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

Oppression-Based Stress and Alcohol Inequities Among Sexual and Gender Minority People: An Intersectional Multilevel Framework

PURPOSE

Sexual and gender minority (SGM) people are at heightened risk for alcohol use, hazardous drinking, and alcohol use disorder compared to heterosexual and cisgender individuals. This paper: (a) presents an oppression framework that integrates intersectionality, stress, stigma, and addiction-based theories to examine the complex and nuanced ways oppression-based stress (e.g., minority stress) leads to sexual orientation and gender identity inequities in alcohol use; (b) conducts a narrative review that summarizes recent and novel advancements in the literature on the impact of oppression-based stressors on alcohol use outcomes across structural, interpersonal, and intrapersonal domains among SGM people; and (c) provides future research and intervention directions for the alcohol field.

SEARCH METHODS

A select review of the literature was conducted on July 10, 2023, using multiple electronic databases (i.e., PsycInfo, PubMed, Web of Science) and focusing on studies that had examined the associations between oppression-based stressors and alcohol use outcomes across structural, interpersonal, and intrapersonal levels. Search terms focused on alcohol consumption; SGM people, particularly SGM people of color; and oppression-based stress. Cross-sectional studies that focused on heterosexism-based and anti-bisexual oppression-based stressors at the interpersonal or intrapersonal levels and alcohol use outcomes were excluded as they have been included in prior reviews of the literature.

SEARCH RESULTS

The initial and combined search across the databases resulted in 3,205 articles. Of those, the narrative review included 50 peer-reviewed articles that focused on the following four areas of the literature on the associations between oppression-based stressors and alcohol use outcomes: (1) experimental, longitudinal, and experience sampling studies of heterosexism- and anti-bisexual oppression-based stressors (22 articles); (2) any studies of cissexism-based stressors (12 articles); (3) any studies of intersectional oppression among SGM people of color (seven articles, one article overlapped with the first category and another overlapped with the fourth category); and (4) any studies of structural oppression (11 articles).

DISCUSSION AND CONCLUSIONS

Results of this narrative review indicate that mounting evidence implicates oppression-based stress in inequities in alcohol use, hazardous drinking, and alcohol use disorder in SGM populations. This reflects SGM people's embodiment of oppression and injustice at the structural, interpersonal, and intrapersonal levels. Given some inconsistent and mixed patterns of findings, future research needs greater specificity in drinking inclusion criteria, robust and well-validated measures, more attention to culturally and developmentally relevant moderating and mediating mechanisms across the lifespan, application of sophisticated methodologies, and integration of intersectional and addiction frameworks.

Structural stigma and LGBTQ+ health: a narrative review of quantitative studies

Health disparities related to sexual orientation and gender identity exist across multiple outcomes. Scholarship has begun to evaluate whether structural stigma-ie, societal-level conditions, cultural norms, and institutional policies that constrain opportunities, resources, and wellbeing-contributes to health burdens among LGBTQ+ individuals. We conducted a comprehensive review of quantitative studies examining this hypothesis. We found 98 articles that linked objective (ie, non-self-reported) measures of structural stigma to mental (n=57), behavioural (ie, substance use; n=27; HIV/AIDS or sexually transmitted infection; n=20), and physical (n=20) health outcomes. There was generally consistent evidence that structural stigma increases risk of poor health among LGBTQ+ individuals. Several methodological strengths were identified, including the use of multiple measures (eg, laws or policies [59%, 58 of 98]), designs (eg, quasi-experiments [21%, 21 of 98]), and samples (eg, probability-based [56%, 55 of 98]). However, important gaps exist. Just over half of studies included area-level covariates or non-LGBTQ+ comparison groups, which are necessary to address alternative explanations for the observed associations. Additionally, while studies (n=90) have begun to identify candidate mechanisms, only nine (10%) formally tested mediation. We offer suggestions for future research to advance this literature, which has implications not only for the identification of structural determinants of LGBTQ+ health but also for the development of public health interventions that reduce LGBTQ+ health disparities.

Health Insurance Coverage and Access to Care by Sexual Orientation During the COVID-19 Pandemic: United States, January 2021-February 2022

Objectives. To compare health insurance coverage and access to care by sex and sexual minority status during the COVID-19 pandemic and assess whether lack of insurance hindered access to care by sexual minority status. Methods. Using Behavioral Risk Factor Surveillance System data (January 2021-February 2022), we examined differences by sex and sexual orientation among 158 722 adults aged 18 to 64 years living in 34 states. Outcomes were health insurance coverage type and 3 access to care measures. Results. Sexual minority women were significantly more likely to be uninsured than were heterosexual women, and lack of insurance widened the magnitude of disparity by sexual minority status in all measures of access. Compared with heterosexual men with health insurance, sexual minority men with health insurance were significantly more likely to report being unable to afford necessary care. Conclusions. During the pandemic, 1 in 8 sexual minority adults living in 34 study states were uninsured. Among sexual minority women, lack of insurance widened inequities in access to care. There were inequities among sexual minority men with health insurance. Public Health Implications. Sexual minority adults may be disproportionately affected by the unwinding of the COVID-19 public health emergency and may require tailored efforts to mitigate insurance coverage loss. (Am J Public Health. 2024;114(1):118-128. https://doi.org/10.2105/AJPH.2023.307446).

Lesbian, Gay, Bisexual, Queer, Questioning and Transgender, Nonbinary, Genderqueer, and Gender Questioning Adult Alcohol Use Outcomes Associated with State Alcohol-Related Laws During the Coronavirus Pandemic in the United States

Purpose: We assessed how COVID-19-related alcohol sales policies influenced alcohol use behaviors during the pandemic for U.S. adults of diverse sexual (lesbian, gay, bisexual, queer, questioning [LGBQ]) and gender identities (transgender, nonbinary, genderqueer, and gender questioning [T/NB/GQ]). Methods: Time-specific, state-level, restaurant, bar, and off-premise alcohol policy data were collected from the National Institute on Alcohol Abuse and Alcoholism-sponsored Alcohol Policy Information System and merged with the 2020 Behavioral Risk Factor Surveillance System survey data. Treatments included bar, restaurant, and delivery alcohol sales policies. Outcomes included past 30-day drinking frequency, quantity, and heavy episodic drinking (HED). We fitted negative binomial regression models for all outcomes, clustered standard errors by state and used sample weights. We also controlled for seasonality, state Alcohol Policy Scale scores, pre-/postpandemic time period, and included demographic control variables in our cross-sectional analyses. Results: The sample included 10,505 adults identifying as LGBQ and 809 as T/NB/GQ from 32 states. Restaurant and bar closures were associated with less alcohol use for LGBQ respondents. Outdoor-only policies at bars were also associated with significantly less quantity of use and HED for T/NB/GQ adults in the sample. Off-premise home delivery was associated with greater quantity of use for LGBQ respondents and less frequency for T/NB/GQ respondents. Conclusion: The COVID-19-related alcohol sales policy changes offer an opportunity to better understand alcohol policy and availability's influence on drinking behaviors among sexual and gender-diverse populations in the United States.

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.

Associations of adult roles and minority stressors with trajectories of alcohol dependence symptoms throughout adulthood among sexual minority women

OBJECTIVE

In the present study, we sought to identify trajectories of symptoms of potential alcohol dependence (AD) among adult sexual minority women (SMW). Theoretical correlates were examined in relation to the empirically identified trajectories.

METHOD

Data were collected at three time points between 2000 and 2012 from SMW drinkers (n = 434) enrolled in a longitudinal study (M Age = 37.49 at baseline, SD = 11.55). Using an accelerated-cohort longitudinal design, latent growth curve mixture models identified homogeneous patterns of any past-year symptoms of potential AD. Correlates of trajectories included alcohol-related developmental risk factors, adult roles, and exposure to minority stressors.

RESULTS

Three trajectories were identified that captured risk of symptoms of potential AD over time, reflecting: (a) relatively consistent, low risk over time; (b) deceleration in risk throughout adulthood; (c) relatively persistent, high risk over time. Consistent with prior work, SMW drinkers who reported higher levels of perceived stigma or masculinity showed persistently high risk of reporting at least one past-year symptom of potential AD.

CONCLUSIONS

Most SMW drinkers report deceleration in risk of AD symptoms over time. Findings have implications for prevention and intervention efforts tailored to SMW drinkers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comparing National College Health Assessment with other surveys of cannabis use and binge drinking among young adult college students 2008-2018

Objective: We considered the utility of National College Health Assessment (NCHA) data relative to other national data for studying college students' cannabis use and binge drinking, and drug policy effects. Participants: Survey data on 18-22-year old college students were drawn from the 2008-2018 NCHA, National Survey on Drug Use and Health (NSDUH), Monitoring the Future (MTF), and Healthy Minds Study (HMS). Methods: Prevalence estimates were compared across data sources in terms of level and change from 2008-2018 using linear regressions, separately for men and women. Results: Mean prevalence estimates for 30-day cannabis use and 2-week binge drinking, and linear time trends did not differ significantly among NCHA, NSDUH, and MTF. Conclusions: NCHA prevalence estimates are similar to those from NSDUH and MTF, NCHA has unique strengths, and some weaknesses can be offset. Findings support the value of NCHA for studying college students' substance use and effects of drug policy.

Impact of the policy environment on substance use among sexual minority women

Background:

Sexual minority women (SMW) are at greater risk for heavy episodic drinking, frequent marijuana use, and tobacco use than heterosexual women. Because past research has suggested the political and social environment may influence disparities in substance use by sexual orientation, this study examined associations of the U.S. state-level policy environment on substance use by SMW.

Methods:

A total of 732 SMW participants were recruited from two national online panels: a general population panel (n = 333) and a sexual minority-specific panel (n = 399). Past year substance use was defined by number of days of heavy episodic drinking (HED; 4+ drinks in a day), weekly tobacco use (once a week or more vs. less or none), and weekly marijuana use (once a week or more vs. less or none). Comprehensive state policy protection was defined by enactment of five policies protecting rights of sexual minorities. Regression models compared substance use outcomes for SMW living in states with comprehensive policy protections to SMW living in states with fewer or no protections. Models also assessed the impact of state policies related to alcohol (state monopoly on alcohol wholesale or retail sales), tobacco (state enactment of comprehensive smoke-free workplace laws) and marijuana (legalization of purchase, possession, or consumption of marijuana for recreational use).

Results:

Comprehensive policy protections were associated with fewer HED days. Recreational marijuana legalization was associated with higher odds of weekly use.

Conclusions:

Findings underscore the importance of policy protections for sexual minorities in reducing substance use, particularly HED, among SMW.

Mental health-related quality of life by sex and sexual identity among U.S. adults with alcohol and tobacco use disorder

INTRODUCTION

Alcohol use disorder (AUD) and tobacco use disorder (TUD) are more severe among some sexual minority subgroups. It is less understood whether mental health indicators also differ by sexual identity among those with more severe forms of AUD and TUD. We examined differences in mental health-related QoL by sex-specific sexual identity subgroup among those meeting criteria for moderate-to-severe AUD or moderate-to-severe TUD.

METHODS

We analyzed data from the National Epidemiologic Study of Alcohol and Related Conditions-III (2012-2013; n = 36,309). Our analyses focused on those meeting criteria for past-year moderate-to-severe AUD (n = 2341) and past-year moderate-to-severe TUD (n = 3675). Using multivariable linear regression, we examined associations of sex-specific sexual identity subgroups with mental health-related QoL, while controlling for (a) sociodemographic characteristics, (b) disorder severity, and (c) risk and protective factors (adverse childhood experiences, parental history of substance misuse, stressful life events, and social support).

RESULTS

Among those with past-year moderate-to-severe AUD, gay men and heterosexual, bisexual, and gay/lesbian women had significantly lower mental health-related QoL compared to heterosexual men in fully adjusted models. Among those with past-year moderate-to-severe TUD, gay men and heterosexual and gay/lesbian women had significantly lower mental health-related QoL compared to heterosexual women. Bisexual and heterosexual women were not significantly different in fully adjusted models.

DISCUSSION

Clinicians should consider the variability in mental health-related QoL among those with moderate-to-severe AUD and TUD particularly for women and sexual minorities. Consideration of current and past stressors and the degree of social support may be beneficial when conducting assessments and forming treatment plans.