Examining perceived effects of same-sex marriage legalization among sexual minority women: Identifying demographic differences and factors related to alcohol use disorder, depression, and self-perceived health.

Background: Reductions in structural stigma, such as gaining access to legalized same-sex marriage, is associated with positive psychological and physical health outcomes among sexual minorities. However, these positive outcomes may be less robust among sexual minority women (SMW). Methods: This study examined how perceptions of the impact of legalized same-sex marriage among SMW may 1) differ by demographic characteristics and 2) predict alcohol use disorder, depression, and self-perceived health. A diverse sample of SMW (N=446) completed an online survey in 2020 assessing the perceived impact of legalized same-sex marriage across six social-ecological domains: 1) personal impact, 2) stigma-related concerns, 3) couple impact, 4) family support, 5) work/school impact, and 6) local social climate towards LGBTQ people. Results: Perceived impact across multiple domains differed by relationship status and sexual identity (e.g., lesbian compared to bisexual identity); only family support differed by race/ethnicity. Stigma-related concerns (e.g., experiencing or witnessing hostility or discrimination because of sexual identity, despite legalized same-sex marriage) were associated with greater odds of depression and lower odds of reporting excellent, very good, or good health. Odds of depression were lower among participants who reported higher personal impact, a greater number of family members supportive of same-sex marriage, and a more positive local social climate. Family support also predicted self-perceived health. However, participants who perceived increased support in work/school contexts after legalized same-sex marriage had higher odds of alcohol use disorder. Conclusions: Overall, findings underscore the importance of policy in improving health outcomes through reducing stigma-related concerns and improving social acceptance.

Corrigendum to 'Impact of the policy environment on substance use among sexual minority women'.

[This corrects the article PMC9262325.].

Examining the differential protective effects of women's spirituality and religiosity on alcohol and marijuana use by sexual identity.

The current study explored how religiosity and spirituality may differentially influence substance use by sexual identity based on a sample of adult sexual minority women (SMW; n = 437 lesbian; n = 323 bisexual) relative to a heterosexual comparison sample (n = 636). We examined three questions: (1) whether spirituality was differentially associated with alcohol and marijuana use by sexual identity; (2) whether religiosity was differentially associated with alcohol and marijuana use by sexual identity; (3) whether observed differences between spirituality or religiosity and substance use by sexual identity persisted after adjusting for religious environment. Measures included spirituality (importance of spirituality), religiosity (importance of religion, attending religious services), and past year substance use (alcohol use disorder [AUD], any marijuana use, and regular marijuana use). Higher levels of spirituality were associated with increased odds of AUD among both lesbian and bisexual respondents relative to heterosexuals. Higher levels of religiosity among lesbian participants were associated with increased odds of AUD relative to heterosexuals with higher levels of religiosity. Consistent with theories of minority stress, findings suggest that spirituality and religiosity are less protective for SMW than heterosexual women and, in some cases, may contribute to greater risk of substance use.

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.

Comparing substance use outcomes by sexual identity among women: Differences using propensity score methods.

BACKGROUND: Differences in alcohol, tobacco, and other drug (ATOD) use by sexual identity vary across samples of women recruited using different sampling methods. We used propensity score (PS) weighting methods to address two methodological questions: (1) Do disparities between sexual minority women (SMW) and heterosexual women persist when differences in risk and protective factors are similarly distributed between groups, and (2) Does accounting for SMW-specific resiliency factors impact differences between non-probability samples of SMW? METHODS: Four samples included SMW from a longitudinal study with a nonprobability sample (n = 373), a national general population panel sample (n = 373), and a national LGBTQ-specific panel sample (n = 311), as well as a national probability sample of heterosexual women (n = 446). Between-groups analyses using double-robust PS weighted models estimated differences in ATOD use under hypothetical conditions in which samples have similar risk and protective factors. RESULTS: After PS weighting, imbalance in confounders between SMW and heterosexual samples was substantially reduced, but not eliminated. In double-robust PS weighted models, SMW samples consistently had significantly greater odds of drug use than heterosexuals, with odds from 8.8 to 5.6 times greater for frequent marijuana use and 4.8-3.2 greater for other drug use. Few differences between SMW samples in ATOD outcomes or other variables remained after PS weighting. CONCLUSION: Relative to heterosexual women, disparities in marijuana and other drug use among SMW are evident regardless of sampling strategy. The results provide some reassurance about the validity of large nonprobability samples, which remain an important recruitment strategy in research with SMW.

Challenges of virtual RDS for recruitment of sexual minority women for a behavioral health study.

Respondent driven sampling (RDS) is an approach commonly used to recruit nonprobability samples of rare and hard-to-find populations. The purpose of this study was to explore the utility of phone and web-based RDS methodology to sample sexual minority women (SMW) for participation in a telephone survey. Key features included 1) utilizing a national probability survey sample to select seeds; 2) web-based recruitment with emailed coupons; and 3) virtual processes for orienting, screening and scheduling potential participants for computer-assisted telephone interviews. Rather than resulting in a large diverse sample of SMW, only a small group of randomly selected women completed the survey and agreed to recruit their peers, and very few women recruited even one participant. Only seeds from the most recent of two waves of the probability study generated new SMW recruits. Three RDS attempts to recruit SMW over several years and findings from brief qualitative interviews revealed four key challenges to successful phone and web-based RDS with this population. First, population-based sampling precludes sampling based on participant characteristics that are often used in RDS. Second, methods that distance prospective participants from the research team may impede development of relationships, investment in the study, and motivation to participate. Third, recruitment for telephone surveys may be impeded by multiple burdens on seeds and recruits (e.g., survey length, understanding the study and RDS process). Finally, many seeds from a population-based sample may be needed, which is not generally feasible when working with a limited pool of potential seeds. This method may yield short recruitment chains, which would not meet key RDS assumptions for approximation of a probability sample. In conclusion, potential challenges to using RDS in studies with SMW, particularly those using virtual approaches, should be considered.

Measuring the impact of legal recognition of same-sex marriage among sexual minority women.

Reductions in structural stigma, such as gaining access to legalized same-sex marriage, is associated with positive psychological and physical health outcomes among sexual minority adults. However, these positive outcomes may be less robust among sexual minority women (SMW; e.g., lesbian, bisexual, queer) than sexual minority men and new measures are needed to develop a more nuanced understanding of the impact of affirming policies on the health and well-being of SMW. This study assessed the psychometric properties of measures developed to assess the psychosocial impacts of legalized same-sex marriage on the lives of SMW. Participants (N=446) completed an online survey assessing the psychosocial impact of legalized same-sex marriage in five domains: 1) personal impact, 2) stigma-related concerns, 3) couple impact, 4) LGBTQ community impact, and 5) political/social environment. Psychometric properties of the scales were examined using traditional and Rasch analyses. Personal, concerns, couple, and political/social environment scales demonstrated high internal consistency (α > 0.80), and acceptable levels of reliability even when scales reduced to five items each. The LGBTQ community scale demonstrated adequate internal consistency (α = 0.79) and could only be reduced to 9 items. These scales may be useful in future studies of SMW health and well-being.

Differential Effects of State Policy Environments on Substance Use by Sexual Identity: Findings From the 2000-2015 National Alcohol Surveys.

INTRODUCTION: This study explored whether structural stigma, defined by U.S. state policies related to sexual minority rights, moderated the relationship between sexual identity identity and heavy drinking, alcohol problems, and marijuana use among men and women. METHODS: Using combined data from the National Alcohol Survey (NAS) series (2000, 2005, 2010, and 2015), the sample included 11,115 men (421 sexual minority and 10,694 heterosexual) and 14,395 women (413 sexual minority and 13,982 heterosexual). State policy environment was assessed using a time-varying dichotomous indicator of comprehensive protections for sexual minorities (4-6 protections vs. limited or no protections). Gender-stratified logistic regression analyses examined the differential effect of the policy environment by sexual identity on three past-year substance use outcomes: high-intensity drinking (8+ drinks/day), any DSM-5 alcohol use disorder, and marijuana use. RESULTS: Among women, sexual minority status was associated with increased odds of all alcohol and marijuana use outcomes. Among men, sexual minority status was associated with decreased odds of high-intensity drinking but increased use of marijuana. Comprehensive policy protections were associated significantly decreased odds of high-intensity drinking among sexual minority men and marginally significant decreases among women. CONCLUSIONS: Comprehensive policy protections appear to be protective for high-intensity drinking among sexual minority men and women. Findings underscore the importance of supportive policies in reducing risk of alcohol-related problems among sexual minorities.

Harm from Others' Drinking Among Sexual Minority Adults in the United States.

Purpose: Due to discrimination and stigma, sexual minority adults may be more likely than their heterosexual counterparts to experience harms from other people's drinking. We compared prevalence of second-hand alcohol harms for sexual minority and heterosexual adults in the United States. Methods: Data from the 2014-15 U.S. National Alcohol Survey (n = 5516; 10.2% sexual minority adults) were analyzed using logistic regression with survey weights to account for sampling and nonresponse. Multivariable models included simple main effects of sexual identity on the past-year harm outcomes, as well as interactions of drinker status with sexual identity. Results: In bivariate results stratified by sex, bisexual women were significantly more likely than heterosexual women to report all five types of harms. Lesbian respondents had greater odds relative to heterosexual women of reporting harm by a friend/coworker and assault or physical harm by a drinker. Bisexual identity among men was associated with greater odds of reporting assault/physical harm relative to heterosexual men in bivariate models. In adjusted models, differences by sexual identity were substantially reduced, with significance remaining only for friend/coworker-perpetrated harms and assault/physical harm among lesbian respondents compared with heterosexual women. For assault/physical harm, an interaction of sexual identity with the respondent's own drinking showed that the increased odds of harm associated with heavy drinking was even greater among sexual minority respondents (both bisexual and lesbian/gay respondents) than among heterosexual respondents. Conclusion: These findings underscore the importance of preventive interventions that consider disparities in risk for alcohol-related harms, particularly interpersonal violence, among sexual minority adults in the United States.

Harmful drinking, tobacco, and marijuana use in the 2000-2015 National Alcohol Surveys: Examining differential trends by sexual identity.

BACKGROUND: Population-based surveys document disparities in substance use among sexual minorities compared to heterosexuals, but few studies examine changes over time. This study compared changes in harmful drinking (including alcohol use disorders and high-intensity drinking), tobacco use, marijuana use, and simultaneous marijuana and alcohol co-use between heterosexual and sexual minority adults over a 15-year period. Methods: Gender-stratified logistic regression analyses using 4 waves of cross-sectional data from the National Alcohol Survey (2000, 2005, 2010, and 2015) were conducted to test overall trends over time and differences by sexual identity, as well as the interaction between survey year and sexual identity. Results: Among women, significant effects for sexual identity were present in all models, reflecting greater odds of use among sexual minorities across waves. Among men, significant effects for sexual identity were found for high-intensity drinking (reflecting less use among sexual minorities) as well as marijuana use and marijuana and alcohol co-use (reflecting more use among sexual minorities). For women and men, tobacco use generally decreased and both marijuana use and simultaneous marijuana and alcohol co-use increased during the study period. Although trends were largely driven by heterosexual respondents, only one instance of an interactive effect was found; reports of harmful drinking were generally stable over time among heterosexual women, but higher and more variable over time among sexual minority women. Conclusions: Findings highlight that differences in patterns of substance use by sexual identity persist and underscore the need for screening, prevention, and intervention, particularly for sexual minority women.

Investigating differential protective effects of marriage on substance use by sexual identity status.

BACKGROUND: Research suggests that marriage is protective against substance use. However, few studies have examined whether this protective effect differs for sexual minorities, a population at increased risk for substance use. Using data from four waves of the cross-sectional U.S. National Alcohol Survey (NAS; 2000, 2005, 2010, and 2015), we investigated whether the protective effects of marriage varied by sexual identity. METHODS: Sex-stratified logistic regression models were used to examine independent and interactive effects of current marital status (being married vs. not) and sexual minority status (lesbian/gay/bisexual vs. heterosexual) on high-intensity drinking, alcohol use disorder, and marijuana use in the past year. RESULTS: Among both women and men, sexual minority status was generally associated with higher odds of these outcomes and marriage was consistently associated with lower odds. Differential effects of marriage by sexual identity with respect to marijuana use were found only among men; marriage was significantly associated with decreased odds of marijuana use among heterosexual men but increased odds among sexual minority men. CONCLUSIONS: Marriage may be less consistently protective against hazardous drinking and marijuana use among sexual minorities than heterosexuals. Findings underscore the importance of both quantitative and qualitative studies designed to better understand disparities in substance use across both sexual identity and relationship statuses.

It's complicated: The impact of marriage legalization among sexual minority women and gender diverse individuals in the United States.

This mixed-methods study explored perceptions of the impact of marriage legalization in all U.S. states among sexual minority women and gender diverse individuals. Survey data were collected from a nonprobability sample of individuals 18 years or older who identified as lesbian, bisexual, queer, same-sex attracted or something other than exclusively heterosexual-as well as individuals who identified as transgender or gender nonbinary (for example, genderqueer, trans woman, trans man, nonbinary, or gender non-conforming). The analytic sample included 418 participants in an online survey who responded to open-ended questions about the perceived impact of marriage legalization. Qualitative analyses revealed perceptions of marriage legalization that situated individual meanings in the context of broader political and social factors. Four themes represented the complex perceptions of participants about marriage legalization: 1) establishing a victory in civil rights, social inclusion, and acceptance; 2) creating a paradox between positives of legalization and limitations of marriage as an institution; 3) amplifying concerns for unaddressed safety and rights issues; and 4) contributing to the erosion of queer identity and community. Quantitative analyses revealed several differences by demographic characteristics, such as greater concern about the erosion of community among unmarried participants compared to participants who were married. Findings underscore the importance of policies that advance equality for sexual and gender minorities (SGMs), as well as the importance of research exploring how policies are perceived by and impact SGM subpopulations.

Impacts of Marriage Legalization on the Experiences of Sexual Minority Women in Work and Community Contexts.

The extension of marriage rights to same-sex couples in the United States provides an opportunity to examine how legalization of same-sex marriage has impacted the experiences of sexual minority women (SMW) in interactions within their extended social networks and local communities. Interviews were conducted with 20 SMW ranging in age from 23 to 75, with varying relationship statuses, and in different regions of the U.S. Inductive thematic analysis of responses revealed both positive and negative/neutral impacts in three broad thematic areas: workplace dynamics and interpersonal interactions in the workplace, social interactions in extended social networks and local communities, and impacts on community climate and queer communities. Findings of the study underscore the importance of evaluating the impact of same-sex marriage legalization in the context of local social and political climates.

Comparing substance use and mental health outcomes among sexual minority and heterosexual women in probability and non-probability samples.

OBJECTIVE: To examine similarities and differences in demographics and key substance use and mental health outcomes in a probability sample of heterosexual women and two samples of sexual minority women (SMW), one recruited using probability and the other using non-probability methods. METHODS: Using data from four waves of the National Alcohol Survey (NAS; n = 315 SMW; 10,523 heterosexual women) and Wave 3 of the Chicago Health and Life Experiences of Women (CHLEW; n = 688 SMW) study, we examined hazardous drinking, drug use, tobacco use, depression, and help-seeking for alcohol or other drug problems. RESULTS: Compared to SMW in the probability sample, SMW in the non-probability sample were older, more likely to be college educated, and more likely to be in a partnered relationship. Compared to heterosexuals, SMW in both the probability and non-probability samples had greater odds of past-year hazardous drinking, marijuana use, and other drug use. We found similar results for lifetime help-seeking for alcohol or drug problems, past week depression, and co-occurring hazardous drinking and depression. In comparisons with heterosexual women, the magnitude of difference for drug use was greater for the SMW non-probability sample; for tobacco use, the difference was greater for the SMW probability sample. CONCLUSION: Given the difficulties recruiting probability samples of SMW, researchers will continue to use non-probability samples in the foreseeable future. Thus, understanding how findings may differ between probability and non-probability samples is critically important in advancing research on sexual-orientation-related health disparities.

Strengths and coping strategies in the life narratives of sexual minority women.

This study explored self-described strengths and strategies for coping with stress among sexual minority women (SMW), drawing on qualitative narratives of sexual minority and heterosexual women who were recruited from a population based sample. In-depth follow-up qualitative telephone interviews were conducted with 48 women who had participated the National Alcohol Survey, a U.S. population-based survey. Participants included 25 SMW and 16 matched exclusively heterosexual women. Narrative data were analyzed using inductive thematic analysis and constant comparison to explore the study aim, with an emphasis on themes that diverged or that were particularly salient for SMW relative to heterosexual women. Strengths and coping strategies that were especially meaningful in the narratives of sexual minority women emerged in two areas. First, participants described development of intrapersonal strengths through nurturing an authentic sense of self and embracing multifaceted identity. Second, participant described multiple strategies for cultivation of interpersonal resources: navigating distance and closeness with family of origin, cultivating supportive friends and chosen family, connecting to community, finding solace and joy with animals, and engaging in collective action. Findings underscore the importance of considering protective factors that are salient to SMW in developing or refining prevention and intervention efforts.

Delivering LGBT-sensitive substance use treatment to sexual minority women.

Epidemiologic studies have consistently found elevated rates of alcohol and other substance use among sexual minority women (SMW), and despite calls for "LGBT-specific" services and culturally-tailored interventions, few such services exist. This study involved qualitative interviews with directors from substance use treatment programs (N=10) about how they addressed the needs of SMW. Strategies implemented primarily focused on creating a safe and welcoming environment for sexual minority clients. Findings highlight challenges involved in meeting the treatment needs of SMW and provide guidance to researchers and service providers on how to improve the quality of care for them.

Alcohol Outcomes by Sexual Orientation and Race/Ethnicity: Few Findings of Higher Risk.

OBJECTIVE: This study sought to confirm a previously identified race by sexual orientation interaction and to clarify men's alcohol-related risk by using an expanded classification of sexual orientation. METHOD: We collapsed three waves of National Alcohol Survey data, restricting the analytic sample to White (n = 5,689), Black (n = 1,237), and Latino (n = 1,549) men with complete information on sexual orientation and alcohol use. Using self-reported sexual identity and behavior, respondents were categorized as exclusively heterosexual (referent), behaviorally discordant heterosexuals (i.e., heterosexual identity and same-sex partners), or gay/bisexually identified men. We used multivariable logistic regression to model lifetime alcohol dependence symptoms, lifetime drinking-related consequences, and past-year hazardous drinking, controlling for age, education, employment, and relationship status and accounting for the complex survey design. RESULTS: There was no difference in risk of past-year hazardous drinking and lifetime drinking-related consequences between heterosexual, behaviorally discordant heterosexual, and gay/bisexual men, independent of race/ ethnicity. Among Black men, behaviorally discordant heterosexuals had three-fold higher odds of lifetime alcohol dependence symptoms than exclusively heterosexual peers (aOR = 3.30, 95% CI [1.19, 9.18], p = .02). Gay/bisexual Latino men had marginally significantly lower odds of lifetime alcohol dependence symptoms (aOR = 0.36, 95% CI [0.12, 1.03], p = .06). CONCLUSIONS: There is little support for broad statements of greater alcohol risk among gay/bisexual men; however, for some subgroups and outcomes the direction and degree of risk depend on race/ ethnicity. Thus, this study underscores the importance of considering the potential interaction of sexual orientation and race/ethnicity, which may exacerbate or attenuate.

Religiosity as a protective factor for hazardous drinking and drug use among sexual minority and heterosexual women: Findings from the National Alcohol Survey.

OBJECTIVE: Despite research documenting disparities in risk for alcohol-related problems among sexual minority women, few studies explore potential protective factors within this population. This study examines how religiosity may function as a protective or risk factor for alcohol-problems or other substance use among sexual minorities compared to heterosexuals. METHOD: Data from 11,169 women who responded to sexual identity and sexual behavior questions from three population-based National Alcohol Survey waves (2000, 2005, 2010) were utilized for analyses of religiosity in relation to lifetime drinking, past year hazardous drinking, and past year drug use. RESULTS: Religiosity was significantly greater among exclusively heterosexual women compared to all sexual minority groups (lesbian, bisexual and heterosexual women who report same sex partners). Lesbians reported the lowest rates of affiliation with religions/denominations discouraging alcohol use. Past year hazardous drinking and use of any illicit drugs were significantly lower among exclusively heterosexual women compared to all sexual minority groups. High religiosity was associated with lifetime alcohol abstention and was found to be protective against hazardous drinking and drug use among both sexual minority and heterosexual women. Reporting religious norms unfavorable to drinking was protective against hazardous drinking among exclusively heterosexual women but not sexual minority women. CONCLUSIONS: Findings reveal the importance of considering sexual minority status in evaluation of religion or spirituality as protective among women. Future studies should explore religiosity in the context of other individual and environmental factors, such as positive identity development and community-level acceptance, which may be salient to resiliency among sexual minorities.

Examining the Sociocultural Context of HIV-related Risk Behaviors Among Kathoey (Male-to-female Transgender Women) Sex Workers in Bangkok, Thailand.

Kathoey (male-to-female transgender) sex workers (KSW) in Thailand are at high risk for sexually transmitted infections; however, few qualitative studies have been conducted to understand the sociocultural context of engaging in HIV risk behaviors. A total of 24 participants were purposively sampled in Bangkok based on KSW work venues and substance use. Results revealed the importance of participants' understanding of the self in relation to establishing economic independence through sex work, which could then be used to re-establish support from family, who often have not accepted a son's gender transition. Participants linked being kathoey to a belief in fate but did not view engagement in sex work in the same way. Different sex work venues exposed KSW to different risky situations. HIV prevention programs for kathoey must address the importance of economic security and its relation to social support and gender transition within a cultural- and work-environment-specific framework.

Conducting qualitative interviews by telephone: Lessons learned from a study of alcohol use among sexual minority and heterosexual women.

This study explored effective interviewer strategies and lessons-learned based on collection of narrative data by telephone with a sub-sample of women from a population-based survey, which included sexual minority women. Qualitative follow-up, in-depth life history interviews were conducted over the telephone with 48 women who had participated in the 2009-2010 National Alcohol Survey. Questions explored the lives and experiences of women, including use of alcohol and drugs, social relationships, identity, and past traumatic experiences. Strategies for success in interviews emerged in three overarching areas: 1) cultivating rapport and maintaining connection, 2) demonstrating responsiveness to interviewee content, concerns, and 3) communicating regard for the interviewee and her contribution. Findings underscore both the viability and value of telephone interviews as a method for collecting rich narrative data on sensitive subjects among women, including women who may be marginalized.