A Scoping Review on the Role of Sexual Orientation and Gender Identity Microaggressions in Substance Use

Abstract

Objectives

Disparities in substance use patterns and outcomes are evident among sexual and gender minority groups. Sexual orientation and gender identity (SOGI) microaggression, or the subtle forms of aggression experienced by lesbian, gay, bisexual, transgender, gender non-conforming/non-binary, and gender diverse individuals, has recently been explored as a mechanism that leads to negative adjustment outcomes, including substance use. In this study we examined extant literature on the association between SOGI microaggression and substance use, and the intermediary factors that mediate or moderate this relationship.

Method

Scoping review method was used to systematically map the literature base using database aggregators (e.g., Scopus, EBSCO) following the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines.

Results

We found that SOGI microaggression is positively associated with substance use and negative consequences, and this relationship is mediated or moderated by motivational, relational, and identity processes.

Conclusion

These findings suggest the need to consider microaggression experience when working with clients of diverse sexual and gender identities. Likewise, additional studies are needed on other intermediary factors and effects of microaggression on substances other than alcohol. Most importantly, this study underscores the need for understanding the link between microaggression and substance use in greater efforts to promote sexual well-being and building competence in fostering the trifecta of sexual health, sexual rights, and sexual pleasure.

Sexual and gender minority (SGM) people, which include persons who are lesbian (L), gay (G), bisexual (B), genderqueer (Q), transgender (T), non-binary (NB), gender non-conforming (GNC) or gender diverse (GD), show higher prevalence of substance use compared to their cisgender or heterosexual counterparts (Hughto et al., 2021; King et al., 2008; Ruppert et al., 2021; SAMHSA, 2020). Compared to the general population, risk for substance use problems is 1.5 times higher among LGB (King et al., 2008) and 1.6 times among TGNC/NB/GD individuals (Hughto et al., 2021; SAMHSA, 2018). LGB people struggle with substance use problems (SAMHSA, 2020). Among LGB adults diagnosed with substance use disorder, 51.6% struggled with illicit drugs, 64.6% struggled with alcohol, and 16.2% struggled with both (SAMHSA, 2020). Likewise, while prevalence rates vary across TGNC/NB/GD subgroups, likelihood of substance use problems in these populations are greater compared to cisgender people (Ruppert et al., 2021; Hughto et al., 2021).

Although numerous studies (e.g., Amadio, 2006; Cochran, et al. 2007; Kidd et al., 2022; Lee et al., 2016; Slater et al., 2017; and models (e.g., minority stress, Meyer, 1995, 2003; developmental, Parent et al., 2019; feminist-embodied, Hunt et al., 2015; Ettorre, 2007; intersectionality, Mereish et al., 2014) have addressed substance use among SGM individuals, sexual orientation (SO) and gender identity (GI) microaggressions (subtle forms of aggression experienced by SGMs; Nadal, Issa, et al., 2011; Nadal, Wong, et al., 2011) has only recently been examined as another potential mechanism in this process (e.g., Dyar, Newcomb, et al., 2019; Livingston et al., 2017; Nadal et al., 2016; Woodford et al., 2012; Ylioja et al., 2018). Given the nascency of the microaggression literature as applied in substance use research, we used a scoping review to examine the extent of research on the role of SOGI microaggressions on substance use. While prior knowledge syntheses on microaggressions exist (Fisher et al., 2019; Lui & Quezada, 2019; Nadal, 2019; Nadal et al., 2016), we are not aware of any that specifically focused on SOGI microaggressions and substance use.

Research indicates that blatant forms of SOGI discrimination and violence are associated with substance use and related problems (Cochran et al., 2007; Gilbert & Zemore, 2016; Slater et al., 2017). Only recently have more subtle forms of discriminatory behavior (i.e., microaggressions) been thoroughly examined (see reviews by Lui & Quezada, 2019 and Nadal et al., 2016). Evidence linking microaggressions to psychological outcomes points toward the plausible link between SOGI microaggressions and substance use.

Microaggressions refer to brief, commonplace, and subtle forms of slurs or slights experienced by minority groups (Sue, Bucceri, et al., 2007; Sue, Capodilupo, et al., 2007). Initially defined as “white put-downs, done in an automatic, preconscious, or unconscious fashion” (Pierce, 1974, p. 515) observed in race-/ethnicity-specific context, the concept expanded its application to experiences of other marginalized people (i.e., women; LGBs, TGNC/NB/GD, people with mental health conditions; Nadal et al., 2015; Sue, 2010; Sue, Bucceri, et al., 2007; Sue, Capodilupo, et al., 2007). Microaggressions manifest in three ways: verbal, nonverbal, or environmental (Sue, 2010; Sue, Bucceri, et al., 2007; Sue, Capodilupo, et al., 2007). It also has three main forms: microassaults (explicit or purposeful; derogatory actions/comments toward marginalized groups), microinsults (often unconscious; tearing down heritage or identity), and microinvalidations (often unconscious; negating lived experiences; Nadal et al.,2017; Nadal, Issa, et al., 2011; Nadal, Wong, et al., 2011; Sue, 2010).

People who do not specifically conform to traditional gender roles and heterosexist expectations experience SOGI microaggressions. They manifest through use of heterosexist/transphobic language, endorsement of hetero/gender normative culture, assumption of a universal LGBT experience, exoticization, disapproval of the LGBT experience, denial of individual or societal heterosexism/transphobia or assumption of sexual abnormality (Nadal et al., 2010; Nadal, Issa, et al., 2011; Nadal, Wong, et al., 2011).

Since microaggressions are often covert and subtle, its impact may be ambiguous (Crocker et al., 1991). However, like blatant forms of aggression, microaggressions are related to minority stress (Dyar, Newcomb, et al., 2019, 2020; Meyer, 2003), which links to variables that are implicated in substance use such as mental health (King et al., 2008; Wilson & Cariola, 2020), internalized heterosexism (Kuerbis et al., 2017; Newcomb & Mustanski, 2010), and other health behaviors (Clayton et al., 2019).

Having a thorough understanding of the link between microaggressions and substance use among sexual and gender minorities, as well as factors involved in such association, is crucial in fostering sexual health and well-being. Sexual health necessitates a “positive approach to human sexuality and an understanding of the complex factors that shape human sexual behavior” (World Health Organization [WHO], 2006, p. 1). On one hand, microaggressions are viewed to be perpetuated by societal attitudes and norms which take a toll on individuals whose sexual orientation and gender identities do not conform to cis-heteronormative expectations (Sue & Spanierman, 2020). On the other hand, extant literature has implicated substance use in both general and gender-related violence (Giles et al., 2009; Leonard & Quigley, 2017, Eckhardt et al., 2015) as well as sexual health risks (Clayton et al., 2019; Poulios et al., 2022; Slavin et al., 2021). Negative interpretations of sexual diversity and the prevalence of discrimination and violence hamper healthy and equitable expression of gender and sexual identities and serve as barriers to sexual health and rights (Ford et al., 2021; World Association for Sexual Health [WAS], 2021).

The present study

The overarching aim for this paper is to map existing evidence on the link between SOGI microaggressions and substance use via a scoping review method. Scoping review is the most appropriate review methodology given the nascency of the topic (Grant & Booth, 2009). The first aim for this paper is to document the nature and magnitude of association between SOGI microaggressions and substance use. The second aim for this paper is to examine what prior research is available on mechanistic and intermediary factors that moderate or mediate the SOGI microaggressions-substance use relationship.

Method

Scoping review design

This study utilized scoping review to map and assess the breadth of empirical research on the relationship between SOGI microaggression and substance use (Levac et al., 2010). The decision to conduct a scoping review was due to the nascency of the research on the association between SOGI microaggression and substance use. The paucity of studies on this topic makes it challenging to implement a systematic and meta-analytic review (e.g., Akobeng, 2005; Catelan et al., 2017; Reis et al., 2021; Tyndall et al., 2022). Similarly, a scoping review is most suited in doing preliminary assessment of evidence in an emerging research area amid lack of empirical literature (Catelan et al., 2017; Grant & Booth, 2009).

We based our protocol on the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Scoping Review (PRISMA-ScR; Tricco et al., 2018; Levac et al., 2010; Peters et al., 2015, 2020). Figure 1 presents the PRISMA-ScR flowchart that summarizes the process in this scoping review.

Figure 1.

Study flow of the scoping review based on PRISMA ScR framework.

We conducted literature searches on database aggregators (i.e., Scopus and EBSCO) from September to December 2021, using adapted and modified search strings from previous studies (Kidd et al., 2022; Gartner et al., 2020; see supplementary materials for search strings used for this study).

Eligibility criteria and article selection

Scholarly documents (i.e., journal article, dissertation) were considered eligible when they describe the link between SOGI microaggressions and substance use among SGMs. Studies were included when they had: (a) sexual and/or gender diverse participants, (b) SOGI microaggressions as predictor, and (c) substance use as an outcome. Since we did not want to exclude potential eligible studies, we broadly defined substance use outcomes as consumption of any licit or illicit substances, whether in the past or present, and related problems or consequences arising from such use. Hence, we included in our search terms a wide array of behaviors related to these substance (e.g., binge, hazardous use, problematic use, related consequences).

Since SOGI microaggressions have some conceptual link with constructs such as sexual prejudice, heterosexism, or bi-/homo-/trans-negativity, we included studies exploring these constructs when they also used a scale measuring SOGI microaggressions. We consulted prior reviews (Fisher et al., 2019; Lui & Quezada, 2019) for the list of these SOGI microaggressions scales. In these prior reviews, scales were included if they fully or partially measure SOGI microaggressions (Fisher et al., 2019) or if they were operationalized as measuring microaggressions (Lui & Quezada, 2019).

Conversely, we excluded studies: (a) investigating other forms of microaggressions (e.g., racial/ethnic) and blatant violence or victimization, (b) using qualitative methods, or (c) when measures used did not disaggregate microaggressions from more blatant forms of violence or discrimination. We did not apply limitations on date of publication or research locale. This selection process yielded a total of 19 eligible studies for review.

Data charting process and synthesis of results

We charted the data by characterizing studies according to author, year of publication, source, research design, sampling and recruitment procedures, participant characteristics, SOGI microaggression measures used, and substance use outcome measures. We also charted findings on bivariate and multivariate analyses done, as well as mediation or moderation models tested.

Results

Search flow

Figure 1 illustrates the steps of the search process in this scoping review. An initial search identified 302 records from electronic database aggregators (i.e., Scopus and EBSCHO databases) and 104 records from the bibliographic section of previous studies on SOGI microaggression or substance use among LGBTQ populations (Fisher et al., 2019; Lui & Quezada, 2019; Nadal, 2019; Nadal et al., 2016, 2017). Of these 406 total records, 65 duplicates were removed. The remaining 341 records were subjected to title and abstract screening. In the screening stage, 293 records which did not meet the study’s inclusion criteria were excluded, yielding a total of 48 eligible studies. Based on the full-text review of the eligible studies, 29 records were further excluded since they did not explicitly measure the relationship between SOGI microaggression and substance use outcomes (e.g., did not measure substance use outcomes, focused on blatant forms of discrimination instead of microaggressions). A total of 19 studies comprised this review.

Study characteristics

Tables 1 and 2 present a summary of the characteristics of studies on SOGI microaggressions and substance use. Eighteen studies were published after Nadal, et al.’s (Nadal, Issa, et al., 2011; Nadal, Wong, et al., 2011) earlier works on SOGI microaggressions; 16 of which were only published in the last five years, indicating growing attention to this subject. Eleven were published in diversity-focused journals, four in aggression or other psychology journals, while four in addiction-related journals.

Table 1.

Data characteristics.

Characteristics	No. of studies
Publication year
2006–2011	1
2012–2016	2
2017–2021	16
Source
Diversity-focused journal
Psychology of Sexual Orientation and Gender Diversity	2
Journal of Bisexuality	2
Journal of Gay and Lesbian Mental Health	2
Cultural Diversity and Ethnic Minority Psychology	1
Journal of Homosexuality	1
Journal of LGBT Youth	1
Sex Roles	1
Psychology of Men and Masculinities	1
Aggression-focused journal
Psychology of Violence	1
Addiction-focused journal
Psychology of Addictive Behaviors	1
Drug and Alcohol Dependence	1
Substance Abuse and Rehabilitation	1
Nicotine and Tobacco Research	1
Clinical psychology journal
Clinical Psychological Sciences	1
Journal of Consulting and Clinical Psychology	2
Research Design
Cross-sectional	14
Intensive longitudinal (i.e., ecological momentary assessment, daily diary study)	2
Longitudinal	2
Dyadic	1
Sampling and Recruitment Procedure*
Purposive sampling	19
Community-based (including online communities)	14
Community-based organizations	6
Online communities (e.g., social media, list serves)	10
Amazon MTurk	2
University-based	6
Country of Study
United States	19
SOGI microaggression measure used*
Anti-Bisexual Experiences Scale (ABES; Brewster & Moradi, 2010; Dyar, Feinstein, et al., 2019)	4
Sexual Orientation Microaggression Inventory (SOMI; Swann, et al, 2016)	4
LGBQ Microaggressions on Campus Scale (Woodford et al., 2015)	2
Bisexual Microaggression and Microaffirmation Scales for Women (BMMSW; Flanders et al., 2019)	2
Homonegative Microaggression Scale (HMS; Wright & Wegner, 2012)	2
People of Color Microaggressions Scale (LGBT-PCMS; Balsam et al., 2011	1
Everyday Discrimination Scale (Williams, et al, 1997) microaggression category
Sexual Orientation Microaggressions Measure (Scharer & Taylor, 2018)	1
Heterosexist Harassment of Workplace Heterosexist Experiences Questionnaire (WHEQ; Waldo 1999)	1
Microaggression items (“daily upsets”) adapted from Williams et al., 1997; Swim et al. 2009; Wright & Wegner, 2012; Nadal, 2013	1
Items as “I heard someone say ‘that’s so gay’ to describe something as negative, stupid, or uncool” and “I heard the phrase ‘no homo.’”	1
Subtle discrimination (personal and ambient incivility)	1
Substance use variables studied*
Alcohol	18
Any use (Y/N)	4
Hazardous use	7
Problematic use	1
Binge drinking	1
Severity	3
Quantity	2
Frequency	1
Consequences	4
Marijuana	5
Any use (Y/N)	3
Hazardous use	4
Smoking/nicotine-products	3
Any use (Y/N)	2
Current smoker (Y/N)	1
Other drugs (e.g., illicit, non-prescribed use)	6
Use (Y/N)	2
Use and/or abuse	2
Problematic use	1
Frequency	1
Consequences	1

*Frequencies are not mutually exclusive.

Table 2.

Summary of studies included in the scoping review.

Study	Journal	Research design	Sampling and recruitment procedure	Participant characteristics
				N	Mage (SD)	Race/ethnicity	Gender identity	Sexual orientation
Bostwick et al. (2021)	Journal of Bisexuality	Cross-sectional	Purposive, community-based	112	34.7 (9.7)	W = 43% B/AA =26% H/L = 16% B/M = 15%	CW = 100%	B = 100.0%
Ehlke et al. (2022)	Psychology of Addictive Behaviors	Intensive longitudinal (i.e., daily diary study)	Purposive; online community (Facebook, Tumblr, Reddit) and university-based sample (research participant pool)	103	21.9 (1.8)	W = 87% H/L = 8% B/AA = 5% B/M = 4% A/PI = 1% Other = 3%	CW = 100%	B = 71.0% L/G = 9.0% Q = 7.0% P = 6.0% S = 5.0% A = 2.0% Qt = 1.0%
Polihronakis et al. (2021)	Psychology of Men and Masculinities	Cross-sectional	Purposive; online community-based (emails, listservs, flyers, Facebook, Tumblr)	505	26.7 (10.7)	W = ∼71% B/M = 10% H/L = 8%, A/PI/=3%, Other = 2% ME/NA= <1% B/AA = 3% AIAN= <1%	CM = ∼46.0% TM = 44.0% GNC = 9.0%	B = ∼70.0% Other = 10.0% Q = 9.0% G = 5.0% S = 3.0% A = 1.0%
Salim et al. (2023)	Psychology of Sexual Orientation and Gender Diversity	Cross-sectional	Purposive; Amazon MTurk	394	32.2 (8.1)	W = 87% H/L = 9% AIAN = 7% B/AA = 5%	CW = 100%	B = 100.0%
Dyar, Feinstein, et al. (2020)	Psychology of Sexual Orientation and Gender Diversity	Cross-sectional	Purposive; community-based (incentivized respondent -driven sampling, online social media, SGM community organizations, referrals)	360	20.2 (3.3)	BAA = 31.9% W = 27.5% H/L = 25.6% B/M = 9.4% A/PI = 5.0% Other=.5%	CW = 71.4% TM = 8.9% GNC = 19.7%	B = 47.2% P = 20.3% Q = 19.7% Other = 13.8%
Dyar, Sarno, et al. (2020)	Journal of Consulting and Clinical Psychology	Longitudinal	Purposive; community-based (venue-based recruitment, social media, and incentivized snowball sampling)	488	20.1 (3.7)	B/AA = 34.8% W = 26.0% H/L = 24.6% Other = 14.5%	CW = 73.8% TM = 9.0% GNC = 17.2%	B = 37.1% L = 23.6% P = 16.8% Q = 13.1% Other = 9.4%
Kalb et al. (2022)	Journal of LGBT Youth	Cross-sectional	Purposive; online community-based (Facebook and Reddit)	252	22.0 (2.2)	W = 68.3% B/M = 19.0% A/PI = 5.6% H/L = 2.8% B/AA = 1.6%	CW = 44.8% CM = 38.5% Q = 5.2% TM = 2.0% TW = 3.6% T = 1.6% Qt = 1.6%	G = 32.0% L = 21.4% B = 21.4% Q = 14.7% P = 6.7%
Swann et al. (2020)	Cultural Diversity and Ethnic Minority Psychology	Cross-sectional	Purposive (snowball sampling); community-based	352	20.3 (3.8)	B/AA = 47.4% H/L = 33.8% B/M = 10.5% A/PI = 6.8% Other = 1.4%	CW = 76.7% GNC = 10.2% Q = 4.8% TM = 6.5% Other = 1.7%	B = 23.9% L = 23.9% P = 16.5% Q = 9.9% Qt = 5.7% G = 3.4% Other = 2.8% A = 0.9%
Dyar, Feinstein, et al. (2019)	Drug and Alcohol Dependence	Longitudinal	Purposive; community-based (venue-based recruitment, social media, and incentivized snowball sampling)	1091	21.4 (3.0)	B/AA = 33.7% H/L = 29.9% W = 25.4% Other = 11.0%	CM = 92.0% T = 8.0%	G = 69.8% B = 21.0% Other = 9.2%
Feinstein et al. (2019)	Clinical Psychological Science	Longitudinal (i.e., dyadic)	Purposive; community-based (venue-based recruitment (e.g., community based organizations that serve LGBT individuals), social media (e.g., Facebook), and snowball sampling	218	22.9 (4.0)	B/AA = 33.0% H/L = 30.7% W = 27.5% Other = 8.7%	CM = 99.9% T=.1%	G = 79.4% B = 15.1% Other = 5.5%
Kelley et al. (2018)	Journal of Bisexuality	Cross-sectional	Purposive; online community-based (Craigslist, Facebook, Tumblr, Reddit) and university-based sample (research participant pool)	225	22.8 (3.4)	W = 57.6% B/AA = 28.6% H/L = 12.9% A = 13.3% AIAN=.9% Other = 7.6%	CW = 100.0%	B = 100.0%
McConnell & Messman-Moore (2019)	Psychology of Violence	Cross-sectional	Purposive; Amazon MTurk	343	29.5 (8.2)	W = 80.3% H/L = 8.9% B/AA = 8.3% AIAN = 4.6% A/PI = 5.2% B/M = 1.7% Other=.9%	CW = 100.0%	B = 100.0%
Winberg et al. (2019)	Journal of Homosexuality	Cross-sectional	Purposive; university-based sample recruited during a conference and online (LGBTQ listservs and networks)	574	22.7 (5.6)	W = 69.9% B/M = 10.8% B/AA = 6.1% H/L = 3.7% A/PI = 3.3% AIAN=.5% ME/NA=.1% Missing = 5.2%	CW = 57.0% CM = 43.0%	G = 32.8% L = 17.9% B = 16.7% A = 1.6% Q = 9.1% P = 6.3% S=.9% Qt = 1.7% Other = 2.8% Missing = 10.3%
Kalb et al (2018)	Journal of Gay and Lesbian Mental Health	Cross-sectional	Purposive; online community-based (Facebook and Reddit)	252	22.0 (2.2)	W = 68.3% B/M = 19.0% A/PI = 6.4% H/L = 2.8% B/AA = 1.6% AIAN=.4% ME/NA=.4% Other=.4%	CW = 44.8% CM = 38.5% Q = 5.2% TM = 2.0% TW = 3.6% T = 1.6% Qt = 1.6%	G = 32.0% L = 21.4% B = 21.4% Q = 14.7% P = 6.7% Qt = 2.8% Other=.8%
Livingston (2017)	Journal of Consulting and Clinical Psychology	Intensive longitudinal (i.e., ecological momentary assessment)	Purposive; university-based sample (i.e., undergraduate research pool)	50	21.8 (4.7)	W = 84%, B/M = 14% NAAN = 2%	CM = 20.0% CW = 62.0% T = 4.0% Q = 2.0% A = 8.0% GF = 4.0%	B = 28.0% L = 20.0% S = 12.0% P = 10.0% G = 6.0% Q = 4.0% Qt = 4.0% F = 4.0% Other = 12.0%
Scharer and Taylor (2018)	Journal of Gay and Lesbian Mental Health	Cross-sectional	Purposive; online community-based (social media, Facebook and LGB-specific online forums)	229	31.0 (11.3)	W = 77% B/AA = 12% H/L = 7%, AIAN = 5%, A/PI = 2%, Other = 4%	CW = 67.0% CM = 28.0% I/Other = 5.0%	L = 38.0% B = 37.0% G = 25.0%
Ylioja et al. (2016)	Nicotine and Tobacco Research	Cross-sectional	Purposive; university-based sample recruited during a conference and online (LGBTQ listservs and networks)	566	22.7 (5.6)	W = 74% POC = 25%	CM = 54.0% CW = 43.0% T = 3.0%	G = 35.0% L = 21.0% B = 17.0% Other = 27.0%
Woodford et al. (2012)	Substance Abuse and Rehabilitation	Cross-sectional	Purposive; university-based sample invited from a census of undergraduate students, a random sample of graduate students, and a convenient sample of members in LGBT student organizations	2497	23.2	W = 72% Other = 28%	CM = 38.5% CW = 61.2% Other=.0%	S = 81.9% SM = 18.1%
Silverschanz et al. (2008)	Sex Roles	Cross-sectional	Purposive; university-based sample (invitation to all student with current addresses on record)	3,128	23.0	W = 90% A/PI = 5% H/L=∼2% NAAN = 1%; B/AA=∼1%	CW = 48.0% CM = 52.0%	S = 88.78% SM = 11.22%

Note. Race or Ethnicity: A/PI: Asian or Pacific Islander; AIAN: American Indian; B/AA: Black or African American; B/M : Biracial or Multiracial; H/L : Hispanic or Latinx; ME/NA : Middle Easter or North African; NAAN : Native Alaskan; W: White. Gender Identity: CW: Cisgender woman or female; CM: Cisgender man or male; TW: Transgender woman (male to female); TM: Transgender man (female to male); T : Transgender (aggregated); GNC: Gender nonconforming or non-binary; GF: Genderfluid; Q: Queer; Qt: Questioning; I: Intersex; A: Agender. Sexual Orientation: A: Asexual S: straight or heterosexual; B: Bisexual; L: Lesbian; G: Gay; P: Poly- or pansexual; Q: Queer; Qt: Questioning or unsure; U: Unsure; F: Fluid; SM: Sexual minority (aggregated); Other: other sexual orientations (e.g., woman having sex with woman, woman loving man, same gender loving, etc.

Fourteen were cross-sectional studies. Two were longitudinal studies (Dyar, Newcomb, et al., 2019; Dyar, Sarno, et al., 2020). Others used either dyadic approach (Feinstein et al., 2019), daily diary method (Ehlke et al., 2022) or ecological momentary assessment (Livingston et al., 2017). All studies reviewed utilized purposive sampling. Most had community-based samples, with a large percentage utilizing online communities (e.g., social media, list serves) as a primary mode of recruitment. Only six studies had university-based participants, typically invited through university research participant pools, or using preexisting database of students who participated in large-scale surveys.

All studies which were eligible for review were conducted in the US. Examining participant demographics however showed wide representation of individuals coming from diverse racial or ethnic background. Study samples are comprised by participants who identified as White (25.4−90%), Black or African American (1−47.4%), Hispanic/Latinx (2−33.8%), American Indian/Alaskan Native (.4−7%), Asian/Pacific Islander (1−13.3%), among others.

Four studies only had bisexual participants and are not represented by other sexual and gender minorities (Bostwick et al., 2021; Kelley et al., 2018; McConnell & Messman-Moore, 2019; Salim et al., 2023;). Two studies (Woodford et al, 2012; Silverschanz et al., 2008) have aggregated sexual minorities into a single category (1.22−18.1%). While most of the studies had great representation of bisexual (15.1−100%), gay (3.4−79.4%), and lesbian (17.9−38%) individuals, people of other sexual orientations (e.g., people who identify as asexual, pansexual, fluid) only comprise a small portion of the sample. Similarly, ten studies had participants who identified as TGNC/NB/GD showing how current research aims for inclusion and diverse gender representation. However, the number of transgender participants in most studies remained limited, comprising .1–44% of the sample, compared to cisgender participants.

Alcohol was the substance most explored. Among these studies, seven explored hazardous use, while four examined alcohol consequences. Only five studies focused on marijuana, six on other drugs, and three on nicotine or smoking.

Role of SOGI microaggressions on substance use

The first aim for this review is to examine the current research on the relationship between SOGI microaggressions and substance use outcomes (see Table 3).

Table 3.

Relationship between SOGI microaggression and substance use outcomes.

Study	SOGI Microaggression		Substance Use		Bivariate	Multivariate
	Measure	Time frame	Measure	Time frame
A. ALCOHOL
Any use
Ehlke et al. (2022)	Selected items from various studies	Daily experience	Use (Y/N)	Daily experience	r = .36**	b = 0.49** to 0.52**
Woodford et al (2012)	Personal Incivility	Past Year	Any use (Y/N)	Past semester		AOR = 1.10 ns
	Ambient Incivility					AOR = 1.39**
Dyar, Sarno, et al. (2020)	SOMI	Past 6 months	Any use (Y/N)	Past 6 months		ORWPC = 1.58* to 1.91* ORWPP = 0.90 ns to 1.05 ns ORBP = 1.63*
Dyar, Newcomb, et al. (2019)	SOMI	Past 6 months	Any use (Y/N)	Past 6 months		ORWPC = 1.00 ns to 1.01 ns ORWPP = 1.15 ns ORBPC = 1.62* ORBPP = 1.49*
Hazardous use
Salim et al. (2023)	BMMSW	Past 6 months	AUDIT	Past year	r = .06 ns	b = −0.39 ns to −0.12 ns
Swann et al. (2020)	SOMI	Past 6 months	AUDIT	Past 6 months	r = .12*	IRR = 1.23**
McConnell & Messman-Moore (2019)	ABES	Not reported	AUDIT	Not reported	r = .31**	b = 0.77*
Winberg et al. (2019)	item “that’s so gay”	Past year	AUDIT ≥8	Past year	r = .13**	AOR = 1.20*
	item “no homo”				r = .16**	AOR = 1.22*
Dyar, Sarno, et al. (2020)	SOMI	Past 6 months	AUDIT	Past 6 months		RRWPC = 0.98 ns to 1.02 ns RRWPP = 0.81 ns to 0.82 ns RRBP = 1.28*
Dyar, Newcomb, et al. (2019)	SOMI	Past 6 months	AUDIT	Past 6 months		RRWPC = 1.05* to 1.06* RRWPP = 0.99 ns RRBPC = 1.17* to 1.22* RRBPP = 1.06*
Feinstein et al (2019)	SOMI	Past 6 months	AUDIT	Past 6 months	r = .16**	b = −0.07 ns to 0.21 ns
Problematic use
Woodford et al (2012)	Personal Incivility	Past Year	CAGE	Past semester		AOR = 1.64**
	Ambient Incivility					AOR = 1.97**
Binge drinking
Bostwick et al. (2021)	LGBQMCS	Past Year	Binge-Drinking (Y/N)	Past year	r =.23*	AOR = 1.97*
Severity
Polihronakis et al (2021)	ABES	Not reported	AUDIT	Not reported	r = .07 ns
Kalb et al. (2022)	HMS	Past 6 months	AUDIT-C	Past year	r = .14*	b = 0.01 ns to 0.02*
Kalb et al (2018)	HMS	Past year	AUDIT-C	Past year	r = .14*	b = −0.01
Quantity
Ehlke et al. (2022)	Selected items from various studies	Daily experience	Total number of drinks	Daily experience	r = .25*	b = 0.15** to 0.16**
Kelley et al (2018)	ABES	Past 30 days	DDQ	Typical week	r = .14**	β = 0.13*
Frequency
Kelley et al (2018)	ABES	Past 30 days	DDQ	Past 30 days	r = .20**	β = 0.09 ns
Consequences
Ehlke et al. (2022)	Selected items from various studies	Daily experience	DACE	Daily experience	r = .51**	b = 0.59** to 0.61**
Kalb et al. (2022)	HMS	Past 6 months	BYAACQ	Past year	r = .35**	b = 0.10** to 0.12**
Kalb et al (2018)	HMS	Not reported	BYAACQ	Past year	r = .40**	b = 0.04**
Scharer & Taylor (2018)	SOMM	Past 6 months	RAPI	Past year	r = .22**	β = 0.12 ns
B. MARIJUANA
Any use
Bostwick et al. (2021)	LGBQMCS	Past Year	Use (Y/N)	Past year	r = .17 ns	AOR = 1.64*
		Lifetime			r = .28**	AOR = 2.04*
Dyar, Sarno, et al. (2020)	SOMI	Past 6 months	Any Use (Y/N)	Past 6 months		ORWPC = 1.08* to 1.16 ns
						ORWPP = 1.67 ns
						ORBP = 2.22*
Dyar, Newcomb, et al. (2019)	SOMI	Past 6 months	Any Use (Y/N)	Past 6 months		ORWPC = 0.93 ns to 0.99 ns
						ORWPP = 0.94 ns
						ORBPC = 1.26*
						ORBPP = 1.09 ns
Hazardous use
Dyar, Sarno, et al. (2020)	SOMI	Past 6 months	CUDIT-R	Past 6 months		RRWPC = 0.96 ns to 1.01 ns
						RRWPP = 0.93 ns to 0.94 ns
						RRBP = 1.27*
Swann et al. (2020)	SOMI	Past 6 months	CUDIT	Past 6 months	r = .17*	IRR = 1.21**
Dyar, Newcomb, et al. (2019)	SOMI	Past 6 months	CUDIT-R	Past 6 months		RRWPC = 1.04*
						RRWPP = 1.02 ns
						RRBPC = 1.12* to 1.15 ns
						RRBPP = 1.06 ns
Feinstein et al (2019)	SOMI	Past 6 months	CUDIT-R	Past 6 months	r = .10 ns	b = −0.04 ns to 0.06 ns
C. NICOTINE/SMOKING
Bostwick et al. (2021)	LGBQMCS	Past Year	Current smoker (Y/N)	Current	r =.13 ns	AOR = 1.27 ns
		Lifetime			r = .22*	AOR = 2.00*
Ylioja et al. (2016)	LGBQMCS items	Past Year	Any use (Y/N)	Past month	r = .14**	AOR = 1.72*
Livingston et al., (2017)	Selected items from various studies	Daily experience	Use (Y/N)	Daily experience		ORWP = 2.99* ORBP > 999.00 ns
D. OTHER DRUGS
Any use
Woodford et al. (2012)	Personal Incivility	Past Year	Any drug use (Y/N)	Past semester		AOR = 1.21 ns
	Ambient Incivility					AOR = 1.25 ns
Livingston et al., (2017)	Selected items from various studies	Daily experience	Alcohol and/or other drugs use (Y/N)	Daily experience		ORWP = 3.59** ORBP = 83.24 ns
Use and/or abuse
Polihronakis et al. (2021)	ABES	Not reported	DAST	Not reported	r = .08 ns
Dyar, Feinstein, et al. (2020)	Brief ABES	Past 6 months	Alcohol and other drug use: Latent factors including AUDIT, CUDIT-R, and use of illicit drugs and prescription medication misuse	Past 6 months	β = .34**	β = .25** to .44**
Problematic use
Woodford et al. (2012)	Personal Incivility	Past Year	CAGE	Past semester		AOR = 1.26 ns
	Ambient Incivility					AOR = 1.58*
Frequency
Winberg et al. (2019)	item “that’s so gay”	Past year	No. of times illicit drugs was used	Past month	r = .10*	β = 0.06*
	item “no homo”	Past year			r = .12*	β = 0.07*
Consequences
Silverschanz et al. (2008)	Ambient HH from WHEQ	Past Year	Student Life Survey	Past year	r = .13*

Note. *p <. 05; **p < .01; ^ns: not significant; r : correlation coefficient; b : unstandardized coefficient; β : standardized coefficient; AOR : adjusted odds ratio; OR : odds ratio; OR_WP : within-person level odds ratio; OR_BP : between-person odds ratio; OR_WPC : within-person concurrent odds ratio; OR_WPP : within-person prospective odds ratio; OR_BPC : between-person concurrent odds ratio; OR_BPP : between-person prospective odds ratio; IRR:incident risk ratio; RR : rate ratio; RR_WPC : within-person concurrent rate ratio; RR_WPP : within-person prospective rate ratio; RR_BPC : between-person concurrent rate ratio; RR_BPP : between-person prospective rate ratio.

SOGI microaggression measures. ABES : Anti-Bisexual Experiences Scale (Brewster & Moradi, 2010; Dyar, Feinstein, et al., 2019); SOMI: Sexual Orientation Microaggression Inventory (Swann et al., 2016); HH: Heterosexist Harassment; WHEQ: Workplace Heterosexist Experiences Questionnaire (Waldo, 1999); HMS: Homonegative Microaggression Scale (Wegner & Wright, 2016; Wright & Wegner, 2012); EDS: Everyday Discrimination Scale (Williams et al., 1997); BMMSW: Bisexual Microaggression and Microaffirmation Scales for Women (Flanders et al., 2019); LGBQMCS: LGBQ Microaggressions on Campus Scale (Woodford et al., 2015); LGBT-PCMS: People of Color Microaggressions Scale (Balsam et al., 2011); SOMM: Sexual Orientation Microaggressions Measure (Scharer & Taylor, 2018).

Substance use measures. AUDIT: Alcohol Use Disorder Identification Test (Saunders et al., 1993); AUDIT-C : three consumption items from AUDIT (Bush et al., 1998; Gordon et al., 2001); CUDIT-R: Cannabis Use Disorder Identification Test – Revised (Adamson et al., 2010); DDQ : Daily Drinking Questionnaire (Collins et al., 1985); DACE : Daily Alcohol-Related Consequences and Evaluations Measure (Lee et al., 2017); CAGE : Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers (Ewing, 1984); RAPI : Rutgers Alcohol Problem Index (White & Labouvie, 1989); BYAACQ : Brief Young Adult Alcohol Consequences Questionnaire (Kahler et al., 2005).

Alcohol Use

Among cross-sectional studies which explored outcomes related to alcohol, 10 found significant bivariate associations between alcohol use and SOGI microaggressions, with small to medium effect size (r = .12 to r = .51), while two found null results (Salim et al., 2023; Polihronakis et al., 2021). More specifically, in the studies reviewed, it was shown that experiencing SOGI microaggressions most often have a weak to moderate positive relationship with alcohol use severity, frequency, and quantity (Ehlke et al., 2022; Kalb et al., 2018, 2022; Kelley et al, 2018), as well as with hazardous use or binge drinking (Bostwick et al., 2021; Feinstein et al., 2019; Kalb et al., 2018; McConnell & Messman-Moore, 2019; Swann et al., 2020; Winberg et al, 2019). Likewise, SOGI microaggression experience has weak to strong positive association with alcohol consequences (Ehlke et al., 2022; Kalb et al, 2018, 2022; Scharer & Taylor, 2018; Silverschanz et al., 2008). Even after controlling for various socio-demographic and person-level factors, SOGI microaggression experience still increases the likelihood of hazardous or binge drinking (Bostwick, et al., 2021; Swann et al., 2020; Kalb et al., 2022; Dyar, Sarno, et al., 2020; Dyar, Newcomb, et al., 2019; Winberg et al., 2019).

Likewise, some cross-sectional studies which found significant bivariate relationships failed to show evidence that these associations hold fast when tested using multivariate models. For instance, Kelley et al. (2018) found no significant relationship between alcohol frequency and past month microaggression experience, when drinking to cope motivation was controlled. Scharer and Taylor (2018), on the other hand, did not find evidence of the link between alcohol consequences and microaggression experience in the past 6 months, when coping styles were included in the model. The same was true in the study of Woodford et al. (2012) where witnessing or experiencing incivility did not significantly correlate with alcohol or drug use when socio-demographic factors such as age, gender, race, or student status were controlled.

The associations found in longitudinal studies are more nuanced. While SGM people (i.e., assigned female at birth) who were exposed to microaggression tend to report more alcohol use, there was no prospective associations found and the concurrent associations between microaggression exposure and hazardous alcohol was not significant (Dyar, Sarno, et al., 2020). Among SGM people who were assigned male at birth, greater alcohol use was evident among those exposed to microaggressions; however, no prospective association was found (Dyar, Newcomb, et al., 2019).

Marijuana use

Among three cross-sectional studies which explored marijuana use, two found significant associations between marijuana use and SOGI microaggressions (Bostwick et al., 2021; Swann et al., 2020), with small effect size (r = .17–.28), while one found null results (Feinstein et al., 2019). More specifically, lifetime, but not past year, exposure to microaggressions was significantly positively associated with marijuana use (Bostwick et al., 2021). The associations found in the two longitudinal studies are more nuanced. SGM people (i.e., assigned female at birth) who were exposed to microaggression tend to report more cannabis use but prospective associations were not significant and no concurrent associations between microaggression exposure and hazardous marijuana use was found (Dyar, Sarno, et al., 2020). Among SGM people who were assigned male at birth, there was also no prospective association found (Dyar, Newcomb, et al., 2019).

Smoking/nicotine use

Both cross-sectional studies looking at smoking or nicotine use found significant associations, with small effect size (r = .14–.22). Experiencing SOGI microaggressions was found to have weak positive relationship with nicotine use/smoking (Bostwick, et al., 2021; Ylioja et al., 2016). In an ecological momentary assessment study (Livingston, 2017), only within-person effect of microaggression on nicotine was significant but not between-person effect. However, one study found a non-significant bivariate association between past year microaggression and current smoking (Bostwick et al., 2021).

Other drug use

Among six studies which explored other drugs, two (Silverschanz et al., 2008; Winberg et al., 2019) found significant bivariate association between SOGI microaggression and use of illicit drugs, with small effect size (r = .10–.13), while one found null results (Pohlironakis et al., 2021). One study, which measured drug use using latent factor including alcohol use, cannabis use, use of illicit drugs, and misuse of prescription medication found significant association both at the bivariate (β = .34) and multivariate (β = .25–.44) levels (Dyar, Feinstein et al., 2020). In another study, only the relationship between ambient civility and problematic drug use had significant association (Woodford et al., 2012). In an ecological momentary assessment study (Livingston, 2017), only the within-person effect of microaggression on alcohol and/or other drug use was significant but not between-person effect.

Intermediary factors in SOGI microaggressions-substance use relationship

The second aim for this scoping review is to determine intermediary factors influencing SOGI microaggressions’ link to substance use. Of the 19 studies included, 11 used moderation or mediation models. Studies utilizing mediation models indicated that internalized homophobia/biphobia (Polihronakis, 2021), negative relationship interaction with a significant other (Feinstein et al., 2019), and coping motives and styles (Kalb et al., 2018; Kelley et al., 2018; see Scharer & Taylor, 2018 for exception) mediated the SOGI microaggressions and substance use and related negative consequences relationship. On the other hand, microaggressions mediated the relationship between sexual minority status and problematic drinking (Woodford et al., 2012).

Studies utilizing moderation models indicated that being a gender minority, being White (Dyar, Feinstein, et al., 2020), and having low ingroup ties and ingroup affect (Kalb et al., 2022) magnified the microaggressions-substance use and related consequences relationship. On the other hand, the experience of microaggressions magnified the relationship between childhood sexual abuse and hazardous drinking (McConnell & Messman-Moore, 2019). One study using an alcohol purchase task (Kaplan et al., 2018) indicated that microaggressions were associated with alcohol use quantity and negative consequences only when the inclination to spend less amount on alcohol was low (i.e., low O_max and P_max) and when there is a tendency to stop drinking at a lower price point (i.e., low breakpoint values).

In one moderated-mediation study among cisgender bisexual women (Salim et al, 2023), receiving negative reactions to sexual assault disclosure mediated the microaggression-hazardous alcohol use relationship, but only when internalized binegativity was high.

Discussion

This scoping review indicated that studies on the role of SOGI microaggression experience on substance use have increased in recent years. Most studies in this review showed that SOGI microaggression experience is associated with increased substance use and related problems. This finding aligns with the minority stress model (Meyer, 2003, 1995), which asserts that minoritized population remain to experience stressors over and above those that are experienced by their non-minoritized counterparts due to stigmatization, discrimination, and violence. These additive stressors are then linked to disparate health outcomes, which include substance use.

Likewise, those studies reviewed, which utilized mediation and moderation models examined how the relationship between microaggressions and substance use is influenced by motivational, relational, and identity processes. People who use substances do it for various reasons and these motives and expectancies predict substance use behaviors and outcomes (Fish & Hughes, 2018). The role of interpersonal relationships in the link between microaggressions and substance use cannot also be overlooked since microaggressions is a social dynamic between the target and the receiver (Vaccaro & Koob, 2019) and social relationships is a salient factor that can either initiate, aggravate, or mitigate substance use (Frost et al., 2016). Most importantly, identity, minority status, and the experiences that come with them, are a crucial element in understanding microaggressions (Sue & Spanierman, 2020), as well as substance use-related behaviors and consequences (Slater et al., 2017).

The dearth in research on microaggression-substance use link in other countries than the US was notable, considering that we did not constrain research locale or place of publication in our search process. This highlights the need for cross-cultural and cross-country examination of microaggression as a phenomenon and how it links to substance use outcomes. There was also substantial lack of attention on the link between SOGI microaggressions and substances other than alcohol and marijuana. Studies of non-alcohol and non-marijuana substances tend to aggregate illicit drugs such that effects of microaggression experience on the use of various drug types could not be established. Future studies will benefit from looking at the differential effects of microaggression experience on drug of choice, patterns of consumption, and related consequences.

Aiming for conceptual clarity of microaggression is desirable, as earlier raised by critics and proponents of this construct (see Lilienfeld, 2017 and Williams, 2020). Increase in psychometric studies of SOGI microaggression measures (Fisher et al., 2019; Lui & Quezada, 2019) signals a growing field and further helps provide discriminant validity evidence to similar or overlapping constructs (e.g., enacted stigma, enacted homo-/bi-/trans-negativity, everyday sexism). Efforts to be inclusive in sampling participants of diverse sexual and gender identities are apparent. However, except among large-scale longitudinal studies, there remains to be low TGNC/NB/GD representation. Ensuring visibility of TGNC/NB/GD subgroups in research will allow a closer look at their nuanced and complex lived experiences.

Related to the need for research in diverse socio-cultural contexts, there is also a need to examine the construct of microaggression as experienced and defined by LGBQ individuals in other countries and societies, especially in areas where there are restrictive policies toward sexual and gender minorities. This may expand existing models and taxonomies of microaggression and provide a nuanced view of this concept, which are more aligned with the socio-cultural experiences, values, and beliefs in these societies and communities. Concomitantly, there is a need to examine factors that influence and motivate people to enact microaggressions. This is another area of research that has only gained attention recently (e.g., Williams et al., 2021).

Above all, findings from this study contribute to the larger discourse on sexual health and well-being. Enforcing binary gender roles, denying the existence of societal transphobia, and exoticizing and pathologizing diverse sexual and gender identities and expression, which are manifestations of SOGI microaggression (Nadal, 2019), jeopardize healthy expression of sexual autonomy and sexual pleasure that are crucial elements of sexual rights (Kismӧdi et al., 2017; Reis et al., 2021). Exposure to microaggressions, although seemingly innocuous, yields adverse consequences among sexual and gender minorities (Lui & Quezada, 2019; Nadal et al., 2016), which impact sexual health, in particular, and overall health and well-being, in general. Sexual health, sexual rights, and sexual pleasures are interlinked dimensions of sexual wellbeing (Sladden et al., 2021).

Empirical investigations on how microaggression and substance use play a role in dimensions of sexual well-being are warranted. For instance, microaggression exposure has been associated with internalized stigma (e.g., Polihronakis, 2021), which in turn has been associated with a host of mental health concerns (Kuerbis et al., 2017; Newcomb & Mustanski, 2010). Notably, great internalized stigma has also been associated with lower sexual satisfaction and overall sexual health (Budge & Katz-Wise, 2019; Rosser et al., 2008). The role that microaggression and substance use play in this mechanism is worthy exploring in future studies.

The present scoping review found limited studies in the context of intimate and romantic relationships, despite the role that negative relationship interactions play in exacerbating the effect of microaggression exposure on substance use (e.g., Feinstein et al., 2019). Further expanding the unit of analysis, it is also essential to examine how microaggressions occurring in various social relationships (e.g., family, peer groups, acquaintances) influence shaping sexual scripts and satisfaction with LGBTQ individuals’ experience of their own sexuality (Budge & Katz-Wise, 2019). Family and peer groups, among others, have been found to attenuate adverse consequences of exposure to victimization among sexual and gender minorities (Gordián-Arroyo, 2022).

Since microaggressions are perpetuated by cis-heteronormative expectations (Sue & Spanierman, 2020) and stigmatization of diverse expression of human sexuality, efforts geared toward sexual health and rights education may serve as an opportunity to mitigate these events and their consequences. Promoting awareness about the plight of LGBTQ individuals and cultivating recognition and affirmation of sexual and gender diversity (Ford et al., 2021; WAS, 2021) will complement and fortify microinterventions geared toward building competencies on how to disarm microaggression and educate offenders (Sue et al., 2019; Sue & Spanierman, 2020). Parallel to this, addressing motivating factors and antecedents of microaggression perpetration may be an important element of programs geared toward building competence on asserting sexual rights, not only among LGBQ individuals but among their cisgender heterosexual counterparts.

Notwithstanding its desire to propel future studies on microaggression, substance use, and their role in overall sexual well-being, this scoping review has certain limitations. We only used electronic databases that are available to us at the time of the study. Likewise, the dearth in literature on SOGI microaggressions and its role on substance use also placed a limit on the studies we can include in the review. As more research emerges, conducting rigorous evidence synthesis that looks at this relationship systematically and meta-analytically will afford greater insights on the complex interplay between microaggressions and substance use.

Conclusion

SOGI microaggressions are, in most cases, associated with increased substance use and related consequences as influenced by motives, relationship, and identity-specific factors. However, there is still a need to further explore other pathways and mechanisms that lead to substance use and negative outcomes. Results of this scoping review, hopefully, would increase the interest in examining the role of SOGI microaggressions in addiction sciences and reduce substance use-related health disparities among sexual and gender diverse populations. Most of all, by highlighting the link between SOGI microaggression and substance use outcomes, this review hopes to inspire empirical investigations on how these variables also connect with other dimensions of sexual health and well-being.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

The authors have no conflicts of interest to declare. No external funding was received by any authors for this study. Each author certifies that their contribution to this work meets the standards of the International Committee of Medical Journal Editors.