Are Outness and Community Involvement Risk or Protective Factors for Alcohol and Drug Abuse Among Sexual Minority Women?

Gay community involvement and the sexual health behaviours of sexual minority men: a systematic review and directions for future research

Considerable research has examined how involvement in gay-affiliated communities is associated with sexual health behaviours in sexual minority men (i.e., gay, bisexual, and other men who have sex with men), yet findings in this domain are often contradictory and inconclusive. This systematic review aimed to (a) synthesise the related empirical literature, and (b) identify potential factors driving inconsistent findings. Peer-reviewed publications were included if they contained quantitative data and at least one measure of the statistical association between gay community involvement and sexual health behaviour. The search strategy was implemented in six databases and returned 6,409 articles, of which 86 met the inclusion criteria. There was considerable heterogeneity in how gay community involvement was assessed across studies. Although gay community involvement was consistently associated with greater engagement in protective behaviours across studies, the association between gay community involvement and risk behaviours appeared to depend on how gay community involvement was conceptualised and measured (e.g., nightlife involvement vs. political activism). Findings emphasise a need for studies that employ validated measures that reflect the multidimensional nature of gay community involvement, as well as research designs better suited to address the causal effects of community involvement on HIV/STI transmission and prevention.

Disparities in Mortality by Sexual Orientation in a Large, Prospective Cohort of Female Nurses

Importance

Extensive evidence documents health disparities for lesbian, gay, and bisexual (LGB) women, including worse physical, mental, and behavioral health than heterosexual women. These factors have been linked to premature mortality, yet few studies have investigated premature mortality disparities among LGB women and whether they differ by lesbian or bisexual identity.

Objective

To examine differences in mortality by sexual orientation.

Design, Setting, and Participants

This prospective cohort study examined differences in time to mortality across sexual orientation, adjusting for birth cohort. Participants were female nurses born between 1945 and 1964, initially recruited in the US in 1989 for the Nurses' Health Study II, and followed up through April 2022.

Exposures

Sexual orientation (lesbian, bisexual, or heterosexual) assessed in 1995.

Main Outcome and Measure

Time to all-cause mortality from assessment of exposure analyzed using accelerated failure time models.

Results

Among 116 149 eligible participants, 90 833 (78%) had valid sexual orientation data. Of these 90 833 participants, 89 821 (98.9%) identified as heterosexual, 694 (0.8%) identified as lesbian, and 318 (0.4%) identified as bisexual. Of the 4227 deaths reported, the majority were among heterosexual participants (n = 4146; cumulative mortality of 4.6%), followed by lesbian participants (n = 49; cumulative mortality of 7.0%) and bisexual participants (n = 32; cumulative mortality of 10.1%). Compared with heterosexual participants, LGB participants had earlier mortality (adjusted acceleration factor, 0.74 [95% CI, 0.64-0.84]). These differences were greatest among bisexual participants (adjusted acceleration factor, 0.63 [95% CI, 0.51-0.78]) followed by lesbian participants (adjusted acceleration factor, 0.80 [95% CI, 0.68-0.95]).

Conclusions and Relevance

In an otherwise largely homogeneous sample of female nurses, participants identifying as lesbian or bisexual had markedly earlier mortality during the study period compared with heterosexual women. These differences in mortality timing highlight the urgency of addressing modifiable risks and upstream social forces that propagate and perpetuate disparities.

Sexual Identity Disclosure and Alcohol Experiences Among LGBTQ+ Adolescents

Sexual and gender minority youth (SGMY) report greater alcohol use in comparison to their heterosexual counterparts. Prior research has found that elevated alcohol use among SGMY can be explained by minority stress experiences. Sexual identity outness may be another factor that drives alcohol use among SGMY, given that outness is associated with alcohol use among older sexual and gender minority samples. We examined how patterns of sexual identity outness were associated with lifetime alcohol use, past-30-day alcohol use, and past-30-day heavy episodic drinking. Data were drawn from the LGBTQ National Teen Survey (N = 8884). Participants were SGMY aged 13 to 17 (mean age = 15.59) years living in the US. Latent class analysis was used to identify sexual identity outness patterns. Multinomial regressions were used to examine the probability of class membership by alcohol use. Six outness classes were identified: out to all but teachers (n = 1033), out to siblings and peers (n = 1808), out to siblings and LGBTQ+ peers (n = 1707), out to LGBTQ+ peers (n = 1376), mostly not out (n = 1653), and very much not out (n = 1307). SGMY in classes characterized by greater outness to peers, friends, and family had greater odds of lifetime alcohol use compared with SGMY in classes characterized by lower outness. These findings suggest that SGMY with greater sexual identity outness may be a target for alcohol use prevention programming. Differences in sexual identity outness may be explained by minority stress factors.

Community connection is associated with lower psychological distress for sexual minority women who view community connection positively

We examined factors associated with sexual minority women's evaluations of belonging to the lesbian, gay, bisexual, transgender and queer (LGBTQ) community in Australia, and assessed whether a positive view of community participation impacted levels of psychological distress. 2424 cisgender sexual minority women participated in a national, online, cross-sectional survey of LGBTIQ adult Australians' health and well-being. Multivariable regression analyses were conducted to investigate sociodemographic factors associated with sexual minority women's belonging to the LGBTQ community, feelings towards community connection, and associations between community connection and recent psychological distress. Most sexual minority women (58.9%) reported feeling that they are part of the LGBTQ community, and a majority of the participants felt positive about being connected to this community (68.5%). Participants who were bisexual, non-university educated, and who resided in an outer-suburban location were least likely to evaluate participation in the LGBTQ community positively. Feeling positive about community connection was associated with lower levels of psychological distress. Feeling a part of LGBTQ community was associated with lower psychological distress, but this link appears contingent upon positive feelings about community participation. Sexual minority women's' relationships to the LGBTQ community are often complex, and community connection and participation in and of itself is not a panacea for the negative outcomes associated with sexual minority stressors.

Structural stigma and alcohol use among sexual and gender minority adults: A systematic review

Background

Sexual and gender minority (SGM) people are more likely than their cisgender, heterosexual counterparts to report negative alcohol-related outcomes. Although the association between individual- and interpersonal-level minority stressors and negative alcohol-related outcomes among SGM people is well-established, structural-level minority stressors are understudied. This systematic review examined structural-level stigma and alcohol-related outcomes among SGM people to inform future research, interventions, and policy.

Methods

We used five electronic databases to search for studies published between January 2010 and May 2022 that examined associations between structural stigma and alcohol use among SGM adults in the United States. Peer-reviewed, quantitative studies available in English were included. We conducted quality appraisal using the Joanna Briggs Institute checklist.

Results

The final sample included 11 studies. Overall, there was moderate to strong support for a positive association between structural stigma and negative alcohol-related outcomes among SGM people, with differences by gender, sexual identity, race, and ethnicity. All studies used cross-sectional designs, and nearly half utilized non-probability samples. Transgender and nonbinary people, SGM people of color, and sexual identity subgroups beyond gay, lesbian, and heterosexual were underrepresented. Structural stigma was most commonly measured as a state-level index. Alcohol measures were heterogeneous. Multilevel stigma and resiliency factors were understudied.

Conclusions

Addressing structural stigma is critical in reducing negative alcohol-related outcomes and inequities among SGM people. Research is needed that includes probability samples, longitudinal designs, and samples that reflect the diversity of SGM people. Future studies should examine the influence of multilevel stigma and resiliency factors on alcohol-related outcomes.

Community Connectedness as a Moderator of the Association between Intersectional Microaggressions and Alcohol Use among Sexual and Gender Minoritized People of Color

Background: Researchers have documented associations between discrete conceptualizations of microaggressions (e.g., sexual identity, gender identity, and racial identity microaggressions) and alcohol use among sexual and gender minoritized people of color (SGM-POC). However, little is known about the association between intersectional microaggressions and alcohol use among SGM-POC. Moreover, protective factors such as community connectedness have been examined via similar discrete conceptualizations instead of examining SGM-POC community connectedness with other SGM-POC individuals. Objectives: The purpose of this study was to explore the association between intersectional microaggressions and alcohol use among SGM-POC and test whether different types of community connectedness moderated this association. Methods: Cross-sectional data were collected from a sample of 267 SGM-POC individuals. Four moderation analyses were done to analyze whether different types of community connectedness (sexual identity, racial identity, gender identity, and SGM-POC identity community connectedness) were moderators of the association of intersectional microaggressions and alcohol use. Results: Intersectional microaggressions were significantly positively correlated with alcohol use. Furthermore, SGM-POC community connectedness moderated this association such that the association was stronger for individuals with higher levels of SGM-POC community connectedness, but not lower levels of SGM-POC community connectedness. Conclusions: These findings showcase the importance of assessing for intersectional microaggressions as a risk factor for alcohol use. Similarly, the findings suggest that SGM-POC community connectedness may be a protective factor against alcohol use for SGM-POC.

Gender self-concept and hazardous drinking among sexual minority women: Results from the Chicago health and life experiences of women (CHLEW) study

OBJECTIVE

Sexual minority women (SMW; e.g., lesbian, bisexual) report substantially higher rates of hazardous drinking (HD) than heterosexual women.Yet, few studies have examined sub-group differences. In this study, we investigated the relationship between gender self-concept and HD among SMW. Research consistently shows a link between heavier drinking and masculinity. SMW are more likely than heterosexual women to be gender nonconforming, and masculinity among SMW is associated with increased minority stress, a key HD risk factor.

METHODS

We used Wave 3 data from the Chicago Health and Life Experiences of Women study, a longitudinal study of SMW (N = 598), which assessed participants' self-perceived levels of masculinity and femininity and their perception of how masculine/feminine others viewed them. Using multivariable logistic regression, we examined the association between gender self-concept and past 12-month heavy episodic drinking (HED), drinking-related problems, and alcohol dependence.

RESULTS

Controlling for demographics and minority stress, greater masculinity (both self-perceived and perceptions by others) was associated with higher odds of HED and alcohol dependence. Masculinity as perceived by others was associated with higher odds of drinking-related problems. Neither femininity measure was associated with HD. Additionally, minority stress (i.e., discrimination, stigma, internalized stigma) did not account for the relationship between gender self-concept and HD.

CONCLUSIONS/IMPORTANCE

In this sample, masculinity, particularly SMW's beliefs that others viewed them as masculine, was associated with HD. This association was not attributable to differences in minority stress and may be related to differences in gendered drinking norms, which could be targeted in intervention studies.

Mental Health and Life Satisfaction on Chilean Gay Men and Lesbian Women: The Role of Perceived Sexual Stigma, Internalized Homophobia, and Community Connectedness

The Minority Stress Model has proposed that connectedness to a specific minority community may be a protective factor for stigmatized groups. This study evaluated the mediational role of connectedness with the gay men's and lesbian women's community on the relationship between two minority stressors (internalized homophobia and perceived sexual stigma) with anxiety-depressive symptomatology and life satisfaction. The sample consisted of 467 Chilean self-identified as gay men (57%) and lesbian women (43%). Results revealed that the two minority stressors were associated with anxiety-depressive symptomatology, but only internalized homophobia was associated with life satisfaction. The mediation hypothesis was partially supported by the relationship between internalized homophobia and life satisfaction. Unexpectedly, we found a negative association between connectedness with the gay men's and lesbian women's community and life satisfaction. This finding introduces a view that contrasts with the literature, which proposes that connectedness with the specific community would be a protective factor against sexual stigma.

Childhood emotional abuse, rejection sensitivity, and depression symptoms in young Chinese gay and bisexual men: Testing a moderated mediation model

BACKGROUND

There is a high and increasing prevalence of depression symptoms among gay and bisexual individuals. Studies have found that childhood emotional abuse (CEA) can impact mental-health problems in adulthood; however, limited research on this association among marginalized populations, especially in China. This study aimed to explore the relationship between CEA and depression symptoms in adulthood among gay and bisexual youths in China and to test the mediating role of rejection sensitivity and the moderating role of sexual identity in this relationship.

METHODS

Participants comprised 496 gay and bisexual Chinese men aged 18-29 years. They responded to a questionnaire that assessed history of CEA, rejection sensitivity, and depression symptoms.

RESULTS

CEA showed a positive association with depression symptoms among participants. Participants' rejection sensitivity played a partial mediating role in the relationship between CEA and depression symptoms. Sexual identity had a moderating effect on the CEA's influence on depression symptoms, with a stronger impact for gay men than bisexual men.

LIMITATIONS

Cross-sectional approach limited casual inferences among variables. Recall bias regarding CEA may have impacted the accuracy of the effect sizes observed.

CONCLUSION

This study contributes to improving understanding of CEA's role as a substantial risk factor for strong depression symptoms in adulthood among gay and bisexual youths and it demonstrates that focusing on educating families and establishing equal policies is important to decrease and eliminate depression symptoms. Theories of sexual minority stress and biphobia are applicable for explaining mental health outcomes among young members of sexual minorities in China.

Everyday Discrimination and Alcohol use among Sexual Minority Adults in a U.S. National Probability Sample

Objective: Limited research assesses how sexual orientation and gender identity and expression (SOGIE)-based discrimination affects alcohol use above and beyond non-SOGIE-related discrimination and how this may differ for sexual minority subgroups. We examined if SOGIE-related discrimination is additive in affecting alcohol use above and beyond non-SOGIE-related discrimination and examined differences in alcohol use, everyday discrimination, and the attribution of discrimination by sex and sexual identity. Methods: A national probability sample of sexual minority adults in the United States was used (N = 1311, female = 56.4%). Bivariate sexual identity and sex-based differences in drinking frequency, heavy episodic drinking (HED), everyday discrimination, and the attribution of discrimination were assessed. Sexual identity and sex-stratified logistic regression models were estimated, where everyday discrimination and the attribution of discrimination predicted drinking frequency and HED. Results: Several differences by sex assigned at birth and sexual identity in drinking frequency, HED, everyday discrimination, and the attribution of discrimination were found in bivariate analyses. In logistic regression models, experiencing SOGIE-related in addition to other types of discrimination was associated with higher odds of HED only for gay males. No other associations were found for everyday discrimination or the attribution of discrimination with drinking frequency or HED. Conclusions: Findings suggest sex and sexual identity-based differences in everyday discrimination and the attribution of discrimination.

Bisexual+ visibility attempts: Associations with minority stress, affect, and substance use in a daily diary study

The efforts of bisexual+ people to make their sexual orientation visible are associated with positive and negative outcomes, but little is known about the temporality or directionality of these associations. Using data from a 28-day diary study with 208 bi+ individuals, we found that bi+ visibility attempts were concurrently associated with more positive affect, higher identity affirmation, less depressed/anxious affect, as well as more anti-bisexual experiences and rejection sensitivity. Prospectively, the likelihood of consuming alcohol (but not marijuana) was higher the day after making a visibility attempt, and positive affect was higher the day before making an attempt. Making visibility attempts in contexts that may have been more supportive (e.g., with friends, partners, and lesbian/gay individuals) was associated with more positive outcomes (e.g., more positive affect), while making attempts in contexts that may have been less supportive (e.g., with family, strangers, people who are unaccepting of bi+ identities, and heterosexual people) was associated with more negative outcomes (e.g., higher rejection sensitivity and more discrimination). These findings suggest that the contexts in which visibility attempts are made may play an important role in the impact that bi+ visibility attempts have on stigma-related stress and wellbeing.

Suicidal Ideation and Suicide Attempts Among Lesbian, Gay, Bisexual, Pansexual, Queer, and Asexual Youth: Differential Impacts of Sexual Orientation, Verbal, Physical, or Sexual Harassment or Assault, Conversion Practices, Family or Household Religiosity, and School Experience

Purpose: This article examines factors associated with suicidal ideation and suicide attempts in the past 12 months among lesbian, gay, bisexual, pansexual, queer, asexual, or other non-heterosexual identifying youth (LGBQA+). Methods: A national Australian cross-sectional online survey was conducted involving 4370 cisgender LGBQA+ participants aged 14-21 years from September to October 2019. Multivariable logistic regression analyses were performed to examine significant factors associated with suicidal ideation and suicide attempts in the past 12 months. Research ethics approval for the WTI4 study was granted by the La Trobe University Human Research Ethics Committee and the ACON Research Ethics Review Committee. Results: Overall, 56.4% of participants reported suicidal ideation and 8.9% a suicide attempt in the past 12 months. Multivariable regression results show that participants aged younger than 18 years, lesbian (compared with gay) identifying, those living in rural or remote locations (compared with inner city), those reporting any verbal, physical, or sexual harassment or assault based on sexual orientation or gender identity, or who had a religious family or household, or had experienced conversion practices in the past 12 months reported higher levels of suicidal ideation or suicide attempts. Those who reported feeling part of their school reported lower levels of suicidal ideation and suicide attempts. Conclusion: High levels of suicidal ideation and suicide attempts among young LGBQA+ people in Australia highlight a need for the ongoing inclusion of LGBQA+ youth as a priority population for suicide prevention. The findings illustrate key factors associated with a greater risk of suicidality among young LGBQA+ people. These findings can be used to inform the provision of tailored support services, including culturally safe suicide prevention programs and efforts to address stigma, discrimination, and conversion practices.

Comparing the Partnering, Minority Stress, and Depression for Bisexual, Lesbian, and Gay Adults from Religious Upbringings

Minority stress impacts the mental health of bi+ individuals (e.g., bisexual, pansexual, queer), similar to gay and lesbian individuals. Bi+ individuals may have difficulty accessing social supports for mitigating minority stress. A religious upbringing may complicate this process. This study sought to compare a survey sample of bi+ individuals (n = 153) and their gay/lesbian (n = 231) peers from religious families on minority stress factors, depression, and partnering. Results highlighted differences between gay/lesbian and bi+ individuals in partnering and LGB community connection with bi+ group reporting more minority stressors. Bi+ individuals in same-gender partnerships reported lower parent rejection and being more out than those who were single or in different-gender partnerships. Family religiosity was associated with family rejection; however, it did not directly predict minority stress factors or depression for bi+ individuals. Implications for future research are discussed in light of the distinctions emerging between gay/lesbian and bi+ adults.

Exploring the relationship between the alcohol policy environment and nondiscrimination laws: Implications for binge drinking disparities among LGB adults in the United States

BACKGROUND

Alcohol policies reduce population-level binge drinking; however, they may not reduce binge drinking disparities between different populations. We examined the association between the alcohol policy environment and binge drinking among Lesbian, Gay and Bisexual (LGB) and heterosexual adults in the presence and absence of state laws protecting LGB people from discrimination.

METHODS

The 2015-2018 Behavioral Risk Factor Surveillance System (BRFSS) provided information about individual-level binge drinking, sexual identity, and individual-level covariates. The Alcohol Policy Scale (APS) score measures the strength of the alcohol policy environment. Presence of state-level nondiscrimination protections based on sexual orientation came from the Movement Advancement Project. Logistic regression models were used to test whether nondiscrimination statutes modified the association between the alcohol policy environment and binge drinking and whether this interaction differed for LGB and heterosexual adults.

RESULTS

Among women, a 10 percentage-point increase in APS score was significantly associated with 7% lower odds of binge drinking in states with inclusive nondiscrimination laws (aOR: 0.93 [95% CI: 0.89-0.97; p = 0.0003]) but was not associated with binge drinking in states without inclusive laws (aOR: 0.98 [95% CI: 0.93-1.03] p = 0.4781). Moreover, binge drinking disparities comparing lesbian/bisexual women with heterosexual women were narrower in states with inclusive nondiscrimination laws. No significant association was found among men.

CONCLUSIONS

Binge drinking disparities between lesbian and heterosexual women are negligible in states with inclusive laws and strong alcohol policy environments. Inclusive nondiscrimination laws are an indicator of less structural stigma directed at lesbian and bisexual women.

Use of different strategies to make one's bisexual+ identity visible: Associations with dimensions of identity, minority stress, and health

Bisexual+ people (i.e., those who are attracted to more than one gender or regardless of gender) use a variety of strategies to make their identity visible to others, but little is known about the extent to which using different strategies is related to other dimensions of identity, minority stress, and health. To address this, we surveyed 715 bi+ people about their use of five different types of visibility strategies (direct communication, indirect communication, community engagement, gender-based visual displays, and public behavioral displays). Results indicated that people who used visibility strategies more often (aggregated across types) reported higher identity centrality and affirmation, and lower internalized bi-illegitimacy and internalized binegativity. However, they also reported more discrimination from heterosexual and gay/lesbian individuals and higher depression and anxiety. When we examined the unique associations between each of the five types of visibility strategies and our other variables, we found different patterns of associations for different strategies. For example, direct communication was uniquely associated with more discrimination from gay/lesbian individuals, while indirect communication, gender-based visual displays, and public behavioral displays were uniquely associated with more discrimination from heterosexual individuals. Only indirect communication was uniquely associated with higher depression and anxiety, while community engagement was uniquely associated with lower anxiety. Finally, public behavioral displays were uniquely associated with more alcohol use problems and a higher likelihood of cigarette use. These findings highlight the importance of examining the specific strategies that people use to make their bi+ identity visible in order to understand their experiences and health.

The role of sexual minority stress and community involvement on disordered eating, dysmorphic concerns and appearance- and performance-enhancing drug misuse

Prior research has established that sexual minority (SM) individuals are more likely to experience disordered body image behaviors and concerns than heterosexual individuals. This increased risk may be explained by minority stress theory - that SM individuals are subject to SM-specific stressors, leading to health disparities - but this has not yet been fully examined. Furthermore, this theory states that SM community involvement may mitigate negative outcomes. The current study examines whether minority stress is associated with screening positive for an eating disorder, screening positive for body dysmorphic disorder, and appearance- and performance-enhancing drug misuse in a sample of SM individuals (483 women and 479 men) in the US. This study also examines whether the effect of minority stress is moderated by SM community involvement. Logistic regressions were conducted for each type of minority stress (internalized homophobia, sexual orientation concealment, and heterosexist discrimination) interacting with community involvement. After correction for multiple comparisons, all minority stressors and community involvement were positively associated with increased odds of disordered body image behaviors and concerns, with no evidence of a buffering effect for community involvement. The lack of a buffering effect is contrary to minority stress theory and may inform future prevention efforts.

Outness, discrimination, and depressive symptoms among bi+ women: The roles of partner gender and sexual identity

Bisexual and other non-monosexual (bi+) women are at higher risk than monosexual women for mental health problems. While being in a relationship is typically associated with better health outcomes, research suggests an inverse association for bisexual women. Despite emerging evidence of differences in bisexual women's experiences based on the gender of their partner, few studies have considered partner sexual identity. To address this gap, the current study examined influences of partner gender and sexual identity on outness, discrimination, and depressive symptoms in a cross-sectional study of 608 bi+ cisgender women. Adjusting for other demographics, being in a relationship with a bisexual cisgender woman, a lesbian cisgender woman, or a bisexual cisgender man was positively associated with outness and discrimination compared to being in a relationship with a heterosexual cisgender man. Findings highlight the importance of accounting for partner gender and sexual identity in order to understand bi+ women's experiences.

L or G or B or T: Matching Sexual and Gender Minorities with Subpopulation-Specific Interventions

Sexual and gender minorities (SGM) may benefit from psychological interventions tailored to specific subpopulations (e.g., lesbians, gay men, bisexual people, transgender people) given differing experiences with stigma. However, determining the inclusion/exclusion process for subpopulation-specific interventions is challenging and recommendations for this process are scarce. We developed and evaluated a matching procedure to place 1183 SGM participants into four targeted online interventions designed to reduce internalized stigma for lesbian, gay, bisexual, and transgender people. We evaluated participant attrition, efficacy, satisfaction with placement, and qualitative feedback across the four interventions. Results indicated that our matching procedure was time-efficient and largely successful in terms of low attrition, high satisfaction, and reaching segments of the SGM population not usually captured with the LGBT acronym. Based on these findings, we offer six practical guidelines for devising the inclusion/exclusion process or matching procedure for future subpopulation-specific SGM interventions studies.

Sexual orientation concealment and mental health: A conceptual and meta-analytic review

Identity concealment affects all sexual minority individuals, with potentially complex mental health implications. Concealing a sexual minority identity can simultaneously generate the stress of hiding, protect against the stress of discrimination, and keep one apart from sexual minority communities and their norms and supports. Not surprisingly, existing studies of the association between sexual orientation concealment and mental health problems show contradictory associations-from positive to negative to null. This meta-analysis attempts to resolve these contradictions. Across 193 studies (n = 92,236) we find a small positive association between sexual orientation concealment and internalizing mental health problems (i.e., depression, anxiety, distress, problematic eating; ESr = 0.126; 95% CI [0.102, 0.151]) and a small negative association between concealment and substance use problems (ESr = -0.061; 95% CI [-0.096, -0.026]). The association between concealment and internalizing mental health problems was larger for those studies that assessed concealment as lack of open behavior, those conducted recently, and those with younger samples; it was smaller in exclusively bisexual samples. Year of data collection, study location, and sample gender, education, and racial/ethnic composition did not explain between-study heterogeneity. Results extend existing theories of stigma and sexual minority mental health, suggesting potentially distinct stress processes for internalizing problems versus substance use problems, life course fluctuations in the experience of concealment, distinct experiences of concealment for bisexual individuals, and measurement recommendations for future studies. Small overall effects, heavy reliance on cross-sectional designs, relatively few effects for substance use problems, and the necessarily coarse classification of effect moderators in this meta-analysis suggest future needed methodological advances to further understand the mental health of this still-increasingly visible population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Engagement with LGBTQ community moderates the association between victimization and substance use among a cohort of sexual and gender minority individuals assigned female at birth

BACKGROUND

Research has documented higher levels of substance use among sexual and gender minority (SGM) individuals - particularly sexual minority women (SMW) and transgender people - than among their heterosexual and cisgender peers. Because SGM substance use is linked to stigma-based victimization, it is crucial to identify social contexts that may buffer the association between victimization and substance use among SGM.

METHODS

We explored how engagement with LGBTQ-specific community influences victimization experiences and substance use among 488 SGM individuals assigned female at birth (FAB-SGM; ages 16-32; 26% White) in a large Midwestern city. We tested whether participants who used LGBTQ community spaces differed from those who do not in levels of victimization and substance use, and whether use of LGBTQ spaces buffered SGM from the negative effects of victimization on substance use.

RESULTS

Results demonstrated significant associations between victimization and alcohol and use of specific drugs. Contrary to expectations, participants who used LGBTQ spaces reported more victimization and more use of certain substances; however, when controlling for being out about non-heterosexual identity, this association remained only for LGBTQ community centers and school groups. Evidence was mixed for community engagement as a moderator of the association between victimization and substance use.

CONCLUSIONS

Overall, results indicated that LGBTQ spaces may be associated with adaptive and maladaptive coping functions and should be considered a potential target for health interventions. Findings emphasize the need for increased research on FAB-SGM, including SMW and transgender individuals, and provide actionable recommendations to reduce incidence of victimization and substance use.

Bisexual Women’s Experiences of Stigma and Verbal Sexual Coercion: The Roles of Internalized Heterosexism and Outness

In the current study, we examined how bisexual women’s unique experiences of sexual identity stigma might elevate their risk for verbal sexual coercion. Online survey data were collected from 350 self-identified bisexual women. Hayes PROCESS macro was used to test moderated-mediation and mediation analyses. Results indicated that anti-bisexual experiences (from both heterosexual and lesbian/gay individuals) were associated with greater internalized heterosexism (i.e., internalization of negative societal attitudes and stereotypes about one’s minority sexual orientation), which in turn was associated with increased odds of experiencing verbal sexual coercion. We did not find moderating effects of outness, such that internalized heterosexism mediated the relation between anti-bisexual experiences and verbal sexual coercion regardless of bisexual women’s levels of outness. Findings suggest that anti-bisexual experiences and internalized heterosexism are associated with bisexual women’s elevated risk for experiencing verbal sexual coercion. There is a need for targeted sexual violence prevention and risk reduction efforts that take into account the unique experiences and vulnerabilities of bisexual women in victimization risk. Results also highlight the need for campaigns that reduce sexual orientation-related stigma at the population level in order to prevent negative health outcomes among bisexual women.

Minority Stress and Mental Health in Italian Bisexual People

Bisexual people are a strongly stigmatized population experiencing health disparities caused by social stigmatization. The predominant framework helping to understand these health disparities and the impact of stigma on mental health of social groups belonging to a sexual minority identity constitutes the minority stress theory. In Italy, studies assessing this model in bisexual populations are very limited. Within this framework, the current study aimed at assessing in 381 Italian bisexual individuals (62 men and 319 women) the effects of anti-bisexual discrimination, proximal stressors (i.e., anticipated binegativity, internalized binegativity, and outness), and resilience on psychological distress. The results suggested that only anti-bisexual discrimination and internalized binegativity were positively associated with psychological distress, and that resilience was negatively associated with mental health issues. Furthermore, the results suggested that internalized binegativity mediated the relationship between anti-bisexual discrimination and mental health problems. No moderating effect of resilience was found. This is the first study to have thoroughly applied minority stress in Italian bisexual people, providing Italian clinicians and researchers with an outline of the associations between minority stress, stigma, resilience, and psychological distress within this population.

Research on alcohol and other drug (AOD) use among sexual minority women: A global scoping review

Until the 1980s, the limited research on alcohol and other drug (AOD) use among sexual minority women (SMW) focused on alcohol and used samples recruited from gay bars, resulting in inflated estimates of hazardous drinking. Over the past several decades the number of AOD studies with SMW has increased dramatically. To characterize this literature, we conducted a scoping review to answer the following questions: What do we know, and what are the gaps in research about AOD use among SMW? We searched multiple electronic databases (Medline [PubMed], CINAHL, PsycInfo, and Web of Science) for peer-reviewed research articles about AOD use among adult SMW published between January 1, 2000 and May 31, 2017. After duplicates were removed the search identified 4,204 articles. We reviewed the titles and abstracts and removed articles that did not meet inclusion criteria. We used full-text review of the remaining 229 articles to make a final determination regarding inclusion and we retained 181 articles for review. Although the quantity of AOD research with SMW has grown substantially, the great majority of studies have been conducted in the United States (US) and most focus on hazardous drinking; relatively little research has focused on other drugs. In addition, although there has been marked improvement in theories and methods used in this research, many gaps and limitations remain. Examples are the lack of longitudinal research; reliance on samples that tend to over-represent white, well-educated, and relatively young women; sparse attention to mechanisms underlying the disproportionately high rates of AOD use among SMW; and the absence of intervention research. In general, more high-quality research on SMW's use of AODs is needed, but gaps and limitations are particularly large in non-western countries. Addressing these research gaps and limitations is essential for providing information that can be used to develop more effective prevention and early intervention strategies, as well as for informing policies that can help to reduce risky drinking and drug misuse among SMW.

Minority Stressors, Rumination, and Psychological Distress in Lesbian, Gay, and Bisexual Individuals

This study tested the mechanisms by which social stigma contributes to psychological distress in lesbian, gay, and bisexual individuals. A large community sample (N = 4248, M age = 29.9 years, 42.9% female, 57.1% male, 35.7% bisexual, 64.3% lesbian/gay, 9.9% non-white) was recruited using targeted and general advertisements for an online cross-sectional survey. Participants completed measures of childhood gender nonconformity, prejudice events, victimization, microaggressions, sexual orientation concealment, sexual orientation disclosure, expectations of rejection, self-stigma, rumination, and distress. Structural equation modeling was used to test the relationships between these variables in a model based upon minority stress theory and the integrative mediation framework with childhood gender nonconformity as the initial independent variable and distress (depression, anxiety, and well-being) as the final dependent variable. The results broadly support the hypothesized model. The final model had good fit χ²(37) = 440.99, p < .001, TLI = .96, CFI = .98, RMSEA = .05 [.05, .06] and explained 50.2% of the variance in psychological distress and 24.8% in rumination. Sexual orientation and gender had moderating effects on some individual paths. Results should be considered in the context of the cross-sectional nature of the data, which prevented tests of causality, and self-report measures used, which are vulnerable to bias. Findings indicate strong relationships between minority stressors and psychological distress in lesbian, gay, and bisexual individuals, which are partially accounted for by rumination. These results may inform the development of interventions that address the added burden of minority stress among lesbian, gay, and bisexual individuals.

Motivations for sexual identity concealment and their associations with mental health among bisexual, pansexual, queer, and fluid (bi+) individuals

Bisexual and other non-monosexual (bi+) people are at increased risk for depression and anxiety compared to both heterosexual and gay/lesbian people. Bi+ people are also more likely to conceal their sexual orientation than gay/lesbian people are, and concealment is generally associated with negative mental health outcomes. Despite evidence that concealment is a particularly salient stressor for bi+ people, there has been a lack of attention to their motivations for concealment. As such, the goal of the current study was to examine the associations among concealment, motivations for concealment, and depression and generalized anxiety symptoms in a sample of 715 bi+ people who completed an online survey. Nearly half of participants endorsed purposely trying to conceal their bi+ identity in their day-to-day life, and concealment was significantly associated with higher levels of depression and generalized anxiety. Using exploratory factor analysis, we identified two motivations for concealment: intrapersonal motivations (e.g., one's bi+ identity not being a central part of one's overall identity, not being comfortable with being bi+) and interpersonal motivations (e.g., concern about being judged or treated negatively, concern about putting oneself at risk of physical harm). Interpersonal motivations were significantly associated with higher levels of depression and generalized anxiety, whereas intrapersonal motivations were not. In sum, while concealment may generally be associated with negative mental health outcomes, this may only be the case for those who conceal out of concern for discrimination and victimization. These findings highlight the importance of examining bi+ people's motivations for concealing their sexual orientation in order to understand the extent to which they experience negative mental health outcomes.

Meeting the Sexual Health Needs of Bisexual Men in the Age of Biomedical HIV Prevention: Gaps and Priorities

The field of HIV/STI prevention has primarily focused on gay men (or "men who have sex with men" [MSM] as a broad category) with limited attention to bisexual men in particular. Although bisexual men are also at increased risk for HIV and other STI, they are less likely to utilize HIV/STI prevention services than gay men, and very few interventions have been developed to address their unique needs. Further, while biomedical advances are changing the field of HIV prevention, bisexual men are also less likely to use biomedical HIV prevention strategies (e.g., pre-exposure prophylaxis [PrEP]) than gay men. In an effort to advance research on bisexual men and their sexual health needs, the goals of this commentary are: (1) to review the empirical literature on the prevalence of HIV/STI among bisexual men, the few existing HIV/STI prevention interventions developed for bisexual men, and the use of biomedical HIV prevention among bisexual men; (2) to describe the ways in which the field of HIV/STI prevention has largely overlooked bisexual men as a population in need of targeted services; and (3) to discuss how researchers can better address the sexual health needs of bisexual men in the age of biomedical HIV prevention.

LGBQ+ adults’ experiences of Improving Access to Psychological Therapies and primary care counselling services: informing clinical practice and service delivery

Lesbian, gay, bisexual, queer and other sexual minority (LGBQ+) people experience higher levels of psychological difficulties than heterosexual people. Evidence suggests that LGBQ+ treatment outcomes within England’s Improving Access to Psychological Therapies (IAPT) services are worse than the outcomes for heterosexuals, especially for bisexual people and sexual minority women. IAPT services provide evidence-based treatments like cognitive behavioural therapy (CBT), typically for anxiety or depression. This study explored LGBQ+ adults’ experiences with IAPT services and/or primary care counselling. LGBQ+ adults (n = 136) answered an online questionnaire (fixed-response and optional open-ended questions) about their access and treatment experiences. Descriptive statistics summarized multiple-choice responses. Qualitative data were analysed through thematic analysis. Before access, 41.9% of participants were concerned about experiencing LGBQ+ stigma/discrimination within psychological services. Only 13.2% of participants thought their sexuality negatively impacted their treatment, although prejudice/discrimination may be underestimated as 33.6% participants did not disclose their sexuality to practitioners and sexuality was not discussed in treatment for 44.0% of participants. Bisexual clients were significantly less likely to disclose their sexuality. The barriers LGBQ+ people described within IAPT or primary care services included: feared or experienced stigma in the services; reluctance to disclose sexuality; inconsistent discussion of sexuality in treatment; a lack of awareness and understanding towards LGBQ+ identities and community-specific challenges; and distrust, disillusionment and exclusion resultantly. Overall, 52.2% thought services could be improved for LGBQ+ individuals. This study identified multiple issues to be addressed in therapist training and service development.

Key learning aims

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Racial/Ethnic Differences in Mental Health, Substance Use, and Bullying Victimization Among Self-Identified Bisexual High School-Aged Youth

Purpose: Sexual minority youth are at increased risk for mental health problems and substance use, and accumulating evidence indicates that bisexual youth are at greatest risk. However, bisexual youth are not a homogenous group and scholars have called for greater attention to the intersections of multiple marginalized identities. As such, we examined racial/ethnic differences in mental health (sadness/hopelessness and suicidal ideation), substance use (cigarette use, binge drinking, marijuana use, and other illicit drug use), and bullying (in-person and electronic) among self-identified bisexual high school-aged youth (overall and by sex). Method: Data from the local versions of the Youth Risk Behavior Survey were pooled across jurisdictions and years (2011-2015), resulting in an analytic sample of 18,515 bisexual youth who were racially/ethnically diverse. Results: Black and Hispanic bisexual youth were less likely to report in-person and electronic bullying than White bisexual youth. In addition, Black bisexual youth were less likely to report sadness/hopelessness and suicidal ideation than White, Hispanic, and Other race/ethnicity bisexual youth. Black bisexual female youth were also less likely to report cigarette use, binge drinking, and other illicit drug use than White bisexual female youth. In contrast to most of our findings, Black bisexual youth were more likely to report marijuana use than White bisexual youth. Most of the significant racial/ethnic differences in mental health and substance use remained significant after controlling for bullying. Conclusion: These findings highlight the heterogeneity of bisexual youth and the need to consider multiple marginalized identities to understand the health disparities affecting this diverse population.

A Multilevel Approach for Reducing Mental Health and Substance Use Disparities Affecting Bisexual Individuals

Despite bisexual individuals being at increased risk for mental health and substance use problems, clinicians' ability to provide affirmative and competent care to bisexual clients is limited by their lack of bisexual-specific training. To address this common gap in training, this article provides a brief review of bisexual health disparities and the factors that influence them. Then, we describe a multi-level approach for improving the health and well-being of bisexual individuals. This approach addresses factors that influence health at the micro-level (e.g., strategies that clinicians can use to help bisexual clients cope with stigma-related stressors), mezzo-level (e.g., adaptations to clinical environments and training programs that promote bisexual-affirmative care), and macro-level (e.g., advocating for political change and implementing strategies to reduce prejudice against bisexual individuals at the population-level). Specifically, we describe how clinicians can adapt evidence-based interventions to tailor them to the needs of their bisexual clients. Additionally, we discuss the need for bisexual-affirmative clinical training and provide recommendations for how clinical training can be adapted to prepare clinicians to work effectively with bisexual clients. Finally, we describe how population-level interventions can be used to reduce prejudice against bisexual individuals in order to reduce bisexual health disparities. Given the striking health disparities affecting bisexual individuals, there is a critical need to develop, test, and disseminate interventions to improve the health of this population and to prepare clinicians to provide bisexual-affirmative care.

The Longitudinal Associations Between Outness and Health Outcomes Among Gay/Lesbian Versus Bisexual Emerging Adults

Sexual minorities are at increased risk for substance use and mental health problems. Although previous studies have examined the associations between outness and health outcomes, few have used longitudinal designs or examined differences across subgroups of sexual minorities. To address these gaps, the current study examined sexual orientation and gender as moderators of the longitudinal associations between outness and substance use (cigarettes, marijuana, illicit drugs, and alcohol) and mental health (depression and anxiety). Data were from a sample of 169 sexual minority emerging adults (98 women and 71 men) who provided self-report data at four times over 3.5 years. Results indicated that sexual orientation moderated the within-person associations between outness and changes in health. For bisexual individuals, being more out was associated with increases in marijuana use, illicit drug use, and depression. In contrast, for gay/lesbian individuals, being more out was associated with decreases in illicit drug use and it was not significantly associated with changes in marijuana use or depression. Additionally, outness was not significantly associated with changes in cigarette use, alcohol use, or anxiety for gay/lesbian or bisexual individuals, and gender did not moderate any of the associations. In sum, being more open about one's sexual orientation had negative consequences for bisexual individuals but not for gay/lesbian individuals. Professionals who work with sexual minorities need to be aware of the potential risks of being open about one's sexual orientation for bisexual individuals. Interventions are needed to facilitate disclosure decisions and to promote the health of sexual minorities.

Stress and substance use among sexual and gender minority individuals across the lifespan

Sexual and gender minority (SGM) individuals face marked disparities in substance use. The present narrative review explores research on substance use in SGM communities using a minority stress theory lens. We define the SGM population and minority stress, and explore stresses and substance use disparities in adolescence, adulthood, and older age. Though research on this topic is beginning to highlight the relationship between stress and substance use for SGM individuals, more work is needed on older SGM populations and in translating research findings to effective interventions.

Differences in HIV Risk Behaviors Between Self-Identified Gay and Bisexual Young Men Who are HIV-Negative

Young men who have sex with men (MSM) are disproportionately affected by HIV, but it remains unclear whether there are differences in HIV risk behaviors between self-identified gay and bisexual young men. To address this, the current study examined differences in condomless sex and substance use before sex with male partners between self-identified gay and bisexual young men who are HIV-negative. Additionally, we examined differences in HIV risk behaviors with male versus female partners among the bisexual men. We used four waves of data spanning 24 months from a cohort of young MSM ages 16-29. At each wave, participants reported on up to four partners, allowing us to examine within-person associations. Compared to gay men, bisexual men reported more insertive condomless anal sex (CAS) with casual partners, they were more likely to report marijuana use before sex, and they were less likely to report lifetime HIV testing and PrEP use. Alcohol and marijuana use before sex were associated with CAS for both gay and bisexual men, but the association between marijuana use and insertive CAS was stronger for bisexual men. Bisexual men reported more condomless sex with female partners compared to male partners, but this was not significant after accounting for alcohol and marijuana use. Bisexual men were more likely to report alcohol and marijuana use with female partners compared to male partners, but both alcohol and marijuana use were associated with condomless sex regardless of partner gender. Findings support the need for tailored HIV prevention for self-identified bisexual men to address their lack of preventive behaviors, their increased engagement in certain risk behaviors with male partners, and their engagement in risk behaviors with female partners.

Bi+ Visibility: Characteristics of Those Who Attempt to Make Their Bisexual+ Identity Visible and the Strategies They Use

There are numerous forms of stigma that contribute to the de-legitimization and erasure of bisexual and other non-monosexual identities (collectively referred to as bisexual+ or bi+ identities). To reduce such stigma, efforts are needed to increase bi+ visibility. Little is known, however, about whether bisexual+ individuals attempt to attain greater bi+ visibility (i.e., make their bisexual+ identity visible to others) and, if so, how they do this. Using data from a mixed-method (quantitative and qualitative) internet survey study of 397 individuals reporting attractions to more than one gender, we examined the proportion who attempted to attain greater bi+ visibility, the strategies they used to do so, and factors that distinguished those who made bi+ visibility attempts from those who did not. Results indicated that 58% made bi+ visibility attempts, with the most common being direct verbal communication (e.g., telling others) and visual displays (e.g., wearing bi/pride clothing, jewelry, tattoos). Less common attempts included indirect forms of communication, engagement in LGBT-related activities, and public behavioral displays. Those who made bi+ visibility attempts differed from those who did not on variables related to identity (e.g., centrality, self-affirmation, community connection) and internalized binegativity. Implications for understanding the reasons for and for not making bi+ visibility attempts, as well as the potential consequences of doing so, are discussed.

A Latent Profile Analysis of Bisexual Identity: Evidence of Within-Group Diversity

Bisexual people experience unique psychosocial vulnerabilities and their mental health needs and social identity remain underserved and understudied, respectively. We report results from a latent profile analysis where we identified a preliminary typology of bisexual identity subgroups and its association with demographic and mental health variables. Bisexual+ adults (N = 292) residing in the U.S. were recruited from Amazon Mechanical Turk and administered a demographic survey, indicators of bisexual identity, and measures of internalizing symptoms and self-esteem. Joint consideration of statistical and substantive criteria in the modeling process yielded a well-differentiated and qualitatively distinctive three-profile solution comprised of Affirmative (e.g., having a positive orientation towards one's bisexuality), Vigilant (e.g., being significantly concerned about others' reactions to one's bisexuality), and Ambivalent (e.g., endorsing mixed but generally negative attitudes and beliefs about one's bisexuality) profiles of bisexual identity. Auxiliary analyses revealed conceptually and statistically significant associations among profile membership, demographic covariates, and mental health outcomes. Some key findings included that compared to the Affirmative profile, men and people of color were overrepresented in the Ambivalent profile, whereas men were overrepresented in the Vigilant profile. Bisexuals with a Vigilant profile displayed the poorest mental health constellation. Our findings highlight the categorically heterogeneous nature of bisexual identity, support the relevance of social identity to mental health among bisexuals, and represent the first attempt to model bisexual identity using mixture techniques. Future studies should consider larger and more demographically diverse samples, address replicability and generalizability, examine additional auxiliary variables, and investigate longitudinal developments in profiles.

Incarceration as a Health Determinant for Sexual Orientation and Gender Minority Persons

Incarceration is considerably more prevalent among sexual and gender minority persons (SGM) than among the general population. Once behind bars, they are at the greatest risk for health-related harms. Although a growing number of studies have assessed health disparities produced by mass incarceration, scholars are yet to systematically assess the health consequences of incarceration on the basis of sexual orientation and gender identity. We invite public health scholars to study the effects of incarceration on health in the SGM population and provide a roadmap to aid these research efforts. First, we document the disproportionate presence of SGM persons in jails and prisons. Second, we note health-related risks that are the most salient for this population. Third, we recommend examining heterogeneity in the effects of incarceration by teasing out distinct risks for groups defined by sexual orientation, gender identity, and race/ethnicity. Fourth, we note methodological challenges with respect to measurement and assessing causality. Finally, we discuss the importance of health care access and quality and the need to study health during incarceration and afterward.

A descriptive analysis of where and with whom lesbian versus bisexual women drink

Purpose

Sexual minority women (SMW) are at increased risk for alcohol use disorders and related problems. Social context (e.g., where and with whom one drinks) has been identified as an important factor associated with drinking behavior, but little is known about social context among SMW. An improved understanding of social context among SMW has the potential to inform efforts to reduce problematic drinking and its consequences in this high-risk population.

Methods

We examined where and with whom SMW drink in a national sample recruited via social media (N = 1,057).

Results

SMW reported more frequent drinking in private locations (compared to public locations), with friends and romantic partners (compared to family members and strangers), and in locations with both heterosexuals and sexual minorities (compared to mostly or exclusively sexual minorities). Additionally, lesbians reported more frequent drinking in bars and in locations with more sexual minorities compared to bisexual women.

Conclusion

Interventions to reduce problematic drinking among SMW may benefit from addressing social context.

Bisexuality, minority stress, and health

PURPOSE OF REVIEW

Bisexual individuals are at increased risk for negative health outcomes compared to heterosexual individuals and often compared to gay/lesbian individuals as well. The goal of this article is to summarize the current evidence-base on bisexual health disparities, to describe factors that influence them, and to review interventions designed to improve the health of bisexual individuals.

RECENT FINDINGS

Based on our review of the literature, we conclude that there is strong evidence that bisexual individuals are at increased risk for mental health and substance use problems. These disparities are evident across dimensions of bisexuality (identity, attraction, and behavior), but there are important nuances to these findings. There is also evidence that bisexual men are at increased risk for sexually transmitted infections (STIs) compared to heterosexual men and that bisexual women are at increased risk for STIs compared to both lesbians and heterosexual women. Although there are numerous causes of these disparities, a leading contributor is stress related to stigma and discrimination. Most of the interventions that have been developed for bisexual individuals are HIV prevention programs for behaviorally bisexual men of color. Despite less attention to mental health and substance use interventions for bisexual individuals, recent developments show promise in their potential application to this population.

SUMMARY

Bisexual individuals are at increased risk for mental health, substance use, and sexual health problems, and this is due, in part, to stigma and discrimination. Future research should continue to examine how different dimensions of bisexuality relate to health disparities and factors that influence them. There is also an urgent need to develop, test, and disseminate interventions to improve the health of bisexual individuals.