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Published in final edited form as: Clin Psychol Rev. 2023 Apr 23;102:102283. doi: 10.1016/j.cpr.2023.102283

Probable PTSD, PTSD symptom severity, and comorbid PTSD and hazardous drinking among sexual minority women compared to heterosexual women: A meta-analysis

Jillian R Scheer a, Emily C Helminen a,b, Cory J Cascalheira a,c, Virinca Jaipuriar a, Thomas J Shaw d, Sasha Zabelski e, Kriti Behari a, Sophia Pirog a, Abigail W Batchelder f,g,h, Kyle Possemato i, Tonda L Hughes j,k, Tami P Sullivan l
PMCID: PMC10205673  NIHMSID: NIHMS1898627  PMID: 37150043

Abstract

Posttraumatic stress disorder (PTSD) is more prevalent among sexual minority women (SMW) than among heterosexual women. PTSD risk varies among SMW, but no meta-analysis has clarified sexual identity-related disparities in probable PTSD among women or SMW’s heterogeneity in PTSD risk. SMW are also at pronounced risk of comorbid PTSD and hazardous drinking (HD). However, the difference in comorbid PTSD/HD between SMW and heterosexual women is understudied. This meta-analysis aimed to provide a comprehensive understanding of differences between SMW and heterosexual women and among SMW across demographic characteristics. Peer-reviewed publications that were written in English and reported quantitative data on PTSD specific to SMW were included. Eligible publications (n = 45) were identified through a systematic search of 11 electronic databases, supplemented by a search of reference lists of relevant papers. We found that probable PTSD, PTSD symptom severity, and probable comorbid PTSD/HD are highly prevalent among SMW, with SMW of color, transgender and gender diverse people, and bi+ women (e.g., bisexual, pansexual, queer) being at greatest risk. These results emphasize the need to improve accurate assessment of trauma-related sequelae among SMW and to develop, disseminate, and implement culturally sensitive treatments to reduce PTSD and comorbid PTSD/HD among at-risk SMW.

Keywords: Sexual minority women, posttraumatic stress disorder, trauma exposure, comorbid posttraumatic stress disorder and hazardous drinking, meta-analysis

Introduction

Posttraumatic stress disorder (PTSD) can occur in individuals following direct or indirect exposure to actual or threatened death, serious injury, or sexual violation (American Psychiatric Association; APA, 2013). PTSD is characterized by intrusive thoughts, persistent avoidance, negative alteration in cognition and mood, and marked alteration in arousal and reactivity (APA, 2013) and contributes to substantial morbidity and mortality (Possemato et al., 2015; Sullivan et al., 2020). PTSD is highly comorbid with hazardous drinking (HD; i.e., high-risk drinking patterns that increase the likelihood of developing alcohol use disorders), especially among women (Castillo-Carniglia et al., 2019; Smith & Cottler, 2018). Women also vary in risk of PTSD and comorbid HD, with findings showing a higher prevalence of PTSD and comorbid PTSD/HD among sexual minority women (SMW; e.g., lesbian, bisexual, queer) than heterosexual women (Evans-Polce & McCabe, 2020). Yet, current literature lacks a comprehensive understanding of these disparities. Identifying marginalized groups, including SMW, at greatest risk of PTSD, severe PTSD symptoms, and comorbid PTSD/HD could help to develop and enhance targeted prevention and intervention efforts.

Gender Disparities in Lifetime, Past-Year, and Past-Month Rates of PTSD

Most psychobiological studies have found higher rates of PTSD in women than men, partly due to lower levels of social support, younger age at the time of trauma, and greater exposure to traumatic events which are strongly predictive of PTSD, including interpersonal violence (vs. war-related trauma or other adversities) (Blanco et al., 2018; Goldstein et al., 2016; Lehavot et al., 2018; Olff et al., 2007). For example, studies among the general U.S. population demonstrate that lifetime prevalence of PTSD is 8.0%–9.5% among women and 3.4%–5.6% among men (Blanco et al., 2018; Lehavot et al., 2018); past-year prevalence of PTSD is 6.0%–6.1% for women and 2.6%–3.2% for men (Goldstein et al., 2016; Lehavot et al., 2018). A recent systematic review found that among studies using large, nationally representative samples, lifetime prevalence of PTSD among women is 8.0%, compared to 4.1% of men; past-year estimates for women are 6.0% and 2.6% for men (Schein et al., 2021). Among a college sample, 32.6% of women met criteria for lifetime probable PTSD vs. 11.4% of men (Cusack et al., 2019). In addition, one study using a nationally representative survey of Black Americans found that 8.7%–14.0% of women vs. 4.6%–6.3% of men met criteria for lifetime PTSD; past-year PTSD estimates for women are 2.9%–6.4% and 2.2%–3.4% for men (Jones et al., 2022). Another study using a nationally representative sample of veterans indicated that past-month PTSD prevalence estimates among women are 11.2% (vs. 4.3% among men; Wisco et al., 2022). Findings are mixed on the presence of gender differences in PTSD symptom severity among those who meet subthreshold PTSD (but not full PTSD; Lehavot, Stappenbeck, et al., 2014; Olff et al., 2007).

SMW’s Heightened Risk of PTSD Relative to Heterosexual Women

Comparative studies have shown that SMW are at least twice as likely as heterosexual women to meet PTSD criteria (20.2%–35.3%; Dworkin et al., 2020; Helminen et al., 2021; Kerridge et al., 2017; Roberts et al., 2010). Other research has demonstrated that SMW have greater PTSD symptom severity than heterosexual women (Lehavot et al., 2019; López & Yeater, 2021). Nonetheless, no study has meta-analyzed sexual identity disparities in probable diagnosis of PTSD (i.e., likelihood of meeting diagnostic criteria for PTSD based on valid cut-off scores using self-report checklists vs. structured clinical interviews; hereafter “probable PTSD”; Steel et al., 2009) and PTSD symptom severity among women. This gap in existing literature can lead to potentially inaccurate estimates and impede work toward mental health equity among marginalized populations exposed to trauma. Indeed, accurately estimating sexual identity disparities in PTSD among women could substantiate the need for clinical research to improve prediction and assessment of PTSD, identify etiologic and maintenance mechanisms of PTSD, and define clinical subtypes of PTSD (e.g., low threshold for activating the adrenergic hyperarousal response, deficits in fear regulation, trauma-related cognitive intrusions) among SMW (Ressler, 2018). Such findings could also inform flexibly applied modular approaches to treating PTSD according to SMW’s concerns (e.g., behavioral health comorbidities, stigma-related stress reactivity; Juster et al., 2019; Karatzias & Cloitre, 2019; Ressler, 2018).

Extensive sexual identity disparities in PTSD diagnosis and severity among women are likely due to SMW’s increased vulnerability to experiencing adverse events that are strongly predictive of PTSD, including dating and sexual violence (McCabe et al., 2022; Porsch et al., 2022). Sexual minority individuals, including SMW, also face stigma-related stressors (i.e., minority stress; Brooks, 1981; Meyer, 2003), including distal stigma-related experiences, such as discrimination, stemming from SMW’s marginalized social statuses (Brooks, 1981; Meyer, 2003; Pachankis et al., 2017; Page, Cerezo et al., 2021). Distal minority stressors can lead to negative psychological processes and compensatory behaviors, such as anticipated rejection, internalized stigma, and identity concealment, in an effort to prevent future stigma (Dyar et al., 2018; Meyer, 2003; Pachankis et al., 2020). Sexual minority people also engage in chronic threat vigilance due to inadequate social safety (e.g., unreliable social inclusion; Diamond & Alley, 2022). This chronic threat vigilance overlaps with complex posttraumatic outcomes common in individuals with early onset, multiple, and extended adverse experiences (Briere & Spinazzola, 2005). Sensitization to early and repeated trauma, chronic minority stress, and inadequate social safety may lower SMW’s threshold for tolerating future distress, contributing to lasting effects on stress reactivity and conferring risk for PTSD and comorbid behavioral health issues, including HD (Diamond & Alley, 2022; Helminen et al., 2021; Juster et al., 2019).

Vulnerable Subgroups of SMW at Increased Risk of PTSD

Differential vulnerability models suggest that some SMW, for example, those with “multi-minoritized identities” (Estrada et al., 2021) are more susceptible to stress sensitization (Hatzenbuehler et al., 2014). Nevertheless, research applying differential vulnerability models to examine potential subgroup differences in PTSD among SMW is sparse as studies tend to aggregate data across SMW subgroups (Hughes et al., 2020). Moreover, results from the few existing studies examining whether PTSD risk varies across SMW subgroups, for example, by race/ethnicity and sexual identity, are inconsistent (Krueger & Upchurch, 2019; McCabe et al., 2020; Ovrebo et al., 2018; Sigurvinsdottir & Ullman, 2016; Veldhuis et al., 2022). Some evidence indicates higher rates of PTSD among SMW of color relative to White SMW (Balsam et al., 2015; Sigurvinsdottir & Ullman, 2016) while others show a significantly higher prevalence of probable PTSD among White than Black and Latinx SMW (Veldhuis et al., 2022). Several studies have found similar rates of PTSD symptom severity between lesbian and bisexual women (Ovrebo et al., 2018; Sigurvinsdottir & Ulman, 2015); other findings suggest that past-year and lifetime prevalence of PTSD are higher among bisexual women (Evans-Polce & McCabe, 2020; Veldhuis et al., 2022). However, no meta-analysis has clarified SMW’s heterogeneity in probable PTSD risk and PTSD symptom severity levels, hindering the development and refinement of interventions that aim to reduce those disparities (Estrada et al., 2021).

SMW’s gender identities and presentations often transcend cisheteronormative gender roles (Halberstam, 2012; Levitt et al., 2012); many SMW identify as gender diverse (e.g., nonbinary; Dworkin et al., 2018; Page et al., 2021). In fact, mental and behavioral health risks associated with societal stress (e.g., heterosexism, sexism, cissexism) differ for SMW based on gender identity and expression (Batchelder et al., 2022; Puckett et al., 2016; Scheer et al., 2021). These intragroup disparities in mental health burdens facing SMW may be explained by higher rates of victimization and intersectional minority stressors (Bostwick et al., 2019; Cerezo & Ramirez, 2020; Dworkin et al., 2018; Sarno et al., 2021; Scheer, Clark, et al., 2022). No studies have reported PTSD diagnosis or symptom severity rates among SMW based on gender identity, limiting our understanding of potential within-group health disparities (Lehavot et al., 2012; Puckett et al., 2016). We aim to address this gap by contacting authors with requests for data on SMW’s risk of probable PTSD and PTSD symptom severity across gender identity.

Prevalence and Etiology of Comorbid PTSD and HD

Knowledge is also limited regarding the relationship between PTSD and co-occurring externalizing behaviors, including HD. While studies with the general U.S. population consistently find that PTSD and HD frequently co-occur, estimates vary widely (e.g., 9.8% to 61.3%, depending on trauma timing and type and cutoff scores used to denote PTSD and harmful drinking; Debell et al., 2014). Other findings suggest that PTSD and alcohol use disorders co-occur in 28% to 85% of treatment-seeking people (Ralevski et al., 2014; Wisco et al., 2016). Comorbid PTSD/HD estimates also vary among women, with some research suggesting that SMW are at heightened risk of comorbid PTSD/HD. For example, one study found that 60.5% of bisexual women in the sample met criteria for past-year alcohol use disorder and had a psychiatric comorbidity, including PTSD, relative to 44.6% of heterosexual women (Evans-Polce & McCabe, 2020). Other research suggests that 8.5%−17.6% of SMW report probable comorbid PTSD/HD (Helminen et al., 2021). PTSD also partly explains SMW’s (but not heterosexual women’s) increased risk of HD (Lehavot, Browne, et al., 2014). While longitudinal research is needed to determine whether PTSD is a proximal antecedent of SMW’s HD (Dworkin et al., 2020), SMW’s heightened risk of comorbid PTSD/HD highlights the need for integrated interventions (Flanagan et al., 2016) that attend to PTSD and HD in this population.

Several etiologic models (e.g., self-medication, mutual maintenance, PTSD susceptibility, negative reinforcement, shared vulnerability) have been tested to explain comorbid PTSD/HD in the general population and among SMW (Dworkin et al., 2020; Hawn, Cusack, et al., 2020; Kelley et al., 2018). Notably, the self-medication hypothesis (Khantzian, 1985), which suggests that alcohol may be used to seek momentary relief from distressing affective states and negative internal experiences, including PTSD symptoms, is the most widely accepted and rigorously tested (Hawn, Cusack, et al., 2020). The “drinking-to-cope” self-medication model postulates that individuals with PTSD may be more prone to developing problematic drinking behaviors, including HD, due to short-term negative reinforcement effects of alcohol (Hawn, Bountress, et al., 2020; Khantzian, 1985). Compared to PTSD and HD alone, comorbid PTSD/HD is associated with worse PTSD and alcohol treatment prognosis, increased alcohol craving, and greater functional impairment (Ralevski et al., 2014). Yet, a precise and systematic evaluation of SMW’s disproportionate risk of comorbid PTSD/HD has not been documented. Such findings are imperative for monitoring equity in service delivery and improving outcomes among SMW.

The Present Study

In this meta-analysis we aimed to examine (1) the proportion of SMW who meet criteria for probable PTSD; (2) mean PTSD symptom severity levels among SMW; (3) whether SMW are more likely than heterosexual women to meet criteria for probable PTSD; (4) whether SMW report greater mean PTSD symptom severity levels than heterosexual women; (5) whether SMW’s likelihood of meeting criteria for probable PTSD varies by race/ethnicity, sexual identity, and gender identity; (6) whether SMW’s mean PTSD symptom severity levels vary by race/ethnicity, sexual identity, and gender identity; (7) the proportion of SMW who meet criteria for probable comorbid PTSD/HD; and, (8) whether SMW are more likely than heterosexual women to meet criteria for probable comorbid PTSD/HD. These findings could yield important clinical insights into risk stratification across treatment settings and improve the lives of SMW, a recognized public health research priority group (National Institutes of Health Sexual and Gender Minority Research Coordinating Committee, 2015; Pérez-Stable, 2016).

Individuals who present with significant, clinical levels of distress but who do not meet full criteria for PTSD (i.e., subthreshold PTSD) report similar impairment as full PTSD (Morgan-López et al., 2020). Thus, we treated PTSD as a categorical diagnostic and a continuous symptom severity variable, aligned with clinical recommendations (Christ et al., 2021).

Methods

This meta-analysis followed guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Page et al., 2021) and was preregistered with PROSPERO (CRD42021233281).

Inclusion Criteria

Inclusion criteria for studies were: (1) reported in English, (2) published in a peer-reviewed journal, (3) presented empirical data on probable PTSD and/or PTSD symptom severity, and (4) presented findings specific to SMW. Furthermore, studies were required to include a search term for: (1) sexual identity, (2) gender, and (3) PTSD.

Within this study, SMW included individuals who identified as cisgender women, transgender men and women, nonbinary, and other diverse gender labels (e.g., genderqueer, agender), consistent with SMW-focused literature (Drabble et al., 2020; Page et al., 2021; Scheer, Clark, et al., 2022). Further, bisexual plus (bi+) included SMW who identified as bisexual, pansexual, queer, and those with attractions to more than one gender regardless of gender identity (Jhe et al., 2021; Mereish et al., 2017).

Search Strategy

We searched 11 electronic databases using search terms related to women, sexual identity, and PTSD. No publication date limit was imposed. Databases included Anthropology Plus, APA PsycArticles, APA PsycInfo, APA PsycTests, Applied Science & Technology, Health and Psychosocial Instruments, Humanities International Index, LGBTQ+ Source, PubMed, Social Work Abstracts, and Women’s Studies International. See the Supplemental Material for a full list of search terms and an example search in PubMed. Papers from databases were gathered until December 2022, and reference lists of relevant papers were searched to include additional papers. For studies that (1) gathered data on gender identity, sexual identity, and PTSD but did not report PTSD data for SMW separately in published articles and (2) gathered data on comorbid PTSD/HD but did not report this data for SMW separately in published articles, authors were contacted with requests for information and given a specific window to respond.

Study Selection and Data Extraction

All papers were gathered using search terms and databases specified previously, and duplicates were removed. Titles and abstracts were screened by independent coders (second, third, fifth, and sixth authors) to remove non-pertinent articles. A third coder (first author) rescreened titles and abstracts for which there were disagreements between the first two coders. Full texts of the remaining articles were reviewed by independent coders (second, fourth, fifth, and sixth authors) and inclusion and exclusion criteria were applied to exclude articles that did not meet criteria. Disagreements between coders for the full-text screening process were re-examined by the meta-analysis team to determine whether to keep the text.

Data for each study, including SMW sample size (and heterosexual women sample size, if applicable), sexual identity, and measures of probable PTSD and PTSD symptom severity, were extracted and are summarized in Appendix B. Empirical data were also extracted, including the proportion of samples that met criteria for probable PTSD, PTSD symptom severity scores, and the proportion of samples that met criteria for probable comorbid PTSD/HD. Data were extracted by independent coders (second, fourth, fifth, and sixth authors), and data were checked for accuracy by an independent coder (third author).

Data Analysis

Meta-analyses, moderation analyses, and publication bias analyses were conducted in R version 4.1.2 using the packages metafor (Viechtbauer, 2010) and meta (Balduzzi et al., 2019). To meta-analyze probable PTSD diagnosis and mean levels of PTSD symptom severity among SMW and between SMW and heterosexual women, when applicable, we used several different types of meta-analytic effect sizes (described below). All individual study effect sizes were inverse-variance weighted to account for sample size of each study, such that studies with larger samples were more heavily weighted in the meta-analyses (Lipsey & Wilson, 2001). An inclusion criterion (sample size ≥30) was added during the search process to reduce threats to internal validity and risks of sampling error (Lin, 2018). For each meta-analysis, only one effect size per population was used to meet the assumption of independence for meta-analysis data.

Probable PTSD and Mean Levels of PTSD Symptom Severity among SMW

Proportions of SMW meeting criteria for probable PTSD were extracted from each study. These proportions were then logit transformed prior to meta-analysis. Logit-transformed proportion effect sizes are recommended when between-study heterogeneity is important (Lipsey & Wilson, 2001). The logit-transformed proportion was used given that this study aimed to examine how methodological and population characteristics influenced overall effect sizes. Once logit-transformed proportions were combined, the aggregate effect size was then transformed back into a proportion for interpretation. Probable PTSD rates were interpreted based on standards for the measure(s) used (e.g., ≥33 on the PCL-5; Bovin et al., 2016). For studies that reported PTSD symptom severity using the same measure (e.g., PCL-5), mean symptom severity levels were calculated across these samples and used as an effect size (Lipsey & Wilson, 2001).

Potential Disparities in Probable PTSD and Mean Levels of PTSD Symptom Severity between SMW and Heterosexual Women

When studies included a heterosexual-women comparison group, separate proportions for SMW and heterosexual women who met criteria for probable PTSD were extracted. Odds ratios were calculated for each study from extracted proportions and log transformed before meta-analysis to center effect sizes around zero and make calculating standard errors easier (Lipsey & Wilson, 2001). Once logit-transformed odds ratios were combined, the aggregate effect size was then transformed back into an odds ratio for interpretation. For studies that reported PTSD symptom severity using a continuous measure, the standardized mean difference (SMD) was used to compare mean levels of PTSD symptom severity.

Probable PTSD and Mean Levels of PTSD Symptom Severity among SMW across Race/Ethnicity, Sexual Identity, and Gender Identity

We examined race/ethnicity, sexual identity, and gender identity as moderators of the proportion of SMW meeting criteria for probable PTSD. Proportions of probable PTSD among different SMW subgroups (i.e., racial/ethnic minority vs. White; bi+ vs. gay/lesbian; transgender or gender diverse vs. cisgender) were separated; odds ratios were calculated for each comparison and logit-transformed before being meta-analyzed. Once logit-transformed odds ratios were combined, the aggregate effect size was then transformed back into an odds ratio.

We also examined race/ethnicity, sexual identity, and gender identity as moderators of PTSD symptom severity among SMW. SMD was calculated for each subgroup comparison and meta-analyzed to report an overall SMD. The SMD was then used to compare PTSD symptom severity among SMW subgroups as it allowed us to analyze PTSD symptom severity across all relevant studies, regardless of the PTSD measure used (Lipsey & Wilson, 2001). We used small, medium, and large effect size designations from Cohen (1988) when interpreting the SMD.

Proportion of SMW with Probable Comorbid PTSD/HD and Disparities in Probable Comorbid PTSD/HD between SMW and Heterosexual Women

For studies that included measures of both PTSD and HD, proportions of SMW reporting comorbid PTSD/HD were extracted, if reported in the paper or provided by study authors separately. Proportions were then logit-transformed and meta-analyzed, and the aggregate effect size was transformed back into a proportion for interpretation. For studies that included proportions of both SMW and heterosexual women with comorbid PTSD/HD, we extracted proportions or requested proportions from authors. We then computed odds ratios for individual studies, logit transformed individual-study odds ratios, meta-analyzed logit-transformed odds ratios, and transformed the aggregate effect size back into an odds ratio for interpretation. HD rates were interpreted based on standards for the measure(s) used (i.e., ≥8 on the AUDIT, ≥3 on the AUDIT-C; and ≥2 on the AUDADIS-5; Babor et al., 2001; Bush, 1998; Grant et al., 2015).

Study Quality Assessment

Study quality was assessed by the fourth and seventh authors with the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional studies (National Heart, Lung, and Blood Institute, 2014), which examines study quality based on 14 criteria related to study planning, recruitment, measures used, and data analysis plan.

Publication Bias Assessment

We assessed publication bias by computing the Egger’s test for each meta-analysis with at least ten effect sizes (Egger et al., 1997). If the Egger’s test was significant, we used the trim- and-fill method (Duval & Tweedie, 2000) to examine the effect of publication bias on our meta-analytic results. Individual study effect sizes and standard errors were plotted to see if the plot forms a funnel shape around the aggregate effect size. After conducting a trim-and-fill analysis, a new overall mean effect size was calculated to determine the extent to which potentially missing studies influenced the original aggregate effect size.

Results

A total of 385 papers were identified during the search process (see Figure 1). Duplicates were removed (n = 185), and remaining titles and abstracts were screened. Next, 79 papers were removed and 132 papers remained for full-text analysis. After applying inclusion and exclusion criteria during full-text review, 45 papers remained and were included in the meta-analysis.

Figure 1.

Figure 1

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Flow Diagram for Including Studies in this Meta-Analysis

Meta-Analyses

SMW with Probable PTSD

Overall, a total of 43 studies reported probable PTSD rates among SMW (N = 17,395). Probable PTSD rates ranged from 7% to 87% across studies. After individual probability estimates were logit-transformed and meta-analyzed, the aggregate proportion of SMW meeting criteria for PTSD was 35% (95% CI = 29–42; p < .001; see Figure 2). The funnel plot for this meta-analysis did not demonstrate significant asymmetry with the Egger’s test (t(41) = 1.54, p = 0.13 (see Supplemental Material)).

Figure 2.

Figure 2

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Proportion of SMW with Probable PTSD

Note. SMW = sexual minority women; RE = random effects; CI = confidence interval; PTSD = posttraumatic stress disorder.

Mean Levels of PTSD Symptom Severity among SMW

Overall, there were enough measurements to meta-analyze symptom severity for two sets of measures (i.e., PCL-C/PCL-S and PCL-5; see Table S.1 in the Supplemental Material). Nine papers reported symptom severity using the PCL-C or the PCL-S, and the meta-analysis demonstrated an overall moderate symptom severity score of 35.08 (Range = 17–85; SD = 15.62). Ten papers reported symptom severity using the PCL-5, and the meta-analysis demonstrated an overall symptom severity score of 24.51, which is below the diagnostic cutoff of 33 (Range = 0–80; SD = 20.45).

Probable PTSD Rates between SMW and Heterosexual Women

SMW were more likely than heterosexual women to meet criteria for probable PTSD (OR = 2.15; 95% CI = 1.70–2.73; p < .001; Figure 3, panel A). The funnel plot for this meta-analysis did not demonstrate significant asymmetry with the Egger’s test (t(26) = −0.26, p = 0.80 (see Supplemental Material)).

Figure 3.

Figure 3

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Comparisons between SMW and Heterosexual Women for Proportion with Probable PTSD (A) and PTSD Symptom Severity (B)

Note. SMW = sexual minority women; HET = heterosexual women; SMD = standardized mean difference; RE = random effects; CI = confidence interval; PTSD = posttraumatic stress disorder. Positive SMD values in Panel B indicate higher symptom severity for SMW compared to heterosexual women.

Mean Levels of PTSD Symptom Severity between SMW and Heterosexual Women

SMW also reported greater mean levels of PTSD symptom severity than heterosexual women, with a medium effect size (SMD = 0.43; 95% CI = 0.21–0.65; p < .001; Figure 3, panel B). The funnel plot for this meta-analysis did not demonstrate significant asymmetry with the Egger’s test (t(24) = −0.22, p = 0.82 (see Supplemental Material)).

Demographic Moderators of Probable PTSD among SMW

SMW of color were more likely than White SMW to meet criteria for probable PTSD (OR = 1.19; 95% CI = 1.01–1.39; p = .03; Figure 4, panel A). Probable PTSD rates did not differ between bi+ and gay/lesbian participants (OR = 1.21; 95% CI = 0.997–1.48; p = .053; Figure 5, panel A). Transgender and gender diverse people were more likely than cisgender SMW to meet criteria for probable PTSD (OR = 1.75; 95% CI = 1.22–2.50; p = .002; Figure 6, panel A).

Figure 4.

Figure 4

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Comparisons between SMW of Color and White SMW for Proportion with Probable PTSD (A) and PTSD Symptom Severity (B)

Note. SMW = sexual minority women; POC = sexual minority women of color; SMD = standardized mean difference; RE = random effects; CI = confidence interval; PTSD = posttraumatic stress disorder. Positive SMD values in Panel B indicate higher symptom severity for SMW of color compared to White SMW.

Figure 5.

Figure 5

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Comparisons between Bi+ SMW and Gay/Lesbian SMW for Proportion with Probable PTSD (A) and PTSD Symptom Severity (B)

Note. SMW = sexual minority women; SMD = standardized mean difference; RE = random effects; CI = confidence interval; PTSD = posttraumatic stress disorder. Positive SMD values in Panel B indicate higher symptom severity for bi+ SMW compared to gay/lesbian SMW.

Figure 6.

Figure 6

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Comparisons between Transgender and Gender Diverse People and Cisgender SMW for Proportion with Probable PTSD (A) and PTSD Symptom Severity (B)

Note. SMW = sexual minority women; SMD = standardized mean difference; RE = random effects; CI = confidence interval; PTSD = posttraumatic stress disorder. Positive SMD values in Panel B indicate higher symptom severity for transgender and gender diverse people compared to cisgender SMW.

The funnel plot for the meta-analysis examining differences across race/ethnicity (t(21) = 2.31, p = .03) and sexual identity (t(21) = −3.21, p = .004) (i.e., race/ethnicity and sexual identity as demographic moderators of probable PTSD among SMW) demonstrated significant asymmetry with Egger’s tests (see Figure S.2 in the Supplemental Material). Using the trim-and- fill method to correct for publication bias, the aggregate effect size comparing probable PTSD between SMW of color and White SMW became non-significant (OR = 1.06; 95% CI = 0.88–1.27), and the aggregate effect size comparing probable PTSD between bi+ and gay/lesbian SMW became significant (OR = 1.44; 95% CI = 1.20–1.72), with bi+ SMW being more likely to report probable PTSD. The funnel plot for the meta-analysis examining differences in probable PTSD across gender identity did not demonstrate significant asymmetry with the Egger’s test (t(11) = 0.13, p = .90).

Demographic Moderators of Mean Levels of PTSD Symptom Severity among SMW

SMW of color reported greater mean levels of PTSD symptom severity than White SMW with a small effect size (SMD = 0.18, 95% CI = 0.10–0.25; p < .001; Figure 4, panel B). Bi+ women reported greater mean levels of PTSD symptom severity than gay/lesbian SMW with a small effect size (SMD = 0.10, 95% CI = 0.03–0.17; p = .004; Figure 5, panel B). Transgender and gender diverse people reported greater levels of PTSD symptom severity than cisgender SMW with a medium effect size (SMD = 0.43, 95% CI = 0.07–0.78; p = .02; Figure 6, panel B).

The funnel plot for the meta-analysis examining differences across race/ethnicity, t(15) = −0.32, p = .76; sexual identity, t(18) = −0.32, p = .75; and gender identity, t(8) = 0.16, p = .87 (i.e., race/ethnicity, sexual identity, and gender identity as demographic moderators of mean levels of PTSD symptom severity among SMW), did not demonstrate significant asymmetry with Egger’s tests (see Supplemental Material).

Probable Comorbid PTSD/HD among SMW

Overall, six studies reported probable PTSD/HD comorbidity among SMW. After individual proportions were logit-transformed and meta-analyzed, the aggregate proportion of SMW who met criteria for probable comorbid PTSD/HD was 17% (95% CI = 10–28; p < .001) (see Figure S.1 in the Supplemental Material).

Probable Comorbid PTSD/HD between SMW and Heterosexual Women

Five studies included a heterosexual comparison group. In these, SMW were more likely than heterosexual women to meet criteria for probable comorbid PTSD/HD (OR = 4.51; 95% CI = 1.49–13.62; p = .008; see Figure 7).

Figure 7.

Figure 7

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Comparisons between SMW and Heterosexual Women for Proportion with Probable PTSD/HD

Note. SMW = sexual minority women; HET = heterosexual women; PTSD = posttraumatic stress disorder; HD = hazardous drinking.

Study Quality Results

The study quality assessment is detailed in the Supplemental Material. The primary study quality concerns identified in this body of literature were related to the use of cross-sectional designs and lack of justification for sample size with a power analysis.

Discussion

Responding to calls for research to identify individuals at greatest risk of developing PTSD (Christ et al., 2021), this meta-analysis yielded the most current and robust estimates of SMW’s disproportionate risk of probable PTSD and PTSD symptom severity compared to heterosexual women. Specifically, SMW were more than twice as likely as heterosexual women to meet criteria for probable PTSD. SMW also reported greater mean levels of PTSD symptom severity. Results further clarified SMW’s distinct risk of probable PTSD and PTSD symptom severity, particularly among SMW of color, transgender and gender diverse people, and bi+ SMW. We also derived estimates of SMW’s disproportionate risk of probable comorbid PTSD/HD relative to heterosexual women. SMW were more than four times as likely as heterosexual women to meet criteria for probable comorbid PTSD/HD.

These findings underscore the need to assess and monitor PTSD and comorbid PTSD/HD among SMW and rapidly connect at-risk SMW to evidence-based, scalable interventions targeting these highly prevalent mental and behavioral health conditions. Our results indicated markedly elevated rates of probable PTSD among SMW, which may be due partly to the increased likelihood of experiencing early, severe, and multiple forms of trauma (Porsch et al., 2022; Salim et al., 2022). In addition, prior evidence suggests that inadequate social support, help-seeking barriers, and self-blame are associated with SMW’s increased risk of negative trauma sequelae, including PTSD (Salim et al., 2022; Sigurvinsdottir & Ullman, 2016). Moreover, SMW face minority-specific stressors (Brooks, 1981; Dyar et al., 2018; Meyer, 2003; Pachankis et al., 2017, 2020), chronic-threat vigilance, and threats to social safety (Diamond & Alley, 2022). These cumulative life stressors may contribute to prolonged and sensitized stress responses, such as blunted cortisol levels, lowering thresholds for tolerating threats and contributing to PTSD risk among SMW (Diamond & Alley, 2022; Juster et al., 2019).

We also found that SMW reported significantly greater PTSD symptom severity than heterosexual women. Differences in PTSD symptom severity levels between SMW and heterosexual women were consistent across measures assessing Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, DSM-5) criteria. These findings are notable given that greater PTSD symptom severity, even among those who do not meet criteria for PTSD (i.e., subthreshold PTSD), is associated with greater functional impairment, alcohol use disorders, and other psychiatric comorbidities (Morgan-López et al., 2020). If left untreated, 20% of those with subthreshold PTSD developed full PTSD within two years (Breslau et al., 2004). As such, early intervention for those with subthreshold PTSD is important, especially for SMW.

Consistent with some prior research (Balsam et al., 2015; Cerezo & Ramirez, 2020; Evans-Polce & McCabe, 2020; Sigurvinsdottir & Ullman, 2016; Veldhuis et al., 2022), this study found that SMW of color, and transgender and gender diverse people were more likely to meet criteria for probable PTSD and report greater PTSD symptom severity levels than White SMW and cisgender SMW, respectively. Bi+ participants also reported greater mean levels of PTSD symptom severity than gay/lesbian SMW. These intragroup disparities in PTSD may be explained by greater exposure to traumatic events that are highly predictive of PTSD, such as assaultive interpersonal violence and “corrective rape” (Pittman et al., 2022; Porsch et al., 2022). Moreover, cumulative adversity may contribute to fewer coping resources that are integral to managing stress among SMW of color, transgender and gender diverse people, and bi+ women (Batchelder et al., 2022; Cerezo & Ramirez, 2020; Jhe et al., 2021; Page et al., 2021).

Other factors compounding risk of PTSD among SMW of color, transgender and gender diverse people, and bi+ women are intersectional minority stressors, such as gendered racism and monosexism (Cerezo & Ramirez, 2020; Dworkin et al., 2018; Jackson et al., 2021; Sarno et al., 2021). For example, Black women are sometimes viewed as oversexualized, stoic, and sexually deviant; these stereotypes increase risk of sexual assault and negatively impact stress and coping (Leath et al., 2022). For SMW who identify as transgender or gender diverse, experiences of sexism might be experienced as incongruent or dysphoric (Scheer et al., 2021), potentially exacerbating mental health issues, such as PTSD. Future research should consider whether higher rates of sexual and gender identity outness among SMW who identify as transgender or gender diverse predict greater adversity and subsequent PTSD (Pachankis et al., 2020). Furthermore, SMW who face multiple forms of social and systemic subordination based on unique combinations of social identities (i.e., negative intersectional experiences; Jackson et al., 2021) also report difficulty accessing adequate services and being dissatisfied with treatment (Scheer, Batchelder, et al., 2022), impeding timely intervention (Livingston et al., 2020).

Notably, meta-analyses examining differences in probable PTSD between racial/ethnic SMW and White SMW, and between bi+ SMW and gay/lesbian SMW demonstrated some publication bias. When including potentially missing effect sizes using the trim-and-fill method, we found inconsistent patterns of effect sizes for race/ethnicity and sexual identity comparisons. After correcting for bias, SMW’s rates of probable PTSD no longer varied across race/ethnicity but did vary across sexual identity. Publication bias did not seem evident in other analyses.

Our findings also provide compelling evidence of frequent comorbidity between PTSD and HD among SMW; 17% met criteria for probable comorbid PTSD/HD. This estimate is higher than previous research using a representative sample of sexual minority people (7.4%; Simpson et al., 2019). In the general U.S. population, estimates of comorbid PTSD/HD vary widely (9.8% to 61.3%; Debell et al., 2014). Strikingly, we also found that SMW were more than four times as likely as heterosexual women to meet criteria for probable comorbid PTSD/HD. Extant research in the general population and among SMW show robust associations between PTSD and HD (Dworkin et al., 2020; Helminen et al., 2021; Hien et al., 2021). According to the self-medication hypothesis (Khantzian, 1985) and consistent with social learning theory (Bandura, 1977), alcohol is used to reduce distressing threat-related symptoms (Patel et al., 2022) and interoceptive cues, such as affect and cognitions (Hawn et al., 2020). Indeed, drinking-to-cope can increase risk of re-victimization and contribute to greater incidence and persistence of PTSD and HD by reducing the ability to accurately detect threat (Kaysen et al., 2017; Steele & Josephs, 1990); diminishing fear extinction learning, leading to dysregulated arousal responses; and, disrupting habituation to trauma-related memory reconsolidation and cues (Straus et al., 2022). Additional work is needed to clarify processes central to the etiology of PTSD/HD among SMW (e.g., permissive beliefs, instrumental thoughts, memory processing, cue reactivity, social influence risk factors; Dyar & Kaysen, 2022; Palmisano et al., 2022) given their unique drinking norms, expectancies, and motives (Ehlke et al., 2022; Hughes et al., 2020).

Clinical and Future Research Implications

While SMW are more likely than heterosexual women to seek mental health treatment (Cochran et al., 2003)—likely because of greater burden of health risks (Evans-Polce & McCabe, 2020; Hughes et al., 2020; Pharr et al., 2019)—they are also more likely to delay needed care and miss appointments because of access barriers, including being uninsured, experiencing and anticipating stigma, and feeling dissatisfied with treatment (Batchelder et al., 2021; Lynch et al., 2021; Pachankis et al., 2021; Scheer, Batchelder, et al., 2022). SMW may seek help when facing severe symptoms and thus may have increased vulnerability to acute PTSD- and alcohol-attributable harm, including death (Lehavot et al., 2017; Livingston et al., 2022; Lynch et al., 2021). Further, nearly 75% of individuals with comorbid PTSD/HD do not seek treatment (Blanco et al., 2013); among those who do, attrition is high (Roberts et al., 2015). Thus, providers have less time to identify and treat SMW with PTSD/HD (Livingston et al., 2022).

SMW may not benefit from existing interventions to the same extent as heterosexual women (Beard et al., 2017; Pachankis et al., 2022). Current evidence-based treatment models targeting PTSD and HD (e.g., prolonged exposure, motivational interviewing) do not explicitly consider SMW’s comorbid health needs, barriers to treatment access and retention in care, or unique risk factors of PTSD and HD, such as enacted, anticipated, and internalized stigma (Pachankis et al., 2022; Scheer, Clark, et al., 2022). In fact, <1% of alcohol interventions have examined sexual identity differences and <18% of substance use facilities in the U.S. have sexual minority-specific programming (Helminen et al., 2022; Williams & Fish, 2020).

Findings from this meta-analysis underscore the importance of effectively screening SMW for PTSD and comorbid PTSD/HD. It is critical for providers to center SMW’s needs and experiences when screening for PTSD and comorbid PTSD/HD, for example, by gathering information about whether SMW’s PTSD-related disruptions in cognition and mood are exacerbated by salient stigma-related experiences, thoughts, and beliefs (Livingston et al., 2020). When delivering treatment involving exposure to trauma stimuli, clinicians should consider safety concerns or reasons for feared consequences that might be salient for SMW, including ongoing violence exposure, family rejection, and likelihood of identity-related assault (Scheer, Clark, et al., 2022). Providers working from a cognitive behavioral therapy (CBT) framework might assess SMW-specific high-risk situations leading to permissive beliefs about using alcohol to cope with stigma- or trauma-related distress (Hien et al., 2021). Clinicians might also assess for PTSD and comorbid PTSD/HD etiologic and maintenance mechanisms (e.g., under- vs. over-modulating negative affect) to improve diagnostic clarity in PTSD symptoms, identify treatment needs, match SMW to personalized treatment, and predict treatment response (Ressler, 2018).

Results from this meta-analysis highlight the importance of increasing access to treatment targeting PTSD and comorbid PTSD/HD, reducing dropout rates among treatment seekers, and improving treatment outcomes among SMW. Recent research suggests that lowering structural stigma, such as systemic discrimination and inadequate government funding, promotes availability of tailored programming for sexual and gender minority people (Cascalheira et al., 2022). Other research has shown that motivational enhancement therapy (MET) increases treatment attendance and retention among individuals seeking treatment targeting PTSD, substance use disorders, and comorbid PTSD/substance use disorders (Kaysen et al., 2022). Moreover, training clinicians to incorporate cultural humility approaches (i.e., accepting feedback about how one’s identities and experiences may bias awareness of clients’ identities and experiences and repairing cultural ruptures within therapeutic relationships; Gonzalez et al., 2021) has led to improved treatment engagement among minoritized clients (Hook et al., 2013). Future research should extend prior research by examining whether training providers in applying cultural humility frameworks and employing culturally tailored MET could lead to increases in SMW’s initiation and retention in treatment targeting PTSD and PTSD/HD.

Recent evidence suggests preliminary efficacy of integrated treatments that combine trauma-focused therapy with cognitive-behavioral approaches to treating substance use disorders (Flanagan et al., 2016). For instance, one meta-analysis (Foa et al., 2007) found that prolonged exposure for PTSD delivered alongside relapse prevention therapy for substance use disorders resulted in greater reductions in PTSD symptoms and substance misuse compared to non-trauma-focused interventions (e.g., mutual-aid groups). Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE; Back et al., 2014) represents one promising integrated CBT-based treatment that has demonstrated initial efficacy (compared to relapse prevention for substance use disorders and an active monitoring control group) in reducing PTSD symptom severity and frequency of recent primary substance use (Persson et al., 2017; Ruglass et al., 2017). To our knowledge, only one known study has demonstrated efficacy of COPE in reducing women’s PTSD and HD severity (Persson et al., 2017). None of this research is specific to SMW with comorbid PTSD/HD and no current evidence-based integrated treatment has been adapted for SMW with PTSD and HD. Nevertheless, meta-analytic findings indicate that culturally adapted interventions produce better outcomes than other conditions, including non-culturally adapted treatments (Hall et al., 2016). Thus, research should develop evidence-based, culturally adapted, and scalable treatments for SMW with probable PTSD, who report severe PTSD symptoms, and with probable comorbid PTSD/HD.

Limitations of this Meta-Analysis

Several limitations of this meta-analysis should be noted. First, most studies used scales measuring past-month PTSD, however a few studies used past-week, past-year, and lifetime timeframes. Research is needed to determine potential sexual identity-related disparities in probable PTSD across various impairment and functioning levels to refine our understanding of PTSD in this population (Sullivan et al., 2016). Moreover, despite heterogeneity in clinical presentations of PTSD (Neria, 2021), the present study did not account for variation in symptom weighting, such as whether symptom clusters (e.g., negative alterations in cognitions and mood vs. marked alteration in arousal and reactivity) may be more heavily connected to PTSD symptom severity in SMW than in heterosexual women or across certain SMW subgroups (Morgan-López et al., 2020). Examining symptom cluster and relevance, such as frequency and intensity, could increase accuracy in using dimensional approaches to examine PTSD disparities among SMW and between SMW and heterosexual women (Ruglass et al., 2020). Attending to heterogeneity in PTSD symptom clusters could improve treatment efficacy, track temporal changes in clinical outcomes, and provide greater diagnostic specificity for PTSD (Neria, 2021). Given inclusion criteria for this meta-analysis, results may overrepresent SMW with PTSD and HD. Thus, future studies should identify the population prevalence of probable PTSD, PTSD symptom severity, and comorbid PTSD/HD among SMW.

Moreover, SMW subgroup differences in PTSD were not examined across other general sociodemographic characteristics, such as income, age, and location, and those specific to SMW (e.g., outness). Further, studies did not assess or report demographic characteristics (e.g., race/ethnicity, sexual identity, gender identity) in consistent ways. Finally, selection bias should be considered (Ahmed et al., 2012). For example, papers from other countries may not have been identified given the English-language criterion of this study. Future work should consider potential cultural differences in studies of PTSD and comorbid PTSD/HD disparities among women and transgender populations. Research is also needed to clarify sexual identity-related disparities in specific PTSD symptoms (e.g., alterations in cognition and mood, persistent avoidance) and comorbid alcohol use disorder and other drug use disorders, such as opioid use disorder, among women (Schuler et al., 2019). Finally, we also did not examine findings from unpublished work, potentially inflating associations found in the present study.

Conclusion

The current meta-analysis clarifies the magnitude of disparities in probable PTSD, PTSD symptom severity, and comorbid PTSD/HD between SMW and heterosexual women. Findings also provide robust evidence that SMW of color, transgender and gender diverse people, and bi+ women are at greatest risk of probable PTSD, PTSD symptom severity, and probable comorbid PTSD/HD. Results emphasize the importance of improving diagnostic assessment of trauma-related sequalae and examining mechanisms influencing the etiology and maintenance of PTSD and comorbid PTSD/HD among SMW. Further, these findings underscore the need to develop, disseminate, and implement culturally sensitive, integrated treatments to increase treatment utilization and retention and reduce risk of PTSD and co-occurring HD among SMW.

Supplementary Material

1

Highlights.

  • SMW were more likely than heterosexual women to meet criteria for probable PTSD.

  • SMW reported significantly greater PTSD symptom severity than heterosexual women.

  • Probable PTSD rates and PTSD symptom severity levels varied across SMW subgroups.

  • Among SMW, 17% met criteria for probable comorbid PTSD/HD.

  • Rates of probable comorbid PTSD/HD were higher among SMW than heterosexual women.

Role of Funding Sources

Jillian R. Scheer acknowledges support from the National Institute on Alcohol Abuse and Alcoholism, K01AA028239–01A1. Cory Cascalheira acknowledges support as a National Institutes of Health RISE Fellow, R25GM061222. Abigail Batchelder acknowledges support from the National Institute on Drug Abuse, K23DA043418. Tonda L. Hughes is supported by funding from NIAAA (R01AA013328, R01AA029088, and R01AA029088). Information in this report is the authors’ own and does not represent the views of the funders, including the National Institutes of Health.

Footnotes

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Conflict of Interest

All authors declare that they have no conflicts of interest.

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