LOS ANGELES — Lesbian, gay, and bisexual adults have a higher risk of substance use disorders than do heterosexuals, but this risk is not uniform among sexual minority groups, according to data from the population-based National Epidemiologic Survey on Alcohol and Related Conditions.

The data also pointed to profound differences in substance abuse rates within commonly grouped sexual orientation categories when participants were categorized not just by the way in which they described their sexual identity (lesbian, gay, bisexual, or heterosexual), but also by the way they described their sexual behavior and attraction.

Two-thirds of 577 lesbian, bisexual, and gay adults reported being discriminated against on the basis of their sexual orientation, gender, race, or a combination of these.

About half of individuals who had experienced all three kinds of discrimination met criteria for a substance use disorder, and among those exposed to “very high levels of discrimination” (above 70 on a 0-72 discrimination scale for overall discrimination in the past year), the probability of a substance use disorder was almost 100%, Dr. Sean Esteban McCabe said at the annual meeting of the American Academy of Addiction Psychiatry. Discrimination was measured by using questions derived from the Experiences of Discrimination scales.

A clear dose-response relationship was seen between scores on the discrimination Sscale and substance use disorders, both for lifetime discrimination and for past-year discrimination, with a sharp increase seen in such disorders beginning at low to moderate discrimination scale scores among people who had recently experienced discrimination.

Conversely, members of a sexual minority group who had not experienced discrimination had rates of substance use disorders “comparable to heterosexuals,” said Dr. McCabe, a psychologist at the Substance Abuse Research Center and Institute for Research on Women and Gender at the University of Michigan in Ann Arbor.

The finding confirmed Dr. McCabe's hypothesis that cultural and environmental factors are the most likely explanation for elevated substance use disorders among sexual minorities—“not… sexual orientation itself.”

Overall, substance abuse disorders were substantially higher among lesbian, bisexual, and gay respondents than among heterosexuals in Wave 2 data from NESARC, a representative survey of nearly 35,000 adults—including the largest national sample of minority sexual groups ever enrolled in study on alcohol and drug use.

Past-year prevalence for any substance disorder was 25.8%, 24.3%, and 5.8%, respectively, among lesbian, bisexual, and heterosexual women, and 31.4%, 27.6%, and 15.6%, respectively, among gay, bisexual, and heterosexual men.

However, “risk was not uniform across dimensions of sexual minority women and men,” emphasized Dr. McCabe. For example, women who reported exclusive same-sex sexual behavior had a past-year prevalence of substance use disorder of 9.1%, statistically similar to the 5.8% rate among heterosexual women.

In contrast, women who reported sexual behavior with both sexes had a past-year prevalence rate of substance abuse of 26.8%, a highly significant elevation over rates in other women.

Women who reported attraction only to the same sex had a past year prevalence rate of substance use disorders of 11.4%, not dissimilar to rate seen in women who said they were attracted equally to both sexes (9.6%), those who said they were mostly attracted to the other sex (13.2%), and those who said they were only attracted to the other sex (5.6%). Among women, the highest past-year prevalence rate of substance abuse disorders was highest, by far, among those who said they were mostly attracted to the same sex, at 24.2%.

Among men, differences were seen among past-year substance use disorder prevalence rates depending on how they described their sexual behavior, but those differences were not as striking as those seen among women.

For example, men who reported only same sex sexual behavior had a rate of 17.9%, compared to a 15.7% rate among men who reported only having sex with women. Men who reported sex with both sexes had a significantly higher rate of substance use disorders—26.3%.

Dr. McCabe reported no disclosures.

My take

Heightened Awareness Is Crucial

Dr. Sean Esteban McCabe's presentation underscores the importance for health care providers to consider lifestyle differences in identifying individuals at greater risk for substance use disorders. Initial screenings should include questions regarding issues of sexual orientation, sexual behavior, and attraction. Further, providers need to develop a heightened awareness for substance use disorders in individuals identified to be in sexual minorities. Brief screening tools, such as the CAGE, should be employed to identify individuals in this population at risk of substance abuse. It is imperative the clinician identify patients in a sexual minority and develop a further understanding of the prevalence of substance use disorders, treatment needs, and appropriate interventions for this population.

TONIA WERNER, M.D., is assistant professor and chief of forensic psychiatry in the department of psychiatry at the University of Florida, Gainesville. She reports no conflicts relevant to this study.

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Discrimination Drives Substance Abuse in Some