Minority stress and the development of problem alcohol use among sexual minority youth: A scoping review synthesizing multidisciplinary mechanisms of risk

Abstract

Beginning in adolescence, lesbian, gay, and bisexual (LGB) individuals exhibit higher levels of problem alcohol use relative to heterosexual populations. Based in minority stress theory, psychological mediation frameworks of LGB psychopathology typically serve as explanatory models of these disparities, suggesting that LGB identity-related stressors lead to social and affect-related mechanisms that proximally influence alcohol use disorder risk. While stress and its psychological consequences are considered universal risk factors, minority stress research has yet to be synthesized with theory and evidence from general adolescent studies of alcohol use. This is needed to translate and refine minority stress theory to the developmental context of emerging use, and to determine plausible targets for prevention and early intervention of alcohol-related health risk. Here, I compare theories from LGB and general youth populations articulating psychological mechanisms linking stress with the development of problem drinking behaviors. I then review studies examining these mechanisms in the prediction of LGB alcohol behaviors in youth. Finally, incorporating multidisciplinary findings, I highlight understudied areas of inquiry in a developmental pathway model of sexual minority alcohol use and disorder that may guide future alcohol research involving LGB youth. This review demonstrated that while studies have focused primarily on negative affect-based mechanisms of alcohol risk, few have examined stress-related changes in positive affect, social contexts, and interactions among these pathways. Studies addressing a confluence of these mechanisms of risk over time are critically needed to better inform etiology, prevention, and intervention of problem alcohol use among younger LGB populations.

1. Introduction

Although epidemiological evidence has consistently shown that lesbian, gay, and bisexual (LGB) adults have higher rates of alcohol use disorder (e.g., Cochran et al., 2004; McCabe et al., 2009; Shokoohi et al., 2022), studies of youth suggest that disparities in problem drinking behaviors (e.g., heavy and binge drinking) begin in adolescence and persist into adulthood (Fish & Pasley, 2015; Needham, 2012). Meta-analytic findings, for instance, have shown that LGB adolescents were over 1.3 times as likely to report heavy drinking (Marshal et al., 2008), and subsequent estimates from large national samples have shown heightened heavy episodic drinking among sexual minority youth relative to heterosexual peers (Corliss et al., 2008; Talley et al., 2014). Studies further indicate that LGB youth initiate substance experimentation earlier; demonstrate higher early levels of use; exhibit more hazardous patterns at earlier stages of use; and show faster increases in use through adulthood (Marshal et al., 2012; Talley et al., 2019). Moreover, it is increasingly recognized that alcohol disparities vary markedly within LGB communities. For instance, consistent with studies of adults (Doan Van et al., 2019; Schuler & Collins, 2020; Shokoohi et al., 2022), bisexual youth (Fish & Pasley, 2015; Watson et al., 2019) and particularly bisexual girls (Fish et al., 2017) may have greatest risk of alcohol use and misuse in adolescence. Literature has also acknowledged differential risk of problem alcohol behaviors at intersections of race, sex, age, and sexual orientation (E. Mereish, 2024; Talley et al., 2016), with some evidence indicating unique patterns of risk among non-White LGB groups (Newcomb et al., 2014; Talley et al., 2014). Given adolescent and young adult alcohol use plays a central role in shaping lifelong alcohol use disorder risk (Chassin et al., 2002, 2013; Chassin & Sher, 2024; McGue & Iacono, 2005), understanding drivers of early alcohol risk among LGB populations is crucial in prevention and intervention of alcohol-related health disparities across the lifespan.

Minority stressors may play a central role in shaping individual differences in early problem drinking risk (Meyer, 2003). LGB-specific stressors can include victimization, expectations of rejection, concealing one’s sexual identity, internalized homophobia, and limited access to coping resources that are thought to induce stress and increase risk for both internalizing and substance-related psychopathology (Keyes et al., 2011). Above and beyond experiences stemming from heterosexism, stressors unique to LGB subpopulations, including monosexism and binegativity, may also represent distinct forms of stigma that confer additional alcohol risk among these communities (Ford et al., 2023). Sexual minority stressors are highly prevalent in adolescence, during which sexuality-related victimization is at a peak across multiple contexts (Russell & Fish, 2015). Meta-analysis has shown, for instance, that sexual minority youth were between 1.2 and 3.8 times more likely than heterosexual peers to have experienced physical or sexual abuse or experience victimization in a school environment (Friedman et al., 2011). LGB youth are also more likely to get involved in fights (Faulkner & Cranston, 1998; Garofalo et al., 1998); skip school (Darwich et al., 2012); be forced out of the home by caregivers due to their sexual identity (Cochran et al., 2002; Fournier et al., 2009); and receive less acceptance and social support from caregivers than their same-age heterosexual peers (Bouris et al., 2010; Ryan et al., 2010). This demonstrates a breadth of exposure to external stressors spanning the home, peer, and school contexts that in turn may produce problem drinking risk.

Minority stress may also be experienced via structural stigma, referring to institutional or community-based factors such as laws, policies, and social attitudes that limit opportunities and resources for LGB individuals and reinforce negative perceptions of sexual minority identity (M. L. Hatzenbuehler, 2016; M. L. Hatzenbuehler et al., 2024). Most commonly, studies have quantified structural stigma by creating measures of state, neighborhood, or country-level measures, such as the (absence of) nondiscrimination protections for LGB communities, conversion therapy bans, and anti-bullying laws that protect LGBTQ students from harassment on the basis of their sexual orientation or gender identity (Movement Advancement Project, 2020; Zollweg et al., 2023). Addressing structural factors specific to LGB youth, these factors may further include measures at the school-level, such as the presence or absence of Gay-Straight Alliances and safe spaces for LGB youth; curricula addressing topics specifically relevant to LGB communities such as HIV prevention; and mandating staff trainings that address supporting LGB student needs (M. L. Hatzenbuehler, 2017). While structural stigma research is relatively nascent for LGB youth populations, reviews have demonstrated a moderate link between measures of structural stigma and problem alcohol behaviors in adulthood (Zollweg et al., 2023).

Despite a clear direct link between sexual minority stress and substance use behaviors (Goldbach et al., 2014), little work has addressed psychological mechanisms through which minority stressors more proximally influence problem drinking among LGB youth. Prior work hypothesized multiple mechanisms linking minority stress with several forms of adult psychopathology, including substance use disorders, that include both social and affect-based mechanisms of risk (Hatzenbuehler, 2009; Pachankis, 2015). However, these mechanisms span several forms of LGB psychopathology and are not specific to conceptualizing risk for early problem drinking. Moreover, these have not incoprorated developmental psychopathology theory and research on alcohol use and disorder in the general population (Chassin et al., 2013), which may critically inform the conceptualization of stress-related risk among LGB youth. For instance, Hatazenbuehler’s psychological mediation framework (Hatzenbuehler, 2009) suggested that the experience of distal stigma-related stressors confer elevated risk for psychopathology via 1.) poorer coping resources for reducing stress-related negative affect (e.g., emotion dysregulation and fewer resources for social support); 2.) social and interpersonal contexts (e.g., permissive substance use norms); and 3.) cognitive changes (e.g., hopelessness, pessimism, and alcohol expectancies) that increase risk for multiple forms of psychopathology. However, Hatzenbuehler reported in this review only one study of LGB young adults linking minority stress (discrimination) with alcohol problems through a proposed mediator (positive alcohol expectencies; Hatzenbuheler, Corbin, & Fromme, 2009) and none from studies of youth. Pachankis (Pachankis, 2015) similarly proposed a transdiagnostic heuristic informing the mental health treatment of sexual minority adult men. They argued that social functioning and positive and negative valance pathways (e.g., approach motivation and avoidance) are common stress-related mechanisms that are critical treatment targets informing shared risk for a range of disorders. Yet, no studies referenced in their work provided empirical support for this model in the study of problem drinking among LGB youth. Although this work provides a crucial foundation for understanding mechanisms of risk for psychopathology among LGB youth, whether and how these mechanisms explain risk specific to problem alcohol use and disorder in youth has yet to be evaluated.

1.1. Purpose of the present paper

This scoping review aims to integrate etiological models of substance use with sexual minority stress theory to formulate a developmental framework of stress-related alcohol use risk among LGB youth. I first review developmental theory that articulates mechanisms linking stress with increased risk for problem alcohol use. Then, I conducted a search for existing mediation research that tested one or several mechanisms described by these models in samples of LGB adolescents, and evaluated findings within the context of these theoretical models. Finally, I synthesize these findings with those reported in general population studies of developing alcohol use and disorder and provide a developmental pathway model of alcohol use disorder that synthesizes recommendations for future LGB alcohol use research.

2. Methods

For this review, I conducted a comprehensive search for articles in the following databases: Google Scholar, MEDLINE, PsycARTICLES (EBSCOhost), PsychINFO (EBSOhost), and PubMED Central. Search terms included the following words or their variations: ‘mediation’, ‘sexual minority’, ‘lesbian’, ‘gay’, ‘bisexual’, ‘LGB’, ‘youth’, ‘adolescent’, ‘substance use’, ‘substance abuse’, ‘alcohol’, ‘drug use’, ‘minority stress’, ‘emotion regulation’, ‘emotion dysregulation’, ‘coping’, ‘vicitimization’, ‘discrimination’, ‘externalizing’, ‘internalizing’, ‘reward sensivity’, ‘social’, ‘enhancement’, ‘sensation seeking’, and ‘norms’. Criteria for inclusion were:

1. the study included LGB youth and were the primary population of interest (i.e., ages 13 years to 17 years);

2. the study referenced and was published after publication of Hatzenbuehler’s psychological mediation framework (2009) through October 2024;

3. the study assessed the relation between sexual minority status or minority stress (e.g., experiences of vicitimization, internalized stigma) and problem alcohol use (e.g., heavy and binge drinking, alcohol use disorder, experiencing alcohol-related problems);

4. the study tested at least one mediated pathway of this relation involving a social (e.g., affiliating with substance-using peers) and/or affective processes of risk (e.g., depression, anxiety, or enhancement motives); and

5. the article was available in English.

Papers satisfying the above criteria were obtained electronically for assessment. Manuscripts were selected for inclusion after full review by the manuscript author.

3. Results

3.1. Negative Affect Pathways of Substance Use

Both substance use literature and minority stress theory have suggested that stress, negative affect (e.g., depression and anxiety), and emotion dysregulation raise risk for alcohol misuse (Hatzenbuehler, 2009; a M. Hussong & Chassin, 1994; Sher et al., 1991; Sher & Grekin, 2007), which may be one pathway by which minority stress experiences influence problem use behaviors (Hatzenbuehler, 2009; Pachankis, 2015; Pitoňák, 2016). Broadly, these perspectives can be understood to reflect a negative reinforcement model of substance use, whereby use is driven by motivation to down-regulate negative emotional experiences.

In the general population, stress and negative affect theories of problem alcohol use have been synthesized in a developmental framework known as the internalizing pathway of alcohol use and disorder (Hussong et al., 2011) that posits how internalizing symptoms confer risk for alcohol-related disorder throughout development. This model is based on a developmental psychopathology perspective (Sroufe & Rutter, 1984) where indicators of depression and anxiety (i.e., internalizing symptoms) present from childhood to young adulthood may increase risk for alcohol misuse by modifying other interrelated risk factors during adolescence. These factors are thought to act in concert to shape risky alcohol use patterns into disordered use over time in the following ways. First, internalizing symptoms may shape drinking expectancies either prior to or in early stages of use, which increases risk for alcohol use engagement and reinforcement from early use that transitions into coping motives and heavier use over time (Rafnsson et al., 2006; Tubman et al., 2003). Second, internalizing symptoms may confer greater risk for interpersonal difficulties, prompting social isolation and a greater likelihood of affiliating with deviant and substance-promoting peers (Lillehoj et al., 2004). Third, they may predict later or continued experiences of internalizing symptomatology, such that youth experiencing greater and more persistent internalizing symptoms will be at greatest risk of developing heavier and more problematic patterns of use over time.

Whereas the models described above suggest that the experiences of distress and negative affect motivate substance use behavior, emotion dysregulation is also thought to increase reliance on substance use as a means of coping with distress in the absence of more adaptive strategies (e.g., Siegel, 2015; Wilcox et al., 2016). Broadly, emotion dysregulation represents conscious or non-conscious difficulties in modulating emotional responses to the environment (Aldao et al., 2010). This can include poor emotional awareness and understanding of emotion; limited access to emotion coping resources and adaptive strategies; and engaging in maladaptive patterns of responding to emotion such as rumination (Gratz & Roemer, 2004). A meta-analysis found that emotion dysregulation was modestly to moderately associated with substance use behaviors (Aldao et al., 2010), and several studies have demonstrated a link between emotion dysregulation and substance use in adolescence. For instance, Nolen-Hoeksema and colleagues (2007) found that rumination predicted substance abuse symptoms one year later in a sample of adolescent females (ages 11–15 years), and Weinberg and Klonsky (2009) found that a composite measure of difficulties in emotion regulation correlated modestly with alcohol use (r = 0.24) and drug use (r = 0.19) in a community sample of 13–17 year olds.

3.1.1. Supporting Evidence among LGB Populations

Overall, several mediation studies to date have tested and provided evidence for negative affect pathways of problem alcohol use among LGB adolescents and young adults. Specifically, findings suggest potential roles of depressive symptomatology and/or coping motives in this association.

Addressing depression as a mediator, Marshal and colleagues (Marshal et al., 2013) examined the effect of sexual orientation, gay-related victimization, and depression symptoms on drug and alcohol use data from 156 adolescent females, 64 of whom reported sexual minority status (i.e., “not 100% heterosexual”). Controlling for age and race, they found that that the relation between sexual orientation and cigarette, alcohol, and heavy alcohol use was explained by both victimization and depression. Similar results were found in a longitudinal sample of 3,710 adolescents between 15 and 18 years (454 identifying as ‘not 100% heterosexual’; Pesola et al., 2014). Controlling for parental drinking, parental depression, and socioeconomic status, they found a mediating effect of depression on the relation between minority status and alcohol problem use, with no gender differences observed (Pesola et al., 2014). In contrast, Kiekens and colleagues (Kiekens et al., 2020) did not observe indirect effects when testing fear of negative social evaluation and lack of social support as mediators in the relation between peer and parental minority stressors and alcohol use. Participants were Dutch adolescents (N = 1738, 151 LGB) measured over five waves of data collection. Covarying gender, parental socioeconomic status and ethnicity, they found no evidence of psychological mediation for alcohol outcomes, nor did they find differences between LGB and heterosexual youth in alcohol use in general.

Addressing coping motives as a mediator, two studies tested a link between minority stress and alcohol use behaviors. First, McGraw and colleagues (McGraw et al., 2023) used a large and representative sample of sexual and gender minority middle and high schoolers (N = 6909; mean age 15.03 years) residing in Utah to examine the impact of sexual minority-related bullying on a substance misuse. Testing four psychological mediators (parental closeness, family conflict, negative cognitions, and motivation for substance use) and including age, grade level, race, and gender as covariates, findings suggested that bullying was associated with substance misuse through heightened motivation for use (quantified as using alcohol or drugs to relieve “sadness, anger, or boredom”). Second, Mereish and colleagues (E. H. Mereish et al., 2024) tested the effects of oppression-based stress on coping motives and alcohol use in a large cross-sectional subsample of sexual and gender minority black or indigenous youth of color from the 2022 LGBTQ National Teen Survey (N = 1365). Oppression-based stress was measured as microaggressions experienced by LGBT people of color that quantified number of microaggressions experienced as well as distress felt by such experiences. Controlling for sexual orientation, age, and gender identity, results indicated that both the count and distress experienced by microaggressions were associated with greater coping motives for alcohol use, which in turn mediated greater odds of alcohol use and hazardous drinking. Sensitivity analyses further showed that this effect was present for biracial/multiracial and White Latine respondents but was not found for Latine racial minority youth.

Finally, although several studies have shown that emotion dysregulation mediated the relation between sexual minority status or stressors and psychological distress (Hatzenbuehler et al., 2008; Hatzenbuehler, Dovidio, et al., 2009; Hatzenbuehler, Nolen-Hoeksema, et al., 2009; Szymanski & Henrichs-Beck, 2013), no studies to date have examined emotion regulation as a mediator between minority stress and alcohol among LGB youth.

3.1.2. Summary

Available evidence suggests that either depressive symptomatology or coping motives may explain the relation between minority stress and problem alcohol use. Moreover, studies consistently controlled for gender, socioeconomic status, age, and race/ethnicity, suggesting mediated effects are likely robust to these potential confounds. However, emotion dysregulation and anxiety symptoms as mediators have yet to be examined for problem drinking outcomes. Although emotion dysregulation (M. L. Hatzenbuehler et al., 2008; A. K. Matthews et al., 2002; C. J. McCabe et al., 2021) and anxiety disorders (Cochran et al., 2003) are both elevated among LGB relative to non-LGB populations, emotion dysregulation may be a more likely mediator. General population studies indicate that while evidence linking emotion dysregulation with early problem alcohol use is emerging (e.g., Nolen-Hoeksema et al., 2007; Weinberg & Klonsky, 2009), findings have been mixed regarding the role of anxiety in alcohol use risk. For instance, one systematic review of general adolescent population studies found that out of 63 tests examining the relation between anxiety and substance use independent of externalizing behavior, only 5 found a positive unique association between anxiety and substance use, 6 found a negative association, and the remaining 52 found no relation (Hussong, Ennett, Cox, & Haroon, 2017). Research testing the mediating role of emotion dysregulation rather than anxiety symptoms may therefore show greater promise in explaining stress-related problem use risk among LGB youth.

Moreover, consistent with a prediction of the internalizing pathway model (Hussong et al., 2011), cognitive aspects of alcohol use per se (e.g., expectancies) may be more proximal mediators in this relation (e.g., Hatzenbuehler et al., 2011). Although positive expectancies of alcohol use are likely to increase coping motives in the presence of stress and negative affect (e.g., believing alcohol will reduce tension; Cooper et al., 1995), no studies I reviewed addressed expectancies in this relation. Expectancies may play a central role in the subjective experience of alcohol use independent of the actual physiological consequences of use (e.g., whether use actually reduced tension). For instance, some evidence has suggested a self-fulfilling link between positive expectancies and subjective experience regardless of the quantity of alcohol consumed (e.g., Lee et al., 2020). Relatedly, a lack of negative expectancies (e.g., that one will become aggressive when drinking) may be a distinct cognitive driver of alcohol use (Adams & McNeil, 1991), though evidence linking negative expectancies and consumption are mixed (Epler et al., 2009). Nonetheless, a systematic review indicated that youth report both declining negative and increasing positive alcohol expectancies throughout adolescence (Smit et al., 2018), suggesting both forms of expectancies may be relevant in the context of adolescent development. Taken together, future research should focus on the impact of stress and internalizing symptomatology on modifying alcohol use expectancies, and whether this in turn predicts problem drinking risk among LGB youth.

Finally, the relation between stress, negative affect and substance use in LGB youth may only be observable in the context of co-occurring risk (Hussong et al., 2011). For instance, in general population studies of adolescence, Colder and Chassin (Colder & Chassin, 1993) found that low positive affect was associated with adolescent alcohol use, but only among those who were also high on impulsivity. A similar relation was found by King and colleagues (King et al., 2011) in which depressive symptoms among young adults was protective against alcohol problems when conscientiousness was high, but were a risk factor when conscientiousness was low. In the context of sexual minority stress, this may indicate that stress and negative affect may operate predominantly as moderators or underlying drivers of separate co-occurring risk factors. These may include cultural factors influencing the availability of substances, such as patronage of gay bars and nightclubs in the transition to young adulthood (Greenwood et al., 2001), alcohol expectancies, or other minority stress-related mechanisms of risk (reviewed hereafter).

3.2. Positive Affect Pathways of Substance Use

The positive affect regulation model of developing alcohol use refers to appetitive drive toward use as a means of enhancement, including using substances to “get high” or to “feel good” (Cooper et al., 1992; Sher et al., 2005). This model suggests that risk for substance use is characterized by sensitivity to positive reinforcement, such that substances are used to enhance (or up-regulate) mood. In contrast to negative affect pathways of use, these models broadly implicate positive reinforcement sensitivity as a critical predictor of vulnerability to alcohol use behaviors. A direct association between positive reinforcement sensitivity and addictive behaviors has been shown in the general population (Dawe et al., 2004; Gullo et al., 2014) and has been linked with having enhancement motives for alcohol use (Kuntsche et al., 2006). For instance, multiple studies of adolescents and young adults have suggested that individuals with greater sensitivity to immediate gratification (MacKillop et al., 2011) or trait indicators of behavioral approach (Mitchell & Potenza, 2014) are associated with substance use and problems in adolescence and young adulthood.

Stress experienced in early life may induce longstanding changes in positive reinforcement sensitivity, in turn heightening approach toward substance use (Andersen & Teicher, 2008, 2009; Brady & Sinha, 2005). Animal and human studies indicate that chronic activation of the stress response system may decrease tonic dopamine activity in reward regions of the brain that induces a baseline anhedonic state (K. Matthews & Robbins, 2003). Moreover, stress experienced in either early childhood (ages 3 to 5) or adolescence (11 to 13) may disrupt the functioning of brain systems involved in re-directing reward-seeking behavior, including the hippocampus and prefrontal cortex (Andersen & Teicher, 2008). Collectively, these changes in childhood and adolescence are thought to increase susceptibility to the positively reinforcing effects of alcohol and drug use via stress-induced alterations of the reward system. As such, stress and victimization experiences among LGB youth may correspond with greater increases in mood enhancement motives for alcohol use, which in turn increases risk for problem drinking behaviors.

3.2.1. Supporting Evidence

In spite of supporting evidence and theory (Andersen & Teicher, 2009; Dawe et al., 2004; Enoch, 2011; Pechtel & Pizzagalli, 2011; Sinha, 2008; Sinha et al., 2009), we found no mediation studies examining positive reinforcement motivation toward substance use that met criteria for review. One study comprised of a mostly young adult sample (age 16 to 29 years, mean age 22.87 years [SD = 3.17]; Feinstein & Newcomb, 2016) reported evidence of a mediating role of drinking to enhance in the relation between internalized stigma and alcohol problems among young men who have sex with men.

3.2.2. Summary

Although a current model of LGB substance use referenced a positive valence pathway (Pachankis, 2015), only one study has addressed a mediated positive affect pathway of alcohol use risk that included youth. Notably, this sample was mostly comprised of young adults and was centered on assessing alcohol risk specifically among young men who have sex with men (Feinstein & Newcomb, 2016). As a whole, this demonstrates that there is almost no evidence to-date that establishes this pathway of risk for youth, representing a critical area of future research. For instance, this work may seek to test whether approach-related risk indicators of substance use such as sensation seeking (Coskunpinar et al., 2013), enhancement motives (Cooper et al., 1995), or enhancement expectancies (Smit et al., 2018) are elevated among LGB youth, and whether these in turn mediate the effects of minority stress on substance use behavior.

3.3. Social Context Pathways of Substance Use

Sexual minority theory has suggested that social context is a mechanism in the relation between minority stress and substance use (Hatzenbuehler, 2009). Namely, minority-related stress (e.g., discrimination and peer rejection) may influence LGB youth toward marginalized social networks that are more permissive of alcohol use, which then shape problematic use through social reinforcement of such behaviors. Reviews have suggested that at-risk social contexts for alcohol misuse mirror many that are common among victimized LGB youth, including low commitment to school, alienation from dominant values in society, and low bonding with family units (Hawkins et al., 1992), among others. For instance, the experience of victimization among LGB youth has been linked to school truancy (Bontempo & D’Augelli, 2002), low school bonding (Murdock & Bolch, 2005), and running away from home or homelessness (Savin-Williams, 1994).

In the general population, social learning theories have posited that both prosocial and deviant behaviors are shaped by the effort to maintain positive bonds a child has to a particular social environment (Bandura, 1971; Catalano & Hawkins, 1996; Moffitt, 1993). Among youth, these primarily include home, school, and especially peer environments. Components of developmental models of alcohol use, including both internalizing and externalizing (i.e., deviance proneness) frameworks (Hussong et al., 2011; Sher, 1991), similarly acknowledge the roles of substance-permissive or substance-promoting environments in alcohol risk. These models suggest that psychopathology symptoms increase affiliation with deviant peers and environments and decrease affiliation with protective contexts, which in turn are among several proximal influences on alcohol use access, engagement, and misuse (Colder et al., 2013; King & Chassin, 2004; Zucker et al., 1995). Moreover, social learning principles suggest that social context serves a significant role in shaping expectancies about alcohol use in early life (Smit et al., 2018). For instance, observing positive responses to alcohol use by parents, peers, and media may reinforce beliefs about the benefits of alcohol use, thereby increases risk of use as well as the perception of positive consequences from use (Campbell & Oei, 2010). Together, these models broadly suggest that the extent to which social environments are permissive of (or directly model) problem use behavior may be a risk factor for engaging in such behavior (Oetting et al., 1998).

3.3.1. Supporting Evidence

Three studies using a sexual minority youth sample have explicitly tested whether the relation between victimization and problem alcohol use was mediated by social contexts pathways, and two of these report disparate findings upon replication. In the first, McGraw and colleagues (McGraw et al., 2023; sample details provided in section 3.1 above) tested parental closeness as a mechanism linking sexual minority bullying with substance misuse, finding that bullying predicted lower parental closeness that in turn predicted more substance misuse. In the second, Huebner and colleagues (Huebner et al., 2015) surveyed 504 LGB or transgender adolescents between 14 and 19 years of age. Participants reported their frequency of both sexual identity-related and unrelated victimization (e.g., being teased or physically harmed) and how often their friends engaged in antisocial behaviors. The authors found cross-sectional evidence of an indirect effect of anti-sexual minority victimization experiences on substance use¹ through affiliation with deviant peers (though not through school bonding), such that the direct relation between victimization and substance use was fully explained by affiliation with deviant peers. In contrast, Dermody and colleagues (Dermody et al., 2016) longitudinally examined the mediating roles of sexual minority-related victimization and affiliation with substance using peers in the relation between sexual minority status and heavy episodic drinking. Using an adolescent sample of 303 adolescents (94 identifying as ‘not 100% heterosexual’), the authors replicated Huebner and colleagues’ (Huebner et al., 2015) findings using cross-sectional data from the first time point of data collection; however, their longitudinal findings indicated that although sexual minority status was indirectly associated with change in heavy episodic drinking through separate mediating pathways of victimization and affiliation with substance-using peers, there was no evidence of serial mediation. That is, sexual minority youth may be at risk for heavy episodic drinking by experiencing more victimization and separately engaging with substance-permissive contexts, but there was no evidence that victimization was related to affiliating with substance-using peers. Together, these findings indicate that although sexual minority youth may be more likely to be in social environments more permissive of alcohol use behavior, it remains unclear whether this is directly explained by experiences of minority stressors.

3.3.2. Summary

A greater examination of a social context pathway of problem alcohol use among LGB adolescents is an essential extension of current research. This is especially critical given that research addressing social risk via deviance proneness has received greater empirical support than internalizing mechanisms in the general population (Hussong et al., 2017), yet the majority of LGB research to date has focused on internalizing pathway models of problem drinking risk. For instance, a recent systematic review showed that although there is some consistent evidence suggesting a positive association between depression and substance use, the evidence favoring a direct role of internalizing symptoms in the prediction of adolescent substance use behaviors is largely inconsistent when controlling for co-occurring externalizing problems (Hussong, Ennett, Cox, & Haroon, 2017). Moreover, though it is possible that the effect of internalizing symptoms on alcohol use may be overshadowed by the predominant influence of social contexts within adolescence, the influence of internalizing symptomatology may also moderate social factors predicting elevated risk for substance use behaviors (Hussong et al., 2011). As such, future work addressing early LGB alcohol use should similarly examine how social and affective mechanisms interact to characterize alcohol use risk.

4. Discussion

4.1. Summary

Disparities in the rates of alcohol use and disorder between sexual minority and non-minority populations have been attributed to the greater frequency, intensity, and chronicity of stressful life experiences, such that minority status functions as an imprecise proxy for stress (M. L. Hatzenbuehler, 2009). The current review focused on stress-related mechanisms proposed in developmental and sexual minority stress models of alcohol use risk, including negative affect, positive affect, and social context mediators. I assessed empirical support for these mechanisms in mediation studies of sexual minority stress and alcohol use behaviors. This review demonstrated that, although some evidence has shown a link between depression and/or coping motives and problem drinking, research is needed to examine the roles of emotion dysregulation, positive affect, and social context as stress-related mechanisms of risk. Moreover, modest evidence across sexual orientation populations supports the hypothesis that stress and negative affect directly confer risk for alcohol use behaviors in adolescence. Evidence predominantly indicated that depression and/or coping motives rather than anxiety may explain how minority stress confers risk for substance use behavior. However, research supporting these findings was limited in that few studies applied a longitudinal design; most included a relatively small number of non-heterosexual participants; and none explicitly tested whether anxiety symptoms or emotion dysregulation were a mediator between sexual minority stress and problem alcohol use.

This review highlighted several important gaps in studies of problem drinking among LGB youth. First, despite some support from studies in the general adolescent population, the effects of minority stress on positive reinforcement sensitivity and social context (e.g., increased affiliation with substance-permissive environments, low parental monitoring, low familial bonding) have rarely been addressed. While examination of the former is almost non-existent (Pachankis, 2015), evidence of the latter is mixed (e.g., Dermody et al., 2016; Huebner et al., 2015), with only two cross-sectional studies providing evidence of a social context pathway and one longitudinal study finding no support with victimization as a causal factor. It is possible that the predominant focus of negative affect pathways toward alcohol use has thus far overshadowed research focus on positive affect and social context pathways. Nonetheless, targeting how both affective and social risk act in concert to predict disparity in problem alcohol use is a critical extension of this work.

Second, there is very little research addressing heterogeneous alcohol risk among sub-populations of sexual minority youth (e.g., among bisexual youth; Watson et al., 2019). For instance, in this review, fewer than half of included studies tested differences in effect based on gender identity (Kiekens et al., 2020; Pesola et al., 2014), only one explicitly addressed racial/ethnic differences in mediated effects (E. H. Mereish et al., 2024), and none compared mediation effects for bisexual compared to lesbian and gay subgroups. These are critical gaps given accumulating evidence that certain forms of minority stressors such as bullying (Feinstein et al., 2019) and racial microaggressions (E. H. Mereish et al., 2023) may be linked with differential alcohol risk among bisexual and racially minoritized LGB youth populations. Relatedly, few studies have explicitly tested differences in alcohol behaviors among youth who are questioning or unsure of their sexual identity (C. J. McCabe et al., 2024; Price-Feeney et al., 2021). Although some have suggested that certain mental health concerns for questioning youth may be elevated compared to heterosexual youth (Kann, 2018; Price-Feeney et al., 2021), only one study to my knowledge has tested alcohol differences treating questioning youth as a distinct sexual orientation subgroup, finding insufficient evidence of differences compared to heterosexual youth (Caputi, 2018). Given adolescence is a crucial period of sexual identity exploration and formation, addressing alcohol disparities among youth who are bisexual or questioning, exploring, or unsure of their sexual identity remains central areas of needed research. This includes determining whether and how each of the pathways proposed in the current review shape alcohol and other substance use experiences within such populations.

Finally, although the need for this work has been highlighted previously (M. L. Hatzenbuehler, 2017), we found no mediation studies that addressed mechanisms of structural stigma on alcohol behaviors among LGB youth. I suspect that this gap is due to several methodological limitations, including the need for multilevel assessment with sufficient variation in measurement at individual and structural levels; the difficulty in obtaining longitudinal assessment at each of these levels; and recruiting a sufficiently large sample of LGB youth to test these hypotheses. Indeed, a recent systematic review has shown that although measures of structural stigma have a moderate effect on increasing alcohol use risk among LGB adults, nearly all of this work was cross-sectional in nature, and none tested psychological mechanisms of risk (Zollweg et al., 2023). Despite these challenges, addressing this gap is critically needed for advancing equity at the public policy level.

4.2. Future Directions

Taken together, I synthesize recommendations for future work in a developmental pathway model of LGB alcohol use (Figure 1). Building upon Hatzenbuehler’s seminal psychological mediation framework (M. L. Hatzenbuehler, 2009), this model summarizes possible mediated pathways within the context of the current evidence base for developing alcohol use risk. First, this model highlights that sexual minority stress may be quantified in several ways that capture stigma experienced disproportionately by LGB youth. Whereas most mediation research has focused on distal forms of discrimination, sequalae of structural stigma (e.g., school resources supporting LGB inclusivity) and group-specific forms of stress (e.g., binegativity, intersectional oppression) are addressed seldomly in minority stress mediation research (Mereish and colleagues [2024] being a notable exception addressing the latter). Attending to these stressors in empirical work may add substantially to identifying intervention points at multiple levels of impact, and/or addressing risk factors unique among specific LGB populations who may be at greatest risk, including bisexual (Ford et al., 2023) and intersectional youth populations (E. Mereish, 2024). Second, building directly from studies conducted in the general population, I emphasize that experiences of sexual minority stress drive multiple social and affective processes that likely act in concert (rather than in parallel) to shape early and escalating risk of alcohol use and disorder into adulthood (A. M. Hussong et al., 2011, 2017). As such, studies focused on examining interaction between social and affective pathways may better characterize how stress drives alcohol use risk. Third, I embed cognitive aspects of alcohol risk (i.e., alcohol expectancies) within each of these pathways. Although sexual minority stressors have a direct impact on other forms of cognitions that drive psychopathology risk (e.g., hopelessness and negative self-schemas; M. L. Hatzenbuehler, 2009), I situate expectancies within each pathway to emphasize that they may shape and be shaped by social modeling (Campbell & Oei, 2010), negative reinforcement via coping (A. M. Hussong et al., 2011), and/or positive reinforcement via enhancement (Cooper et al., 1995). Finally, consistent with developmental psychopathology perspectives from the general population (Chassin et al., 2013; Chassin & Sher, 2024), this model highlights change-over-time as a central component in understanding long-term risk for alcohol use disorder. Several longitudinal studies have demonstrated that alcohol use is initiated earlier and escalates more quickly from adolescence through young adulthood among LGB compared to heterosexual youth (Dermody et al., 2020; Marshal et al., 2009). Addressing temporal dynamics of alcohol use behaviors through longer-term developmental studies (e.g., C. J. McCabe et al., 2021; Talley et al., 2010, 2019) or intensive repeated assessment (e.g., Mereish et al., 2022) may be essential in clarifying how alcohol use cascades into disordered use over time.

Figure 1.

Developmental pathway model of sexual minority alcohol use and disorder.

The effects of stress on brain and behavior varies as a function of intensity, developmental timing, and a multitude of genetic and environmental factors (Lupien et al., 2009). The consideration of alcohol use risk at multiple levels of analysis may therefore be needed to more fully explain how minority stress confers risk for alcohol use and disorder. For instance, the mechanisms described above parallel many normative indicators of adolescent alcohol risk, including reward and affect sensitivity, difficulties in emotion regulation, and sensitization to social contexts (Casey, 2014; Casey & Jones, 2010; McLaughlin et al., 2015; Steinberg, 2010). Perhaps these mechanisms among LGB youth may be better characterized as stress-related alterations in normative developmental vulnerabilities to problematic alcohol use behavior (Diamond, 2003). Put simply, the question of how stress characterizes risk for alcohol use and disorder is complex and multi-faceted regardless of sexual orientation. A comprehensive understanding of these relations among LGB youth therefore requires an interdisciplinary approach that converges developmental, neurobiological, and sociocultural perspectives of alcohol use and disorder risk. This review aimed to facilitate this perspective; however, continued efforts directed at an integrated (rather than parallel) approach to LGB and non-LGB alcohol use research is an essential direction in understanding risk both within and across sexual orientation populations.