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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2024 Jan 18;36(1):59–76. doi: 10.1080/19317611.2024.2303517

Substance Use and Misuse among Sexual and Gender Minority Communities Living in Former Soviet Union Countries: A Scoping Review

Tural Mammadli a,✉, Chenglin Hong b
PMCID: PMC10903640  PMID: 38600900

Abstract

Objectives

We reviewed literature examining substance use among sexual and gender minorities (SGM) living in the former Soviet Union (USSR) nations

Methods

Searches were conducted across five databases (PubMed, SocINDEX, CINAHL, PscyInfo, LGBTQ + Source) to identify peer-reviewed literature.

Results

Across 19 studies, high hazardous substance use prevalence was documented. Substance use was correlated with (a) sexual health and behaviors and (b) mental wellbeing and the use of other substances.

Conclusion

We discuss minority stress implications and challenges presented by the paucity of evidence in the literature examining substance use among SGM women and SGM living in countries unrepresented in reviewed studies.

Keywords: Substance use, sexual and gender minorities, scoping review, former USSR countries, minority stress model

Introduction

Sexual and gender minority (SGM) communities experience a disproportionate substance use burden compared to their heterosexual and cisgender counterparts, including in the use of alcohol, illicit substances (e.g., opioids), tobacco, and cannabis (Capistrant & Nakash, 2019; Connolly & Gilchrist, 2020; Duncan et al., 2019; Gonzales et al., 2016; Gonzales, 2020; Han et al., 2020; Hughto et al., 2021; Jackson et al., 2016). Stemming from the minority stress model (Hatzenbuehler & Pachankis, 2016; Hendricks & Testa, 2012; Meyer, 2003), an extensive literature has identified experiences of anti-LGBTQ + discrimination, marginalization, stigma, and violence, also referred to as minority stressors, as a link to hazardous substance use, with some studies documenting substance use as a maladaptive coping strategy (Lipperman-Kreda et al., 2020; Ryan et al., 2009; Russell et al., 2011; Shires & Jaffee, 2016; Wong et al., 2010). In a study of 600 transgender adults living in Rhode Island and Massachusetts, Wolfe et al. (2021) found that experiencing high levels of transphobic discrimination was associated with 3.6 times higher odds of substance use disorder diagnosis. Literature has also demonstrated that victimization experiences can be especially detrimental for SGM persons. Research has indicated elevated rates of substance misuse, encompassing alcohol, cannabis, tobacco, cocaine, and ecstasy, among SGM individuals who have experienced victimization (Edwards et al., 2015; Goldbach et al., 2014; Hinds et al., 2022; Scheer et al., 2022; Swann et al., 2019).

The current understanding of substance use disparities among SGM communities has been through the perspective of those living in Western and English-speaking world, including the US, Canada, and the Western Europe (Connolly & Gilchrist, 2020; Daly et al., 2023; Gambadauro et al., 2020; Slemon et al., 2022; Pakula et al., 2016). SGM living in numerous countries comprising the former Union of Soviet Socialist Republics (USSR)1 are also reportedly exposed to increased minority stress experiences (Amnesty International, 2017; Dailey, 2023; Hylton et al., 2017; ILGA, 2022; Kottasová, 2022; MacFarquhar, 2023; Voyles & Chilton, 2019). For instance, five former USSR countries were represented among the 15 countries deemed to be the least socially accepting of LGBTQ persons from a UCLA survey of participants in 175 countries (Flores, 2021). Estonia, Latvia, and Lithuania were the only former USSR countries that made the top half of that same list (Flores, 2021). Although Estonia became the first nation to legalize same-sex marriage in 2023 among the former USSR nations (Sakawed, 2023), the freedoms of many LGBTQ persons have back-slid in many of the former USSR nations (Dailey, 2023; Kottasová, 2022; MacFarquhar, 2023). For instance, a month after the legalization of same-sex marriage in Estonia, Russia adopted a ban on gender affirming surgeries for transgender persons (MacFarquhar, 2023). Further, many SGM living in the region are targeted for violent attacks due to their identity, including being beaten, raped, and tortured by law enforcement and homophobic vigilante gangs (Amnesty International, 2017; Steinmetz, 2019; Synovitz & Safarova, 2017). Many SGM living in former Soviet nations also experienced increasing discrimination, marginalization, and violence, including murders, during the COVID-19 pandemic, with some scapegoating the community for COVID infection surges and using the pandemic to limit the basic human rights of these communities (ILGA, 2022).

Considering the increasing minority stress experiences, including discrimination, marginalization, and victimization of SGM living in many former USSR nations as well as the theoretical and empirical literature linking minority stress and substance use, understanding the substance use burden experienced by SGM is especially vital. Substance use represents a particularly important vulnerability to examine among SGM in the region, as substance use, including hazardous use, remain to be highly prevalent and concerning among the general population in former USSR nations (European Monitoring Centre for Drugs and Drug Addiction, 2021; Kirtadze et al., 2018; Probst et al., 2021; Rosenkranz et al., 2016; The Lancet, 2019; United Nations Office on Drugs and Crime, 2015). As an example, despite a substantial reduction, Russia is still among the countries with the highest levels of alcohol consumption (The Lancet, 2019). It is also estimated that as high as 6% of the Russian population use drugs, with an increasing prevalence in the use of hard drugs such as heroin (Galeotti, 2016). Increased use of hard drugs have been accompanied with rampant incarceration of drug users and an ongoing HIV epidemic linked to substance use (Galeotti, 2016; Pape, 2022). Concerning patterns of hazardous use of alcohol and substances have been documented across other former USSR countries as well, including in Azerbaijan, Armenia, Kazakhstan, and Georgia among others (Azbel et al., 2015; Arka News Agency, 2019; Kauschanski, 2019; Probst et al., 2021; Sirbiladze et al., 2017; Schulte et al., 2020; World Health Organization, 2018; WHO, 2019). Given that high levels of hazardous substance use are of concern among the general population, it is plausible that substance use related disparities documented by existing global literature are even more pronounced for SGM living in this region. Therefore, the current scoping review aims to summarize the state and content of literature examining substance use and misuse prevalence and patterns among SGM living in the region in addition to delineating correlates of hazardous substance use and charting directions for future research.

Terminology in the current study

Sexual minorities are persons with sexual identities that fall outside of those of the often-heterosexual majority group, (e.g., gay, lesbian, bisexual, pansexual persons) whereas gender minority persons have gender identities that differ from their sex assigned at birth (e.g., transgender men and women, gender diverse persons) (Suen et al., 2020). Consistent with previous reviews (Ayhan et al., 2020; Layland et al., 2020; Pratt-Chapman et al., 2021), the term sexual and gender minorities or SGM in the current review is used as an inclusive term to refer to persons with a wide variety of minority gender and sexual identities that include but are not limited to lesbian, gay, bisexual, and transgender (LGBT) persons (National Institutes of Health, 2015). In addition, current literature often uses the terms men who have sex with men (MSM) and women who have sex with women (WSW) to describe persons who are engaged in sex with a person of the same gender, regardless of their sexual orientation (Young & Meyer, 2005). Following previous reviews on the health of SGM (Ayhan et al., 2020; Layland et al., 2020; Pratt-Chapman et al., 2021), persons identifying as MSM and WSW are included as part of the current review.

Materials and methods

The current scoping review was guided by the five-stage scoping review framework developed by Arksey and O’Malley (2005). The stages consist of (1) identifying research questions, (2) identifying relevant studies, (3) selecting relevant studies, (4) charting data from selected articles, and (5) collating, summarizing, and reporting results. The results of the current review were reported in line with the procedures outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).

Stage 1: identifying research questions

The aim of the current scoping review is to identify substance use and misuse prevalence and correlates among SGM communities living in 15 countries that previously comprised the USSR. The questions examined as part of this review are as follows:

  1. What’s the current state of the literature on the substance use and misuse of SGM in the former USSR countries?

  2. What are the substances used by SGM?

  3. What are the demographic disparities experienced by SGM in their substance use and misuse prevalence?

  4. What are the correlates of substance use and misuse by SGM?

Stage 2: identifying relevant studies

Searches were conducted via five databases: PubMed, SocINDEX, CINAHL, PscyInfo, and LGBTQ + Life. To identify relevant records, these databases were searched using a comprehensive list of terms corresponding to three main concepts: substance use and misuse (outcome of interest), sexual or gender minority identity (the population of interest), and residence in formerly USSR countries and municipalities (the location of interest). (See Table 1 for a comprehensive list of search terms). Search terms were selected to be as comprehensive as possible and did not place restrictions on substances or the way the substance use patterns are characterized. Following previous syntheses of evidence (Davlidova et al., 2021) conducted in the region, search terms representing the location of interest included names for the regions (e.g., Soviet Union, Central Asia, Caucus, Baltic*), ethnicities, and names of the 15 countries as well as their capital cities, three largest cities, and autonomous regions. When differentiating between terms corresponding to the same concept and in between concepts, Boolean operators “or” and “and” were employed, respectively. When intending to expand certain terms, the Boolean modifier (*) was employed. Each included record’s reference list was also manually searched to identify any further eligible records. All searches were conducted in July, 2023, and no restrictions were placed on date of the records.

Table 1.

Search terms.

Concept Search terms
Gender or sexual ID: LGBT* OR “sexual minority” OR “gender minority” OR lesbian OR gay OR bisexual OR transgender OR nonbinary OR “gender diverse” OR queer OR “gender nonconforming” OR “Gender expansive” OR “transwoman” OR “transman” OR “gender identity” OR “gender expression” OR “sexual orientation” OR “men who have sex with men” OR “msm” OR pansexual OR “sexual identity” OR transfeminine OR transmasculine OR transsexualism OR transsexual
Substance use “Substance” OR “Substance induced disorder” OR “Substance related disorder” OR “Drug use disorder” OR “Drug substance disorder” OR Alcohol OR Addict OR “Oral substance abuse” OR “Intravenous substance abuse” OR “Intravenous substance use” OR “Risky use of alcohol” OR “Excessive drinking” OR “Alcohol induced disorder” OR “Alcohol related disorder” OR “Binge drinking” OR Smoking OR tobacco OR Cigarette OR nicotine OR Vape OR Vaping OR Cocaine OR “Cocaine related disorder” OR Heroin OR Opioid OR “Opioid related disorder” OR “Amphetamine related disorder” OR Marijuana OR Cannabis OR “Opiate use” OR “Prescription drug abuse” OR “Prescription drug misuse” OR “Illegal substance” OR “Illicit drug” OR “Narcotic related disorder” OR “Harmful substance use” OR “Harmful drug use” OR “chemsex”
Former USSR country “Union of Soviet Socialist Republics” OR “Soviet Union” OR Armenia* OR “Yerevan” OR “Gyumri” OR “Vanadzor” OR “Azerbaijan” OR Azeri OR Baku OR Sumqayit OR Ganja OR Karabakh OR Nakhichevan* OR Nakhichivan* OR Belarus* OR Minsk OR Homyel OR Hrodna OR Estonia OR Tallinn OR Tartu OR Narva OR Georgia* OR Tbilisi OR Kutaisi OR Batumi OR Adjara OR Abkhazia OR Ossetia OR Kazakhstan OR Kazakh* OR Astana OR Almaty OR Shymkent OR Kyrgyzstan OR Osh OR Jalal-Abad OR Kyrgyz* OR Bishkek OR Latvia OR Riga OR Daugavpils OR Liepaja OR Lithuania* OR Vilnius OR Kaunas OR Klaipėda OR Moldova OR Chisinau OR Tiraspol OR Bălți OR Transnistria OR Gagauzia* OR Tajikistan OR tajik* OR Gorno-Badakhshan OR Dushanbe OR Khujand OR Qurghonteppa OR Kurganteppa OR Bokhtar OR Uzbekistan OR uzbek* OR Karakalpakstan OR Tashkent OR Samarkand OR Namangan OR Turkmenistan OR Turkmen* OR Turkmenabat OR Ashgabat OR Dashoguz OR Ukraine OR Kyiv OR Kharkiv OR Odesa OR Crimea OR Caucasus OR Baltic* OR Russia* OR Moscow OR Saint Petersburg OR Novosibirsk OR Adygea OR Altai OR Bashkortostan OR Buryatia OR Chechen OR Chechnya* OR Chuvash OR Dagestan OR Ingushetia OR Kabardino-Balkar* OR Kalmykia OR “Karachay-Cherkessia” OR Karelia OR Khakassia OR Komi OR Mari El OR Mordovia OR “North Ossetia–Alania” OR Sakha OR Yakutia OR Tatarstan OR Tuva OR Udmurt OR “Central Asia” NOT “Atlanta"
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Stage 3: selecting relevant studies

Selection of relevant studies was conducted using the following inclusion criteria: (a) published in a peer reviewed academic journal, (b) published in English, (c) conducted using empirical data, (d) conducted with SGM communities living in a former USSR country, and (e) studied substance use, misuse, or other related behavioral patterns. If a study consisted of both SGM and non-SGM participants, it was included only if it disaggregated substance use findings by sexual or gender identity. Similarly, studies that included participants from former USSR and non-USSR countries were only eligible if they disaggregated findings from the country of origin. Quantitative, qualitative, and mixed-methods literature was included without placing any restrictions on methodology or design. Other review or evidence synthesis literature, grey literature, and non-peer reviewed records such as dissertation and reports by nonpartizan groups were not included in the current study.

Following the identification of records in the five aforementioned databases, all records were imported into Covidence Systematic Review Software (2023), a software that aids evidence synthesis. Initially, duplicate records were identified and removed by Covidence. The lead author then screened the de-duplicated title and abstracts of each record. Full-text of each identified record was reviewed to determine eligibility for inclusion by the lead author. At this stage, the reasoning for the exclusion of each recorded after full-text review was documented.

Stage 4: charting data from selected articles

Data extraction from included studies was conducted via a pre-developed Excel sheet by the lead author. Table 2 provides a detailed list of relevant data to be extracted from eligible studies. In short, the data extracted form contains general study bibliographic information (e.g., author name, year, location, study design, sampling strategy, and sample characteristics such as sample size and participant demographics) and study-specific outcomes including the types of substances reported, prevalence, socio-demographics disparities, substance use and misuse correlates, protective factors, and theoretical framework.

Table 2.

Data extracted.

Data type Variables
Technical data and methods publication year, location (country, state, or city), study setting (e.g., community, clinical) methodology (i.e., qualitative, quantitative, mixed methods), design (i.e., longitudinal, cross-sectional), sampling strategy, year of data collection,
Research objectives study aims
Sample information sample size, demographic characteristics (e.g., race, country of origin, gender identity, age, sexual orientation, education level, socio-economic status)
Outcome and measures Types of substances, prevalence of substance use, demographics disparities, variable operationalization factors associated with (adverse) substance use, disparities; quotes and themes
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Stage 5: collating, summarizing, and reporting results

Qualitative and quantitative evidence were synthesized in a narrative format. Descriptive statistics were used to present the characteristics of included studies. No ethical approval was required as all study data were from published literature.

Results

Study selection

Figure 1 details the PRISMA-ScR chart and exclusion rationales. The searches of the five databases yielded 697 results. Three additional sources were identified via a manual search of the reference lists of the included studies. Of the 700 identified records, 105 were automatically removed by Covidence as duplicates. Title and abstract screening eliminated 550 articles. Full text reviews were conducted for 45 records. Upon full-text review, 26 of these records were excluded due to not being conducted in a former USSR country (n = 16), not disaggregating substance use data by country of origin (n = 6) or by SGM identity (n = 1), not examining substance use (n = 2), and lacking empirical data (n = 1). Nineteen studies were included.

Figure 1.

Figure 1.

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PRISMA-ScR.

Basic characteristics of the included studies

All eligible studies were conducted with participants living seven former USSR republics, with most being conducted in Russia (n = 8), followed by Estonia (n = 4) and Georgia (n = 3). Ukraine, Kazakhstan, Lithuania, and Moldova each were home to one study. Notably, no studies were identified in the majority of the former USSR states, including in Azerbaijan, Armenia, Belarus, Turkmenistan, Tajikistan, Uzbekistan, Latvia, or Kyrgyzstan. Most studies were quantitative (n = 15, 78.9%), with only two qualitative and mixed-methods studies, respectively. Most were conducted with men who have sex with men (MSM), including male sex workers (MSW) (78.9%) whereas two studies examined substance use among transgender persons and MSM and one solely included transgender participants. Only one study examined the experiences of non-transgender gender minority persons, referring to them as “other transgender persons” (Chumakov et al., 2023). Further, sample size varied across quantitative analysis, ranging from 50 (Baral et al., 2010) to 5035 (Berg et al., 2017). Some studies were conducted using the same dataset. Specifically, three included studies from Estonia (Parker et al., 2015, 2016; Rüütel et al., 2017) and two studies from Russia utilized the same dataset (Wirtz et al., 2016a, 2016b). These studies were nevertheless included as they examined distinct correlates of substance use.

Further, most studies examined substance use as part of HIV-related behaviors or in the context of sexual risks (42.1%) with seven mainly examining substance use (42.1%). Only four studies explicitly stated a theoretical orientation (21.1%), all of which were guided by the minority stress model (Table 3).

Table 3.

Basic characteristics of included studies assessing substance use among sexual and gender minority communities in the former USSR countries (n = 19).

Characteristics Total
19 (100%)
Study design  
 Quantitative 15 (78.9%)
 Qualitative 2 (10.5%)
 Mixed-Methods 2 (10.5%)
Study population  
 MSW/MSM 16 (84.2%)
 Transgender & MSM 2 (10.5%)
 Transgender 1 (5.3%)
Study focus  
 HIV/sexual-risk behavior 7 (36.8%)
 Substance usea 7 (36.8%)
 Mental health 4 (21.1%)
 Hepatitis C testing intervention 1 (5.3%)
Theoretical framework  
 Atheoretical 15 (78.9%)
 Minority Stress Model 4 (21.1%)
Sample size  
 ≤100 participants 6 (31.6%)
 ≤1000 participants 9 (47.4%)
 >1000 participants 4 (21.1%)
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Male sex worker (MSW)/men who have sex with men (MSM).

aincludes sex-related substance use.

Substances and measures

A variety of substances were examined across studies. Studies assessed alcohol (n = 14), unspecified drug (n = 8), opioids/injection drug (n = 8), club drugs (n = 4), stimulants (n = 3), cannabis (n = 3), chemsex/sexual performance drugs (n = 6), polydrug (n = 3), inhalant (n = 1), and tobacco (n = 1) use. Most examined substance use prevalence over the past year (n = 10), followed by life-time (n = 9), current (within the past 30 d) (n = 6), and unspecified timeline (n = 6). Further, all 19 studies examined the use of substances whereas hazardous use or dependence was examined in seven studies. Only one study examined willingness to quit substance use. Most studies did not utilize a validated measurement to examine the patterns or severity of substance use and misuse. Alcohol Use Disorders Identification Test (AUDIT) was utilized in two studies using the same sample (Wirtz et al., 2016a, 2016b). Similarly, the “Cut down, Annoyed, Guilty, and Eye-opener” (CAGE) questionnaire was employed in three studies (Parker et al., 2015; Rüütel et al., 2017). Lastly, HIV Risk Behaviors (Lee et al., 2022) and Fagerstrom tolerance (Chkhartishvili et al., 2021) questionnaires were each utilized in one study (Table 4).

Table 4.

Substances use operationalization and patterns in reviewed studies.

Characteristics Total n (%)
Substancesa  
 Alcohol 14 (73.9%)
 Unspecified drug use 8 (42.1%)
 Opioids/IDU 8 (42.1%)
 Club drugs (e.g., MDMA; GHB) 4 (21.1%)
 Stimulants (e.g., cocaine) 3 (15.8%)
 Chemsex/performance drugs 6 (31.6%)
 Polydrug use 3 (15.8%)
 Inhalant 1 (5.3%)
 Tobacco 1 (5.3%)
 Cannabis 3 (15.8%)
 EMUP 1 (5.3%)
Substance Use Timeline  
 Current/past-week/past 30-days 6 (31.6%)
 Past year 10 (52.6%)
 Life-time 9 (47.4%)
 Unspecified 6 (31.6%)
Substance Use Patterns  
 Use 19 (100%)
 Hazardous use/dependence/addiction 7 (36.8%)
 Willingness to quit 1 (5.3%)
Measures  
 No formal measure for any substances 12 (63.2%)
 CAGE 3 (15.8%)
 AUDIT† 2 (10.5%)
 HIV Risk Behaviors questionnaire 1 (5.3%)
 Fagerstrom tolerance questionnaire 1 (5.3%)
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aTotal column % may not equal 100%, as some studies examined multiple substances. †Both articles utilized the same dataset that included AUDIT (Wirtz et al., 2016a, 2016b).

Substance use prevalence

Alcohol

Current alcohol use (up to past 30 d) prevalence ranged between 52.8% and 92% (Baral et al., 2010; Chkhartishvili et al., 2021; Chumakov et al., 2023; Kasianczuk et al., 2009; Rosińska et al., 2018; Skryabin et al., 2020; Tripathi et al., 2009; Wirtz et al., 2016a, 2016b; Zohrabyan et al., 2013). Binge drinking prevalence ranged from 4% (daily) to 89.8% (lifetime) (Lee et al., 2022; Wirtz et al., 2016a). Regarding the frequency of alcohol use among SGM in the region, daily alcohol use varied between 6.3% and 15.1% whereas studies reported that 42.2% –50.8% of SGM consumed alcohol weekly (Kasianczuk et al., 2009; Tripathi et al., 2009; Wirtz et al., 2016a). Lastly, 20.3%–32.8% of SGM reported alcohol dependency across studies with one study identifying 32.4% of the participants as hazardous drinkers (Parker et al., 2015, 2016; Rüütel et al., 2017; Wirtz et al., 2016a, 2016b).

Opioid and injection drug use

Injection drug use was often not specified in studies and were mixed in descriptions of the use of opioids. For instance, Baral et al. (2010) indicate that some substances injected among people who inject drugs included opium, heroin, and ephedrine. The prevalence of IDU varied widely (1.01%–8%) (Baral et al., 2010, 2012; Fajardo et al., 2022; Tripathi et al., 2009; Wirtz et al., 2016a, 2016b; Zohrabyan et al., 2013). Similar variation in prevalence was observed in studies that specified the substance used as “heroin”, “opioids”, “China White”, or “White Persian” (3.5%–13.5%) (Baral et al., 2010; Lee et al., 2022; Tripathi et al., 2009).

Club/party drugs and stimulants

Studies differed substantially in their classification of substances as club or party drugs or as stimulants. Among them, cocaine was prevalent among 7.2%–16.7% of the participants whereas 2.4%–53.3% indicated the use of club or party drugs (e.g., MDMA, GHB/GBL, mephedrone) (Baral et al., 2010; Berg et al., 2017; Lee et al., 2022; Rosińska et al., 2018; Skryabin et al., 2020; Tripathi et al., 2009).

Cannabis

Noteworthy, no studies in Russia examined cannabis use. In countries where cannabis use was documented (i.e., Estonia, Kazakhstan, Lithuania), reported usage ranged from 3.1% to 57.6% (Lee et al., 2022; Rosińska et al., 2018; Tripathi et al., 2009).

Unspecified and other drug use

Eight studies examined drug use without specifying the type of drugs (e.g., any drug use, illegal drug use). Rates of unspecified drug use over the past year was reported among 5.1%–23% of the participants (Chkhartishvili et al., 2021; Kasianczuk et al., 2009; Parker et al., 2015, 2016; Rüütel et al., 2017; Tripathi et al., 2009; Zohrabyan et al., 2013) with one study examining lifetime illegal drug use found a prevalence of 46% among MSM in Estonia (Parker et al., 2016).

Regarding the use of other substances, tobacco use was assessed in one study in Georgia where authors found that 73.8% of participants reported current smoking, with smokers reporting an average of 19.8 cigarettes per day (Chkhartishvili et al., 2021). Chemsex or sexual performance (e.g., poppers) drugs were used by 0.3%–13.3% of the participants (Rosińska et al., 2018; Skryabin et al., 2020). Polysubstance use (45.4%–60%) (Lee et al., 2022; Parker et al., 2015; Skryabin et al., 2020), extra-medical use of prescriptions (37.8%) (Chumakov et al., 2023), and inhalant use (44.7%) were also prevalent (Lee et al., 2022).

Demographic differences in substance use

Although not many studies explicitly examined demographic differences, some disparities were identified. In one study conducted in Estonia (Tripathi et al., 2009), participants of Russian ethnicity living in Estonia were more likely to engage in the use of illicit substances relative to their ethic Estonian counterparts. Disparities were observed among participants based on sexual orientation whereby bisexual participants were identified as more likely to belong to harmful or dependent alcohol users’ group in Russia (Wirtz et al., 2016a). In Estonia, however, bisexual persons drank alcohol at lower levels than their homosexual counterparts (Tripathi et al., 2009). Disparities were also observed based on the level of education. Those who reported higher educational attainment reported lower alcohol consumption (Tripathi et al., 2009) and higher levels of cigarette quitting importance (Chkhartishvili et al., 2021). Lastly, belonging in an older age group (>25) was associated with a greater number of cigarette smoking per day among MSM in Georgia (Chkhartishvili et al., 2021).

Factors associated with substance use and misuse

Overall, two main themes emerged in relation to factors associated with substance use from the 19 studies that were categorized as the following: (a) sexual health and behaviors and (b) mental wellbeing and the use of other substances.

Sexual health and behaviors

HIV specific

HIV specific outcomes were examined in four studies (Baral et al., 2010, 2012; Lee et al., 2022; Wirtz et al., 2016b). Conflicting evidence was reported between the studies, with injection drug use being linked to higher odds of HIV infections among MSM in Russia in one study (Baral et al., 2012) while two other studies conducted with 50 MSW and 1367 MSM in Russia, respectively, revealed no significant differences in HIV infection odds for IDU or hazardous alcohol use (Baral et al., 2010; Wirtz et al., 2016b). Further, one study conducted among MSM and transgender participants living in Kazakhstan (Lee et al., 2022) identified higher odds of lifetime HIV testing among participants who reported polydrug use.

Sexual behaviors and relaxation

Most commonly, substance use was discussed in the context of sexual relations. In Estonia (Tripathi et al., 2009), Russia (Wirtz et al., 2016a), and Ukraine (Kasianczuk et al., 2009), hazardous alcohol use among MSM was associated with lower odds of condom use. In Russia (Skryabin et al., 2020), nonspecific chemsex and party drugs were also implicated with the same outcome among MSM in Russia (Berg et al., 2017) whereas such correlation was not identified with any substances among MSM in Moldova (Zohrabyan et al., 2013). Additionally, chemsex, party drugs, and hazardous alcohol use was correlated with higher odds of intercourse with multiple partners, engaging in sex work, and early sex debut among MSM in Russia (Skryabin et al., 2020; Wirtz et al., 2016a).

Participants indicated that chemsex, moderate alcohol use, poppers, and sometimes unknown substances aided with relaxation and enhanced confidence during sexual encounters, while these practices also fulfilled sensations of pleasure and risk seeking (Meyer et al., 2010; Niccolai et al., 2013; Skryabin et al., 2020). One 18-year-old MSW living in Russia explained, “I think alcohol is quite appropriate. Before the act, to relax, to create an atmosphere where people are more at ease. Especially when it’s the first encounter, when you see a person for the first time, so that you can have closer communication … I think wine is enough. [Interviewer: And, hard liquor – vodka, cognac?] I think it’s unnecessary.” (Niccolai et al., 2013). In another instance, one MSM noted, “I had no idea what the substance it was. A man at the private party just offered me that and I agreed. Surely, I knew it was quite risky, but this risk was so attractive…” (Skryabin et al., 2020).

Simultaneously, the use of substances was associated with safety concerns among MSM. Traumatic sexual encounters (violent or unwanted), non-sexual violence, and theft was described by MSM in Russia (Niccolai et al., 2013; Skryabin et al., 2020). For instance, a 22-year-old MSW living in Russia discussed “I have one friend who was robbed. He met a boy at a gay club, got drunk, and brought the boy to his place. The boy gave him some kind of pills that put him to sleep, and the boy took 1000 roubles from him. A credit card with the PIN-code was also in the bag.” (Niccolai et al., 2013). Men discussed reducing or eliminating alcohol and drug use to minimize such risks. In one study, a 31-year-old MSW living in Russia explained the following as a risk-mitigating strategy, “I used cocaine once. But that was a long time ago. And I said to myself that that’s it, if a client suggests cocaine, I will just turn around and say ‘goodbye’. I now dictate the conditions and they are drug-free.” (Niccolai et al., 2013).

Some MSM differentiated between different subgroups of “MSM” and related substance use. For instance, in a study conducted in Georgia (Meyer et al., 2010), substance use to be more prevalent among “elite MSM”, who can actually afford the use of such substances. One MSM in his mid-20s living in Georgia indicated, “[The elite] may inject drugs and meet their requirements for everything. They have more to do with drugs. As for [the lower classes], this is not the case among them. I think it will never be the case…. They have no financial standing and so drugs are also out of the question here.” (Meyer et al., 2010).

Mental wellbeing and the use of other substances

Use of substances were also associated with poorer mental wellbeing (Parker et al., 2015; Rüütel et al., 2017; Skryabin et al., 2020). Anxiety, shame, and apathy were associated with unspecified chemsex or pre-sex alcohol use (Parker et al., 2015; Rüütel et al., 2017) while alcohol dependence, but not use of illicit drugs, was associated with increased odds of suicidal ideation among MSM (Skryabin et al., 2020). In the same vein, 37.8% of transgender participants living in Russia reported extra-medical use of prescription substances in order to improve mental well-being or mood (Chumakov et al., 2023).

Use and hazardous use of alcohol, and dependence on the substance were associated with the use of other substances among MSM (Chkhartishvili et al., 2021; Parker et al., 2015; Tripathi et al., 2009; Wirtz et al., 2016a). Namely, the implicated substances were unspecified recreational, illegal, and injection drugs, tobacco, and sedatives (Chkhartishvili et al., 2021; Parker et al., 2015; Tripathi et al., 2009; Wirtz et al., 2016a). Certain substance use behaviors and patterns were also described in increased use of other substances, with frequent use and polydrug use being linked to dependence, (Parker et al., 2015; Tripathi et al., 2009). Lastly, higher average number of cigarettes smoked per day (>20) and smoking within 30 min of waking up predicted lower quitting confidence levels (Chkhartishvili et al., 2021).

Discussion

The current review, to the best of the authors’ knowledge, is the first examining substance use and misuse among sexual and gender minorities living in former USSR countries. We identified 19 articles that presented the prevalence and correlates of substance use, examined demographic disparities related to substance use, and the associations between substance use and sexual health, mental wellbeing, and the use of other substances. Sexual and gender minorities across studies reported a high prevalence of regular and hazardous alcohol use and dependence, tobacco, stimulant or club drug use, engagement in chemsex, and unspecified substance use. The use of injection drugs, including opioids, was reportedly not as high as other substances but remained prevalent. In samples of the included studies, hazardous alcohol use and dependence rates were highly prevalent (Parker et al., 2015; Parker et al., 2016; Rüütel et al., 2017; Wirtz et al., 2016a). Of note, despite the rates of hazardous alcohol use and alcohol use dependence among sexual and gender minority individual in included studies being lower than the “high risk samples” documented in Russia (58%) (Lan et al., 2017), they were markedly higher compared to the general population in Russia and Estonia (Lan et al., 2017; Poznyak & Rekve, 2014; Rehm et al., 2022; The International Association of National Public Health Institutes, 2022). Similar patterns were observed in tobacco use. In the only study examining cigarette smoking, 73.8% of the Georgian MSM participants reported smoking (versus 29.9-52.8% reported among in the general population) (Healthy Initiatives, 2021; Roberts et al., 2012). Observed high substance use prevalence and related disparities between the general population and SGM in the region could be suggestive of minority stress experiences among MSM in the region (Hendricks & Testa, 2012; ILGA, 2022; Meyer, 2003). Chumakov et al. (2023) found that among transgender participants, half of whom experienced stigma-related barriers in seeking mental health treatment, 37.8% engaged in extra-medical use of substances to improve their mental health. Minority stress experiences among SGM are increasingly exacerbated in the region as reporting points to violence including homicide, free speech limitations, preemptive constitutional bans on marriage equality, and state-sponsored anti-LGBTQ media propaganda as some of the recent minority stress experiences among the community (Amnesty International, 2017; ILGA, 2022; Kottasová, 2022; Zavalei, 2020).

There were also demographic disparities observed in some studies. For example, higher education status was a protective factor and was associated with improved substance use patterns, such as lower alcohol use and higher confidence in quitting cigarette smoking (Chkhartishvili et al., 2021; Tripathi et al., 2009). These findings regarding education status and alcohol use are aligned with previous literature which has found a relationship between lower educational attainment and higher alcohol use (Katikireddi et al., 2017; Mackenbach et al., 2015; Rehm et al., 2006; Schmengler et al., 2022). Previous studies conducted in the U.S. among the general population suggested that individuals with higher educational backgrounds were more likely to attempt to quit smoking (Zhuang et al., 2015) and succeed in quitting (Cao et al, 2023). One plausible explanation is that higher educational attainment and its relationship with higher socioeconomic status (SES) and improved access to resources associated with higher SES may explain higher alcohol use among SGM with lower educational attainment (Assari & Lankarani, 2016; Cao et al, 2023; Katikireddi et al., 2017; Mackenbach et al., 2015; Schmengler et al., 2022; Zhuang et al., 2015). Our review also identified conflicting alcohol use patterns related to the sexual orientation of participants in Russia and Estonia, whereby bisexual participants reported lower consumption of alcohol in Estonia compared to their homosexual counterparts whereas Wirtz et al. (2016a) found that bisexual participants were more likely to be harmful or dependent alcohol users than low-level users or abstainers. It is possible that the conflicting results are a product of the differences in geography and sample composition. However, high levels of alcohol use have also previously been documented among bisexual persons relative to gay or lesbian persons, as the former group may experience biphobia in addition to LGBTQ-related discrimination leading to disproportionate minority stress burden (Demant et al., 2017; Talley et al., 2014; Schuler & Collins, 2020; Zivony & Saguy, 2018). These complex interplay between alcohol use, sexual orientation, and gender identity suggest the need for a comprehensive and nuanced approach to understanding and addressing the multifaceted dynamics in the specific social and cultural context among SGM living in this region.

In terms of the associations between substance use and sexual health, contradictory results emerged concerning connections to sexual behaviors and HIV infections. There was no evidence suggesting a correlation between HIV infection risk and alcohol use in included studies. This is in stark contrast to previous literature, which suggested higher odds of HIV infections among individuals who use alcohol (Baliunas et al., 2010; Kenyon et al., 2018). Interestingly, we did identify a relationship across studies highlighting substance use, including alcohol use, before sexual encounters to be associated with unprotected anal intercourse and inconsistent condom use. Hesitancy in condom use and engagement in unprotected sexual activities have been linked to the use of alcohol and other substances previously (Hibbert et al., 2019; Kenyon et al., 2018; Khumaidi et al., 2021; Maxwell et al., 2019; Maviglia et al., 2022). It is likely that reduced condom use, and increased engagement in unprotected sexual activities stem from reduced inhibition associated with substance use as echoed in previous studies. Such an assertion is supported by SGM across studies describing the use of substances prior to sexual encounters as a mechanism to reduce inhibition, induce relaxation, and seek risk and sensation. Many also associated the use of substances with poorer mental wellbeing, such as anxiety, suicidal ideation, shame, and the use of other substances. Similar patterns have been identified among MSM engaging in chemsex (Hibbert et al., 2019; Íncera-Fernández et al., 2021; McKirnan et al., 1996; Nöstlinger et al., 2020). Given the lack of temporal precedence in the reviewed studies, establishing a direction in substance use and mental health concerns is not possible. Considering the exposure to high levels of minority stressors among SGM in this region, they may experience poor mental wellbeing even prior to initiating the use of substances. Perhaps, the use of substances, whether it be in relation to sexual encounters or independent of them, are a mechanism of cognitive escape (Card et al., 2020; Manser & Du Bois, 2021; McKirnan et al., 1996) from minority stress experiences. Cognitive escape has been found to be related to sex-related substance use to facilitate a reduction in stress and engagement in more fulfilling encounters (Alvy et al., 2011; Card et al., 2020; Íncera-Fernández et al., 2021; Perdue et al., 2003). A growing literature has also documented the use of substances as a correlate of minority stressors among SGM (O’Cleirigh et al., 2015; Goldbach et al., 2014; Gonzales & Ehrenfeld, 2018; Hatzenbuehler et al., 2014; Manser & Du Bois, 2021) as well as a relationship between minority stressors and unprotected anal sex among SGM (Hatzenbuehler et al., 2008; Meyer, 2003; Rood et al., 2018; Yunyong et al., 2016). More research is needed to better understand the minority stress experiences of SGM living in former USSR nations in relation to substance use, mental wellbeing, and sexual health.

It is noteworthy that even though literature has linked victimization experiences to particularly hazardous substance use patterns, only two studies inquired about victimization experiences of SGM in the region (Baral et al., 2010; Niccolai et al., 2013). Studies found that male sex workers in Russia experienced violence from clients but did not explore how such experiences were related to poorer mental wellbeing, substance use, or sexual behaviors. Considering the victimization experiences of SGM in the region and the links to hazardous substance use patterns, it is critical for future literature to study how victimization of SGM living in former Soviet nations may contribute to substance use disparities.

It is also important to note that much of the reviewed studies focused on experiences of MSW or MSM who engage in sex work. Given the previously documented high substance use prevalence among persons engaging in sex work (Iversen et al., 2021; Pandey & Seelman 2022; Ulibarri et al, 2014), the high rates of regular and disordered use of substances may in part be attributable to the population sampled in these studies. As such, it is plausible that substance use prevalence and experiences described in studies in the current review are influenced by their experiences related to sex work and are not entirely reflective of the experiences of SGM who do not engage in any sex work. Future research examining substance use behaviors among SGM in the region should strive to recruit samples comprising of SGM with more demographic and socioeconomic diversity.

The dire need for more diverse samples of SGM from this region is further underscored by our review, considering the scant nature of substance use literature among SGM women in this region. Most studies examined substance use among cisgender men, with only three studies including transgender persons and a single study assessing outcomes among transgender women (Chumakov et al., 2023). Related, substance use experiences of SGM living in Armenia, Azerbaijan, Kyrgyzstan, Latvia, Tajikistan, Turkmenistan, and Uzbekistan were completely absent while only a single study was conducted with SGM living in Ukraine, Kazakhstan, Lithuania, and Moldova. The notable absence of the voices of SGM women and SGM living in former USSR countries where no studies were identified limits our ability to make inferences about their experiences. The need for additional research examining minority stressors and related substance use among SGM in the region that transcend the experiences of men who have sex with men or substance use related to sex work is abundantly clear.

Limitations

The current review is not without limitations. Particularly, only studies published in English were reviewed, potentially excluding valuable insights published in other languages. Furthermore, the methodological quality of the reviewed studies was not examined. Similarly, findings across studies were synthesized narratively as heterogeneity in reviewed studies did not allow for a meta-analysis. Additionally, the experiences of gender-diverse individuals who do not explicitly identify as transgender are reflected only in one study, limiting our review in its ability to provide insights into the minority stress experiences and substance use patterns of non-transgender gender diverse persons.

Conclusion

Our review contributes to current literature by examining substance use and misuse and related correlates among SGM living in post-USSR countries. Our findings point to high substance use prevalence and hazardous use patterns of a number of substances among men and transgender persons across studies in the region. Substance use was reported related to sexual encounters to induce relaxation, at times being associated with reduced sexual protection, traumatic experiences, the use of other substances, and exacerbated mental wellbeing. The current review also identified a substantial gap in literature examining substance use among SGM in majority of the former-USSR countries and among SGM who are not MSM. More research is necessary to add complexity to our understanding of substance use patterns among SGM that transcend sexual experiences and tap into minority stressors for some of the most marginalized communities in the region. This is especially critical now as reporting from international organizations paint an increasingly dire image of basic human rights for SGM living in former USSR nations.

Note

1

Armenia, Azerbaijan, Belarus, Georgia, Estonia, Kazakhstan, Kyrgyzstan, Lithuania, Latvia, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, Uzbekistan.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contributions

TM conceptualized the study, developed the search strategy, conducted record search, study selection, and data extraction, and drafted the manuscript. CH assisted in the development of the search strategy, drafting of the methods and results, and review and editing of the manuscript.

Disclosure statement

The authors report there are no competing interests to declare.

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