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JIVXXX10.1177/0886260519898423Journal of Interpersonal ViolenceMendoza-Perez and Ortiz-Hernandez

Original Research
Journal of Interpersonal Violence

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Discrimination and
Violence and Mental
Health in Homosexual
and Bisexual Men in
Mexico

Juan C. Mendoza-Perez1,2 
and Luis Ortiz-Hernandez2 

Abstract
The aim of this study was to determine whether the experiences of direct
or subtle forms of discrimination and violence are associated with mental
health in Mexican gay, homosexual, and bisexual (GHB) men. A cross-
sectional survey was conducted online; the sample consisted of 4,827 GHB
men. Ten forms of overt and subtle sexual orientation–based discrimination
and violence (SO-DV) were assessed. Linear and logistic regression models
were used to evaluate the association between SO-DV experiences and
mental health outcomes. Physical violence was reported less frequently than
the other forms of SO-DV. As the number of settings in which SO-DV were
experienced increased, a stronger association with negative mental health
outcomes was observed. Experiences of subtle SO-DV were associated
with increased distress, lower vitality, and increased risk of suicidal ideation.

1
Universidad Nacional Autónoma de México, Ciudad de México, Mexico
2
Universidad Autónoma Metropolitana Xochimilco, Ciudad de México, Mexico

Corresponding Author:
Luis Ortiz-Hernandez, Departamento de Atención a la Salud, Universidad Autónoma
Metropolitana Xochimilco, Calz. del Hueso 1100, Col. Villa Quietud, Coyoacán, CP 04960
Ciudad de México, Mexico.
Email: lortiz@correo.xoc.uam.mx
2 Journal of Interpersonal Violence 00(0)

Disapproval of gender nonconformity was associated with negative mental

health outcomes independently of violence based on sexual orientation.
Subtle forms of SO-DV are more common than direct and overt forms. Both
types of SO-DV could negatively affect mental health. Studies investigating
these negative experiences are required to gain an understanding of the
health inequalities faced by non-heterosexual populations.

Keywords
violence, discrimination, LGBT people, victimization, mental health, suicidality,
psychological distress, homophobia, sexual orientation change efforts

Introduction
Sociocultural Norms and Prejudice Experiences
Gay, homosexual, and bisexual (GHB) men are at a greater risk of suffering
psychological distress, mental health disorders, and suicidal behavior (Haas
et al., 2011; Hottes et al., 2016) than their heterosexual counterparts. These
health disparities associated with sexual orientation have been attributed to
the experience of minority stress in GHB men because they belong to a stig-
matized group (Meyer, 2003). Minority stress involves two types of stressors:
distal processes or prejudice events, such as sexual orientation–based dis-
crimination and violence (SO-DV); and proximal processes, including expec-
tations of rejection, concealment, and internalized homophobia.
The stigma faced by GHB individuals originates from the three social
norms encompassed in the gender system: compliance with gender stereo-
types, heterosexism, and androcentrism (Ortiz-Hernández & Granados,
2006). Heterosexism refers to the ideology that posits that heterosexuality is
the only valid sexual orientation. Gender stereotypes represent the expected
identity and behavior that people should supposedly adopt according to their
assigned sex, that is, women should be feminine, and men should be mascu-
line. Androcentrism establishes the superiority of masculinity over feminin-
ity; this norm implies not only the dominance of men over women but also
the superiority of masculine symbols over feminine ones. From this perspec-
tive, SO-DV represents a social sanction suffered by subjects because they
do not comply with these social norms. These socio-culture norms explain
why GHB men suffer higher rates of violence than lesbian and bisexual
females (Katz-Wise & Hyde, 2012; Ortiz-Hernández & Granados, 2006) as
follows: Violence experienced by GHB men is a result not only of their
sexual orientation (i.e., because they transgress heterosexism) but also their
feminine traits or behaviors (i.e., they do not comply with gender stereo-
types and adopt a devalued identity).
Mendoza-Perez and Ortiz-Hernandez 3

We distinguished two groups of prejudice experiences: overt or direct vio-

lence and subtle violence (Galtung, 1990). Overt or direct violence includes
two types of acts: physical and extreme violence, which physically affects the
victim and is related to the use of an instrument by the perpetrator (e.g.,
hands, knives, gas, stones, etc.), and verbal and psychological violence,
which affects emotions and feelings of victim (e.g., lies, threats, or insults).
Subtle forms of SO-DV include manifestations such as microaggressions,
heterosexist discrimination, and symbolic violence. Microaggressions “are
behaviors and statements, often unconscious or unintentional, that communi-
cate hostile or derogatory messages” toward certain groups (Nadal et al.,
2016, p. 488). Insidious trauma refers to the negative experiences of mem-
bers of oppressed groups (Szymanski & Balsam, 2011). Some of these expe-
riences (e.g., hate crimes) can yield injury or threats to one’s physical
integrity; however, some events (e.g., heterosexist discrimination) do not
involve physical consequences but enact a detrimental treatment based on the
belonging to a stigmatized group.
Symbolic violence is an implicit manifestation of heterosexism, expecta-
tions of gender stereotypes, and androcentrism in interpersonal relationships.
Cultural or symbolic violence (Bourdieu, 2012; Galtung, 1990) is commonly
subtle because there is no overt condemnation of homosexuality, but there is
an implicit negative judgment of homosexuality or feminine traits in men.
People suffering from symbolic violence receive the message that their iden-
tity or behavior is socially undesirable because they deviate from social
norms. Thus, symbolic violence is stable (and therefore a chronic stressor)
because it is a part of the structures of society and contributes to the mainte-
nance of inequality because it is the reproduction of an unequal power distri-
bution. In congruence, qualitative research (Nadal et al., 2016) has showed
that a common microaggression faced by GHB men is “the policing of mas-
culinity and the endorsement of masculine gender roles for men and boys” (p.
9). In this way, the phrase “That’s so gay” is a slur or offense that degrades a
man (independently of his sexual orientation) by associating him with the
adoption of feminine behaviors. Because of microaggressions, LGBT (les-
bian, gay, bisexual, and transgender) people have emotions such as discom-
fort, feelings of unsafety, anger, frustration, and shame, and these experiences
can be associated with symptoms of depression, anxiety, and post-traumatic
stress disorder (Nadal et al., 2011).

Current Context of Research Investigating SO-DV and Mental

Health
In many Western societies, legal and institutional changes protecting the
rights of LGBT populations have been implemented. In the case of Mexico,
4 Journal of Interpersonal Violence 00(0)

since 2011, “sexual preferences” have been included in the constitution as a

basis on which one may not discriminate. Another emblematic change has
been the modification, in 2009, of the Mexico City’s civil code to allow the
marriage of same-sex couples.
Changes in the tolerance of homosexuality have also occurred. However,
although most overt manifestations of homophobia have decreased, subtler
negative perceptions of homosexuality persist. In the Americas, there is
ambivalence toward homosexuals because although most people think that
human rights should be respected regardless of sexual orientation (69%), at
the same time, frequently people report that they would be angry if their son
or daughter were to fall in love with a person of his or her same sex (64%;
International Lesbian, Gay, Bisexual, Trans and Intersex Association, 2017).
In Mexico, although more than half of the population thinks that minority
sexual preferences should be respected, four out of 10 individuals report that
they would not allow a homosexual to live in their house (Consejo Nacional
para Prevenir la Discriminación, 2011).
Studies investigating the effects of SO-DV experiences on mental health
in GHB men must consider the changing sociocultural context described
above. Research about changes and continuities of homophobia are relevant
for public health practitioners because such studies could provide a better
understanding of the health inequalities faced by LGBT populations.
Most studies have focused on rejection or physical, verbal, or sexual vio-
lence (Collier et al., 2013; Mustanski et al., 2016; Schneeberger et al., 2014).
However, recently, subtle forms of SO-DV have been documented as also
having negative effects on the mental health of GHB men (Nadal et al., 2016).
Research has frequently paid attention to victimization experienced in
school (Collier et al., 2013), family (McGeough & Sterzing, 2018), and
workplace (Bauermeister et al., 2014; Ortiz-Hernández & Granados, 2006)
settings. For example, in a review (Haas et al., 2011), rejection from family
and school-based harassment were identified as risk factors of suicide
attempts in LGB youth. We were unable to find previous studies exploring
the relationship between mental health and SO-DV in other settings, such as
justice services, commercial settings, and outdoor places.
Because gender nonconformity in GHB men has been associated with
higher rates of victimization (D’Augelli et al., 2006; Hidalgo et al., 2015;
Toomey et al., 2010), some authors (Collier et al., 2013; Sandfort et al., 2007)
have proposed that it is necessary to distinguish the effect of violence moti-
vated by sexual orientation on GHB men’s mental health from the effect of
violence motivated by gender nonconformity. To the best of our knowledge,
no previous study has explored this issue.
Mendoza-Perez and Ortiz-Hernandez 5

Based on the theoretical and empirical background, we proposed the fol-

lowing three hypotheses:

Hypothesis 1: SO-DV has a cumulative effect because as the number of

settings in which SO-DV is experienced increases, the probability of nega-
tive mental health outcomes is higher.
Hypothesis 2: Independently of direct SO-DV, subtle forms of SO-DV are
positively associated with negative mental health outcomes.
Hypothesis 3: Violence based on gender nonconformity has an effect on
mental health independent of violence based on sexual orientation.

Method
Procedures
A cross-sectional survey involving a non-probabilistic sample of LGBT peo-
ple in Mexico was conducted as a part of The Situational Diagnosis of LGBT
Populations in Mexico 2015 project. The self-administered survey was
accessed through the web platform Surveygizmo between February and
September 2015. This research was coordinated by the Universidad Autónoma
Metropolitana Xochimilco (UAMX) and the non-governmental organization
Inspira Cambio. The survey was distributed through social networks, such as
Facebook and Twitter, and through other electronic media targeting GHB
men (e.g., Manhunt), civic associations, and news websites. The survey was
promoted nationally, and participants from all Mexican states were included.
Ethical approval was granted by the Divisional Council of Biological and
Health Sciences of UAMX. Before the participants started the survey, they
received information regarding the project’s objectives, anonymity of their
responses, voluntary nature of participation, and contact details of the research
team. No personal information that could be used to identify the participants
was collected.

Participants
The participants selected one option from a list of 11 categories of sexual
orientation and gender identity, including all LGBT population groups. For
this manuscript, we selected the participants who chose the following two
options: “gay/homosexual” or “bisexual man.” These options reflect a mea-
sure of one dimension of sexual orientation (i.e., identity; Sell, 1997) and
culturally relevant groups in the Mexican context (Laguarda, 2007). The
6 Journal of Interpersonal Violence 00(0)

Table 1.  Sociodemographic Characteristics of Gay, Homosexual, and Bisexual

Men: Mexico, 2015.

Sociodemographic characteristics n %
Sexual orientation identity
 Homosexual/gay 4,177 86.5
 Bisexual 650 13.5
Age (years)
 18–20 473 9.8
 21–25 1,315 27.2
 26–30 1,008 20.9
 31–45 1,438 29.8
 46+ 593 12.3
Marital status
 Single 2,169 84.6
  With partner 375 14.6
 Separated/divorced 16 0.6
 Widowed 5 0.2
Education of participants
  High school or less 1,218 25.3
  Bachelor’s or more 3,588 74.7
Education of household head
  Junior high school or less 597 12.4
  High school 721 15.0
  Bachelor’s degree 2,556 53.0
 Post-graduate 943 19.6
Geographic region
 North 1,052 21.8
 West 874 18.1
 Center 957 19.8
 South 562 11.7
  Mexico City 1,382 28.6

term “gay” is mainly used by younger men who have access to Western
media, whereas the term “homosexual” is more common among older men
from small cities.
Data were collected from 6,052 GHB men. After excluding the incomplete
responses and responses from participants aged younger than 18 years, a
sample of 4,827 GHB Mexican men remained.
Gay men represented the greatest proportion of the participants, and
bisexual men constituted the less frequent group (Table 1). The sample con-
sisted predominantly of young people (58% of the participants were aged
Mendoza-Perez and Ortiz-Hernandez 7

between 18 and 30 years) and people with an academic degree. The most
common level of household head education was an academic degree. The
regions with the greatest participation were the northern region and Mexico
City (former Federal District).
Some of the characteristics of the participants in our study are similar to
those of probabilistic samples. For example, Mexican youth who have same-
gender romantic relationships tend to live in households in which the house-
hold head has higher education (Mendoza-Pérez & Ortiz Hernández, 2019). In
addition, similar to our sample, most men who have sex with other men (MSM)
who are recruited in LGBT avenues have an education level of a bachelor’s
degree or higher (Bautista-Arredondo et al., 2013). These data suggest that our
sample provides an adequate picture of Mexican GHB men that adopt a gay or
bisexual identity and keep in contact with the LGBT community.

Measures
We analyzed the experiences of SO-DV in seven settings: family, school,
workplace, health services (clinics, hospitals, or by health care workers), jus-
tice services (police or public prosecutor’s office), commercial settings (dis-
cotheques, restaurants, clubs, or malls), and outdoor spaces (parks, plazas, or
streets). The interviewees indicated whether they had experienced six forms
of SO-DV in the seven settings (Forms A, B, C, F, G, and H are listed in the
first column of Table 2). We inquired about one form of discrimination (Form
I: denial of access to services or spaces) in all settings, except for the family
setting. In addition, three types of SO-DV experiences were assessed in the
family setting (Forms D, E, and J). The questions were developed based on a
previous study (Instituto Nacional de Estadística y Censos, 2013).
To test Hypothesis 1, dummy variables were created to identify whether
the participants had experienced any type of SO-DV across contexts (see the
last row of Table 2). A count variable that described the number of settings in
which the person had been discriminated against was created and had values
from 0 to 7 settings. This variable was recoded to form four categories: none
experience, 1 or 2 experiences, 3 or 4 experiences, and 5 to 7 experiences.
To assess Hypotheses 1 and 2, the 10 forms of SO-DV were classified into
two categories: (a) Indirect forms of SO-DV, including the following experi-
ences: people made the participants feel that they should be more masculine
(Form A), people know the sexual orientation of the participants but refuse to
talk about it (Form B), and people accept the participant, but not his partner
(Form C). This category was considered expression of subtle or symbolic
violence. (b) Direct forms of SO-DV that includes sexual orientation change
efforts (SOCEs, Forms D and E), verbal violence (Form F), physical violence
(Form G), and rejection (Forms H, I, and J). These two categories of SO-DV
8 Journal of Interpersonal Violence 00(0)

Table 2.  Sexual Orientation–Based Discrimination and Violence Experiences and

the Settings in Which They Were Experienced by Gay, Homosexual, and Bisexual
Men in Mexico (N = 4,827).
Health Justice Commercial Outdoor
Family School Workplace Services Services Settings Spaces
Forms of discrimination or
violence (%) (%) (%) (%) (%) (%) (%)

 A. They made you feel like 27.8 37.1 17.4 3.1 7.7 8.7 15.4
you should be more
masculine
 B. T  hey know about your 35.0 11.2 17.0 3.5 2.9 3.7 4.9
sexual orientation, but
they don’t want to talk
about it
C. They accept you but not 8.9 2.5 3.4 2.4 2.4 2.8 4.7
your partner
  Any form of lack of full 36.8 12.6 18.5 5.3 4.6 5.8 8.2
recognition of sexual
orientationa
D. They forced you 6.4  
to attend religious
ceremonies
E. They forced you to 13.0  
go to a psychologist, a
psychiatrist, a priest, or a
pastor to “cure you” or
“change you”
  Sexual orientation change 15.5  
effortsb
F. They shouted at you, 13.9 34.2 12.0 2.6 8.5 10.5 26.4
insulted, threatened, or
mocked you
G. They hit you or assaulted 4.2 10.8 1.5 0.3 2.6 2.1 5.4
you physically
H. T  hey threw you out of 4.0 1.7 3.3 1.0 2.1 9.0 9.7
the place or house
  I. They denied you the 1.0 1.7 4.0 3.3 1.5 3.2
service
 J. One or more relatives 13.5  
stopped talking to you
  Any form of rejectionc 14.8 2.3 4.2 4.3 4.4 9.5 10.9
  Any form of violence or 50.8 49.5 31.7 10.6 15.5 24.1 36.5
discrimination

a
Includes B and C.
b
Includes D and E.
c
Includes H, I, and J.

were created for two groups of settings: (a) family, school, and workplace
(FSW) and (b) health services, justice services, commercial settings, and out-
door spaces (HJCO). These groups of settings were created because most
Mendoza-Perez and Ortiz-Hernandez 9

research has been focused on experiences of SO-DV at FSW. In this way, four
dichotomous variables were created to identify any experience of indirect
forms of SO-DV at FSW, indirect forms of SO-DV at HJCO, direct forms of
SO-DV at FSW, and direct forms of SO-DV at HJCO.
To test Hypothesis 3, only the items that explicitly inquiry about violence
associated with sexual orientation or gender nonconformity were consid-
ered. The variable of main interest was disapproval of gender nonconformity
(Form A: people made the participants feel that they should be more mascu-
line). Experiences of violence related to sexual orientation considered for
this hypothesis were lack of full recognition of sexual orientation (Forms B
and C: people know the sexual orientation of the participants but refuse to
acknowledge it), SOCE (Forms D and E), and rejection because of sexual
orientation. Four variables were created to identify any of these forms of
violence.
The Mental Health subscale of questionnaire SF-36 (Zúniga et al., 1999),
which collects information regarding thoughts over the previous month, was
used. The responses were provided on a 6-point scale (from never to always)
and were converted into a score ranging between 0 and 5. Through explor-
atory factor analysis, two groups of items were identified: (a) psychological
distress (five items, for example, “You felt very anxious” or “You felt
depressed or sad”) and (b) vitality (four items, for example, “You felt full of
life” or “You felt happy”). The Bartlett score was derived for each factor
(using the command predict in the STATA software). The Cronbach’s alphas
of these measures were .87 and .86. The presence of suicidal ideation and
attempts was determined by an affirmative response to the questions “Have
you ever seriously thought about suicide?” and “Have you ever tried to com-
mit suicide?” These items were derived from the Composite International
Diagnostic Interview (Borges et al., 2010).
Five categories of participants’ ages were created (18–20, 21–25, 26–30,
31–45, and 46+). Marital status was determined using the following options:
single, in a relationship (“civil union,” “domestic partnership,” and “mar-
ried”), separated/divorced, and widowed. Information regarding the educa-
tion of participants and household heads was obtained. The participants’
education was classified into two groups: high school or less and bachelor’s
degree or higher. The education of the household head was considered as a
proxy of socioeconomic position and was classified in low (junior high
school or less), medium (high school), and high (bachelor’s degree, and post-
graduate). Household heads were defined as individuals with the greatest
contribution to their family’s income. The states in which the participants
lived were classified into five geographic regions: northern, western, central,
southern, and Mexico City.
10 Journal of Interpersonal Violence 00(0)

Table 3.  Linear and Logistic Regression Models of the Association of Number of
Settings Where Sexual Orientation–Based Discrimination and Violence Experiences
Occurred With Mental Health Outcomes in Gay, Homosexual, and Bisexual Men in
Mexico, 2015 (n = 4,551).
Psychological
Distress Vitality Suicidal Ideation Suicidal Attempt

Crude Adjusted Crude Adjusted Crude Adjusted Crude Adjusted

Model Model Model Model Model Model Model Model
Number of
settings % B B B B OR OR OR OR

 None 34.3 Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
  One or two 22.7 0.04 0.05 0.02 0.03 1.88*** 1.92*** 2.00*** 2.06***
  Three or four 28.0 0.28*** 0.28*** −0.15*** −0.14*** 2.36*** 2.40*** 2.50*** 2.59***
  Five or seven 15.0 0.43*** 0.43*** −0.25*** −0.24*** 4.12*** 4.17*** 4.71*** 4.81***
 Constant −015*** 0.44*** 0.08 −0.00 0.26*** 0.46*** 0.07***  

Note. In the adjusted models, sexual orientation identity, age, and education of participants; household
head education; and geographic region were introduced. % = distribution of participants; B = regression
coefficient; OR = odds ratio; Ref. = reference group.
*p ≤ .05. **p ≤ .01. ***p ≤ .001.

Analytical Approach
Stata software version 14.2 (StataCorp., College Station, TX) was used to
perform the statistical analysis. The distribution of the participants was esti-
mated according to the sociodemographic characteristics and SO-DV experi-
ences (Tables 1 and 2).
Linear regression models of continuous dependent variables (i.e., psycho-
logical distress and vitality) and logistic regression models of binary depen-
dent variables (i.e., suicidal ideation and attempt) were estimated using
experiences of SO-DV as independent variables. The regression coefficients
of the linear regression models and the odds ratios (OR) of the logistic regres-
sion models are reported. An association was considered statistically signifi-
cant if p ≤ .050. In the first series of models, the independent variable was
the number of settings in which the participants had been discriminated
against (Table 3). These models were aimed to test Hypothesis 1. In addition
to crude models, models adjusted by demographics were estimated. The vari-
ables included in the adjusted models were identity based on sexual orienta-
tion, age (as a continuous variable), participant education, household head
education, and geographic region.
To assess Hypotheses 1 and 2, two groups of models were estimated
(Table 4). In “models adjusted by demographics,” the four variables that
distinguish the two forms of SO-DV (indirect or direct) in the two groups
of settings (FSW and at HJCO) were introduced separately as independent
Mendoza-Perez and Ortiz-Hernandez 11

Table 4.  Linear and Logistic Regression Models of the Association of Indirect and
Direct Forms of Sexual Orientation–Based Discrimination and Violence (SO-DV)
With Mental Health Outcomes in Gay, Homosexual, and Bisexual Men in Mexico,
2015 (n = 4,551).
Psychological
Distress Vitality Suicidal Ideation Suicidal Attempt

Model I Model II Model I Model II Model I Model II Model I Model II

Forms of SO-DV B B B B OR OR OR OR

Indirect forms of 0.28*** 0.14*** −0.17*** −0.16*** 2.50*** 1.60*** 2.56*** 1.21
SO-DV at FSW
 Constant 0.44*** 0.03  
Indirect forms of 0.31*** 0.20*** −0.14*** −0.08* 1.81*** 1.10 2.00*** 1.19
SO-DV at HJCO
 Constant 0.49*** −0.02  
Direct forms of 0.25*** 0.10** −0.10** 0.02 2.42*** 1.64*** 3.00*** 2.22***
SO-DV at FSW
 Constant 0.46*** −0.02  
Direct forms of 0.19*** −0.02 −0.09** 0.02 1.89*** 1.21* 2.19*** 1.38**
SO-DV at HJCO
 Constant 0.51*** 0.40*** −0.03 −0.03  

Note. Model I (adjusted by demographics): Each form of SO-DV in the two groups of settings was
introduced individually. Model II (adjusted by other forms of SO-DV): Both forms of SO-DV in the two
groups of settings were introduced simultaneously. All models were adjusted for sexual orientation
identity, age, and education of participants; household head education; and geographic region. B =
regression coefficient; OR = odds ratio; FSW = family, school, and workplace; HJCO = health services,
justice services, commercial settings, and outdoor spaces.
*p ≤ .05. **p ≤ .01. ***p ≤ .001.

variables. The “model adjusted by other forms of SO-DV” included simul-

taneously the four variables that identify forms of and settings where
SO-DV was experienced. All models were adjusted by other covariates.
To test Hypothesis 3, first, each of the following variables was introduced
as independent variable in separated models (models adjusted by demograph-
ics): disapproval of gender nonconformity, lack of full recognition of sexual
orientation, SOCE, and rejection because sexual orientation (Table 5). Later,
the four variables were introduced in the same model (model adjusted by
other forms of violence). All models were adjusted by other covariates.
In addition, we tested the effects of interactions of some variables of
SO-DV with demographics on mental health outcomes. The variables about
SO-DV considered were the count variable with the number of settings in
which experiences of SO-DV happened and two variables that identify
whether participants faced any indirect or direct form of SO-DV. In this
case, we did not make distinction between the two groups of settings where
SO-DV happened. All pairs of interactions between SO-DV variables and
12 Journal of Interpersonal Violence 00(0)

Table 5.  Linear and Logistic Regression Models of the Association of Mental
Health Outcomes With Experiences of Violence Associated With Gender
Nonconformity or Sexual Orientation in Gay, Homosexual, and Bisexual Men in
Mexico, 2015 (n = 4,551).
Psychological
Distress Vitality Suicidal Ideation Suicidal Attempt

Model I Model II Model I Model II Model I Model II Model I Model II

Forms of violence B B B B OR OR OR OR

Disapproval of gender 0.30*** 0.19*** −0.15*** −0.10** 2.19*** 1.50*** 2.28*** 1.34**
nonconformity
 Constant 0.44*** 0.01  
Lack of recognition of 0.11*** 0.07*** −0.07*** −0.06*** 1.32*** 1.14*** 1.33*** 1.14***
sexual orientation
 Constant 0.49*** −0.00  
Sexual orientation 0.23*** 0.08 −0.11** −0.04 2.41*** 1.62*** 2.76*** 1.78***
change efforts
 Constant 0.55*** −0.05  
Rejection of sexual 0.23*** 0.06 −0.05 −0.06 2.19*** 1.46*** 2.84*** 1.91***
orientation
 Constant 0.53*** 0.40 −0.06 0.02  

Note. Model I (adjusted by demographics): Each form of discrimination and violence was introduced
individually. Model II (adjusted by other forms of violence): The four forms of discrimination and violence
were introduced simultaneously. All models were adjusted for sexual orientation identity, age, and
education of participants; household head education; and geographic region. B = regression coefficient;
OR = odds ratio.
*p ≤ .05. **p ≤ .01. ***p ≤ .001.

demographics (identity based on sexual orientation, age, and education of

participants; household head education; and geographic region) were esti-
mated. An interaction was considered statistically significant if p ≤ .10. In
the final model, only significant interactions were included. These models
were intended to know whether demographics moderate the relationship
between SO-DV and mental health. Because of their exploratory character,
we did not propose any hypothesis for these analyses.

Results
Distribution According to SO-DV
Family and school were the principal settings in which SO-DV was experi-
enced, followed by outdoor spaces and workplaces (Table 2). Disapproval of
gender nonconformity was the most frequent experience of SO-DV in most
settings, except for the family and outdoor spaces. In the family, workplaces,
and health services, the lack of recognition of the sexual orientation was another
Mendoza-Perez and Ortiz-Hernandez 13

frequent form of SO-DV. Verbal violence was common in school, legal set-
tings, commercial settings, and outdoor spaces. In family, approximately 15%
of the participants experienced rejection. Physical violence was reported to a
lesser extent than the previous forms of SO-DV. Two thirds of participants
reported any experience of SO-DV (Table 3). One third of participants faced
SO-DV at three or four settings.

Association Between SO-DV and Mental Health

In both crude and adjusted models, the number of settings in which SO-DV
was experienced increased, the distress increased but vitality decreased
(Table 3). Experiences of SO-DV in more settings was associated with higher
risk of suicidal ideation or suicide attempt; this association kept after adjust-
ing for demographics.
When the two forms of SO-DV (indirect or direct) in the two groups of
settings (FSW or HJCO) were introduced in different models, they were asso-
ciated with the four mental health outcomes (Table 4). However, after the
four variables of SO-DV were included in the same model, the higher levels
of psychological distress were associated with indirect forms of SO-DV at
FSW or at HJCO, and direct forms of SO-DV at FSW. After adjusting for
other forms of SO-DV, only indirect forms of SO-DV at FSW or at HJCO
were related with lower levels of vitality. Independently of other forms of
SO-DV, indirect forms at FSW and direct forms at FSW and at HJCO were
associated with higher risk of suicidal ideation. After adjusting for other
forms of SO-DV, higher probability of suicidal attempt was associated with
direct forms at FSW and HJCO.
Almost all associations of disapproval of gender nonconformity and the
three forms of violence based on sexual orientation with mental health out-
comes were significant when they were introduced in separated models. The
exception was the lack of association between rejection of sexual orientation
and vitality. When the four exposures were introduced simultaneously, only
disapproval of gender nonconformity and lack of recognition of sexual orien-
tation were related with higher levels of psychological distress but lower lev-
els of vitality. Higher risk of suicidal ideation and attempt was observed when
participants experienced disapproval of gender nonconformity, lack of recog-
nition of sexual orientation, SOCE, or rejection, and these relations were
independent of each other.

Moderating Role of Demographics

The results of the models estimated to test the interaction between SO-DV
and demographics are reported in Tables A and B in the Supplementary
14 Journal of Interpersonal Violence 00(0)

Material. The positive association between the number of settings in which

SO-DV happened and psychological distress was stronger among partici-
pants of the western region (Table A). Among participants of the southern
region did not exist the negative association between vitality and the number
of settings in which SO-DV occurred. The positive association between the
risk of suicidal ideation and number of settings in which SO-DV occurred
practically was non-existent among Mexico City’s participants. Among
bisexual men and participants with high socioeconomic position, the associa-
tion between the number of settings in which SO-DV happened and suicidal
attempt was stronger.
The positive association of indirect forms of SO-DV and psychological
distress was stronger among western region’s residents and bisexual men
(Table B). The negative relationship of indirect forms of SO-DV and vitality
was absent among the southern region residents. Among older participants,
the negative relationship of direct forms of SO-DV and vitality was stronger.
The risk of suicidal attempt associated with indirect forms of SO-DV was
higher among center region’s residents and bisexual men. The positive asso-
ciation of direct forms of SO-DV and suicidal attempt was stronger among
older participants but weaker in bisexual men.

Discussion
Settings Where Violence Occurs
Supporting our Hypothesis 1, the number of settings in which SO-DV was
experienced had a linear relationship with negative mental health outcomes. In
addition, some Mexican GHB men experienced the same category of SO-DV
in different settings. These results indicate that experiences of SO-DV can
negatively affect psychological well-being in a cumulative way, that is, as
prejudice experiences are suffered in more settings, the negative impact on
mental health is greater. In an American sample, the same finding was observed
(Mustanski et al., 2016).
In addition, prejudice experiences in settings different to FSW can also have
negative effects on mental health. For example, indirect forms of SO-DV at
HJCO was associated with higher levels of psychological distress and lower
levels of vitality; whereas the direct forms at the same settings were related to
higher probability of suicidal behavior. The documentation of the correlation
between negative mental health outcomes and SO-DV in many different
spheres clarifies how widespread discrimination is and its potential negative
effect on the mental health of GHB men. These correlations also emphasize the
need to continue to study these phenomena in different settings.
Mendoza-Perez and Ortiz-Hernandez 15

Among the Mexican GHB men, SO-DV was more frequently experienced
in FSW, and these experiences were associated with negative mental health
outcomes. Previous research has showed that mental health is negatively
related to SO-DV in family (Haas et al., 2011; McGeough & Sterzing, 2018),
school (Collier et al., 2013), and workplace (Bauermeister et al., 2014; Ortiz-
Hernández & Garcia, 2005) settings. These settings are essential for individ-
ual development (e.g., during childhood, economic and emotional dependence
on family exists), individuals spend most of their time in these spaces, and in
most cases, are environments that are not chosen by subjects.

Relevance of Subtle Violence

The following results support our Hypotheses 2 and 3: (a) Subtle or indirect
forms of SO-DV could have negative effects on mental health, and this asso-
ciation is independent of direct forms of violence, and (b) violence motivated
by gender nonconformity has a negative impact on mental health nearly
equivalent to that of violence motivated by sexual orientation.
Expressions of subtle prejudice (and their consequences on mental health)
should be considered deeply rooted in social norms related to the gender
system (Ortiz-Hernández & Granados, 2006). First, because such norms are
socially constructed, most people are expected to accept them. Indeed, the
forms of symbolic violence were the most frequent prejudice experience,
which could reflect that most people consider homosexuality and gender
nonconformity as deviations from social norms. Second, the symbolic link
between homosexuality and gender nonconformity is an expression of the
gender system. Therefore, notably, the violence experienced by GHB men is
more frequently motivated by their gender identity than their sexual orienta-
tion. Third, one of the key characteristics of symbolic violence (Bourdieu,
2012) is that it can operate only if the members of the stigmatized group
accept the evaluations of the dominant group. Therefore, whether the partici-
pants are able to freely talk about their sexual orientation or feel compelled to
modify their gender identity depends on whether they consider homosexual-
ity and femininity in men as negative qualities. These individuals accept such
stigma because they share the social norms with other members of society.
The sense of dignity is at the core of the negative effects of subtle forms of
SO-DV, that is, symbolic violence entails that GHB men know that most peo-
ple do not consider them as equal or do not respect them because they are part
of a stigmatized group. These subtle forms of prejudice do not produce physi-
cal damage or generate fear of victimization; however, these forms of violence
lead individuals to believe that they are socially devalued. Disapproval of gen-
der nonconformity and the lack of full recognition of sexual orientation
16 Journal of Interpersonal Violence 00(0)

reinforce their stigmatization, which, in turn, leads to a loss of social status

among people who have these characteristics (Link & Phelan, 2001). This
type of prejudice can produce feelings of guilt or shame (Bourdieu, 2012).
Thus, GHB men construct their identity around a negative perception of their
sexual orientation and gender identity.

Additional Findings
Most results of the moderation analysis could be attributed to regional or
temporal differences in the sociocultural environment where GHB men lived
or their higher vulnerability. The relationship between SO-DV and mental
health outcomes were stronger among residents of western and center regions,
older participants, and bisexual men; on the contrary, in residents of southern
region and Mexico City, the association was weaker. Older cohorts can be
more reactive to the same prejudice experiences because they grew in a more
intolerant society; whereas younger GHBs had been raised when institutional
and legal changes that promoted the acceptance of homosexuality occurred.
Many Mexican states located in the western region has been characterized
by the predominance of Catholic Church, which has maintained and dissemi-
nated homophobic attitudes. In contrast, in the south, the proportion of indig-
enous population is high, and tolerance of gender nonconformity is part of
their culture (e.g., muxes of Oaxaca state). Mexico City is the state where a
strong LGBT movement exists, and it has driven the legal and institutional
changes to protect their rights. Different explanations exist for the higher
vulnerability of bisexual men compared with gay men: experiences of mono-
sexism (even within the LGBT community), lack of bisexual-affirming social
support, and some people adopt a bisexual identity as part of questioning
their sexuality, which could be distressing (Salway et al., 2019).
In our study, experiencing SOCE was associated with poor mental health
outcomes. In other LGBT samples, SOCE was correlated with suicidal
behavior, depression, anxiety, and low self-esteem (Flentje et al., 2014; Ryan
et al., 2018). Our measure focused on encouragement of SOCE by parents. In
American LGBT young people, SOCE conducted by a therapist or religious
leader was related with depression and suicidal behavior, and these associa-
tions were stronger when parents encouraged SOCE (Ryan et al., 2018). In
Mexico, the debate to legally forbid this type of practice has begun. Our
results should inform this discussion.

Strengths and Limitation of the Study

A strength of our study is that the data were gathered via the Internet, which
facilitated the recruitment of a large sample of participants from every Mexican
Mendoza-Perez and Ortiz-Hernandez 17

state. Participation was not limited to users of LGBT recreational settings or

civic associations, which tends to be the dominant sampling strategy (Hottes
et al., 2016). This approach tends to exclude individuals with less acceptance
of their sexual orientation. Because of the anonymity, questionnaires via a
computer can lead to more honest responses than face-to-face interviews (Van
Gelder et al., 2010).
However, online surveys lack representativeness because access to a com-
puter and the Internet is lower among people and places of low socioeco-
nomic position. Our results can be affected by self-selection because perhaps
people who responded to our survey are more conscious of SO-DV and/or are
more concerned about participating in LGBT social movements. Although
sexual orientation is a multi-dimensional construct, we only used a measure
of identity (i.e., self-perception). One risk of this approach is that some men
are attracted to or have sex with other men but do not perceive themselves as
gay or homosexual. There is a high probability that our study excluded them.
In addition, the recruitment of participants was based on gay organizations
and websites in which men who adopt a gay identity are overrepresented.
However, we decided not to include other dimensions of sexual orientation as
a strategy to reduce the respondent burden. We expected to recruit youths
who have not become sexually active, and for them, sexual behavior is not an
adequate indicator of sexual orientation.

Implications
In conclusion, among the GHB men in this study, a relationship was found
between experiencing SO-DV and lower levels of mental health. SO-DV
had the greatest effect when experienced in FSW settings and when the
number of settings in which SO-DV was experienced increased. The legal
changes that prevent discrimination have perhaps been successful because
more open and direct forms of SO-DV occur less frequently than other
forms. However, the results showed that prejudice against LGBT people
has persisted and continues to be expressed in subtle or indirect forms of
SO-DV. These forms of SO-DV could also have effects on mental health;
therefore, the challenge is to develop methodologies to document their
existence and effects.
Our results have implications for understanding and preventing vio-
lence. Frequently, academic research and reports of violations against
LGBT people’s human rights (e.g., Inter-American Commission on Human
Rights, 2015) are restricted to intentional acts that produce evident or
immediate effects. These approaches resonate the concept of violence pro-
posed by the World Health Organization (WHO; Krug et al., 2003), which
defines it as
18 Journal of Interpersonal Violence 00(0)

The intentional use of physical force or power, threatened or actual, against

oneself, another person, or against a group or community, that either results in
or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment or deprivation. (p. 5)

Therefore, frequently, the proposed policies (e.g., McGeough & Sterzing,

2018) to ameliorate the impact of violence on GHB men’s mental health only
focus on changes in interpersonal relationships in families and schools
through education programs and training at schools and family services.
These approaches are needed but insufficient because they target more direct
and overt prejudice experiences. Our data make clear the need for public poli-
cies aiming to prevent and eliminate both direct and subtle forms of SO-DV.
We believe that intentionality should be removed from the violence defini-
tion because the subtle forms of violence we studied do not involve such
characteristic but could have a negative impact on mental well-being.
According to the WHO concept of violence, power is recognized as an ele-
ment that can create harm; however, research or prevention strategies based
on this idea are scarce. We offer evidence suggesting that symbolic violence
could be associated with negative health outcomes. Symbolic violence oper-
ates through the power that acceptance of social norms produces, which
sometimes involves the stigmatization of some groups. And acceptance of
social norms does not depend on the intentions of persons.
Viewing violence in this broad perspective is conductive to considering that
to prevent prejudice events, all manifestations (from subtle to hate crimes) of
stigmatization of homosexuality and gender nonconformity should be eradi-
cated, which can only be achieved through major sociocultural changes in all
societal spheres and not only by changing individual attitudes. Policies at the
institutional level (e.g., regulation of media and prohibition of hate discourses
by dominant institutions) should be implemented to de-stigmatize the non-dom-
inant expressions of gender identity and sexual orientation.
Replication of our results in other populations is required. Future research
could investigate how GHB men react to SO-DV and whether similar results
are obtained among lesbian and bisexual women because the gender system
affects men and women differently (Ortiz-Hernández & Granados, 2006).
Some results of moderating analysis were unexpected (e.g., the relationship
between direct forms of SO-DV and suicidal attempt was weaker in bisexual
men) and deserves more research.

Authors’ Note
Juan Carlos Mendoza-Perez was a student of the Doctorate in Collective Health
Sciences, Universidad Autónoma Metropolitana Xochimilco, when the research was
Mendoza-Perez and Ortiz-Hernandez 19

conducted. He is now at the Public Health Department, Medicine Faculty, Universidad

Nacional Autónoma de México.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iDs
Juan C. Mendoza-Perez   https://orcid.org/0000-0002-1178-6251
Luis Ortiz-Hernandez   https://orcid.org/0000-0002-5870-1729

Supplemental Material
Supplemental material for this article is available online.

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22 Journal of Interpersonal Violence 00(0)

Author Biographies
Juan C. Mendoza-Perez is a biologist with a master's in health sciences with major
in epidemiology and a doctor degree in collective health sciences. He is an activist in
HIV, sexual diversity and human rights. He was a professor at the Metropolitan
Autonomous University at Xochimilco and he is currently a professor at the National
Autonomous University of Mexico (UNAM) in the Department of Public Health of
the Faculty of Medicine. His research is focused on LGBT health.
Luis Ortiz-Hernandez has a bachelor’s degree in nutritional sciences, a master’s in
social medicine, and a doctor’s in collective health. He works as a full professor in the
Health Care Department of the Metropolitan Autonomous University at Xochimilco.
His expertise areas are the negative impacts of cultural and interpersonal homophobia
on the well-being of Mexican LGBT people, as well as socioeconomic disparities in
health, nutrition, and physical activity.