Latinx Sexual Minority Individuals, Linguistic Acculturation, and Behavioral Health: Evidence of a Healthy Migrant Effect

doi:10.21203/rs.3.rs-4862353/v1

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Latinx Sexual Minority Individuals, Linguistic Acculturation, and Behavioral Health: Evidence of a Healthy Migrant Effect

https://doi.org/10.21203/rs.3.rs-4862353/v1

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Purpose: Stress-based theories suggest that sexual minority Latinx migrants are at increased risk of adverse behavioral health outcomes. However, a body of descriptive evidence shows migrants exhibit improved health outcomes. Responding to calls for intersectional investigations of the ‘healthy migrant effect,’ we quantitatively examine whether sexual minority status moderates the relationship between English proficiency (a proxy for acculturation) and behavioral health.

Methods: We used pooled cross-sectional data from the Latinx respondents to the 2015-2019 National Survey on Drug Use and Health. We used logistic regression models to examine the association of the level of English proficiency with past-year major depressive episode (MDE) and past-year substance use disorder (SUD) and used interactions to examine the moderating effect of sexual minority status.

Results: For both MDE and SUD, sexual minority Latinx individuals with lower levels of English proficiency had lower odds of reporting adverse outcomes than sexual minority individuals with higher levels of English proficiency and did not have significantly different outcomes than their heterosexual counterparts. The direction of these relationships did not change when stratified by gender.

Conclusions: There appears to be a healthy migrant effect with regard to sexual minority Latinx individuals and behavioral health outcomes. This also suggests that acculturation may be a uniquely important risk factor for this population. Preventative efforts should be targeted at this group to avoid the development of behavioral health concerns.

Despite progress on LBGT + rights in many parts of Latin America,¹ violence and discrimination related to sexual minority status remain a commonly cited motivation for emigration from Latin America to the United States (U.S.).² A recent Williams Institute report estimated that there are over 600,000 Latinx sexual minority immigrants residing in the U.S.³ These include some of the most vulnerable sexual minority immigrants; currently, over half of LGBT + individuals claiming asylum in the U.S. are from the Northern Triangle nations of Central America (Guatemala, El Salvador, and Honduras).⁴

LGBT + individuals, regardless of ethnicity, have long been found to experience higher rates of adverse mental health and substance use outcomes relative to their heterosexual peers.⁵ Sexual minority individuals’ higher prevalence of adverse behavioral health outcomes has typically been explained by minority stress theory, which posits that stressors related to stigma towards non-heterosexual sexual orientations lead to worse behavioral health outcomes.⁶ Such stressors include victimization, discrimination, harassment, and social rejection. Adverse behavioral health outcomes among sexual minority individuals represent a significant public health challenge, including much higher rates of suicidality and self-harm.⁷

At the same time, additional work in the stress and coping literature around cultural stress theory has highlighted the role that post-migration stressors play in migrant behavioral health outcomes.⁸ An important component of cultural stress is difficulties related to language barriers, which have been found to be associated with adverse behavioral health outcomes.⁹ Post-migration stressors may be particularly acute for individuals without formal legal status in the U.S. due to immigrant enforcement activities¹⁰ and structural racism for minoritized immigrant groups.¹¹ For Latinx sexual minority immigrants, negative experiences in sending communities, stigma and discrimination related to being LGBT+, and acculturative and minority stressors in the U.S. can all combine to lead to adverse behavioral health outcomes.¹² For both Latinx LGBT + individuals born in the U.S. and those born in other countries, discrimination and psychosocial distress from societal marginalization can also contribute to adverse behavioral health outcomes.^13,14

However, although evidence is mixed, immigrant groups in the U.S. have been found to experience better behavioral health outcomes than their U.S.-born counterparts.¹⁵ This health advantage decreases with the length of residency in the U.S. This has been referred to as the “healthy migrant effect” Refugee individuals have been found to be far less likely to endorse substance use disorders than U.S.-born individuals,¹⁶ and acculturation has been found to be a risk factor for all Latinx individuals, regardless of nativity.¹⁷ While several theoretical explanations for the healthy migrant effect have been put forward, the empirical evidence does not strongly support any of them and the reasons for the effect are not clear. There have been recent calls for intersectional research to better understand the role of overlapping social positions on migrant health and behavioral health outcomes to better explain the effect.^10,15 To this end, in this study we examine whether sexual minority status moderates the relationship between English language proficiency (a measure of linguistic acculturation) and two adverse behavioral health outcomes—depression and substance use disorder—for Latinx individuals in the U.S. We hypothesize that sexual minorities with lower English proficiency will experience more adverse behavioral health outcomes as compared to both their heterosexual counterparts and sexual minority individuals with greater English proficiency.

Data and Sample

This study uses pooled cross-sectional data from the 2015–2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is an annual survey that provides population estimates for a variety of substance use and health-related behaviors in the U.S. general population. It uses multistage area probability sampling methods and includes all 50 states, Puerto Rico, and the District of Columbia. Each annual sample is considered nationally representative of the non-institutionalized population age 12 years or older. A fuller description of NSDUH procedures is available elsewhere.¹⁸

The NSDUH began collecting information on sexual orientation in 2015. Due to changes in how the survey was administered during the COVID-19 pandemic, it is not recommended that NSDUH samples from 2020 onward be combined with past samples. The analytic sample for this study was restricted to adult (18+) participants who self-reported their ethnicity as Hispanic, for a total sample of N = 35,737. The analytic sample was primarily heterosexual (n = 33,138, 94.5%) but included many sexual minority participants (n = 2,599, 5.6%). The majority of the sample reported speaking English “Very well” (n = 23,376, 58.9%), with many reporting speaking “Well” (n = 5,463, 16.5%) and “Not well/Not at all” (n = 6,898, 24.6%).

Measures

Major Depressive Episode (MDE). Past-year MDE (0 = no, 1 = yes) was determined by 9 self-report items derived from the DSM-IV for major depressive disorder (e.g., felt sad most of the day, lost interest or pleasure in activities, restlessness and/or lethargy). Participants who endorsed at least 5 of the 9 items in the past year were considered to have MDE.

Substance Use Disorder (SUD). Past-year SUD (0 = no, 1 = yes) was determined by 7 self-report items derived from the DSM-IV criteria for abuse and dependence of alcohol, illicit drugs, and prescription medication misuse. Prior methodological studies have found acceptable agreement between the NSDUH measures and clinical interview data (Jordan et al., 2008).

Sexual Minority Status. Sexual minority status (0 = no, 1 = yes) was self-reported via one item: “Which one of the following do you consider yourself to be?” with response options of heterosexual (straight), gay/lesbian, or bisexual. Individuals reporting either gay/lesbian or bisexual as their sexual orientation were considered to be sexual minorities.

English proficiency. English proficiency was self-reported via one item: “How well do you speak English?” Response options were very well, well, not well, or not at all. “Not well” and “Not at all” had a small number of observations and were collapsed into one category to increase model stability.

Sociodemographics. Self-reported gender was measured as a binary outcome (male/female; the NSDUH does not include an “other” or non-binary category, and respondents are not asked if they identify as transgender). Other demographic factors include: age, educational attainment, and employment status. Categories for each item are listed in Table 1.

Table 1

Sample characteristics and adverse behavioral health outcomes
	N (%)^a	% MDE^a	% SUD^a
Total	35,737
Sexual minority status
Sexual minority	2,599 (5.6)	17.2	17.3
Not sexual minority	33,138 (94.5)	5.3	7.0
English proficiency
Very well	23,376 (58.9)	7.8	10.0
Well	5,463 (16.5)	4.4	5.2
Not well/Not at all	6,898 (24.6)	2.5	3.4
Gender
Male	16,594 (50.1)	4.1	10.5
Female	19,143 (49.9)	7.8	4.7
Age
18–25	14,453 (19.4)	10.7	13.6
26–34	7,927 (20.5)	6.2	10.8
35–49	9,206 (29.7)	4.9	6.3
50–64	2,872 (19.8)	4.4	3.8
65+	1,279 (10.6)	2.6	1.0
Education
Less than high school	9,236 (29.0)	3.6	5.6
High school	10,576 (26.2)	5.7	8.6
Some college	11,162 (28.3)	8.2	8.8
College or more	4,763 (16.5)	6.4	7.3
Employment status
Full-time	17,944 (51.1)	5.0	8.4
Part-time	5,448 (12.2)	8.9	8.7
Unemployed	2,752 (6.2)	7.4	13.2
Other^b	9,593 (30.5)	6.0	4.6
Survey year
2015	7,395 (19.2)	5.0	8.8
2016	6,849 (19.5)	5.7	7.3
2017	6,926 (20.1)	5.8	7.1
2018	7,172 (20.4)	6.1	7.6
2019	7,395 (20.9)	6.9	7.0
^aPercentages are adjusted for survey weights
^b“Other” includes those not in labor force

Statistical Analysis

Statistical analyses were conducted in several steps. All analyses were survey-weight adjusted using Stata 17’s svyset command per NSDUH methodological guidelines. First, descriptive statistics were used to determine the prevalence of MDE and SUD for each independent variable. Next, binary logistic regression models were fitted to examine the association between sexual minority status and English proficiency and the two outcome variables, while controlling for demographic covariates and survey year. Finally, a model was fitted interacting sexual minority status and English proficiency to test the intersection of sexual minority status and English proficiency on MDE/SUD.¹⁹ For the interaction models, predicted probabilities and multiple linear combinations using Stata 17’s mlincom command were used to test for the significance (using t statistics) of the interactions as examining the p-value of the interaction term to determine significance can be misleading in non-linear regression models.²⁰ We also conducted a sensitivity analysis by stratifying models by gender.

As shown in Table 1, weighted prevalence estimates for past-year MDE and SUD were higher for sexual minority Latinx individuals (17.2% and 17.3%, respectively) than for heterosexual Latinx individuals (5.3% and 7.0%, respectively). Prevalence estimates for MDE and SUD were also higher for Latinx individuals who reported speaking English “Very well” (7.8% and 10.0%, respectively) compared to those who reported speaking English “Well” (4.4% and 5.2%) and those who reported speaking English “Not well/Not at all” (2.5% and 3.4%). As shown in Table 2, when controlling for demographic factors, sexual minority was positively correlated with both MDE (aOR: 2.72, 95% CI: 2.24, 3.31) and SUD (aOR: 2.26, 95% CI: 1.96, 2.61). English proficiency was negatively correlated with both MDE (aOR: 0.67, 95% CI: 0.59, 0.75) and SUD (aOR: 0.65, 95% CI: 0.58, 0.73). The interaction between sexual minority status and English proficiency was not jointly significant for either MDE or SUD.

Table 2

The Association of English Proficiency and Sexual Minority Status on MDE and SUD
	MDE		SUD
	aOR - Model 1^a	aOR - Model 2^a	aOR - Model 1^a	aOR - Model 2^a
Sexual minority status
Heterosexual	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Sexual minority	2.72 (2.24, 3.31)	3.32 (2.05, 5.38)	2.26 (1.96, 2.61)	2.91 (1.85, 4.57)
English proficiency	0.67 (0.59, 0.75)	0.68 (0.60, 0.76)	0.65 (0.58, 0.73)	0.65 (0.58, 0.74)
SMS x English Proficiency	--	0.85 (0.57, 1.26)	--	0.81 (0.57, 1.15)
Gender
Male	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Female	1.86 (1.61, 2.14)	1.86 (1.61, 2.14)	0.42 (0.37, 0.48)	0.42 (0.37, 0.48)
Age
18–25	1 (ref)	1 (ref)	1 (ref)	1 (ref)
26–34	0.66 (0.56, 0.78)	0.66 (0.56, 0.78)	0.86 (0.76, 0.98)	0.86 (0.76, 0.98)
35–49	0.62 (0.52, 0.75)	0.62 (0.52, 0.75)	0.54 (0.45, 0.67)	0.55 (0.45, 0.67)
50–64	0.55 (0.41, 0.74)	0.55 (0.41, 0.74)	0.34 (0.25, 0.45)	0.34 (0.25, 0.45)
65+	0.28 (0.19, 0.42)	0.29 (0.19, 0.42)	0.11 (0.06, 0.20)	0.11 (0.06, 0.20)
Education
Less than HS	1 (ref)	1 (ref)	1 (ref)	1 (ref)
High school	1.13 (0.91, 1.41)	1.13 (0.91, 1.41)	0.95 (0.77, 1.16)	0.95 (0.77, 1.16)
Some college	1.45 (1.19, 1.79)	1.46 (1.19, 1.79)	0.90 (0.74, 1.09)	0.90 (0.74, 1.09)
College or more	1.34 (1.07, 1.67)	1.34 (1.07, 1.67)	0.89 (0.68, 1.16)	0.89 (0.68, 1.16)
Employment status
Full-time	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Part-time	1.39 (1.20, 1.60)	1.39 (1.20, 1.60)	1.00 (.86, 1.17)	1.00 (0.86, 1.17)
Unemployed	1.48 (1.20, 1.81)	1.48 (1.20, 1.82)	1.58 (1.25, 1.99)	1.58 (1.25, 1.99)
Other^b	1.51 (1.32, 1.73)	1.51 (1.32, 1.73)	0.87 (0.73, 1.03)	0.86 (0.73, 1.03)
^aModel also adjusted for survey year

Based on the interaction models, sexual minority Latinx individuals who reported speaking English “Very well” had a significantly higher predicted probability of MDE (15.1%, 95% CI: 12.3–17.8%) than their heterosexual counterparts (6.1%, 95% CI: 5.4–6.7%). Sexual minority Latinx individuals who reported speaking English “Well” also had a significantly higher predicted probability of MDE (9.3%, 95% CI: 5.6–13.1%) as compared to their heterosexual counterparts (4.2%, 95% CI: 3.7–4.8%), although it was lower for both groups than for those reporting speaking English “Very well.” Sexual minority Latinx individuals who reported speaking English “Not well/Not at all” did not have a significantly higher predicted probability of MDE (5.6%, 95% CI: 1.2–10.0%) than their heterosexual counterparts (2.9%, 95% CI: 2.2–3.5%), and both groups had lower predicted probabilities than those reporting greater English proficiency. Full results are shown in Table 3 and displayed graphically in Fig. 1.

Table 3

Predicted Probability of BH Outcomes by Sexual Minority Status and English Proficiency
	Sexual Minorities	Heterosexuals	P-value^a
MDE
Very well	.151 (.123, .178)	.061 (.054, .067)	.000
Well	.093 (.056, .131)	.042 (.037, .048)	.005
Not well/Not at all	.056 (.012, .100)	.029 (.022, .035)	.203
SUD
Very well	.144 (.125, .163)	.070 (.064, .076)	.000
Well	.085 (.065, .106)	.048 (.043, .053)	.001
Not well/Not at all	.048 (.022, .075)	.032 (.025, .039)	.245
^aP-values between predicted probabilities calculated using Stata’s mlincom command

For SUD, a similar pattern was observed. Sexual minority Latinx individuals who reported speaking English “Very well” had a significantly higher predicted probability of SUD (14.4%, 95% CI: 12.5–16.3%) than their heterosexual counterparts (7.0%, 95% CI: 6.4–7.6%). Sexual minority Latinx individuals who reported speaking English “Well” also had a significantly higher predicted probability of SUD (8.5%, 95% CI: 6.5–10.6%) as compared to their heterosexual counterparts (4.8%, 95% CI: 4.3–5.3%), although it was lower for both groups than for those reporting speaking English “Very well.” Sexual minority Latinx individuals who reported speaking English “Not well/Not at all” again did not have a significantly higher predicted probability of SUD (4.8%, 95% CI: 2.2–7.5%) than their heterosexual counterparts (3.2%, 95% CI: 2.5–3.9%), and both groups had lower predicted probabilities than those reporting greater English proficiency. Full results are shown in Table 4 and displayed graphically in Fig. 2.

For the sensitivity analyses, all trends were in the same direction for the stratified models as for the main models, although specific point estimates were different (results not shown). This suggests that the patterns found are similar for male- and female-identified sexual minorities.

This study examined whether sexual minority status moderated the relationship between English proficiency and two adverse behavioral health outcomes: depression and substance misuse. To our knowledge, this is the first study to quantitively examine this relationship, using a large, nationally representative sample. Despite theoretical perspectives that posit that sexual minority Latinx individuals with low English proficiency experience a greater number of stressors, which, in turn, would predict higher levels of adverse behavioral health outcomes, in this sample, low-acculturated Latinx sexual minorities reported better outcomes than their more highly-acculturated counterparts and the same outcomes as their heterosexual counterparts. Our findings, to the extent that temporal processes of acculturation can be inferred from these data, suggest that acculturation may be a uniquely important risk factor for Latinx sexual minorities as compared to their heterosexual counterparts.

These results also provide evidence that the healthy migrant effect extends to sexual minority migrants as well. Interestingly, one proposed explanation for the health migrant effect is that migrants, particularly Latinx migrants, have greater social support due to a strong emphasis on family ties. However, sexual minority individuals frequently experience family rejection, and there is some evidence that Latinx sexual minority individuals experience higher rates of family rejection than non-Latinx sexual minority individuals.²¹ It may be that other identity- or context-related factors influence the behavioral health outcomes examined. Our data do not allow us to examine potential factors, but such factors could be examined in future studies.

In terms of practice, again, to the extent that processes of acculturation can be inferred from these findings, they suggest that recently migrated Latinx sexual minority individuals may be an ideal population for targeted prevention efforts. Tailored, culturally-congruent preventative interventions could help mitigate the risk of psychological disorders arising as the length of residence in the U.S. increases.²² To our knowledge, no such interventions exist, indicating a clear need for intervention development and implementation. In terms of policy, both migrants and LGBT individuals experience unique or additional barriers to healthcare and typically disproportionately face poorer social determinants of health.¹¹ Policy efforts to to facilitate access to appropriate behavioral health services for sexual minority Latinx individuals and improve social determinants of health can also help prevent the development of disorder or mitigate the negative impacts of those disorders after they develop.

Limitations

These results should be considered with several limitations in mind. First, the dataset does not directly measure nativity, so we use linguistic acculturation as a proxy (assuming that individuals reporting lower levels of English proficiency are migrants). While we believe this to be a reasonable assumption, ideally, nativity would be directly measured. Furthermore, we want to stress that there is considerable diversity both within the Latinx community as well as the LGBT + communities that we are unable to capture with these data. Experiences of acculturation vary by national origin and receiving community, and experience with behavioral health outcomes varies by gender and sexual orientation.²³ Ideally, a larger dataset could account for more granular distinctions. However, this is a problem common to intersectional quantitative epidemiological studies,²⁴ and it represents an advance in that we have a large enough sample to examine the intersection of sexual minority status and English proficiency. Finally, we assume that a longitudinal acculturation process can be inferred from repeated cross-sectional data. Again, we believe this is a reasonable assumption, but future work using prospective, longitudinal designs is needed to confirm these processes. Comparative qualitative work could also help shed light on these processes.

This study adds an intersectional lens to the growing body of evidence for the healthy migrant effect, finding that it also holds for sexual minority Latinx individuals. Despite theoretical frameworks suggesting that sexual minority Latinx individuals with limited English proficiency should have more adverse behavioral health outcomes that either their heterosexual counterparts or sexual minority Latinx individuals with greater English proficiency, we found that that sexual minority Latinx individuals with limited English proficiency had better behavioral health outcomes that their counterparts with greater English proficiency and no significant differences from their heterosexual counterparts. These findings, like the larger body of evidence regarding the health migrant effect, remain unclear. There is a need for further explanation to better understand why acculturation may be a uniquely important risk factor for sexual minority migrants, which seems to represent an ideal target for preventative efforts.

Author Contribution

J.H. conceptualized the study and conducted the primary analyses. All authors contributed equally to drafting, revising, and editing the manuscript.

Declaration of Competing Interests: The authors have no conflicts of interest to disclose.

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No competing interests reported.

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Latinx Sexual Minority Individuals, Linguistic Acculturation, and Behavioral Health: Evidence of a Healthy Migrant Effect

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Data and Sample

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Statistical Analysis

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Discussion

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