Latino sexual minority men’s intersectional minority stress, general stress, and coping during COVID-19: A rapid qualitative study

Abstract

Introduction:

Sexual minority men face mental health, substance use, and HIV disparities, all of which can be understood by minority stress and intersectionality theories. With the emergence of COVID-19 and considering its disproportionate impact on Latinx and sexual minority communities, Latino sexual minority men (LSMM) may be facing unique consequences of this new pandemic that intersect with pre-COVID disparities. The purpose of the current study is to explore the impact of the COVID-19 pandemic on LSMM’s intersectional minority stress, general stress, and coping, filling a gap in the current literature.

Methods:

The current rapid qualitative study explores the impact of COVID-19 on LSMM in South Florida who reported being HIV-negative (N=10) or living with HIV (N=10).

Results:

The rapid analysis revealed themes of exacerbated intersectional minority stress and general stress in the context of COVID-19, some of which was related to the impact of pre-COVID-19 disparities in the LSMM community. Participants reported a variety of coping responses, some of which participants found helpful and others (e.g., substance use) which further exacerbated disparities.

Conclusion:

The findings underscore the need to scale up and disseminate behavioral health resources to LSMM to address the impact of the COVID-19 pandemic on this community’s health and well-being.

Prior to the emergence of COVID-19, Latino sexual minority men (LSMM) experienced significant health disparities. Compared to their heterosexual and non-Latino peers, LSMM face greater rates of mental health and substance use challenges (Goldstein et al., 2016; Rodriguez-Seijas et al., 2019), as well as suboptimal access to mental health treatment (Burns et al., 2015). The disproportionate impact of the HIV epidemic on LSMM is another health disparity the LSMM community has experienced, with disparities worsening in the past decade (Centers for Disease Control and Prevention, 2020b). Furthermore, pre-COVID-19 research suggests that mental health and HIV disparities affecting LSMM have a synergistic effect on one another (Martinez et al., 2016). In other words, there is a bidirectional relationship between the HIV and mental health disparities LSMM face, with both worsening the other.

Minority stress and intersectionality theories (Crenshaw, 1989, 1991; Meyer, 1995, 2003) provide a useful framework for understanding health disparities affecting Latinx,¹ sexual minority men (SMM), and LSMM communities. Minority stress theory suggests that sexual minority communities experience chronic stigma-related stress, in addition to the stressors of daily living, based on their sexual orientation identities (Meyer, 1995, 2003). This added stress accumulates, compounds, and creates the mental health disparities that are known to affect sexual minority communities in general, and Latinx sexual minority communities in particular (King et al., 2008; Rodriguez-Seijas et al., 2019). Meyer’s (1995, 2003) early writings about minority stress theory suggest that the theory may be applicable to the stigma-related stress that individuals with other minoritized identities face, including individuals positioned at the intersections of multiple systems of oppression including Black and Latinx sexual minority communities (McConnell et al., 2018; Noyola et al., 2020; Schmitz et al., 2019) and SMM living with HIV (Rendina et al., 2016). Intersectionality theory further explicates that the systems of oppression and marginalization that create health disparities are not unidimensional; they interact and worsen at the intersections of these systems of marginalization (Crenshaw, 1989, 1991). For example, Latino and Black SMM face intersectional stigma; that is, discrimination based on race, ethnicity, and sexual orientation converge to worsen health outcomes in these communities (English et al., 2018, 2021). As such, LSMM’s pre-COVID-19 mental and sexual health disparities can be understood within an intersectional minority stress framework, such that intersectional stigma, discrimination, and inequities lead to suboptimal health outcomes (Algarin et al., 2019; Earnshaw et al., 2015; English et al., 2018; McConnell et al., 2018; Schmitz et al., 2019).

Minority stress and intersectionality theories, as applied to the health disparities faced by LSMM, have largely been understood and examined prior to the emergence of COVID-19 (Rodriguez-Diaz et al., 2021). The COVID-19 pandemic has required people to engage in a variety of prevention and mitigation measures (e.g. social distancing), leading to new daily and compounding stressors and population-wide increases in mental health concerns (Gruber et al., 2020). Individuals living in geographic areas most impacted by COVID-19 report the greatest elevations in stress, anxiety, and depression (Lima et al., 2020; Wang et al., 2020; Xiao et al., 2020). As such, it is possible that the stress associated with the COVID-19 pandemic could uniquely impact LSMM, a population already facing substantial mental health disparities before the emergence of COVID-19. The possibility of unique mental health impacts of COVID-19 on the mental health of LSMM is underscored by the fact that Latinx and sexual minority communities have each been disproportionately impacted by the COVID-19 pandemic in the United States. For LSMM, at the intersection of these two groups disproportionately affected by COVID-19, and who already faced substantial disparities connected to intersectional minority stress, it is possible that they are now experiencing exacerbated disparities.

Early in the pandemic, it became clear that, compared to their non-Latinx White peers, Latinx people faced higher COVID-19 morbidity and mortality (Rodriguez-Diaz et al., 2020). Despite representing only 18% of the U.S. population, Latinx communities bear over one third of documented COVID-19 cases, which may be an underestimation of the true case burden (Centers for Disease Control and Prevention, 2020a; United States Census Bureau, 2019). In Florida, the geographic focus of the current study, 25% of the population identifies as Latinx yet 40% of new cases occur among Latinx individuals (Johns Hopkins University & Medicine, 2020).

COVID-19 is also disproportionately impacting sexual minority communities. A rapid online survey revealed that among 1051 U.S. gay, bisexual, and other men who have sex with men, participants reported worsened mental health, social support, access to basic resources, and substance use during the early emergence of COVID-19 (Sanchez et al., 2020). Participants also reported increased difficulty seeking HIV prevention and treatment services in the context of COVID-19, suggesting that the impact of COVID-19 on SMM included a potential worsening of pre-COVID-19 HIV disparities that have impacted SMM since the start of the HIV epidemic (Centers for Disease Control and Prevention, 2020b; Sanchez et al., 2020). Some of the impacts of COVID-19 on SMM, such as increased substance use, could in turn pose increased risk of acquiring COVID-19 among SMM (Carrico et al., 2020).

An intersectional minority stress framework suggests COVID-19 disparities affecting Latinx and sexual minority communities are rooted in identity-based systems of marginalization and oppression. Among Latinx individuals, COVID-19 disparities have been explained by inadequate access to healthcare, living in population dense households and communities, exposure to air pollution, and employment in lower paying public-facing professions (Hooper et al., 2020; Melin et al., 2021; Rodriguez-Diaz et al., 2020). These factors, perpetuated by systemic inequities, contribute to COVID-19 morbidity and mortality directly, as well as indirectly through their influence on other established health disparities (e.g., poorer health, underlying medical conditions) responsible for worse COVID-19 related outcomes. Systemic inequities can also explain COVID-19 disparities in sexual minority communities. A report from OutRight Action International revealed the unique vulnerabilities of sexual and gender minority (SGM) communities to the impacts of COVID-19, based on the pre-COVID-19 minority stress these communities face (Bishop, 2020). For example, SGM individuals already facing rejection from family may be even further isolated in the context of COVID-19. Researchers have in turn highlighted the intersectional inequalities faced by LGBTQ immigrants, including undocumented Latinx LGBTQ communities, in the context of COVID-19 and underscored the need to attend to the unique ways social and political factors worsen COVID-19 outcomes in these communities (Kline, 2020).

Although substantial evidence has converged to illustrate the overall COVID-19 disparities in Latinx and sexual minority communities, empirical research has not yet documented the potential unique mental health and stress-related impacts of COVID-19 on the LSMM community in particular. Given that LSMM are living at the intersection of multiple pandemics/epidemics (COVID-19, HIV, and mental health) and at least two marginalized identity statuses (Latino ethnicity and sexual minority identity), it is likely that LSMM are facing increased stress in relation to COVID-19. However, the nature of LSMM’s stress in the context of COVID-19 is yet to be explicitly documented. Further, given that intersectional minority stress has been used to understand mental health and HIV disparities affecting LSMM before the emergence of COVID-19, it is important to explore LSMM’s experiences with intersectional minority stress in the context of COVID-19. LSMM have long been shown to be resilient to numerous adversities, including the multiple systems of oppression that drive mental health and HIV disparities (Bogart et al., 2020; Earnshaw et al., 2015). As such, there is also a need to understand the ways in which LSMM are coping with the stress of the COVID-19 pandemic, which may articulate both adaptive strategies that can be leveraged and maladaptive strategies that may need to be addressed to prevent worsening health disparities in this community.

In summary, there is a gap in the scientific knowledge regarding the extent and nature of LSMM’s stress and coping in the context of COVID-19. The current study seeks to fill that gap by exploring qualitatively the impacts of COVID-19 on LSMM’s stress and coping. Specifically, this study was guided by three research questions: (1) How are LSMM experiencing intersectional minority stress during COVID-19? (2) What general stressors are LSMM facing during COVID-19, and (3) How are LSMM coping with stress during COVID-19?

Methods

Participants and Procedures

Participants included 20 LSMM living in South Florida, a region of the US that has been both a COVID-19 and HIV epicenter (Centers for Disease Control and Prevention, 2020b; Johns Hopkins University & Medicine, 2020). Miami, Florida, a geographic area with a large population of LSMM, became a US COVID-19 epicenter in the summer of 2020, at its peak experiencing over 17,000 reported new cases per day (Johns Hopkins University & Medicine, 2020). Participants were recruited from two ongoing survey studies in which LSMM provided their consent to be contacted for future studies. Both surveys had separate aims from the current qualitative study. First, we recruited participants from a survey study examining LSMM’s use of behavioral health and HIV-prevention services. These participants reported being HIV-negative, which was one of the inclusion criteria for the prior study. Given the impact of the HIV epidemic on LSMM communities, we wanted to ensure representation of LSMM living with HIV, as well as those who reported being HIV-negative. To facilitate this representation, we recruited the other 10 interviewees from an ongoing community survey related to HIV treatment and care among individuals living in the South Florida. Recruitment from both surveys occurred simultaneously. Using purposive recruitment, we also achieved equal representation of LSMM who were born in the US and outside the US.

For the current study, participants were eligible based on (1) identifying as a sexual minority man (i.e., gay, bisexual, or a man who has sex with men), (2) identifying as Latino/Hispanic, (3) living in Greater Miami, FL (e.g., Miami-Dade County, Broward County), and (4) being 18–60 years old. Participants were excluded if they were unable to provide consent or unable to speak and/or read in either English or Spanish. Enrollees who were interested and eligible were interviewed and compensated $25. The study was conducted in Miami, FL. All study procedures were reviewed and approved by the Institutional Review Board at University of Miami.

Research Team

Our team of seven LGBTQ and Latinx affirming researchers identified with a variety gender, sexual orientation, and race/ethnicity identities. Team members also varied in terms of their professional experience and training. Our team included undergraduate, masters and doctoral students, faculty, and volunteers. Team members had academic and professional experience in public health, psychology, and medicine. All team members were part of research groups that focus on HIV and mental health disparities affecting SGM and in particular, LSMM, communities, and as such, had training and appreciation of minority stress and intersectionality theories in relation to disparities. This training and perspective likely informed the types of questions asked and our interpretation of the information provided, which we acknowledge as a part of our team’s overall grounding and perspective. Four team members were bilingual and bicultural, therefore we were able to conduct interviews in English or Spanish, based on participant preference. Of note, not all team members identified as Latinx, SMM, or LSMM, and as such, some of our outsider identity statuses with respect to participants’ lived experiences may have also informed our collective interpretations of the data. At the same time, we strove for all team members to be able to equitably voice their perspectives in team consensus meetings to ensure fair and accurate representation of the findings. Most team members had prior experience with qualitative research, and some specifically with LSMM; however, some had not and therefore training was provided by the lead author. All team members received an initial training in qualitative research (e.g., interviewing, rapid qualitative analysis) and the study objectives. Ongoing weekly meetings scaffolded the initial training, and allowed time for questions, supervision, and completing the rapid qualitative analysis.

Data Collection

Interviews were completed remotely between June 11^th, 2020 and August 1^st, 2020. This period of the COVID-19 pandemic in South Florida overlapped with both a resurgence of COVID-19 cases and Phase 1 of reopening.

Prior to any study activities, participants provided consent to participate (following IRB-approved study procedures). Our consent protocol involved participants viewing consent information, which informed them of the study procedures, risks and benefits of participating, the voluntary nature of their participation in the study, their right to withdraw from the study, and contact information for the study team and overseeing IRB. After viewing this information, which was embedded in a secure REDCap survey, they indicated “Yes, I consent to participate,” and then proceeded to complete a brief demographic survey prior to their interview. The demographic survey included questions about HIV status, age, gender identity, nativity, race/ethnicity, preferred language, education, employment status, and other key demographics.

After the demographics survey, participants completed semi-structured interviews with trained study staff in English (n = 17) or Spanish (n = 3). Bilingual and bicultural research staff were available to conduct the interviews and as such, all participants were given the option to participate in the study in English and/or Spanish. A semi-structured interview guide (≈45–60 minutes) developed by the first and second author guided the interviews. The interview guide explored several areas including stress, sexual health, and access to healthcare services. Due to the depth and breadth of the interview guide, the current analysis focuses specifically on the themes that emerged in relation to the stress component of the interview guide. Within the stress component of the interview guide, participants were asked to describe (1) the stressors that they had faced during COVID-19 (e.g., how COVID-19 affected participants’ lives overall, new challenges associated with COVID-19), (2) their experiences of minority stress in terms of sexual orientation, racial/ethnic identity, immigration status, HIV status, and/or other identities during COVID-19 (e.g., extent to which this type of stress was exacerbated and/or ameliorated during COVID-19), and (3) the ways they had been coping with their stress during COVID-19 (e.g., coping strategies and the degree to which these strategies were helpful or unhelpful). Upon completion of the interviews, data was securely stored online using a university-approved platform for secure data storage, as approved in our IRB protocol.

Qualitative Analysis

Rapid qualitative analyses, an established qualitative approach developed by Hamilton and colleagues (2020; 2013; 2019) for rapid turn-around health services research was employed to analyze the data in the current study. Rapid qualitative analysis is an approach that balances rigor and efficiency to expedite the analysis and dissemination of qualitative research findings. In a direct comparison to another established qualitative analytic approach, thematic analysis, rapid qualitative analysis was found to yield equitably rigorous results (Taylor et al., 2018). Another advantage of rapid qualitative analysis is that it does not require qualitative analysis software; all aspects of the analysis can be conducted in word processing and spreadsheet software. Because rapid qualitative analysis is a rigorous approach that yields more efficient findings, we decided to employ this approach, as described by Hamilton and colleagues, given the need to understand the impact of a new and evolving pandemic on LSMM’s lives and disseminate findings to expediently inform research and practice.

Rapid qualitative analysis involves the following steps. First, an “interview summary” template is developed. Following Hamilton and colleague’s guidelines, the lead author completed the first step of this process, which was to develop an “interview summary” template and corresponding written guidelines for completing an interview summary. The purpose of the interview summary is for team members to reduce the data from the entire interview down to the key domains and information relevant to the research questions. As such, creating interview summaries is a non-interpretive process; it involves documenting key statements made by participants during the interview. The lead author provided didactic and experiential training to all team members on how to use the interview summary template to document systematically all key statements from each interview.

Following the training, the team followed a structured process for completing and auditing interview summaries for each participant: (1) the interviewer completed the original interview summary, (2) a second team member audited the interview summary, checking for accuracy, and (3) the lead author audited the interview summary as a final quality control. Key statements from interviews completed in Spanish were translated and documented in English by bilingual/bicultural team members. All interview summaries were produced directly from the audio recordings of the interviews, omitting the need for full transcriptions of the interviews and facilitating a rapid analysis (Vindrola-Padros & Johnson, 2020). Key quotations were transcribed and placed within the interview summaries.

The next step in Hamilton and colleagues’ rapid qualitative guidelines is to transfer key statements to a matrix summary, allowing analysts to view participant responses within each domain (i.e., intersectional minority stress, general stress, coping) collectively instead of individually (Averill, 2002; Miles et al., 1994). Upon completing the first ten interviews (which were completed in no particular order) and transferring these to the matrix summary document, three team members began identifying emergent themes. To carry out this step, the three analysts independently reviewed all the data within each domain (within the matrix summary) to identify and define themes. They also extracted illustrative quotations of the themes they identified. The lead author then reviewed the themes identified by the analysts to assess consistency. Themes that were not consistent across analysts were discussed as a team until consensus was reached. Participants continued to be interviewed until coding saturation, which refers to the phenomenon of additional themes not emerging despite the addition of more participants to the analytic sample (Guest, Bunce, & Johnson, 2006). We reached saturation at 15 participants, meaning that new themes emerged with the addition of participants 11–15, but not with participants 16–20. All authors reviewed and agreed on the accuracy of the findings, reported below.

Results

Participant Demographics

All participants identified as Latino in terms of ethnicity and either Black (10%) or White (90%) in terms of race. The average age of participants was 32.7 (SD = 12.21). Participants were born in the continental U.S. (n=9, 45%) and Puerto Rico, a U.S. territory (n=1, 5%), or outside the U.S., in nations that included Brazil, Costa Rica, Cuba, Honduras, and Venezuela. Although nearly half were born outside the U.S. (n=11, 55%), the majority reported they are currently U.S. citizens (n = 16, 80%). Among those born outside the U.S., participants reported living in the U.S. for an average of 10.82 years (SD = 8.93). In terms of sexual orientation, participants identified as gay (n=18, 90%) or bisexual (n=2, 10%). Overall, this group of LSMM had high access to education (60% reported a college degree) and financial resources (65% reported earning $2,000 per month or more). Additional participant demographics are reported in Table 1.

Table 1.

Demographics^*

Characteristic	n	%	Mean (SD)
Age			32.7 (12.21)
Race and Ethnicity
White-Latino	18	90
Black-Latino (Afro-Latino)	2	10
Sexual Orientation
Gay	18	90
Bisexual	2	10
Nativity
Caribbean (Cuba, Puerto Rico)	4	20
Central America (Costa Rica, Honduras)	2	10
South America (Brazil, Venezuela)	5	25
United States (continental)	9	45
Highest level of education
High school of less	2	10
Some college/university	6	30
College/university degree	12	60
Monthly income
Less than $2000	5	25
$2000 or higher	13	65
Decline to answer	2	10
Citizenship
US citizen	16	80
Non-US citizen	4	20

^*Summary of key demographic information of the sample population. All participants identified as Latino sexual minority men.

Main Findings: Qualitative Themes

The rapid qualitative analysis revealed 12 themes across the three primary domains from the interview guide: intersectional minority stress, general stress, and coping. Within the intersectional minority stress domain, participants described exacerbated sexual minority stress due to less identity-affirming support, decreased sexual minority stress due to less public exposure, added stress associated with COVID-19 as a stigmatized virus, and additional stress at the intersection of multiple minoritized identities during COVID-19. Within the general stress domain, participants described worsened mental health and physical health problems, reduced social support, disruptions to daily activities, media-related stress, and worry about family and friends. Finally, in the coping domain, participants identified strategies including using or providing social support, staying physically active and engaging in healthy lifestyle behaviors, and using distraction or avoidance to reduce the stress associated with COVID-19. Each of the themes, sorted by domain, are described below, with a summary of the findings and additional quotations presented in Table 2.

Table 2.

Summary of Findings with Example Quotations

Category/Theme	Example Quotation
Minority Stress
COVID-19 worsened or had the potential to worsen sexual minority stress for LSMM	It’s been an addition to the stressors of my everyday living. It puts me on edge…I’m already in a state of more fight or flight. - White Latino gay man, mid-20s, South/Central American-born, HIV-negative
Less exposure to others led to less sexual minority stress for some LSMM	I’m not really interacting outside of the house…it’s probably gone down…I’m less exposed to it, being quarantined at home. - White Latino gay man, late-20s, US-born, HIV-negative
LSMM now have another stigmatized virus to navigate	It’s already scary enough to worry about one virus, so I wouldn’t want to worry about another one. - White Latino bisexual man, late-20s, US-born, HIV-negative
LSMM experienced additional identity-based stress during COVID-19	It’s already exhausting to have all this anxiety piled up [due to immigration stress] and have to deal with it on a daily basis. - White Latino gay man, mid-20s, South/Central American-born, HIV-negative
General Stress
COVID-19 has led to the exacerbation and emergence of mental and physical health concerns	Anxiety has been pretty off the walls. - White Latino gay man living with HIV, mid-20s, US-born
The impact of reduced social interaction varied across LSMM	I just didn’t talk…there were days that I just didn’t talk, and I wanted to. - White Latino gay man living with HIV, late-50s, Caribbean-born
Disruptions to academic, work, and daily routines were challenging to adjust to	[I’m] frustrated because the economy is being prioritized over health. - White Latino gay man, mid-20s, South/Central American-born, HIV-negative
COVID-19 media consumption was unhelpful and stressful	Reading about it gives me anxiety, seeing how bad it is. - White Latino gay man, late teens, South/Central American-born, HIV-negative
LSMM were distressed about family and friends’ experiences of COVID-19	COVID has impacted my ability to interact with my mother…to not be able to hug your mother, the most basic of things. - White Latino gay man living with HIV, mid-50s, US-born
Coping
Utilizing and providing social support	I have been more attentive about contacting family members who are out of the area. - White Latino gay man, late-30s, South/Central American-born, HIV-negative
Staying physically active and engaging in healthy lifestyle behaviors	When I’m walking, exercising, or living my life, I don’t feel as fearful. - White Latino gay man living with HIV, mid-50s, US-born
Distracting and/or avoiding during COVID-19	[Using substances] allows me to not worry about the things I can’t control. - White Latino gay man living with HIV, late-20s, South/Central American-born

Intersectional Minority Stress

Semi-structured interviews assessed identity-based stress that participants experienced during COVID-19. Interviews probed experiences of minority stress related to sexual minority stigma, as well as minority stress that existed alongside or that intersected with sexual minority stress (e.g., stigma-related stress based on race/ethnicity, immigration status, HIV status).

COVID-19 Worsened or Had the Potential to Worsen Sexual Minority Stress for LSMM.

Participants described feeling that others may assume that because someone is LGBTQ, they may be engaging in sexual behavior with casual partners and not following COVID-19 prevention guidelines, contributing to a sense of stigmatization based on their sexual orientation identity. For example, one participant described concerns over being associated with “hook up culture” during the pandemic:

“There’s a stigma, a lot of us tend to hook up and have this kind of hook up culture…I was worried about somebody going ‘oh you’ve probably been hooking up this entire time, not really isolating, quarantining yourself, or practicing social distancing.’” (Black Latino bisexual man, early-20s, US-born,² HIV-negative)

COVID-19 also deteriorated LSMM’s social support networks, with events like LGBTQ Pride being canceled, clubs where LSMM convene being closed, and “stay at home” orders preventing gathering with LGBTQ friends who normally offered support prior to COVID-19. One participant described his experience:

“Gay men, bi men, all that kind of stuff, we’re all so very dependent on friends and community. Going to gay bars or big gay clubs, that stuff is not available to us right now, so it is a huge aspect of our social life that we’re not able to have…Going to clubs and stuff is like a coping mechanism that we have. It is like an escape that we have from the normal world that doesn’t completely accept us. I feel like that is a way that we have to not feel so apart from society. Not feel so lonely.” (White Latino gay man, late teens, South/Central American-born, HIV-negative)

Another described how COVID-19 exacerbated the hypervigilance he already felt as a gay Latino man who was a recent immigrant to the US: “It’s been an addition to the stressors of my everyday living. It puts me on edge…I’m already in a state of more fight or flight,” (White Latino gay man, mid-20s, South/Central American-born, HIV-negative).

Less Exposure to Others Led to Less Sexual Minority Stress for Some LSMM.

Participants also noted that in some cases, COVID-19 could alleviate sexual minority stress that was experienced prior to COVID-19, due to less exposure to other people. For example, one participant described that he was less likely to experience discrimination based on his gender expression, as were his friends, while quarantining: “The fact that I’m not going outside eliminates the possibility of being harassed. I have been harassed in the past specifically because I do ‘look gay,’” (White Latino gay man, early-20s, US-born, HIV-negative).

LSMM now have another Stigmatized Virus to Navigate.

Many participants compared COVID-19 to the early and ongoing HIV epidemic and suggested intersections between sexual minority stress and HIV in the context of COVID-19 for LSMM. COVID-19 brought out fears and anxieties they had long felt with respect to HIV, which as noted above, disproportionately affects LSMM in the U.S. One participant explained, “[It has] been stressful to have to deal with a second pandemic, considering that we still haven’t even finished with HIV yet,” (White Latino gay man living with HIV, early-30s, US-born). Participants also remarked on how COVID-19 and HIV both invoke similar fears related to sexuality and intimacy: “Before it was just HIV fear, now there’s also the fear of not even able to kiss due to COVID,” (White Latino gay man, late-30s, South/Central American-born, HIV-negative). Although participants of all ages compared HIV and COVID-19, some discussed their age in relation to these comparisons: “I’m older, it reminded me a lot of the HIV epidemic.” (White Latino gay man living with HIV, late-50s, Caribbean-born). Another explained:

“I’ve seen a lot of the angst, I’ve seen a lot of the fear and I’ve seen a lot of discrimination that I saw in the 80s and 90s with HIV in our community. There is a stigma associated with COVID much like there was and still is with HIV.” (White Latino gay man living with HIV, mid-50s, US-born)

Furthermore, participants described fears of acquiring and transmitting COVID-19, most of whom likened these fears to the HIV epidemic. One participant, a caretaker for his aging parent, described his fears of transmitting COVID-19 to his parent, and elaborated on the connection he observed between COVID-19 and HIV:

“Having friends that either end up in a very serious medical situation or even worse, have passed on because of COVID and not being able to go see them in the hospital… it brought back a lot of memories of the HIV/AIDS epidemic.” (White Latino gay man living with HIV, mid-50s, US-born)

Another shared this sentiment:

“I got depressed, I felt confined, claustrophobic, lost, and couldn’t sleep at the very beginning. It reminded me a lot of the HIV epidemic. I was very young at the time… I basically relived that time – it was very painful,” (White Latino gay man living with HIV, late-50s, Caribbean-born).

LSMM Experienced Additional Minority Stress during COVID-19.

In addition to worsened sexual minority stress during COVID-19, participants experienced or felt that other LSMM were experiencing additional minority stress related to immigration status, HIV status, Latino identity, and ability status, which they felt was worsened by COVID-19. For example, immigration status added stress, due to uncertainties of being able to remain in the U.S. and family separation caused by the pandemic: “Because of COVID there is an added stress of having to figure out ‘what’s gonna happen to me?’ ‘what’s gonna happen to my visa status?’” (White Latino gay man, late teens, South/Central American-born, HIV-negative). Another stated, “It’s already exhausting to have all this anxiety piled up and have to deal with it on a daily basis,” (White Latino gay man, mid-twenties, South/Central American-born, HIV-negative) while describing his experience of COVID-19 in the context of his immigration status.

General Stress

Participants were also asked about experiences of overall stress during COVID-19. As such, the next set of themes pertains to general stressors that LSMM reported during COVID-19. We defined general stress as any stress that was not necessarily specific to LSMM and/or participants did not specifically attribute to identity-based stigma. Although these themes may apply to other communities, they may uniquely impact the LSMM community in terms of severity or worsening of existing disparities. Furthermore, although participants may not have attributed some of these stressors to identity-based stigma, this still could have been an underlying driver of the general stressors described below.

COVID-19 has led to the Exacerbation and Emergence of Mental and Physical Health Concerns.

LSMM reported new or worsened mental health and physical health concerns, including depression, anxiety, general stress, substance use, and high blood pressure, during COVID-19. For some, pre-COVID-19 mental health concerns like substance abuse or depression worsened: “I was dealing with [substance use] before, but now it adds a little bit more…I’ve been depressed…what has increased is the feeling that it is harder to pull out of [depression] because the barriers are larger,” (White Latino gay man living with HIV, mid-50s, US-born). Others found that they were experiencing new mental and physical health concerns, which they attributed to COVID-19 and resultant preventive measures. For example, hyperawareness about symptoms that previously seemed benign created anxiety:

“If somebody coughs around you or sneezes around you, six months ago you wouldn’t even think about it. Now, instantly your mind goes to ‘oh my God did they sneeze on me…’ you know you have a fever, you wake up and any little body ache, of course there’s anxiety that comes with all that.” (White Latino gay man living with HIV, mid-50s, US-born)

Another described worsening physical health: “I was having chest pressure/chest pain and it turns out my blood pressure has gone through the roof… I feel like that’s because I’m more sedentary than ever…and the anxiety I’m dealing with on a day to day basis,” (White Latino gay man, late-20s, US-born, HIV-negative).

The Impact of Reduced Social Interaction Varied Across LSMM.

The impact of COVID-19 “stay at home” and social distancing measures varied across LSMM. Many found themselves lonely, bored, and unsure about how to spend sudden empty periods of time, leading to increasing anxiety, depression, and stress. One participant explained “Just the fact of like being alone in the house for so long, and like my family being so far away…just staying home alone for so long like…I’ve definitely had some depressed moments,” (White Latino gay man, late teens, South/Central American-born, HIV-negative). For others, decreased social engagement led to positive changes, such as devoting more time to important relationships or engaging in personal self-reflection and growth.

Disruptions to Academic, Work, and Daily Routines were Challenging.

Participants’ academic, work, and other daily routines were disrupted by COVID-19. However, these disruptions may have been particularly impactful for LSMM at the intersection of multiple systems of oppression that already created barriers to academic and work stability before COVID-19. One participant described the difficulties of transitioning to remote and online interactions and classes: “Getting somebody on the phone was a nightmare. Trying to make an appointment for something was a nightmare…to me, nothing was simple… everything was very difficult…that transition period was very hard,” (White Latino gay man living with HIV, late-50s, Caribbean-born). Another described sleep disruptions leading to sleep problems and worsened mental health: “My sleep schedule has gone out of whack because I don’t have anything necessarily to wake up for,” (Black Latino bisexual man, early-20s, US-born, HIV-negative). One participant who continued working in person described stress due to his work environment:

“I don’t really want to be there. I feel like I am risking my life for a paycheck. I only do it because we need to do it to have a place to live and be comfortable. It has stressed me out for sure.” (White Latino gay man living with HIV, early-30s, US-born)

Those who lost employment also felt hopeless: “Well shit, what am I supposed to do now [that I’ve lost my job]” (White Latino gay man living with HIV, late-20s, South/Central American-born).

COVID-19 Media Consumption was Unhelpful and Stressful.

Participants generally reported that media consumption related to COVID-19 caused further stress and anxiety. For instance, participants described having to sort through overwhelming amounts of (mis)information: “…even though I try to stay informed, the stress level that comes with 24/7 hearing truth and non-truths certainly creates anxiety,” (White Latino gay man living with HIV, mid-50s, US-born).

LSMM were Distressed about Family and Friends’ Experiences of COVID-19.

Many participants reported distress about the degree to which their friends and family, both locally and internationally, were impacted by COVID-19. Their concerns were for their family and friends’ health (i.e., if they were sick or had died from COVID-19) as well as their economic and emotional well-being. For those with family living outside the U.S., COVID-19 prevalence in their home countries increased concerns over their families’ health. In one instance, COVID-19 travel restrictions caused family separation, exacerbating concerns.

“My family being so far away, and the condition of COVID in [country masked for anonymity] is not great either, so there’s a lot of anxiety about it… My mom lives here. I’m at her house, but she went to [country masked for anonymity] to renew her visa right before quarantine and obviously she’s stuck there now.” (White Latino gay man, late teens, South/Central American-born, HIV-negative)

In another example, a participant described the difficulties with wanting to help family abroad but being unable to:

“Currently since I’m an immigrant it’s also been a stress factor to think about my family that’s outside of the country… it’s been very restricting to know there’s no way to travel other than ‘thoughts and prayers’ and maybe sending a little money,” (White Latino gay man, mid-20s, South/Central American-born, HIV-negative).

Coping

Finally, participants were asked to describe how they had been coping with the stressors they experienced during COVID-19. Participants described how they were coping in response to both minority and general stress. We defined coping as any strategy participants were using to manage the stress that they were experiencing during COVID-19. Participants described some coping strategies as helpful, whereas others they described as unhelpful.

Utilizing and Providing Social Support.

As with many people, LSMM used technology to connect with friends and family during COVID-19, as well as participating in socially distant gatherings. LSMM found it helpful to think about the ways in which they were connected to a broader community to help them feel “less alone” during COVID-19: “Generally speaking as a community we’ve all been going through the same thing…it actually does comfort you,” (White Latino gay man, late-20s, US-born, HIV-negative). LSMM who were partnered appeared to have less difficulty accessing this social support, finding relationships to be a reprieve: “You feel the support and the love, and you don’t have to primarily focus on the pandemic,” (White Latino gay man, early-20s, US-born, HIV-negative). Those who were connected to and supported by their family found it easier to cope. Utilizing videoconferencing tools to connect virtually appeared to have mutually beneficial effects.

“To see somebody in real time and have that contact…absolutely made things a little more normal than if we didn’t have that…again, even with my mom – the times when I haven’t been able to physically be there – to be on a FaceTime conversation with her…at least I have some interaction and the other person does as well. I think it reduces the feelings of isolation and loneliness on all sides.” (White Latino gay man living with HIV, mid-50s, US-born)

Some felt their social interactions were improved as a result of the pandemic:

“The interactions we’re having [online and on social media apps] are more enhanced than the norm and we think it’s because COVID-19 is forcing people to have to stay social distant so people are trying to find a way to connect so for me this has been a huge coping mechanism.” (White Latino gay man living with HIV, early-30s, US-born)

Those who were not able to tap into this social support during the pandemic felt particularly isolated. One participant described having a smaller social network and wished his family would be more connected, particularly in the context of COVID-19:

“They’re always in my mind. I love them but they’re not really there. Just my mom and dad, and basically one of my sisters. They call once in a while…I’m a person with a small family…and we’re just not connected like that. I wish, but no it doesn’t happen like that with our family,” (White Latino gay man, late-20s, US-born, HIV-negative)

Finally, LSMM also found it helpful to be providers of social support to others: “…interacting with others and helping others has been therapy for me” (White Latino gay man living with HIV, mid-50s, US-born).

Staying Physically Active and Engaging in Healthy Lifestyle Behaviors.

Participants found it helpful to stay physically active and practice self-care activities such as meditation, yoga, self-reflection, or spending time outdoors. Participants were able to use these activities to reframe their situation and step back from the anxieties that they felt about COVID-19, sometimes using physical activity to change their daily routines:

“…walking a lot more, getting outside a lot more. My exercise consisted a lot more of just working out indoors… a lot of times I didn’t get out as much outside to do physical activity as I should…[COVID-19] has gotten me outside of the house walking around a lot more, so that’s a positive.” (White Latino gay man living with HIV, mid-50s, US-born)

Distracting and/or Avoiding during COVID-19.

Finally, participants described engaging in activities to distract themselves from COVID-19 and/or avoid their emotional reactions to it. Some participants described staying busy with chores, cooking, and watching TV as ways to “temporarily escape” from the stress of COVID-19: “At least I’m doing something to get me through the day…it’s a temporary fix until our situation gets better,” (White Latino gay man, mid-20s, South/Central American-born, HIV-negative). Participants also described increased substance use and excessive sleep as coping strategies that were almost universally described as unhelpful. One described the negative effect of excessive sleep on his mental health: “It gives you the complete opposite effect of endorphins,” (White Latino gay man living with HIV, mid-50s, US-born). Another described his increase in substance use, “There’s nothing to do but drink and smoke weed all day, it definitely increased my substance use…you can drink beer all day anytime,” (White Latino gay man living with HIV, late-20s, Caribbean-born). One participant also described a COVID-19 “scare” after using substances with a friend:

“I was hanging out with a friend and they told me later that someone they knew tested positive, and I was just sitting at home for like a week and a half seeing if any symptoms come up and waiting for my friend to get tested.” (White Latino gay man, late teens, South/Central American-born, HIV-negative)

Discussion

The purpose of the current study was to explore LSMM’s experiences of COVID-19 in terms of intersectional minority stress, general stress, and coping, using a rapid qualitative analytic approach. LSMM are at the intersection of at least two marginalized groups – SMM and Latino communities – both of whom have been disproportionately impacted by COVID-19, HIV, and mental/behavioral health disparities (Centers for Disease Control and Prevention, 2020b; Martinez et al., 2017; Rodriguez-Diaz et al., 2020). Consistent with intersectionality theory, our findings suggest that LSMM are at a crossroads of COVID-19 vulnerabilities that are driven by social inequities, marginalization, and stigma (Bowleg, 2020). Collectively, the findings illustrate that many LSMM are experiencing new or worsening forms of intersectional minority stress and increased general stress in the context of COVID-19. Alongside this, LSMM are coping in a variety of ways, with some coping strategies helping LSMM get through an acute period of stress while others are potentially leading to challenges such as worsened mental health, substance use, or possible exposure to COVID-19. Below, we discuss and contextualize in the extant literature our findings across the three primary domains of the current study (intersectional minority stress, general stress, and coping).

In terms of minority stress experiences during COVID-19, LSMM in the current study described increased or decreased sexual minority stress, depending on their circumstances. Increased sexual minority stress was frequently discussed in the context of isolation from LGBTQ-affirming physical spaces and people, including Pride, gay bars/clubs, and peer groups. Increased sexual minority stress during COVID-19 may be particularly accentuated for LSMM who are quarantining or socially isolated in non-affirming home environments or whose primary sources of emotional support are public spaces where LSMM can convene and be mutually affirmed. Although all SGM people could be negatively affected by these types of COVID-19 related changes (Bishop, 2020; Kidd et al., 2021; Salerno et al., 2020), they may be particularly relevant to LSMM, as Latinx adults are more likely than their non-Latinx White peers to be living with family of origin (e.g., parents) (Pew Research Center, 2020) and Latinx communities are more likely to live in multigenerational homes (Cross, 2018). In contrast, for LSMM living in homes where support and affirmation are available, this may serve as a unique protective factor for LSMM, aligning with our findings that LSMM found integral support from family during COVID-19. In contrast, in homes where LSMM anticipate or have experienced rejection based on their identity, minority stress during COVID-19 may be uniquely exacerbated. Similarly, for this group, LGBTQ community support may be particularly important, yet was less accessible during COVID-19, potentially amplifying disparities.

Another example of minority stress that LSMM in the current study described was the degree to which they viewed COVID-19 as a new and stigmatized virus. HIV is a virus that disproportionately impacts LSMM (Centers for Disease Control and Prevention, 2020b). Our findings that COVID-19 was experienced by LSMM through the lens of the HIV epidemic was also observed in a recent multisite mixed methods study of SGM individuals, in which many connected their experiences living through the early days of the HIV epidemic to the current COVID-19 pandemic (Quinn et al., 2021). LSMM may be particularly sensitized to the potential for stigmatization based on COVID-19 due to their prior experience in the HIV epidemic, an experience not necessarily shared to the same extent with the broader Latinx community or with their non-Latino White SMM peers, for whom HIV incidence has been steadily declining over the past decade. Additionally, scientific and media outlets have reported extensively on the disproportionate impact of COVID-19 on Latinx communities (Rodriguez-Diaz et al., 2020). As such, LSMM, in comparison to their non-Latino White SMM peers, may again be hyperaware of their specific potential to be impacted by COVID-19 or stigmatized in relation to it.

In addition, this study offers insights into the level of sexual minority stress that LSMM were facing prior to COVID-19. The fact that some participants reported less sexual minority stress during COVID-19 due to not being in public spaces is noteworthy and suggests an urgent need to address the pre-COVID-19 minority stress that LSMM face on the basis of their sexual orientation in general, and in relation to their gender expression, race/ethnicity, and HIV status in South Florida. Although to the authors’ knowledge this has not been systematically explored in the empirical literature, anecdotal evidence suggests that some individuals may have felt less constrained by gender expectations during the pandemic, providing a unique opportunity to experiment with authentic gender expression (Thornton, 2020; Woulfe & Wald, 2020). These findings underscore the need to create safe social environments outside the context of COVID-19 social distancing for LSMM to express their authentic selves.

In terms of general stress, LSMM in the current study reported many similar stressors to the general adult population. COVID-19 and quarantine-related stressors in the general population include anxiety, insomnia, traumatic stress, depression, irritability, confusion, fear, loneliness, substance use and grief (Brooks et al., 2020; Horigian et al., 2020), many of which were reported by LSMM in the current study. Paralleling our findings, recent research with racially and ethnically diverse SMM living in the U.S. South documented increased general stress during COVID-19, in the form of worry, hopelessness, and isolation (Rhodes et al., 2021). Despite the similarities in the general stressors LSMM in the current study reported compared to the general population, pre-COVID-19 disparities are a key difference. Compared to the general population, LSMM already faced substantial mental health, substance use, and HIV disparities prior to COVID-19 (e.g., Arnold et al., 2014; Bogart et al., 2020; English et al., 2018; Rodriguez-Seijas et al., 2019). These pre-COVID-19 disparities were synergistic and mutually reinforcing (Martinez et al., 2016). The emergence of COVID-19 and the general stressors that LSMM are facing in the context of this new pandemic create another synergistic component of the twin HIV and mental/behavioral health disparities that LSMM faced before COVID-19. The current findings underscore that, for many LSMM, COVID-19 is likely to be worsening existing disparities. As such, it is imperative for psychologists and policymakers to consider how to respond to the direct impacts of COVID-19 on LSMM and other marginalized groups, while also maintaining an appreciation of the many pre-COVID-19 challenges these groups have experienced and are now exacerbated due to COVID-19.

Finally, the coping responses that LSMM endorsed in many ways were not culturally specific, and included utilizing social support, maintaining an active/healthy lifestyle, and using avoidance or distraction to cope. Similar to our findings, Rhodes and colleagues (2021) found that racially and ethnically diverse SMM in the South reported increased use of social media for social support during the pandemic. An international study found that SMM used social technology (e.g., text messaging, phone, social media and websites, video calls) as a strategy for coping with the effects of physical distancing (Holloway et al., 2021). Although SMM in general benefitted from giving and receiving social support and using these technologies to do so during the COVID-19 pandemic, LSMM may have uniquely benefitted from such support. For example, familismo, a cultural value centering the importance of giving and receiving emotional and instrumental support with family members, can be a protective factor for mental health among Latinx populations (Corona et al., 2017; Perez & Cruess, 2014). As such, LSMM may have been particularly likely to leverage and provide social support within the family to cope with the pandemic, as well as utilize social technologies to build this familial support during the pandemic. Similarly, although the general population may have worried about the safety of family and friends during COVID-19, this may have been accentuated particularly for LSMM with transnational families, as the COVID-19 pandemic had unequal impacts across Latin American countries, with some particularly under resourced to respond adequately (Burki, 2020), adding to LSMM’s stress. Furthermore, for LSMM who normally receive social support via visiting family outside the U.S., they were faced with an enduring period of physical separation that was acutely stressful for some.

Clinical Significance

Our findings suggest the need to ensure that LSMM have access to resources to support their mental health and well-being as they continue to experience the brunt of two, co-occurring pandemics: COVID-19 and HIV, along with mental health/substance use disparities. Before the emergence of COVID-19, LSMM had inadequate access to culturally relevant, affirming mental health and substance use treatment services (McIntyre et al., 2012; Moe & Sparkman, 2015; Wilson & Yoshikawa, 2007). Prior to COVID-19, there was already a need to address gaps in the scale up and dissemination of these resources to LSMM. Furthermore, another analysis found that, despite need, LSMM had inadequate access and worsened barriers to behavioral health services during COVID-19 (Harkness et al., 2021). The World Health Organization (2021) also identified major international disruptions to healthcare, with mental health services particularly affected. Amidst these disruptions, LSMM are reporting increased stress, warranting timely delivery of evidence-based mental health and substance use treatment services.

Interventions to support LSMM’s mental health and well-being during COVID-19 may be informed by what some LSMM indicated they are already doing to cope with COVID-19. For instance, some LSMM used coping strategies such as exercise (e.g., running, going to the gym, biking), meditative practices (e.g., yoga, mindfulness), and self-care activities (e.g., pleasurable activities like cooking) to cope with the anxiety and frustration they were experiencing due to the pandemic. As mentioned previously, many of these coping strategies are not culturally specific. More culturally specific coping may have taken place in interpersonal contexts. For example, participants were also able to benefit from both receiving and providing support within family and friendship networks, suggesting the potential roles of leveraging values such as familismo and altruism to promote LSMM’s mental health and coping during COVID-19. The roles of culturally specific coping resources could be further explored in future research.

As with all research, the strengths of the current study must be considered in the context of its limitations. Our data provides insights into a specific population (LSMM in South Florida); however, the results are not generalizable. Although we consider it a strength that we were able to represent LSMM of varying HIV statuses and countries of origin, we also realize that this diversity could mask within-group differences. For example, it is possible that the experiences of persons living with HIV, and of those who were older, may have been distinct from those who were HIV negative or younger, given the overlap with their lived experiences of the HIV epidemic. Older LSMM and LSMM living with HIV may have experienced COVID-19 through a lens and historical context of the HIV pandemic in a different and more immediate extent than those who were younger and did not live through the early days of the HIV pandemic, and those without personal experience living with HIV. Given the hypothesis-generation versus hypothesis-testing focus of qualitative research, we are unable to make systematic comparisons in the current analysis considering the sample sizes at these intersections. These potential differences could be further distinguished at additional intersections such as nativity. For example, there may be multiple interaction effects that could be further assessed in a larger qualitative study (i.e., with sufficient representation of subgroups to reach qualitative saturation for each subgroup) and subsequent quantitative research (i.e., testing interaction effects of HIV status, age, and nativity on COVID-19 related stress).

Additionally, it is important to note that LSMM are not “raceless” and in fact have a wide variety of racial identities and experiences with racism (Adames et al., 2020). Consistent with the overall population of Latinx individuals in South Florida (U.S. Census Bureau, 2019), the majority of participants in the current study identified as White Latino, limiting our understanding of the extent to which racism further intersected with the stressors described in the current manuscript. For example, although we reached qualitative saturation with the current sample, it is possible that with additional representation of participants who identified as Black, Indigenous, or multiracial, additional themes could have emerged. Similarly, although we achieved approximately equivalent representation of U.S. and non-U.S. born LSMM in the study, those who were non-U.S. born were mostly U.S. citizens and had lived in the U.S. for an average of about ten years. As such, the experiences of recent immigrants and those who are undocumented could further elicit more themes. Additional exploration of the unique experiences of those groups least represented in our current study is warranted to ensure full representation of the heterogeneous experiences of LSMM during COVID-19.

In summary, the findings presented here underscore the impact of COVID-19 on LSMM’s stress and coping. LSMM are a group already overly burdened by mental health and substance use disparities, as well as HIV disparities, all of which are driven by intersectional minority stress and inequities. Our findings provide insights into the impact of COVID-19 on LSMM’s stress and coping, suggesting the need to ensure LSMM have access to supportive resources as they continue to navigate the COVID-19 pandemic. Even as the acute phase of the COVID-19 pandemic comes to an end, the findings also have implications in the context of the ongoing COVID-19 pandemic and future infectious disease pandemics that could emerge in the future. The current findings illustrate the importance of attending to both general and intersectional minority stressors in the context of COVID-19 when providing clinical care to LSMM, as well as leveraging the coping skills LSMM described in the current study.