Stress, Coping, and Context: Examining Substance Use Among LGBTQ Young Adults With Probable Substance Use Disorders

Youths and young adults who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ) or as other sexual and gender minorities experience disparities in substance use and disorders (1–7). These disparities have been predominantly explained by minority stress theory, which posits that LGBTQ-related stressors shape negative mental health outcomes and associated coping behaviors, including substance use (8–11). Emerging from research on racial minority stressors and health (12, 13), minority stress theory identifies proximal (i.e., intrapersonal) and distal (i.e., interpersonal and structural) stressors experienced by LGBTQ individuals, such as self-stigma and discrimination, as determinants of health.

Although minority stress theory describes how stress and coping shape health among LGBTQ individuals, it does not provide a nuanced perspective on why some LGBTQ people develop substance use disorders, whereas most do not. LGBTQ youths initiate substance use earlier and escalate use more rapidly than their non-LGBTQ peers (14–17). How youths cope with LGBTQ-related stressors during identity development may shape substance use disorders in adulthood. For example, adolescents who employ avoidant coping strategies (e.g., substance use) in response to LGBTQ-related stressors experience more stress (18), lower self-esteem and life satisfaction (19), and lower educational attainment (20), compared with those who employ more healthful coping strategies.

Sociocultural influences, such as more permissive substance use norms (21, 22) in the LGBTQ community and targeting of LGBTQ people by alcohol and tobacco companies (23–25), also contribute to substance use disorders among LGBTQ people. Bars frequented by LGBTQ people may be especially relevant, because such establishments offer “paradoxical space” for community building and high levels of substance use and other risky behaviors (26, 27), contributing to substance use and other health disparities (24, 28, 29).

Few studies have qualitatively examined relationships between experiences of LGBTQ-related stressors, substance use, and sociocultural influences in adolescence and young adulthood. This research is needed to understand youth substance use initiation and escalation, how these processes contribute to the development of substance use disorders, and effective substance use disorder prevention strategies (24, 30, 31). This study qualitatively examined narratives from LGBTQ-identified young adults about their substance use initiation, escalation, and use in adolescence and young adulthood vis-à-vis their LGBTQ identities.

Methods

Data were collected between 2015 and 2017 from participants in an ongoing, U.S. longitudinal cohort, the Growing Up Today Study; this study originally enrolled participants in 1996 or 2004 (N=27,805). Participants in the cohort are children of nurses enrolled in the Nurses’ Health Study II. They complete paper or Web-based questionnaires covering a variety of health-related domains annually or biennially. More information about the cohort is available elsewhere (32, 33).

In 2015, we invited recent Growing Up Today Study responders (N=13,340) to complete a questionnaire assessing lifetime and current substance involvement, past 12-month probable substance use disorders based on DSM-IV criteria, and substance use treatment histories (response rate of 73%, N=9,683). Among those meeting criteria for a substance use disorder or reporting a history of substance use treatment (N=1,789), we purposively sampled a subset of participants based on sexual orientation and gender identity to participate in a follow-up qualitative telephone interview (N=179).

A total of 126 participants (70% of those invited) engaged in semistructured interviews with trained interviewers (average duration, 1 hour; range 18–150 minutes). First, interviewers asked participants about their use of specific substances by gathering a detailed substance use history. If a participant indicated use, the interviewer asked follow-up questions about the context of the participant’s use of each substance, such as How old were you when you first used [X]? How did your use change over time? and What factors contributed to that change/increase/decrease in use?

Next, interviewers asked participants open-ended questions about their current sexual orientation and gender identity, including specific categories to select from if necessary (i.e., Are you completely heterosexual? mostly heterosexual? gay or lesbian? bisexual? pansexual or asexual? Or, are you not sure? Are you male, female, transgender, or another identity?). Interviewers then asked participants to describe how their gender or gender identity and sexual orientation influenced their substance use: How has your gender/gender identity and experiences as a [gender identified by the participant] influenced your substance use? and How has your sexuality and experiences as a [sexual orientation identified by the participant] influenced your substance use? When further response seemed relevant, interviewers elicited elaboration. Interviews were audio recorded, transcribed verbatim, and deidentified. Participants provided informed consent and received a $50 gift card for their time. We obtained ethics approval from Partners Healthcare Human Research Committee/Institutional Review Board.

For the study reported here, we analyzed data from participants explicitly identifying as LGBTQ in the interview (N=59) by using an iterative, thematic analytic process to examine participants’ narratives within their own social and historical contexts (34). We developed a codebook of a priori codes (e.g., “substance use in the context of sexual orientation”) and codes grounded in the data (e.g., “influence of relationships on substance use”). Two analysts (including L.K.) tested codes on transcripts (N=13), resolving discrepancies until achieving sufficient agreement. The two analysts then coded the remaining transcripts based on the revised coding schema (84% reliability). We identified emergent themes via analysis of coded excerpts, code co-occurrence, analytic memos (applied throughout data collection and analysis), and discussion with the study team (34–36).

Results

Characteristics of the sample are summarized in Table 1. The mean±SD age of participants was 28±3 (range 21–34). Most participants were non-Hispanic white (78%); 49% of participants identified as cisgender female, 39% as cisgender male, and 12% as gender minorities (i.e., transgender, gender nonbinary, or gender queer). Most identified as lesbian or gay (58%), with the remainder identifying as bisexual (36%) and queer (7%).

Minority- and LGBTQ-Related Stressors and Coping

Participant narratives highlighted experiences of stress and coping in response to LGBTQ-related stressors. Most participants described coping with specific stressors in adolescence and young adulthood via substance use. Generally, participants described proximal stressors (those internal to the individual) during adolescence and distal stressors (those outside the individual, at the interpersonal and structural levels of the social ecology) during young adulthood.

Proximal stressors: identity formation and disclosure and substance use in adolescence.

Cisgender participants detailed exposure to and experiences with intrapersonal LGBTQ-related stressors—i.e., internalized stigma, concealment, and fear of identity disclosure—in early and middle adolescence, concurrent with sexual orientation development. Often, these stressors were related to fears of rejection, rather than to actual rejection. In fact, some participants described relief and decreased stress after disclosing their sexual orientation to supportive friends and family. For example, one participant explained that prior to coming out, he used substance use as a coping strategy for dealing with identity concealment (Table 2, excerpt 1). After coming out to a supportive family, his fears and stress decreased, but his substance use continued.

Similar to cisgender participants, participants who identified as a gender minority (N=7) described intrapersonal stressors related to identity development. Their narratives, however, suggested more severe self-stigma, concealment, fear, and experiences of rejection. Participants who identified as gender minorities also described developing and disclosing their gender identities at older ages and experiencing less acceptance and more negative consequences while coming out. One participant reflected on how youths who identify as a gender minority may miss developmental milestones during adolescence, because their primary need is to address a discordant gender identity (Table 2, excerpt 3).

Distal stressors: interpersonal and structural stressors and substance use in young adulthood.

Participants highlighted distal stressors in the context of young adult relationships and settings, including family, work, and college, and associated coping via substance use. For example, one participant explained that her substance use decreased after distancing herself from an unsupportive family (Table 2, excerpt 4), whereas another explained that marijuana use was a key coping mechanism for dealing with negative reactions and family rejection (Table 2, excerpt 5). These two narratives suggest that distance from an unsupportive family may decrease stress and substance use for some LGBTQ young adults and increase or compound stress and substance use for others.

Participants also reflected on structural-level LGBTQ-related stressors (e.g., discriminatory laws and policies) and substance use. Some described general structural stressors (e.g., “living in a predominantly hetero world”), whereas others explained that specific governmental policies (e.g., “Don’t ask, don’t tell”) engendered stress and increased substance use. A few participants specifically reflected on the interaction of multilevel stressors in shaping substance use. For example, one participant commented that stressors affecting LGBTQ people individually also affect LGBTQ communities broadly (Table 2, excerpt 7). His discussion of being stressed out “as a queer person” living in a country with a president who is widely perceived as anti-LGBTQ provides an example of how structural factors can influence stress and coping among LGBTQ people, even in the absence of specific intrapersonal or interpersonal stressors.

Sociocultural Influences: Outsider Identities, Community Norms, and the “Gay Bar”

Intersecting with participants’ descriptions of LGBTQ-related stressors and coping were discussions of sociocultural influences and substance use. Many participants described predominantly socializing with LGBTQ peers in substance-saturated environments (e.g., “gay bars”) and at substance-saturated events (e.g., Pride parades) (Table 2, excerpt 8). Although participants appreciated the historical and cultural significance of these environments for LGBTQ people, they suggested that overreliance on gay bars may contribute to the development of substance use disorders among LGBTQ people, with one participant explaining that sobriety and gay bars are “incompatible” (Table 2, excerpt 9).

Several male participants (both cisgender and gender minority) discussed feeling social pressure to use substances while spending time with LGBTQ friends. For example, one participant explained that he would be “overjoyed” if “the predominant gay activity” were to go on a hike rather than to a gay bar, because he often had to choose between spending time with his gay or straight friends (Table 2, excerpt 10). Similarly, some male participants (both cisgender and gender minority) described internal and external pressures to use substances to “fit in” with LGBTQ peers, especially during identity development (Table 2, excerpt 11).

Intersection of Sexual- and Gender-Minority Identities and Substance Use

All participants who identified as a gender minority also identified as a sexual minority (i.e., LGBQ). Because of their intersecting “minority” identities, these participants often reflected simultaneously on how both sexual- and gender-minority–related stressors and sociocultural influences shaped their substance use. A few participants who identified as a gender minority described having more than one period of identity development and disclosure (one for sexual orientation and the other for gender identity), each with its own unique stressors. For example, a transgender man described substance use escalation following rejection by his family after coming out as a lesbian and then again when transitioning to a different gender (Table 2, excerpt 12). Another participant, who identified as gender queer (i.e., outside the gender binary) and who used “they/them/theirs” as gender pronouns, described their gender and sexuality as “intertwined,” reflecting on substance use as self-medication during adolescence—a time when they could not imagine a path to societal acceptance of their identities. Although this participant described decreased use over time, they also explained that persistent gender-identity–related stress shaped their current substance use (Table 2, excerpt 13). These findings suggest that adolescents and young adults who are both sexual and gender minorities may have compounded “outsider” identities that make identity development and disclosure processes more complex and that this group may experience intersecting stressors, shaping substance use and disorders over time.

Divergent Cases: “I’ve Never Really Thought About It Like That”

Our analysis yielded a small proportion of thematically divergent cases. These participants (all cisgender) perceived little or no relationship between their sexual orientation, related stressors, sociocultural factors, and substance use. For example, one participant explained that he had “never thought about” a connection between his experiences as a bisexual male and his substance use (Table 2, excerpt 14). Another participant also did not perceive a connection between sexual orientation and substance use, suggesting that her experiences as a lesbian were positive (Table 2, excerpt 15). Finally, a bisexual female participant indicated experiencing few LGBTQ-related stressors because she is perceived as heterosexual. She explained that when perceived as “not entirely straight,” however, her social interactions are more negative (Table 2, excerpt 16).

Discussion

Substance use among LGBTQ young adults with probable substance use disorders may be understood within the context of multilevel LGBTQ-related stressors and coping (10) and sociocultural influences (21). Similar to results of other studies of LGBTQ stress, coping, and health (18, 19), our findings highlight adolescence as a critical period shaping substance use and substance use disorders over time, including use of substances as an avoidant coping strategy in response to intrapersonal stressors during LGBTQ identity development (8, 37). Our findings also contextualize previous quantitative research identifying adolescence as the developmental period with the largest disparities between LGBTQ and non-LGBTQ individuals in substance use initiation and escalation (14, 38–40).

Several cisgender participants in our study described decreased stress after coming out to family or accepting their sexual orientation, aligning with research findings that identity integration (e.g., disclosure) may be protective for health (41). For these participants, substance use may have become a habitual coping strategy that they continued to employ in the face of stressors, even those that were not LGBTQ related, leading to the development of substance use disorders over time. Participants also described coping with distal stressors, such as family rejection, and structural stressors, such as an anti-LGBTQ political climate. This emphasis on structural stressors aligns with research highlighting the link between “structural stigma” and higher rates of substance use among LGBTQ youths (42, 43).

It is critical to highlight the age of our participants. Because all are young adults now, the adolescent experiences they described occurred between 5 and 20 years ago. We found that regardless of whether these experiences occurred in the 1990s or the 2010s, participants detailed similar intrapersonal stressors in adolescence. This finding suggests that LGBTQ-related intrapersonal stressors may affect contemporary LGBTQ adolescents, despite growing acceptance of LGBTQ people nationally, echoing findings of persistent disparities in substance use among LGBTQ adolescents, even as overall adolescent substance use declines (44).

Overlapping with LGBTQ-related stressors were descriptions of sociocultural influences on participants’ substance use, including the role of gay bars and other LGBTQ-specific environments (e.g., Pride events). Despite the importance of such venues, participants described them as contributing to a culture of normative substance use. As in other research on identity construction among LGBTQ people (45), some participants described pressures to use substances in order to be part of the LGBTQ community.

Gender-minority participants described experiencing unique stressors, often intersecting with their sexual-minority identities. This is an important nuance emerging from our data and supported by a recent study of substance use among young adult transgender women in which researchers found that sexual-minority transgender women (i.e., lesbian, bisexual, and queer) evidenced greater disparities in heavy episodic drinking and illicit prescription drug use than did heterosexual transgender women (46).

Treatment Implications

Based on our findings, we offer the following recommendations for treatment providers working with LGBTQ clients. First, providers should explicitly address experiences of multilevel LGBTQ-related stressors and sociocultural influences and concurrent substance use during identity development (especially among adolescents) and in personal and professional contexts (especially among young adults). Identification of harmful or avoidant coping strategies may be especially useful for preventing the development of substance use disorders among young adults.

Second, providers should embrace “cultural humility” as a guiding approach to their interaction with clients. Differing from more traditional, static “cultural competency,” cultural humility requires ongoing, active learning about clients’ intersecting cultural identities and how a lack of societal power and privilege shapes one’s individual experiences (47–50).

Third, providers should stay abreast of current LGBTQ rights–related policies, because these may profoundly affect clients’ mental health and substance use. For example, although the Supreme Court struck down state bans against same-sex marriage in 2015 (51), many state and federal policies continue to restrict LGBTQ rights and promote anti-LGBTQ sentiments (52). Therefore, LGBTQ people living in conservative communities may need additional support from substance use treatment providers during treatment interactions—something providers who are aware only of broad-scale, pro-LGBTQ policies may fail to provide.

Fourth, providers should discuss with LGBTQ clients their current social support networks and the role of substance use in social interactions. This may be useful for identifying and discussing concrete strategies to address substance use within clients’ social contexts.

Finally, treatment environments should be welcoming to LGBTQ people (e.g., providing gender-neutral restrooms and LGBTQ-specific reading materials). Providers should adopt LGBTQ-inclusive screening procedures and carry out LGBTQ-affirming interactions with clients. These affirming practices are critical to supporting LGBTQ people in substance use treatment (Box 1). (A guide for further reading is provided in an online supplement to this article.)

Study Limitations and Future Directions

Our findings represent narratives of young adults with probable substance use disorders who are children of nurses and primarily non-Hispanic white. Therefore, the extent to which findings are generalizable to LGBTQ people broadly is unknown. Indeed, a robust theoretical literature (e.g., 53, 54), and to a lesser extent, a scientific evidence base (e.g., 55, 56), highlight the additional, intersecting stressors and health disparities experienced by LGBTQ people of color and of varying socioeconomic positions. Future studies should build on this work by further explicating how LGBTQ-related stressors and sociocultural contexts influence substance use and disorders across the life course among diverse groups of LGBTQ people.

Our sample included seven individuals who identified as a gender minority. Future research should explore the unique experiences of a larger sample of individuals with a gender-minority identity and probable substance use disorders to better understand and address the stressors and sociocultural contexts shaping their substance use and coping. Furthermore, research on substance use and disorders among gender minorities should also examine nuances at the intersection of gender identity and sexual orientation, because people who identify as both gender minorities and sexual minorities may have unique experiences and outcomes, compared with those who identify as exclusively heterosexual.

Finally, our study did not address alternatives for LGBTQ people to socialize and build community outside of substance-saturated environments, although such environments are emerging in direct response to some of the sociocultural influences identified in our analysis (57). Future research should explore these alternative spaces and the needs and desires of LGBTQ subgroups with respect to opportunities for socializing and their potential to decrease substance use and disorders among LGBTQ people.

Conclusions

Our study extends the literature by examining how LGBTQ young adults with probable substance use disorders perceive their substance use in the context of an LGBTQ identity over time. Our findings highlight the role of minority stress and sociocultural influences in adolescence and young adulthood in shaping substance use and disorders. These findings have implications for treatment providers and prevention researchers.