of the social norms about homosexuality in his upper Manhattan neighborhood.

You know, I’m living in society, and I’m not living in a mountain somewhere. I have to adhere by society’s rules. So, society says, you know, I think maybe you shouldn’t be kissing that man, you know, not here. It’s the majority rules. So, in Chelsea, it’d be okay, you know, different neighborhoods, different behavior, with different things. It’d be okay to do things a certain way. But in other places, you have to behave according to what the majority would allow.

Rodrigo went on to describe the fear that stemmed from how he would be viewed by his friends and family were they to find out about his relationships with men:

I mean, you have fear that would lead you to say, you know… people are going to classify me a certain way. And that way would lead towards, you know, quote-unquote gay-bashing or that would lead towards a place that I don’t even know yet. I haven’t experienced it, so I have a fear of going there. But, you know what I’m saying?

Michael, described above, expressed shame and confusion when referring to his experiences of attraction for men while in a relationship with his female partner:

I think a lot of my problems have to do with some of the confusion of sexuality. Now, I feel like I’m not totally a homosexual, but I’m being aroused by a man, and it’s like real confusing and real hard…a real emotional struggle, like a war inside. I want to deny it, and I don’t…I don’t want to. I’m ashamed of it, you know. But I get, you know, aroused. And I feel like, even if I am aroused with all that, I’ve made up my mind, my decision to [be with] my daughter and my wife that after the relationship is over with this man I’m currently with, I mean, I’m never going through that again.

Michael went on to speak at length about feeling “disgusted” and “guilty” with himself for having simultaneous sexual relationships with male and female partners. He described his attraction for men as immoral when he stated:

Because I feel like I’m a Christian, and I feel like this is a sin what I’m doing. And I believe it’s a sin…I told God I’m not perfect, that I fell into temptation and abomination, and that’s how…I’m attracted to, just that temptation and not go back to those pleasures of the flesh.

When asked what would happen if his female partner were to find out about his relationships with men, Michael stated:

Oh, forget about it. I think she would need therapy. She would jump on me, kill…you know, tell everybody in the family that I’m a faggot and shit like that. She’ll destroy my life for a little while, you know, because it will hurt her so much and she’ll feel…she’ll feel very dissed and all that.

When probed further about the perceived mental health consequences that would result from disclosure of his same sex sexual behavior to his female partner, Michael envisioned a bleak future:

I would have to leave New York, because I won’t be able to face my friends and everybody, you know. I have, in my neighborhood, I got a reputation and so forth, and I won’t be able to look anybody in the eye.

Michael went on to indicate that this disclosure might prompt him to “have a nervous breakdown, go into drugs…or even [commit] suicide.”

DISCUSSION

The present study was a qualitative exploration of stresses experienced by Latino men who engaged in same sex sexual behavior but did not publicly identify with a sexual minority sexual identity (i.e., gay or bisexual). These MSMW experienced stresses related to failure to uphold perceived standards of Latino masculinity, stresses related to hiding their same sex sexual behavior from female partners and stresses related to anticipated consequences of disclosure of same sex sexual behavior. Self-monitoring of one’s behavior and movement, and the pressure to enact masculinity through heterosexual performance, contributed significantly to participants’ experiences of stress, generating negative feelings about themselves and potentially contributing to mental health problems. Based on this and previous work (Decena, 2011; Diaz, 1998; Finlinson et al., 2006; Muñoz-Laboy, 2008), it is evident that Latino MSMW must negotiate constrained social structures when engaging in sexual relationships with other men. The findings from this study also highlighted the utility of a minority stress framework for examining mental health, and well being in this population, which has implications for intervention development with Latino MSMW.

Men in our study primarily identified as bisexual to the interviewer but almost unanimously hid their same sex sexual behavior from their female partners. Participants expressed fear of their female partners finding out about participants’ sexual relationships with men and, as a result, took measures to conceal those same-sex sexual relationships. These men relied on family and community social support networks and feared that disclosure of same-sex sexual behavior to female partners would result in estrangement, isolation, and, in some cases, serious mental health problems. As such, participants limited their interactions with male partners to avoid suspicion of same-sex sexual behavior. Only one of the men described himself as gay to the interviewer; the majority of the study participants had no affiliation with a gay community, which can be a source of considerable support for sexual minority individuals and can buffer minority stress (Meyer, 2003). The group level resources that can counter societal stigmatization related to prejudice and discrimination (Frost & Meyer, 2009; Kertzner, Meyer, Frost, & Stirratt, 2010) were largely unavailable to the men in this study.

Not self-identifying as gay or publicly acknowledging a bisexual identity was likely rooted in perceptions of masculinity among participants and stigmatization of same-sex sexual behavior. Descriptions of masculinity indicated heteronormative constructions of how masculine men should look and act and were generally consistent with the ethnographic literature on (heterosexual) masculinities in the Hispanic Caribbean (Decena, 2011; DeMoya & García, 1999; Padilla, 2007). Participants described masculinity explicitly as not “jodiendo” (playing around) with homosexual men and implied a social cost to doing so. Another common definition of masculinity these men expressed was related to being a womanizer (“un mujeriego”) or sexually involved with many women, a behavioral expectation that directly contradicted sexual relationships with men. In his work on minority stress, Meyer (2003) stated that, “The greater one’s perceived stigma, the greater is the need for vigilance in interactions with dominant group members” (p. 251), which may be why participants publically exaggerated behaviors viewed as typically masculine. The definitions of masculinity espoused by participants emphasize the intersection of multiple identities for this population and the difficulties involved in integrating these identities.

Latino MSMW in our study faced considerable stress related to understanding and integrating their same-sex attraction and behavior into their everyday lives. Overall, participants described their same-sex relationships as secondary to their relationships with primary female partners and preferred non-disclosure to the potential problems they feared would result from discovery of same sex sexual behavior by their wives and girlfriends. Considerable attention has been focused on the “down low” and its relationship to HIV transmission in racial/ethnic minority populations (Martinez-Donate et al., 2010; Millett, Malebranche, Mason, & Spikes, 2005); however, the mental health burden of concealing same-sex attraction and behavior among men who engage in opposite-sex sexual behavior and have stable heterosexual partnerships has been largely ignored (Schrimshaw et al., 2013). Our findings indicated that the mental health burden for men who engage in same sex sexual behavior is significant and future research is warranted to address this gap in the extant literature.

The cultural and community pressures associated with masculinity were barriers to affiliation with gay-identified men, which contributed to feelings of isolation. The men in our study expressed negative views of homosexuality while engaging in same-sex sexual behavior. Internalized homophobia has been shown previously to predict anxiety and depressive symptoms (Igartua, Gil, & Montoro, 2003; Rosser, Bockting, Ross, Miner, & Coleman, 2008) as well as lower levels of self-esteem and emotional stability among men who engage in same-sex sexual behavior. While internalized homophobia has been positively associated with seeking mental health services among individuals openly identifying with a sexual minority sexual identity (Owens, Riggle, & Rostosky, 2007), we could find no studies examining mental health treatment service utilization among men who consider themselves heterosexual and engage in same-sex sexual behavior. The findings from this study on stress processes of Latino MSMW and the dearth of mental health services literature indicate a need for further research on barriers to treatment with this population.

Limitations

The limited representation of Latino nationalities recruited only from the New York City area was a limitation of the study. Results should be carefully interpreted given the small sample size and the way in which men were recruited (i.e., convenience, snowball sampling). Inclusion of 20 participants in our study may point to limited variation in the experiences of Latino MSMW. However, redundancy in participants’ descriptions of stress experiences and the presence of negative case examples lends confidence to the thorough exploration of the conceptual categories of interest. While we present quantitative data on participants’ demographic characteristics and disclosure practices, our study does not present quantitative data on mental health outcomes or demonstrate that mental health problems are higher in our sample than among Latino MSMW who publicly identify as gay or bisexual or Latino men in general. However, this work provide a depth of understanding about the stress experiences of Latino MSMW who do not publicly identify as gay or bisexual; larger studies with more ethnically and geographically diverse Latino MSMW as well as those who disclose their same sex sexual behavior are warranted.

Conclusion

For the men in our study, disclosure of same-sex sexual behavior represented a threat to their personal relationships and integration into community and society. It is important to note that these men’s fears were based on their lived experiences in the communities in which they reside and were neither irrational nor representative of irresponsible behavior, as has been suggested in popular discourse about men with primary female partners who also have sex with men (commonly referred to as the “down low”). Based on the participants’ descriptions, disclosure of same-sex sexual behavior to female partners or others may not be the ultimate goal of mental health services for this population. Indeed, nearly half of the participants indicated that it was “not at all important” their female partners know more about their sexual relationships with men. Identity integration may best be focused on identity management that feels most safe and comfortable for Latino MSMW. Renado, a 32-year-old Puerto Rican man from the Bronx, spoke about an ideal situation where his male and female partner could know about each other and feel comfortable with his relationships with both. For some men, this may be possible, but this is an unlikely strategy for others. Finally, several of the participants expressed gratitude to the interviewer for discussing these issues them. While anecdotal, this appreciation may indicate a desire by Latino MSMW to speak to a person from outside their community about their same-sex attraction and behavior. Future research should seek to understand the feasibility of this approach and how best to reach this population.