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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: J LGBT Youth. 2020 Jun 24;19(4):396–412. doi: 10.1080/19361653.2020.1777245

Internalizing Symptoms and Externalizing Behaviors in Latinx Adolescents with Same Sex Behaviors in Miami

Manuel A Ocasio 1, Gregory R Tapia 2, Alyssa Lozano 2, Adam Carrico 2, Guillermo Prado 2
PMCID: PMC9562298  NIHMSID: NIHMS1660155  PMID: 36247028

Abstract

Sexual minorities report poorer mental health relative to heterosexual counterparts, but this is underexplored in Latinx youth. This study compares internalizing symptoms and externalizing behaviors in Latinx adolescents with Same Sex Behaviors (LASSB) to their Latinx adolescent peers who did not report same sex behaviors (non-LASSB). It also explores the moderating role of biculturalism on the relationship between internalizing symptoms and externalizing behaviors, and same-sex behaviors. Individual-level baseline data (Total N=1,634; LASSB n=195) from five trials of a preventive intervention for Latinx adolescents were synthesized. Normal and clinical levels of internalizing symptoms and externalizing behaviors were determined, and logistic regression models were conducted to determine the odds of LASSB reporting these behaviors relative to non-LASSB. Additional adjusted models tested for the moderating effect of biculturalism. LASSB reported significantly higher odds of normal levels of all externalizing behaviors and clinical levels of anxious/depressed compared to non-LASSB. Biculturalism significantly moderated the association between same-sex behavior and clinical levels of internalizing behaviors; however, in subgroup analyses among LASSB, biculturalism did not significantly predict any of these behaviors. Latinx adolescents exhibited mental health disparities by same-sex behavior. Biculturalism may be an important indicator for describing these disparities in LASSB and should be further explored.

Keywords: Adolescents, Latinx, depression, culture

Introduction

Sexual minorities are a group defined by having a sexual identity, behavior and/or attraction that is not exclusively heterosexual (e.g., gay, bisexual, men who have sex with men) (Math & Seshadri, 2013). They exhibit poorer physical and mental health outcomes than non-sexual minorities (Kann et al., 2016). Studies have documented a higher prevalence of internalizing symptoms and externalizing behaviors among sexual minority adults (Everett, 2015). These inequities have been largely attributed to the unique and chronic stressors experienced by sexual minorities as being part of a stigmatized group (Meyer, 2003).

A majority of sexual minority mental health research in the extant literature remains largely focused on primarily racially non-Latinx White and adult samples (Russell & Fish, 2016). Relative to their White, non-Latinx sexual minority counterparts, racial and ethnic sexual minorities are at greater risk of poor health outcomes ranging from HIV/AIDS (Wolitski & Fenton, 2011) to substance abuse (Conron, Mimiaga, & Landers, 2010; Ocasio, Feaster, & Prado, 2016), as well as some evidence indicating poorer mental health (Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007). Although the field is growing, additional studies focused on racial and ethnic sexual minorities are needed.

While some studies have provided insight into racial and ethnic sexual minority groups, many have focused on adults, and studies pertaining to younger ages tend to report experiences retrospectively (Mustanski, 2015). This leaves mental health in childhood and adolescence among sexual minorities largely underexplored. Adolescence is particularly important because it is a critical developmental period in which mental illnesses may occur (McConnell, Birkett, & Mustanski, 2016). If left untreated, symptoms can persist well into adulthood leading to increased risk of suicide, substance use, continued mental health problems, and overall poor quality of life (Jones et al., 2016). These youth may also experience various forms of active discrimination related to their same-sex behaviors at school and other facets of their daily lives, which in turn can lead to poorer behavioral health outcomes (Goldbach & Gibbs, 2017).

In addition to stressors associated with same-sex behaviors, sexual minority Latinxs of all ages may undergo unique experiences directly related to their Latin American identity, such as ethnic discrimination and acculturation processes (Schwartz et al., 2017). Acculturation is broadly defined as changes that occur through the adoption of a host country’s culture, customs, and norms while retaining or losing origin heritage (Sam & Berry, 2010). However, this process is not static, and in adolescents, combines with other processes such as identity development and adjustment that differ from adults (Schwartz et al., 2017).

Acculturation is not a unidirectional process and involves understanding one’s degree of affiliation to both the host and origin culture. Biculturalism quantifies how much and what aspects of both host and origin cultures are simultaneously accepted, retained, rejected, and integrated (Schwartz & Unger, 2010). Although not always consistent (Smokowski et al., 2014), previous research has linked higher levels of Americanism (e.g., enjoyment and engagement in American cultural practices) to increased risk of adverse mental health outcomes in Latinx adolescents (Lawton & Gerdes, 2014). Retention of Latin American culture and customs with less retention of American culture may be protective against both externalizing behaviors and internalizing symptomatology (Lorenzo-Blanco, Unger, Ritt-Olson, Soto, & Baezconde-Garbanati, 2011) in Latinx youth.

Some studies have examined associations of cultural variables with negative outcomes among Latinx sexual minorities, in particular men who have sex with men (MSM). One study reported that in adult Latinx MSM, lower affinity for Latin American cultural practices was predictive of drug use while American cultural affinity showed no association. This is comparable to what has been observed in studies with general Latinx populations; however, other studies provide contradictory findings. Warren et al (2008) observed that in a sample of young Latinx MSM (mean age 19.6), those with more ethnic identification were more likely to engage in unprotected anal intercourse compared to those with less ethnic identification. Although interrelated, it is important to note that ethnic identification and acculturation are distinct and complex concepts. Youth of later generations may be described by the surrounding host society in terms of their ethnic group membership as opposed to their own personality traits and attributes, which may make youth more aware of their ethnicity as a result of acculturation processes (Matsunaga, Hecht, Elek, & Ndiaye, 2010). It is also conceivable that a US resident of Latin American descent may strongly identify with their heritage ethnicity but feel more comfortable speaking English than Spanish. Furthermore, Mitrani et al. (2017) found an inverse association between Americanism and depressive symptoms among adult Latinx MSM. Among Latinx adolescents with same sex behaviors (LASSB), little is known about cultural processes and how they relate to adverse mental health outcomes.

To address the gap in the sexual minority adolescent mental health literature, this manuscript focuses on mental health disparities among Latinx adolescents by comparing LASSB to Latinx adolescents who do not report same-sex behaviors (non-LASSB). Research that characterizes mental health disparities among LASSB is needed to formulate targeted high-risk behavior prevention methods suitable for clinical practice. We compared baseline differences across internalizing symptoms and externalizing behavior subscales between LASSB and non-LASSB who were enrolled in a family-based, culturally-tailored preventive intervention for Latinx families in the United States. Using previously validated scales, we evaluate differences at both normal and clinical levels of these behaviors. We hypothesize that across all internalizing symptoms and externalizing behavior scales, LASSB will report significantly higher propensity for these behaviors relative to non-LASSB. Given the limited and conflicting findings of how cultural variables impact these behaviors in Latinx sexual minorities, we perform an exploratory analysis to test for the potential moderating role of acculturation, specifically biculturalism, in the relationship between same-sex behaviors (LASSB vs. non-LASSB) and internalizing symptoms and externalizing behaviors.

Methods

Data Source

We pooled baseline, cross-sectional data from five completed studies (N = 1,634; LASSB n = 195) of a family-based preventive intervention targeting high-risk problem behaviors in Latinx adolescents in the United States. Across studies, Latinx adolescents ranging from 12 to 17 years of age and one parent (over 80% of whom were mothers) were recruited through the Miami-Dade County Public School system throughout the academic school year via mail, distribution of flyers, word-of-mouth, and referrals. One study also recruited an indicated sample of youth with prior documented behavior infractions in the Miami-Dade Public School System and through the Department of Juvenile Services. Prior to study enrollment, parent-adolescent dyads were individually described the study by the recruiter. This study was approved by the Social and Behavioral Sciences Institutional Review Board. Parental consent and adolescent assent were obtained for all participants.

Using Audio Computer Assisted Self-Interview Survey (ACASI), one parent and their adolescent child completed confidential assessments separately. Surveys were available in English and Spanish. Data capturing the language in which the adolescent survey was completed were only available for two of the studies (Estrada et al., 2017; Estrada et al., 2015). Across these two studies, 17.6% completed the survey in Spanish. For the remaining studies (Pantin et al., 2009; Prado et al., 2012; Prado et al., 2007), a question regarding first or usual language use was asked and 59.1% reported Spanish. Adolescent responses for all variables were used in analyses except for family income and externalizing behaviors, which were ascertained from parents. Research shows that subjective states, such as internalizing symptoms, may be best suited to self-report whereas behaviors that are observable (i.e., externalizing behaviors) can be more objectively reported by another informant, such as a parent (Thomas, Forehand, Armistead, Wierson, & Fauber, 1990). LASSB were identified by responses pertaining to their sexual behavior. Adolescents who self-reported having anal, vaginal, or oral sex with at least one sexual partner of the same sex were labeled LASSB with the remainder of participants grouped as non-LASSB. Identity measures often used to classify sexual minorities were not available in any of the study batteries (e.g., gay, bisexual)

Externalizing Behaviors

Parent responses to subscales derived from the validated Revised Behavior Problem Checklist (RBPC) (Quay & Peterson, 1993) were used to assess adolescent externalizing behaviors: conduct disorders (22 items, α = 0.97), socialized aggression (17 items, α = 0.97), attention problems (16 items, α = 0.96), psychotic behavior (6 items, α = 0.93) and motor excess (5 items, α = 0.86). Response options across subscales were measured on a three-point ordered categorical scale ranging from “no problem” to “severe problem.” Subscale means were calculated and adjusted allowing for up to 25% non-response across items within a given subscale. We used the RBPC manual to establish cut-off values to dichotomize variables and facilitate analysis. We selected two sets of cut-off values to maximize comparability to the general adolescent population and provide estimates of relative clinical levels of these behaviors. The first set was chosen based on mean values drawn from a synthesized dataset of adolescents from multiple community samples (Quay & Peterson, 1993). Mean scores and standard deviations were reported by adolescent gender and age group. Specifically, we used means reported for 12-16-year olds for males and females, separately, as the cut-off values (see Table 1).

Table 1.

Scale score values used to dichotomize normal and clinical levels of internalizing symptoms and externalizing behaviors by gender

Normal Clinical
Males Females Males Females
Anxious/Depressed 3.4 5.1 12 15
Withdrawn/Depressed 2.7 3.1 9 10
Conduct Disordera 6.1 2.3 14.8 14.8
Socialized Aggressiona 1.5 0.4 6.1 6.1
Attention Problemsa 5.6 2.4 4.2 4.2
Psychotic Behaviora 0.5 0.2 0.5 0.5
Motor Excessa 1.5 0.5 1.4 1.4
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a

Sample means by gender were not reported for clinical levels of externalizing behavior subscales.

The second set utilized data based on a subsample of youth recruited from a psychiatric residential facility for whom psychiatric diagnoses based on the DSM-III were available (Quay & Peterson, 1993). DSM-III diagnoses were then combined and categorized to match the RBPC subscales for externalizing behaviors. Cut-off values were established by subtracting half a standard deviation for the means reported for each externalizing behavior subscale. If scores were at or above the established cut-off values, they were labeled as positively endorsing the given externalizing behavior (see Table 1).

Internalizing Symptoms

Adolescent responses to questions from the validated Youth Self Report (YSR) were used to measure internalizing symptoms (Achenbach & Rescorla, 2001). These survey items were only administered in four of the five studies; thus, analyses were conducted for only a subset of the entire synthesized sample. The synthesized data sample had a total of 1,204 Latinx adolescent participants of which 166 were LASSB. Mean scores from two subscales were used: anxious/depressed (13 items, α = 0.84) and withdrawn/depressed (8 items, α = 0.74). Response options ranged on a three-point ordered categorical scale from “not true” to “very true or often true.” Two cut-off values for each subscale were used based on scale scores for multicultural normative samples as reported in the manual by Achenbach and Rescorla (2007). The first was based on means for a normal sample and the second was the lowest score in the clinical range (see Table 1).

Biculturalism

Biculturalism was measured by responses to the Bicultural Involvement Questionnaire – Revised, which was included in adolescent surveys across studies (Szapocznik, Kurtines, & Fernandez, 1980). This scale comprises two subscales of 11 items each (22 in total), and measures degrees of enjoyment and comfort engaging in American and Hispanic cultural practices (e.g., watching American TV, reading Hispanic books and magazines). Americanism, is measured with items such as “How much do you enjoy American TV?”, “How comfortable do you feel speaking English in general?” The Hispanicism subscale measures are identical to the Americanism items in practices and comfort, and only differed in specifying ‘Hispanic’ or ‘Spanish’. Questions assessing preferred language (English, Spanish) use across multiple contexts (e.g., at home, in school) are also included. Response options for each item are measured on a five-point ordered categorical scale ranging from “not at all” to “very comfortable.” Responses to both the Americanism (α=0.89) and Hispanicism (α=0.90) subscales exhibited excellent internal consistency in the synthesized sample. The sum scores for each subscale were calculated and a difference score between the two subscales was used (i.e., Americanism score minus Hispanicism score) to create a continuously-distributed biculturalism variable.

Analytic Plan

Pearson chi-square statistics were used to test for bivariate associations between same-sex behaviors (LASSB vs. non-LASSB) with sociodemographic characteristics (gender, family income, nativity status, time in the US). Externalizing behavior and internalizing symptom subscale prevalence estimates are reported for normal and clinical samples, separately. Independent samples t-tests assessed for mean age and biculturalism differences between LASSB and non-LASSB. Multiple univariate and multivariable binary logistic regression models tested for the association between same-sex behaviors and each internalizing symptoms and externalizing behavior indicator, separately. Multivariable models controlled for sociodemographic characteristics (age, gender, nativity status, years living in the US, and family income) and an additional covariate to reflect the study from which the participant was drawn. Additional biculturalism-adjusted multivariable models were conducted in which a bicultural covariate and same-sex behaviors with biculturalism interaction term were added to the previously-mentioned adjusted models. For cases in which the interaction term emerged significant, subgroup analyses testing for the adjusted effect of biculturalism on outcomes were pursued in LASSB only. A priori significance was set at α < 0.05. Data were analyzed using SPSS version 24.

Results

Across all studies, a total of 195 participants were identified as LASSB. LASSB were more likely to be older, male, and born outside of the US compared to non-LASSB (see Table 2). There were also significant differences in country of origin with more non-LASSB reporting being born in the United States (56.3% vs. 41.5%) and less likely to have been born in Cuba (15.9% vs. 19.0%) compared to LASSB. LASSB had a significantly higher prevalence of all normal levels of externalizing behaviors; however, there were no significant differences in internalizing symptoms. Prevalence estimates based on clinical cut-offs for all subscales were significantly higher in LASSB, except for withdrawn/depressed, socialized aggression, and psychotic behavior. Finally, LASSB were significantly lower in their propensity for American cultural practices than non-LASSB.

Table 2.

Sociodemographic characteristics and prevalence of internalizing symptoms and externalizing behaviors for Familias Unidas adolescent participants by same-sex behaviors

LASSBa   Non-LASSB
n mean (SD) n mean (SD) p-value
Age 193 14.2 (1.2) 1,419 13.8 (1.1) <0.001
Biculturalismb 195 7.5 (13.9) 1,435 10.3 (13.8) 0.008
 Americanism 195 46.0 (8.5) 1,436 47.5 (8.0) 0.02
 Hispanicism 195 38.5 (11.2) 1,437 37.2 (10.4) 0.10
n % n % p-value
Sociodemographic Characteristics
Gender
 Male 143 73.3 747 52.0 <0.001
 Female 52 26.7 689 48.0
Nativity Status 0.001
 US Born 67 41.6 724 54.9
 Foreign Born 94 58.4 595 45.1
Country of Origin <0.001
 United States 81 41.5 817 56.3
 Cuba 37 19.0 230 15.9
 Central America 44 22.6 179 12.3
 Caribbean 16 8.2 51 3.5
 South America 14 7.2 159 11.0
 Missing Data 3 1.5 15 1.0
Family Income 0.001
 <$25,000 147 78.6 954 70.4
 $25,000+ 40 21.4 402 29.6
Time in US <0.001
 <3 yrs 52 26.8 231 16.1
 3 yrs+ 142 73.2 1,203 83.9
Internalizing Symptoms and Externalizing Behaviors – Normal (Yes %)
Anxious/Depressed 77 46.4 475 39.6 0.093
Withdrawn/Depressed 89 53.6 638 53.1 0.905
Conduct Disorder 120 61.5 767 53.6 0.037
Socialized Aggression 115 59.0 680 47.6 0.003
Attention Problems 129 66.2 789 55.1 0.004
Psychotic Behavior 94 48.2 534 37.3 0.003
Motor Excess 113 57.9 702 49.1 0.020
Internalizing Symptoms and Externalizing Behaviors – Clinical (Yes %)
Anxious/Depressed 17 10.2 60 5.0 0.006
Withdrawn/Depressed 15 9.0 73 6.1 0.146
Conduct Disorder 57 29.2 262 18.3 <0.001
Socialized Aggression 35 17.9 212 14.8 0.253
Attention Problems 108 55.4 622 43.4 0.002
Psychotic Behavior 60 30.8 373 26.0 0.162
Motor Excess 80 41.0 426 29.7 0.001
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a

LASSB=Latinx Adolescents with Same Sex Behaviors.

b

Biculturalism was operationalized as the difference between the sum score for Americanism minus the sum score for Hispanicism (i.e., Americanism-Hispanicism).

Results for unadjusted and adjusted logistic regression models are shown in Table 3. Similar trends were found in unadjusted models as those for prevalence estimates reported above. Point estimates for adjusted models remained higher for a majority of both internalizing and externalizing behavior subscales (except for clinical psychotic behavior); however, only a few retained statistical significance. In models using normal sample cut-off values, LASSB had significantly higher odds of conduct disorder (Adjusted odds ratio (aOR) = 1.48; 95% confidence interval (CI): 1.01-2.15) and attention problems (aOR=1.49; 95% CI: 1.01-2.19) compared to non-LASSB. LASSB also had over two-fold higher odds of having clinical levels of anxiety/depressed (aOR=2.29; 95% CI: 1.18-4.47).

Table 3.

Unadjusted and adjusted odds ratios of internalizing symptoms and externalizing behaviors in Latinx Adolescents with Same Sex Behaviors relative to their non-sexual minority counterparts

Unadjusted   Adjusteda   Biculturalism Adjustedb
OR 95% CI c aOR 95% CI aOR 95% CI
Normal
Anxious/Depressed 1.32 0.95-1.83 1.44 0.99-2.10 1.48 0.93-2.33
Withdrawn/Depressedd 1.02 0.74-1.41 1.08 0.74-1.58 1.48 0.93-2.34
Conduct Disorder 1.39* 1.02-1.88 1.48* 1.01-2.15 1.66* 1.09-2.53
Socialized Aggression 1.59* 1.17-2.15 1.40 0.96-2.04 1.45 0.96-2.20
Attention Problems 1.59* 1.16-2.18 1.49* 1.01-2.19 1.42 0.93-2.17
Psychotic Behavior 1.56* 1.16-2.11 1.34 0.93-1.93 1.48 0.98-2.23
Motor Excess 1.43* 1.06-1.94 1.22 0.85-1.74 1.15 0.76-1.73
Clinical
Anxious/Depressedd 2.17* 1.23-3.82 2.29* 1.18-4.47 3.70* 1.71-7.99
Withdrawn/Depressedd 1.54 0.86-2.74 1.49 0.75-2.96 3.00* 1.34-6.73
Conduct Disorder 1.85* 1.32-2.59 1.29 0.85-1.95 1.35 0.85-2.14
Socialized Aggression 1.26 0.85-1.87 1.02 0.64-1.62 0.94 0.55-1.60
Attention Problems 1.62* 1.20-2.18 1.31 0.90-1.90 1.34 0.88-2.02
Psychotic Behavior 1.26 0.91-1.75 0.85 0.57-1.27 0.88 0.55-1.39
Motor Excess 1.64* 1.21-2.23 1.17 0.81-1.70 1.17 0.76-1.78
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*

These point estimates are statistically significant (p < .05).

a

All adjusted models included the following covariates: age, gender, nativity status, family income, time in the US and study.

b

All biculturalism-adjusted models included covariates from the adjusted models, in addition to a biculturalism variable (Americanism-Hispanicism) and a variable reflecting the interactions between same-sex behaviors and biculturalism.

c

95% CI=95% Confidence Interval.

d

Models in which the biculturalism-by-LASSB status interaction term emerged significant in biculturalism-adjusted models and subgroup analyses were pursued.

In bicultural-adjusted models, biculturalism was not found to moderate the association between same-sex behaviors and any of our externalizing behaviors (normal and clinical). Normal levels of conduct disorder did remain significant with LASSB having 66% higher odds of exhibiting this behavior relative to non-LASSB (aOR=1.66; 95% CI: 1.09-2.53). The biculturalism by same-sex behaviors interaction term was significant for all internalizing behavior subscale models, except in the model predicting normal levels of anxious/depressed. Thus, we pursued subgroup analyses among LASSB and non-LASSB for clinical levels of anxious/depressed and normal and clinical levels of withdrawn/depressed. Biculturalism was not statistically significant predictor in any of these models; however, point estimates and a large portion of the corresponding 95% confidence intervals were all at or below 1. Adjusted odds ratios for LASSB were 0.94 (95% CI: 0.88-1.00) for clinical levels of anxious/depressed 0.96 (95% CI: 0.90-1.02) for clinical levels of withdrawn/depressed, and 0.98 (95% CI: 0.96-1.01) for normal levels of withdrawn/depressed (results not listed in table). Among non-LASSB, all aOR point estimates were statistically significant and slightly above 1 (ranging from 1.01-1.03). Point estimates below 1 suggest that increasing propensity for American cultural practices relative to Latin American cultural practices decreases the odds for endorsing these behaviors (and vice versa for aOR values above 1).

Discussion

This study compares LASSB to their heterosexual counterparts across validated subscales reflecting internalizing symptoms and externalizing behaviors in a Miami-based sample. Our analyses reveal significant differences in mental health symptoms, but not in all cases. Using clinical cut-offs, a significantly higher prevalence of conduct disorder, motor excess, attention problems, and anxious/depressed was found in LASSB compared to non-LASSB. There was a significantly higher prevalence of externalizing behaviors among LASSBs compared to non-LASSBs, notably in conduct disorder, which supports extant research with racially/ethnically diverse sexual minority adolescent samples (Mustanski, Garofalo, & Emerson, 2010). This finding contributes to scant data on specific behavioral symptoms among LASSB.

A 2016 study identified similar sexual orientation disparities in anxious/depressed symptoms in a diverse sample of adolescents and young adults (Shearer et al., 2016). Of particular concern is the over two-fold likelihood of LASSB exhibiting clinical levels of anxious/depressed. Anxiety and depressive symptoms have been shown to exacerbate externalizing disorders and increase the risk of suicidality among youth (Hill, Castellanos, & Pettit, 2011). According to data from the U.S. Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System (YRBS), sexual minority youth who identify as lesbian, gay, or bisexual had a higher prevalence of seriously considering suicide, making a plan, and actually attempting it compared to non-sexual minority youth (Zaza, Kann, & Barrios, 2016). This constitutes an urgent and salient public health concern among youth because the effects of having multiple marginalized identities may increase the risk of suicide (Lytle, De Luca, Blosnich, & Brownson, 2015).

When considering the potential moderating impact of biculturalism, our analyses revealed interesting results, though not statistically significant in LASSB subgroup analyses. The interaction of biculturalism with same-sex behaviors was significant in three of our internalizing symptom models (two clinical, one normal), but not in externalizing behavior models. Results from LASSB subgroup analyses examining the association between biculturalism and internalizing symptoms did not reach significance, likely due to lack of power to detect these effects. Previous research with general Latinx adolescent samples indicate that increasing Americanism is associated with increasing poorer mental health (Lawton & Gerdes, 2014). This was confirmed in the subgroup analyses with non-LASSB. There is mixed evidence among Latinx sexual minority samples. A recent study examined the cross-sectional association between cultural orientation and minority stressors and their impact on depressive symptoms in young Latinx sexual minorities (mean age=20). After adjusting for minority stressors (internalized homonegativity, LGBT discrimination), depressive symptoms were positively associated with affinity to American culture and negatively associated with affinity to Latin American culture (Anhalt, Toomey, & Shramko, 2020). A study with adult Latinx MSM, however, documented an inverse association between Americanism and depressive symptoms (Mitrani et al., 2017). Samples in these studies were slightly older than the sample in this study. Additional studies to understand how biculturalism may have a distinct impact on mental health in younger Latinx sexual minorities, particularly in adolescents, are needed.

Traditional Latin American cultural ideals can foster negative attitudes toward homosexual thoughts and behaviors (Warren et al., 2008). Culturally-driven expectations around gender norms, such as machismo (hyper-masculinity) and experiences of ethnic/racial discrimination have been associated with depressive symptoms (Fragoso & Kashubeck, 2000) in Latinx sexual minorities. Compared to their non-Latinx sexual minority counterparts, Latinx sexual minorities have reported more negative reactions from disclosure of their sexual identity to their families (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). These negative family reactions may be particularly difficult for those from collectivist cultures (i.e., Latin American), which prioritize community and family over individual needs and desires. This may make sexual minority stressors in the family context more impactful on mental health and drive sexual minority Latinxs toward a potentially more accepting American culture and further from their traditional heritage culture.

There are limitations that should be considered in light of these findings. Sexual orientation also includes dimensions of attraction and identity, in which research has shown differential associations with various sexual risk behaviors when comparing across these sexual orientation groups (Everett, 2015; Everett, Schnarrs, Rosario, Garofalo, & Mustanski, 2014); however, other measures such as sexual identity, were not included in the survey batteries. This introduces a source of misclassification bias, particularly amongst adolescent participants who may identify as sexual minorities (e.g., gay, bisexual) but have yet to engage in same sex sexual behavior. Data on minority stress constructs pertaining to sociocontextual experiences, such as peer victimization, parental acceptance of same-sex behaviors, and internal processes (e.g., expectations of identity rejection, internalized homonegativity) could have provided additional insight in understanding and interpreting results (Goldbach & Gibbs, 2017).

Participants in all synthesized studies were Latinx and from Miami, and not representative of all Latinxs nationally; however, our sample was diverse with respect to age, gender, and nativity status with various Latin American countries of origin represented (e.g., Cuba, Nicaragua, and Mexico). The synthesis was necessary in order to contribute to our limited understanding of this vulnerable subgroup. Only in recent years have we seen data become available for sexual minority adolescents, including LASSB. The Department of Health and Human Services’ (HHS) data progression plan aimed to advance sexual orientation data collection efforts in all federally-funded surveys did not begin until 2011 (Wolff, Wells, Ventura-DiPersia, Renson, & Grov, 2017). Further, national surveys such as the YRBS did not begin to include questions asking about sexual identity and sex of sexual contacts in the core questionnaire until 2015 (Kann et al., 2016). Despite having the ability to examine mental health in sexual minority adolescents with these data, they still do not include key measures (i.e., biculturalism) relevant to ethnic minority subgroups, such as LASSB.

Even though we combined data across five studies to create a suitable sample for analysis, we could not separate LASSB who reported same- and opposite-sex behavior (i.e., bisexual behavior) at the risk of losing statistical power. Sexual minorities who report both-sex sexual contact are often at higher risk of poorer health and should be evaluated as a separate group (Marshal et al., 2011). The cross-sectional design of this study limited our ability to not only establish temporal precedence of same-sex sexual contact with mental health outcomes, but also changes in developmental processes such as acculturation. Longitudinal data could help elucidate these relationships to better capture the dynamic interplay of all these developmental processes with mental health outcomes (Everett, 2015). Additionally, the baseline data were collected from 2000 to 2011. Except toward the end of the decade, most of that period saw limited legal and societal advancements in sexual minority and gender equality in the United States (Goldbach & Gibbs, 2017) compared to 2011 to 2016. Our findings are interpreted in a social climate that differs from the data collection period. However, we believe the results continue to remain relevant given the uncertainty in today’s dynamic political and legal environments.

Despite these limitations, our results demonstrate sexual orientation disparities in internalizing symptoms and externalizing behaviors within a sample of Latinx adolescents, particularly clinical levels of internalizing symptoms. To our knowledge, no studies have previously explored whether the impact of biculturalism differs between LASSB and non-LASSB. Our study also found that biculturalism moderates this relationship. There are currently no evidence-based mental health interventions specifically designed for Latinx sexual minority youth, including LASSB. Due to the unique values, beliefs, behaviors, and histories that directly impact Latinxs and therefore their health, culturally-tailored interventions are necessary (Mitrani, 2009). Latin American culture has been cited as a primary reason why Latinx sexual minorities do not even disclose their sexual orientation to their families (Gattamorta & Quidley-Rodriguez, 2018). It may be that the tension between familial cultural practices and beliefs and preferences of the youth lead to internalizing symptoms in Latinx sexual minority adolescents (Prado & Pantin, 2011). This cultural tension between Latinx sexual minority adolescents and their caregivers may be a vital focal point for family-based interventions, as it is for non-sexual minority Latinx adolescents (Molgaard & Spoth, 2001).

LASSB are more likely to report clinical levels of internalizing symptoms compared to their counterparts even after controlling for potential confounders. Previous mental health research with Latinx sexual minority samples have not consistently shown how cultural factors influence mental health in Latinx sexual minorities, particularly among adolescents, prompting the need for additional research. We recommend cohort studies with Latinx sexual minority adolescents examine acculturative processes, such as biculturalism, and minority stressors and how they interact over time and affect a wide variety of behaviors in this group to inform tailored preventive interventions.

Acknowledgments

Study Funding: Funding has come from the following sources: National Institute on Drug Abuse Grant No. F31DA040562 (PI: Manuel A. Ocasio); National Institute on Drug Abuse Grant No. R01DA025192 (PI: Guillermo Prado); National Institute on Drug Abuse Grant No. R01DA025894 (PI: Guillermo Prado); National Institute on Drug Abuse Grant No. R01DA017462 (PI: Hilda Pantin); Centers for Disease Control and Prevention Grant No. U01PS0000671 (PI: Guillermo Prado); National Institute of Mental Health Grant No. R01MH63042 (PI: José Szapocznik). These funding sources had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; nor in the decision to submit the article for publication.

Footnotes

Ethical Information: This study was approved by the University of Miami Social and Behavioral Sciences Institutional Review Board (Protocol ID: 20150665).

Conflict of Interest: The author(s) have declared that they have no competing or potential conflicts of interest.

Disclosure Statement: There is no financial interest or benefit that has arisen from the direct applications of this research.

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