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. Author manuscript; available in PMC: 2025 Aug 12.
Published before final editing as: Psychol Sex Orientat Gend Divers. 2024 Aug 12:10.1037/sgd0000751. doi: 10.1037/sgd0000751

Testing reciprocal prospective associations between descriptive norms and alcohol and cannabis use among sexual minority women and gender diverse individuals assigned female at birth: Identification of relevant normative referents and correlates of descriptive norms

Christina Dyar 1, Isaac C Rhew 2, Christine M Lee 2
PMCID: PMC12330992  NIHMSID: NIHMS2002668  PMID: 40809802

Abstract

Sexual minority women (SMW) and sexual minority gender diverse individuals (SMGD) are at elevated risk for alcohol and cannabis use disorders; however, very little research has examined the role of descriptive norms in these disparities. This study aimed to test reciprocal prospective associations between descriptive norms for different normative referents (e.g., women, SMW, gender diverse individuals) and alcohol and cannabis consumption and problems among SMW and SMGD individuals. We used data from a study of substance use among 429 SMW and SMGD individuals assigned female at birth. We also aimed to identify the most relevant normative referents for SMW and for SMGD individuals by examining the unique effects of more specific normative referents (e.g., SMW) while controlling for less specific referents (e.g., women). Further, we examined potential covariates of norms, including those derived from social and minority stress theories of substance use among sexual and gender minorities. Among SMW, perceptions of heavier alcohol/cannabis use among other SMW predicted subsequent increases in alcohol/cannabis problems, but not consumption. Among SMGD individuals, descriptive norms did not predict subsequent changes in alcohol/cannabis consumption or problems. Little evidence was found to support reciprocal associations. Concurrent and prospective correlates of norms were also identified. Findings indicate that SMW-specific norms are most relevant for SMW. Less evidence was found for associations between norms and substance use among SMGD individuals. We discuss potential implications for the adaptation of normative feedback interventions for SMW and SMGD individuals.

Keywords: alcohol, cannabis, descriptive norms, sexual minority, gender minority

Introduction

Sexual minority cisgender women (SMW; i.e., lesbian, bisexual, queer, and other non-heterosexual individuals who were assigned female at birth and identify as women) are at elevated risk for alcohol and cannabis use disorders compared to heterosexual cisgender women (Kerridge et al., 2017; Schuler & Collins, 2020), and sexual minority gender diverse individuals assigned female at birth (SMGD; i.e., individuals who were assigned female at birth and identify outside of the gender binary; e.g., nonbinary) use these substances at rates similar to SMW (Fahey et al., 2023; Watson et al., 2020). Further, among these populations, rates of substance use and related disorders are highest in early adulthood (ages 18–25; Hughto et al., 2021; Rice et al., 2019; Schuler et al., 2018; Schuler et al., 2019), making this a particularly important developmental period to study. Research has predominately focused on the role of minority stress (i.e., chronic stress experienced by sexual and gender minority individuals as a result of the stigmatization of non-heterosexuality and gender diversity) in the development and maintenance of these disparities. However, perceptions of alcohol and cannabis use as normative in the sexual and gender minority community has also been proposed as another potential contributor (Condit et al., 2011; Litt et al., 2015). A handful of existing studies have begun to provide support for this hypothesis (Ehlke et al., 2019; Hatzenbuehler et al., 2008; Litt et al., 2015; Mereish et al., 2017), but this literature remains limited. The current study aims to build on this nascent literature to further advance our understanding of reciprocal, prospective associations between perceived alcohol and cannabis use among young adult sexual minority and gender diverse communities and SMW and SMGD individuals’ own substance use.

Descriptive Norms for Substance Use among Sexual and Gender Minority People

Historically, spaces where it was safe for sexual and gender minority people to socialize have been alcohol-centric (e.g., gay bars and clubs). This has been theorized to contribute to perceptions of alcohol and other substance use as more normative among sexual and gender minority people (Green & Feinstein, 2012; Hughes & Eliason, 2002). Studies have demonstrated that SMW spend more time in heavier drinking contexts than heterosexual women (Trocki et al., 2005) and drink more heavily and frequently in bars and other contexts compared to heterosexual women (Hequembourg et al., 2020). Research has also demonstrated that sexual minority individuals perceive alcohol use to be heavier among their sexual minority peers (Litt et al., 2015) and even among peers whose sexual identities are not specified (Hatzenbuehler et al., 2008; Mereish et al., 2017). These findings provide converging initial support for this theory by demonstrating that sexual minority people spend more time in drinking contexts and believe that other sexual minority individuals drink more heavily than heterosexual individuals.

In the general population, substantial research has amassed linking an individual’s perceptions of their peers’ substance use (i.e., descriptive norms) with their own use. These studies demonstrate that perceiving one’s peers as using a substance more heavily is associated with one’s own heavier use of that substance (Buckner, 2013; Collins & Spelman, 2013; Neighbors et al., 2008; Quinn & Fromme, 2011; Scaglione et al., 2013; Walters & Neighbors, 2005). This has also been supported among a few studies with sexual minority samples. Hatzenbuehler et al. (2008) and Mereish et al. (2017) demonstrated that perceiving one’s peers (unspecified sexual identity) to more heavily use alcohol and cannabis was associated with an individual’s own heavier use. Further, sexual minority people’s elevated descriptive norms helped to explain disparities in the use of these substances between sexual minority and heterosexual individuals (Hatzenbuehler et al., 2008; Mereish et al., 2017).

Studies with the general population also indicate that the effects of descriptive norms on an individuals’ own substance use are stronger when the peer group referenced (i.e., the normative referent) shares more characteristics with the individual and shared characteristics that are important or meaningful to the individual have the largest influence (LaBrie et al., 2011; Larimer et al., 2011; Liu et al., 2017; Rimal, 2008; Rimal et al., 2005). For example, when a normative referent group is comprised of women (rather than being gender neutral, e.g., typical person), descriptive norms are more strongly associated with women’s own alcohol use (Borsari & Carey, 2003; Lewis & Neighbors, 2006). Two studies have examined the impact of descriptive norms from different normative referent groups on drinking among SMW. In a cross-sectional study, Ehlke et al. (2019) demonstrated that descriptive norms for bisexual women (but not lesbian or heterosexual women) were significantly associated with drinking frequency and binge drinking among bisexual women. Similarly, Litt et al. (2015) found that SMW who perceived that other SMW drank more heavily experienced subsequent increases in their own alcohol consumption; however, descriptive norms for a “typical woman” did not. These studies provide critical evidence that descriptive norms for SWM contribute to SMW’s own drinking. The current study aims to build upon these findings in two ways: 1) by examining both alcohol and cannabis norms; and 2) by including sexual minority gender diverse individuals (SMGD) in order to examine the relevance of gender-specific referents for this population.

Reciprocal Associations between Descriptive Norms and Substance Use

Social learning theory’s principle of reciprocal determinism posits that perceptions and behaviors influence one another in a reciprocal fashion (Bandura & Walters, 1977). In the general population, studies have tested for reciprocal associations between descriptive norms and substance use, but evidence has been mixed with some studies finding a reciprocal association (Lee, Geisner, et al., 2010; Lewis et al., 2015; Meisel & Colder, 2020; Neighbors et al., 2006), while others do not (Angosta et al., 2023; Farrell, 1994; Graupensperger et al., 2020; Napper et al., 2016; Read et al., 2005). Only Litt et al. (2015) has tested for such a reciprocal association among sexual minority samples, revealing that SMW-specific descriptive norms prospectively predicted participants own drinking and vice versa. The current study will extend this prior work by also testing for reciprocal associations between cannabis norms and cannabis use among SMW and extending this to SMGD individuals.

Potential Correlates of Descriptive Norms

What factors may contribute to perceptions that SMW and SMGD use alcohol and cannabis heavily? Two theoretical frameworks have proposed contributing factors; however, these hypotheses have rarely been tested. Given that theory posits that the heavy substance use-centric contexts in which sexual and gender minority people tend to socialize contribute to perceptions of heavier substance use among sexual minority people (Condit et al., 2011), we expect that individuals who are more involved in sexual and gender minority specific social activities (particularly attendance at LGBTQ+ bars and clubs) will be associated with perceptions that sexual and gender minority people engage in heavier substance use. These associations are expected to be particularly marked with reference to drinking norms as the socialization contexts specific to sexual and gender minority communities tend to be more alcohol than cannabis focused (e.g., bars and clubs). Such findings would have the potential to inform interventions aiming to reduce substance use disparities affecting sexual and gender minority populations by indicating that community norms and activities may be potential contexts in which interventions may reduce substance use disparities.

Another potential pathway that may also lead to perceptions of heavier substance use among sexual and gender minority populations may arise from societal messages that encourage and normalize the use of substances to cope with minority stress (e.g., microaggressions), anxiety, and depression within the sexual and gender minority community. Studies examining coping strategies utilized early in the COVID-19 pandemic demonstrate that sexual and gender minority individuals (and SMW in particular) were more likely to engage in the use of alcohol and cannabis to cope with stress arising from the pandemic (Krueger et al., 2021; Slemon et al., 2022). This suggests that sexual and gender minority people may be more likely to use substances to cope with stress than cisgender heterosexual individuals, which may contribute to perceptions that using substances to cope is more acceptable among sexual and gender minority communities. Additionally, at least one qualitative study of cannabis use and mental health among a sexual and gender minority sample identified multiple themes related to the use of cannabis to cope with both experiences of minority stress and with anxiety and depression (Parent et al., 2021). A recent prospective longitudinal study also demonstrated that experiences of minority stress predicted subsequent increases in the likelihood of using cannabis to cope later on the same day or during the next day (Dyar, Kaysen, et al., 2022). Again, this suggests that such responses are commonplace and thus may contribute to general perceptions that using cannabis and other substances to cope with minority stress and symptoms of anxiety and depression is common and acceptable in the sexual and gender minority community. Sexual and gender minority individuals who experience more minority stress, anxiety and depression or use substances to cope more frequently may perceive these norms regarding the acceptability of using to cope among sexual and gender minority communities as being more relevant to themselves and result in perceptions that substance use is heavier among sexual and gender minority people for these individuals. This is in line with several existing theories, which posit that distal antecedents to behavior (e.g., depression, anxiety, past experiences) predict behavior by influencing an individual’s beliefs and perceptions, including perceived substance use norms (Ajzen, 1991; Cox & Klinger, 1988; Rosenstock, 1974; Smith & Anderson, 2001). Research with the general population has provided some support for this hypothesis, linking hopelessness and depressive symptoms with elevated descriptive norms and, in turn, heavier alcohol use (Linden & Lau-Barraco, 2013; Pearson & Hustad, 2014). Therefore, we expected that individuals who experienced more microaggressions based on their sexual or gender identity, used substances to cope, and had more symptoms of anxiety and depression would perceive substance use to be heavier among sexual and gender minority people. Further, we expected that these associations would persist in prospective analyses, with these factors predicting subsequent changes in alcohol and cannabis norms. If identified as risk factors for subsequent increases in perceptions of alcohol and cannabis use as normative, these factors may be ideal targets for interventions aiming to reduce substance use among sexual and gender minority people.

Current Study

The current study aimed to advance our understanding of associations between descriptive substance use norms and substance use among SMW and SMGD individuals by testing reciprocal prospective associations between descriptive substance use norms from different normative referents (e.g., typical woman; typical SMW) and alcohol and cannabis consumption and problems. Among SMW, we examined alcohol and cannabis norms for women broadly and for SMW specifically. Among SMGD individuals, we examined alcohol and cannabis norms for a typical person (gender not specified) and GD individuals in order to extend research on the relevance of gender-specific referents to SMGD individuals. Finally, we examined cross-sectional and prospective associations between potential correlates and descriptive norms for alcohol and cannabis use for SMW and SMGD individuals. We made the following hypotheses:

  1. Among SMW, heavier perceived alcohol and cannabis norms for SMW will prospectively predict increases in alcohol and cannabis consumption and problems one month later and heavier alcohol and cannabis consumption will prospectively predict increases in the perceived use of alcohol and cannabis among SMW one month later, creating a reciprocal relationship. In contrast, descriptive norms for women broadly (i.e., “typical woman”) are not expected to be associated with alcohol and cannabis consumption or problems.

  2. Among SMGD individuals, heavier alcohol and cannabis norms for gender diverse individuals are expected to be prospectively associated with alcohol and cannabis consumption in a similar reciprocal fashion. However, descriptive norms for individuals whose gender was not specified (e.g., a typical person your age) are not expected to be associated with alcohol and cannabis consumption or problems.

  3. The following covariates are expected to be cross-sectionally and prospectively associated with perceiving SMW and SMGD individuals as using alcohol and cannabis more heavily: greater LGBTQ+ social involvement (particularly bar/club attendance), experiences of microaggressions, coping motives for substance use, and symptoms of anxiety and depression.

Methods

Participants and Procedures

The current analyses used data from a longitudinal study of substance use among 429 SMWGD conducted between August 2020 and May 2021. Participants were recruited via online advertisements on social media (e.g., Facebook). The study included a baseline assessment (day 0), a 30-day EMA study (days 1–30), and a follow-up assessment. The follow-up assessment was sent to participants on day 31 and participants had up to 14 days to complete it. This study uses data from the baseline and follow-up assessments. The study received IRB approval at Northwestern University (where data were collected) and Ohio State University (where data are stored). See Dyar, Kaysen, et al. (2022) for further details about the study.

Eligible participants were 1) U.S. residents, 2) 18–25 years old, 3) assigned female at birth, 4) identified as women or under the non-binary/gender diverse umbrella (e.g., non-binary, genderqueer, agender, gender fluid), 5) identified as lesbian, bisexual, pansexual, or queer, and 6) met alcohol or cannabis use criteria (i.e., reported having four or more drinks at least twice and/or using cannabis on at least three days in the past month). Participants were paid up to $150: $20 for baseline, $20 for follow-up, $1 for each EMA survey, and a $5 bonus for every six EMA surveys completed in a row.

The sample included 429 participants (Table 1) and was comprised predominately of people of color, with 33.6% identifying as non-Latine White. More than a quarter of participants were gender diverse (26.8%). The majority of participants completed both the baseline and follow-up assessments, with 21 participants (4.9%) not completing the follow-up assessment.

Table 1.

Demographics of Analytic Sample at Baseline (N = 429)

Demographic Variable n %
Sexual Identity
  Lesbian 112 26.10%
  Bisexual 111 25.90%
  Pansexual 112 26.10%
  Queer 94 21.90%
Race/Ethnicitya
  White 235 54.80%
  Black 102 23.80%
  Latine 129 30.10%
  Asian 53 12.40%
  Other Race/Ethnicity 34 7.90%
Gender Identity
  Cisgender Women 314 73.20%
  Gender Diverse 115 26.80%
Included in Alcohol Analyses
  Cisgender Women 307 71.56%
  Gender Diverse 115 26.81%
Included in Cannabis Analyses
  Cisgender Women 262 61.07%
  Gender Diverse 95 22.14%
Age (M, SD) 22.27 (2.01)
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a

Percentages add up to more than 100% because participants could select multiple racial/ethnic identities.

Measures

Only participants who reported drinking at least once in the past month were asked items about alcohol use, while only participants who reported cannabis use in the past month were asked items about cannabis use.

Alcohol and Cannabis Variables: Assessed at Baseline and Follow-up

Alcohol and Cannabis Use Norms were assessed by asking participants to indicate the perceived quantity and frequency of alcohol and cannabis use for groups of individuals. The following item structures were used for each alcohol use norm: “How many days, on average, do you think a typical [group descriptor] drinks during a typical month?” and “How many drinks, on average, do you think a typical [group descriptor] has during a typical occasion?” The following item structures were used for each cannabis use norm: “How many days, on average, do you think a typical [group descriptor] uses cannabis during a typical month?” and “How many hours, on average, do you think a typical [group descriptor] is stoned or high on a typical day when they used cannabis?” All participants were asked to answer these questions thinking about “a typical person your age.” SMW were asked to also answer these questions with regard to “a typical woman your age” and “a typical [lesbian/bisexual/pansexual/queer] woman your age.” SMGD participants were also asked to answer questions about “a typical [nonbinary/genderqueer/other identity] person your age.” Participants’ own sexual and gender identities were piped into the spaced denoted by [], so that they answered questions about people who shared their specific identities. Response options for the frequency items ranged from 0 (never) to 8 (daily), while responses for the quantity items ranged from 0 (0 drinks/hours) to 10 (10 or more drinks/hours). These items were adapted from the measure of norms used by Litt et al. (2015). Responses to the quantity and frequency items were multiplied to create perceived alcohol and cannabis norm scores for each group.

Alcohol Use Disorder Identification Test (AUDIT) was administered to participants to assess alcohol problems (Babor et al., 2001; Bradley et al., 2007). The AUDIT includes 10 items rated on different scales. For example, the item “How often during the past 30 days have you failed to do what was normally expected of you because of drinking?” is rated on a scale of 0 (never) to 4 (daily or almost daily). Responses were summed and Cronbach’s alpha was acceptable at both baseline and follow-up (a = .78–.81). For sensitivity analyses, we created a sum of the items capturing alcohol problems (items 4–10), excluding items capturing alcohol quantity, frequency, and binge drinking.

Cannabis Use Disorder Identification Test – Revised (CUDIT-R) was administered to participants to assess cannabis problems (Adamson et al., 2010). The CUDIT-R includes 8 items rated on different scales. For example, the item “How often in the past 30 days have you devoted a great deal of your time to getting, using, or recovering from marijuana?” is rated on a scale of 0 (never) to 4 (daily or almost daily). Responses were summed and Cronbach’s alpha was acceptable at both baseline and follow-up (a = .79–.83). For sensitivity analyses, we created a sum of the items capturing cannabis problems (items 3–8), excluding items capturing cannabis use quantity and frequency.

Quantity and frequency of alcohol and cannabis use was assessed by asking participants to indicate “How many days, on average, do you drink/use cannabis during a typical month?”; “How many drinks, on average, do you have during a typical occasion?”; How many hours, on average, are you stoned or high on a typical day when you used cannabis?” Participants were asked to consider the past 30 days in responding to these items. Response options for the frequency items ranged from 0 (never) to 8 (daily), while responses for the quantity items ranged from 0 (0 drinks/hours) to 10 (10 or more drinks/hours). Responses to the quantity and frequency items were multiplied to create alcohol and cannabis consumption items.

Potential Correlates of Norms: Assessed at Baseline

Coping motives for alcohol and cannabis use were assessed by asking participants to think about their motives for use in the past 30 days. Coping motives for alcohol use were assessed using a six-item version of the coping motives subscale (e.g., “to forget my worries;” α=.82) of the Drinking Motives Measure (Grant et al., 2007). Coping motives for cannabis use were assessed using a 2 item version of the coping subscale (e.g., “to forget your problems;” α=.84) of the Comprehensive Marijuana Motives Measure (Lee et al., 2009). The third item on this subscale was not included in this study in order to reduce participant burden. The two items with the highest factor loadings on the coping motives subscale of the measure were retained. Responses for both measures were assessed on a scale of 1 (almost never/never) to 5 (almost always/always).

LGBTQ+ community involvement.

Engaging in four different types of activities within the LGTBQ+ community were assessed using a scale developed by Johns et al. (2013). Participants were asked to indicate how many times in the past month they had: “attended programs at an LGBTQ+ organization,” “gone to LGBTQ+ social events (e.g., parties, dances, Pride events),” “gone to an LGBTQ+ bar or club,” and “engaged with LGBTQ+ groups on social media.” The fourth item was added to update the measure to capture interactions via social media. Responses were provided on a scale of 0 (not at all) to 5 (daily). However, as few participants reported engaging in the first three activities more than once in the past month (< 10%), these three items were dichotomized. Given that these items capture a range of activities that may be differentially associated with perceived substance use norms in the LGBTQ+ community, we examined each item separately.

Microaggressions

Sexual identity microaggressions were measured using the Sexual Orientation Microaggression Inventory (Swann et al., 2016). This measure includes 19 items capturing participants experiences with microaggressions related to their sexual orientation in the past month (e.g., “You heard someone say ‘that’s so gay’ in a negative way.”). Items were rated from 1 (not at all) to 5 (about every day) and averaged to create a total score (α=.93).

Gender identity microaggressions were measured using the gender non-affirmation subscale of the Gender Minority Stress and Resilience measure (Testa et al., 2015). Gender diverse participants were asked to indicate how much they agreed or disagreed with each item (e.g., “I have to repeatedly explain my gender identity to people or correct the pronouns people use.”). On a scale of 1 (strongly disagree) to 5 (strongly agree). Items were averaged to create a total score (α=.89).

Anxiety Symptoms were assessed using the Generalized Anxiety Disorder 7 (Spitzer, Kroenke, Williams, & Lowe, 2006). Participants were asked, “How often during the past month have you felt bothered by…” each of seven symptoms (e. g., “Feeling nervous, anxious, or on edge”; α = 0.91) on a scale of 0 (not at all) to 3 (nearly everyday). Items were summed to create a subscale score.

Depression Symptoms were assessed using the eight item Patient Health Questionnaire (Kroenke et al., 2009). Participants were asked, “How often during the past month have you felt bothered by…” each of eight symptoms (e. g., “Feeling down, depressed or hopeless”; α = 0.89) on a scale of 0 (not at all) to 3 (nearly everyday). Items were summed to create a subscale score.

Data Analyses

Analyses were conducted with Mplus version 8.9. A total of 2.0% of data were missing and were handled using full information maximum likelihood. First, cross-lagged panel models were estimated separately for SMW and SMGD individuals (see Table 1 for number of individuals in each analysis). In models for SMW, reciprocal associations between substance use norms (for women broadly and SMW specifically) and a participant’s own substance use were modeled. Specifically, perceived substance use among women and SMW at baseline were included together as predictors of the substance use outcome at follow-up and the outcome at baseline also predicted perceived substance use among women and SMW at follow-up. Autoregressive associations between each variable at baseline and follow-up were also included and all variables at baseline were allowed to correlate with one another, as were all variables at follow-up. Covariates included age, sexual identity (dummy coded with lesbian as the reference group), and race/ethnicity (including binary variables indicating identification as White, Black, Latine, Asian, and with other racial/ethnic groups on this multiselect variable) as each of these variables has been associated with substance use among sexual and gender minority samples (e.g., Dyar et al., 2021; Dyar, Feinstein, et al., 2022). All participants who reported using alcohol at least once in the past month (SMW n = 307; SMGD n = 115) or cannabis at least once in the past month at baseline (SMW n = 262; SMGD n = 95) were included in analyses for the relevant substance. Four substance use outcomes were examined for each substance: alcohol and cannabis consumption and alcohol and cannabis problems. These outcomes were treated as continuous and a robust maximum likelihood estimator was used to correct for the positive skew present in these variables. Count distributions were not appropriate for these variables in this sample as they did not follow a count distribution. We identified five outliers. However, when these individuals were excluded from analyses, the pattern of results remained the same. Therefore, we include these individuals in the analyses presented in the manuscript.

We examined a separate set of models for SMGD individuals. These models followed the structure of the models for SMW described above, with the exception that norms for different referent groups were examined. We examined the effects of norms for a typical person and for a typical gender diverse person by examining the two as simultaneous predictors and outcomes. As in prior analyses, age, sexual identity and race/ethnicity were included as covariates.

Given that the AUDIT and CUDIT include items that capture quantity and frequency of use as well as problems related to use, we conducted sensitivity analyses in which we examined the same models described above with the traditional total AUDIT and CUDIT scores replaced by AUDIT problems and CUDIT problems scores, scores which only included items that captured problems resulting from use rather than quantity and frequency of use.

Next, we examined cross-sectional and prospective associations between potential covariates of perceived substance use norms for SMW and gender diverse individuals. We examined three potential groups of covariates: social factors (LGBTQ+ community involvement); minority stress factors (microaggressions based on being a sexual minority or gender diverse); and coping factors (coping motives and symptoms of anxiety and depression). In these models, covariates at baseline predicted norms at baseline as well as change in norms from baseline to follow-up (by controlling for norms at baseline). As in prior analyses, age, sexual identity and race/ethnicity were included as covariates. Associations with perceived substance use norms for SMW were examined among SMW participants and those for gender diverse individuals were examined among the SMGD subsample.

Results

We examined correlations between baseline and follow-up assessments of each variable to determine the amount of variation in these variables that represented change over time. Norms for alcohol use (r = .43–.70), norms for cannabis use (r = .61–.67), and participant alcohol/cannabis consumption/problems (r = .67–.75) all demonstrated high correlations between their baseline and follow-up assessments. Despite these high correlations, 40% or more of the variance in each represented change within-persons over time (calculated via 1-r2), indicated more than adequate variability in norms and substance use to examine changes in these variables from baseline to follow-up.

Cross-Lagged Model: Alcohol among SMW

In the cross-lagged models of alcohol use among SMW (Figure 1; Table 2), higher perceived alcohol use among SMW at baseline predicted subsequent increases in alcohol problems from baseline to follow-up (see association labeled M2 in Table 2 and Figure 1). No associations between norms for women and alcohol outcomes were significant (M1), nor were associations between SMW-specific norms and alcohol consumption. Further, alcohol consumption and problems at baseline did not predict changes in norms (M3 and M4). Cross-sectional correlations at baseline and follow-up indicate that heavier perceived alcohol use among SMW was consistently correlated with higher levels of alcohol consumption and problems at both timepoints (C3 and C6). Perceived alcohol use among women broadly was only correlated with alcohol consumption (C2 and C5).

Figure 1.

Figure 1.

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Diagram of cross-lagged model for SMW participants. Different line colors and width represent different types of associations (e.g., autocorrelations, main prospective associations, correlations). Each association is labeled to allow easy translation between Figure 1 and Table 2.

Table 2.

Cross-Lagged Models: Sexual Minority Women

Alcohol Problems Alcohol Consumption Cannabis Problems Cannabis Consumption
Type of Association Label Predictor Outcome β p β p β p β p
Autocorrelations A1 Women Norms T1 Women Norms T2 .51 < .001 .51 < .001 .58 < .001 .58 < .001
A2 SMW Norms T1 SMW Norms T2 .38 < .001 .38 < .001 .51 < .001 .48 < .001
A3 Outcome T1 Outcome T2 .64 < .001 .67 < .001 .65 < .001 .78 < .001
Main Prospective Effect M1 Women Norms T1 Outcome T2 −.08 .12 −.07 .22 −.03 .61 −.11 .06
Main Prospective Effect M2 SMW Norms T1 Outcome T2 .18 .002 .10 .10 .17 .01 .08 .26
Prospective Controls B1 Women Norms T1 SMW Norms T2 .18 .02 .18 .02 .14 .09 .14 .08
Main Prospective Effect M3 Outcome T1 SMW Norms T2 .06 .23 .06 .28 −.03 .49 .08 .36
Prospective Controls B2 SMW Norms T1 Women Norms T2 .16 .02 .16 .02 .08 .24 .05 .53
Main Prospective Effect M4 Outcome T1 Women Norms T2 .05 .29 .03 .61 .03 .58 .13 .08
Correlations C1 Women Norms T1 SMW Norms T1 .62 < .001 .62 < .001 .71 < .001 .71 < .001
C2 Outcome T1 .13 .05 .22 < .001 .09 .10 .20 .001
C3 SMW Norms T1 Outcome T1 .20 < .001 .33 < .001 .17 .004 .29 < .001
C4 Women Norms T2 SMW Norms T2 .62 < .001 .62 < .001 .64 < .001 .64 < .001
C5 Outcome T2 .14 .04 .28 < .001 −.03 .58 .10 .15
C6 SMW Norms T2 Outcome T2 .16 .01 .24 < .001 .12 .06 .17 .01
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Models include all cisgender SMW who reported at least monthly drinking or cannabis use at baseline. A total of 307 cisgender SMW were included in analyses of alcohol use and norms, while 262 were included in analyses of cannabis use and norms. Covariates included age, sexual identity, and race/ethnicity. SMW (sexual minority women); T1 (time 1); T2 (time 2).

Cross-Lagged Model: Cannabis among SMW

Similar to the models for alcohol use, higher perceived cannabis use among SMW at baseline predicted subsequent increases in cannabis problems from baseline to follow-up (see association labeled M2 in Table 2 and Figure 1). No other prospective associations between norms and cannabis outcomes were significant in either direction (M1, M3, and M4). Cross-sectionally, heavier perceived cannabis use among SMW was also correlated with higher levels of all cannabis consumption and problems at baseline and with cannabis consumption at follow-up (C3 and C4). Heavier perceived cannabis use among women broadly was only associated with cannabis consumption at baseline (C2 and C5).

Cross-Lagged Model: Alcohol among SMGD Individuals

In models examining norms among SMGD individuals (Table 3 and Figure 2), GD-specific norms did not predict subsequent changes in alcohol consumption or problems (see M2 in Table 3 and Figure 2). Heavier alcohol consumption at baseline predicted subsequent increases in perceived alcohol use among SMGD individuals (M3). No other prospective associations between norms and outcomes were significant in either direction (M1 and M4). Cross-sectionally, heavier perceived alcohol use among gender diverse individuals was correlated with higher levels of alcohol consumption at baseline and follow-up (C3 and C6). Heavier perceived alcohol use for a typical person was also associated with heavier alcohol consumption at baseline and follow-up (C2 and C5).

Table 3.

Cross-Lagged Models with Gender-based Referents: Sexual Minority Gender Diverse Participants

Alcohol Problems Alcohol Consumption Cannabis Problems Cannabis Consumption
Type of Association Association Label Predictor Outcome β p β p β p β p
Autocorrelations A1 Person Norms T1 Person Norms T2 .76 < .001 .75 < .001 .44 < .001 .46 < .001
A2 GD Norms T1 GD Norms T2 .22 .10 .23 .07 .69 < .001 .64 < .001
A3 Outcome T1 Outcome T2 .66 < .001 .74 < .001 .55 < .001 .59 < .001
Main Prospective Effect M1 Person Norms T1 Outcome T2 .06 .52 .05 .61 −.17 .23 −.08 .45
Main Prospective Effect M2 GD Norms T1 Outcome T2 .05 .53 .05 .65 .14 .28 .15 .20
Prospective Controls B1 Person Norms T1 GD Norms T2 .26 .05 .24 .07 −.02 .86 .01 .93
Main Prospective Effect M3 Outcome T1 GD Norms T2 .16 .03 .16 .06 .01 .91 .13 .10
Prospective Controls B2 GD Norms T1 Person Norms T2 −.25 .01 −.24 .02 .31 .003 .28 .01
Main Prospective Effect M4 Outcome T1 Person Norms T2 .15 .11 .11 .30 .05 .48 .10 .21
Correlations C1 Person Norms T1 GD Norms T1 .60 < .001 .60 < .001 .71 < .001 .71 < .001
C2 Outcome T1 .14 .16 .20 .04 −.07 .53 −.02 .85
C3 GD Norms T1 Outcome T1 .27 .001 .23 .01 .11 .29 .19 .07
C4 Person Norms T2 GD Norms T2 .42 < .001 .43 < .001 .35 .03 .33 .04
C5 Outcome T2 .06 .58 .29 .01 −.08 .52 .11 .50
C6 GD Norms T2 Outcome T2 .13 .16 .35 .001 −.04 .74 .14 .14
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Models include all gender diverse individuals who reported at least monthly drinking or cannabis use at baseline. Covariates included age, sexual identity, and race/ethnicity. A total of 115 SMGD participants were included in analyses of alcohol use and norms, while 95 were included in analyses of cannabis use and norms. GD = gender diverse.

Figure 2.

Figure 2.

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Diagram of cross-lagged models for SMGD participants. Different line colors and width represent different types of associations (e.g., autocorrelations, main prospective associations, correlations). Each association is labeled to allow easy translation between Figure 2 and Table 3.

Cross-Lagged Model: Cannabis among SMGD Individuals

In models examining norms among SMGD individuals (Table 3 and Figure 2), heavier perceived cannabis use among gender diverse individuals did not predict subsequent changes in cannabis consumption or problems (M2). Heavier perceived cannabis use among a typical person did not predict subsequent changes in cannabis consumption or problems (M1). In these models, there were no significant correlations between norms and cannabis outcomes.

Sensitivity Analyses for Cross-Lagged Panel Models

Sensitivity analyses that excluded items on the AUDIT and CUDIT that captured quantity and frequency of use demonstrated the same pattern of results as analyses reported above that included AUDIT and CUDIT items capturing both problems and quantity/frequency of use.

Correlates of Substance Use Norms

Cross-sectional and prospective associations between three sets of potential correlates of perceived alcohol and cannabis use were examined (Table 4). Only one aspect of LGBTQ+ community involvement was associated with norms and only concurrently. Specifically, individuals who had gone to an LGBTQ+ bar or club in the past month reported perceiving heavier alcohol use among SMW. LGBTQ+ community involvement did not prospectively predict changes in alcohol or cannabis use norms.

Table 4.

Correlates of SMWGD Alcohol and Cannabis Norms

SMW Drinking Norms GD Drinking Norms SMW Cannabis Norms GD Cannabis Norms
Predictor Concurrent Prospective Concurrent Prospective Concurrent Prospective Concurrent Prospective
Social Factors
  LGBTQ+ Social Event Attendance .07 −.08 −.09 .02 .01 .003 .18 −.01
  LGBTQ+ Programs/Organization Attendance .08 −.02 .004 .12 .11 .04 .17 .06
  LGBTQ+ Bar/Club Attendance .13 −.03 .04 .14 .10 −.01 .15 −.07
  LGBTQ+ Social Media Groups .04 .01 .003 .01 .08 .05 .19 .01
Minority Stress Factors
  SM Microaggressions .09 −.01 - - .23 .06 - -
  Gender Non-Affirmation - - .09 .09 - - .19 .06
Coping Factors
  Coping Motives .11 −.04 .05 .27 .21 .08 .02 −.02
  Anxiety Symptoms .03 .02 .02 −.02 .24 .08 .07 −.04
  Depression Symptoms .10 .07 .001 .07 .24 .10 .21 −.06
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Standardized regression coefficients are presented. Significant values at p < .05 are presented in bold. Correlates of SMW norms were examined among SMW, while correlates of gender diverse norms were examined among gender diverse individuals. Covariates included age, sexual identity, and race/ethnicity.

Factors related to minority stress and coping were also significantly associated with norms. In concurrent associations, individuals who experienced more sexual identity microaggressions perceived heavier cannabis use among SMW, while SMGD individuals who experienced more gender-related microaggressions perceived heavier cannabis use among gender diverse individuals. With regard coping motives, individuals who reported more coping motives for alcohol and cannabis use also reported perceiving alcohol and cannabis use to be heavier among SMW during the same observation. Among SMGD, coping motives for alcohol use at baseline predicted subsequent increases in perceptions of heavy alcohol use among gender diverse individuals. Finally, with regard to symptoms of anxiety and depression, individuals who reported more symptoms of anxiety at baseline also perceived SMW as heavier cannabis users at baseline. Individuals who reported more symptoms of depression at baseline perceived heavier cannabis use among SMW and gender diverse individuals at baseline. Further, individuals with more symptoms of depression at baseline experienced subsequent increases in their perceptions of SMW’s cannabis use.

Discussion

The current study extends the nascent literature examining associations between descriptive norms and substance use among sexual and gender minority people. This study was the first we are aware of to examine prospective effects of descriptive norms for cannabis use among a sexual and gender minority sample and to examine relevant normative referents for SMGD individuals. Results broadly indicate that descriptive norms for other SMW are the most relevant predictors of substance use problems for SMW, while norms for women broadly did not prospectively predict increases in consumption or problems for SMW. Less evidence was found that an individual’s own alcohol or cannabis use prospectively predicted changes in norms, and little prospective support was found for the relevance of descriptive norms (gender-neutral or GD-specific) for SMGD populations. Despite somewhat limited evidence for prospective associations, concurrent associations between norms and substance use, demonstrated consistent and strong associations between perceived alcohol/cannabis use among SMW and SMW’s own alcohol and cannabis consumption. Associations between perceptions of GD individuals’ substance use and SMGD participants’ own consumption were limited to alcohol for SMGD individuals. Further, correlates and predictors of changes in descriptive norms for SMW and SMGD individuals were also identified. Results substantially expand our understanding of the roles of descriptive substance use norms among SMW and SMGD individuals and point to several directions for future research.

Among SMW, we found that perceiving alcohol or cannabis use to be heavier among other SMW (but not women broadly) prospectively predicted increases in alcohol and cannabis problems, but not consumption. This is partially consistent with our hypothesis that norms for SMW (but not women broadly) would predict substance use outcomes. This findings is consistent with prior research indicating that norms have a stronger impact when the normative referent shares more characteristics with the individual (Borsari & Carey, 2003; LaBrie et al., 2011; Larimer et al., 2011; Lewis & Neighbors, 2006; Liu et al., 2017; Rimal, 2008; Rimal et al., 2005). This finding is also partially consistent with Litt et al. (2015), who also found that only SMW norms predicted SMW’s own alcohol consumption; however, Litt et al. (2015) found associations between SMW norms and alcohol consumption but did not examine alcohol problems. Why might norms predict alcohol problems but not consumption in the current study? One possibility is that perceiving heavier substance use among SMW may contribute to the use of substances in contexts or patterns that are associated with more problems (e.g., binge drinking; drinking in bars and clubs), rather than simply contributing directly to heavier consumption. In the current study, we may not have detected associations between norms and consumption, as Litt et al. (2015) did, due to the shorter timeframe used for the current study (one month compared to one year). Future research should continue to examine prospective associations between norms, different patterns of consumption, and problems to clarify discrepancies between results of the current study and Litt et al. (2015).

Among SMGD individuals, we did not find evidence that either norms for GD-specific referents or for a gender-neutral referent (e.g., typical person) prospectively predicted SMGD individuals’ alcohol or cannabis consumption or problems. These findings are not consistent with prior research linking norms for various referent groups with individuals’ own patterns of use. One potential explanation for this finding is the relatively small sample size for these analyses, which include 115 individuals for analyses of alcohol use and 95 for analyses of cannabis use. These are relatively small samples for analyses of prospective associations, which left us with less change in norms and substance use in this subgroup, limiting our ability to identify predictors of change. Future research should explore whether larger samples of SMGD individuals may be better able to detect potential associations between changes in descriptive norms and substance use.

In contrast to our expectations, we found limited evidence that an individual’s own use prospectively predicted changes in descriptive norms. Only one prospective association was significant in this direction, with alcohol problems predicting subsequent increases in descriptive alcohol norms for gender diverse individuals. The only prior study to examine such reciprocal associations among SMW found evidence of norms prospectively predicting use and vice versa (Litt et al., 2015). Inconsistent findings between the current study and Litt et al. (2015) are in line with the mixed literature on the presence of these reciprocal associations in the general population (e.g., Angosta et al., 2023; Graupensperger et al., 2020; Lewis et al., 2015; Meisel & Colder, 2020). However, the shorter timeframe of the current study (one month) compared to Litt et al. (2015; 1 year) may also have contributed to our null findings. Future research with the sexual and gender minority population and the general population should continue to examine when and for whom reciprocal and unidirectional associations between norms and substance use are present.

We also examined correlates of descriptive norms for SMW and SMGD individuals. We found some limited support for correlates derived from the theory that heavier drinking norms arising from the centrality of alcohol-centric contexts for socialization among sexual and gender minority communities. Specifically, individuals who attended LGBTQ+ bars and clubs also perceived heavier drinking among SMW. However, this finding did not extend to gender diverse individuals, and we did not find evidence that LGBTQ+ bar or club attendance predicted subsequent changes in perceptions of alcohol use. This may have been a result of limited variation in LGBTQ+ bar or club attendance, which was dichotomized into a binary variable. Samples with more variation in LGBTQ+ bar attendance that are able to examine associations between frequency of attendance and norms may have different findings.

In contrast, minority stress, coping motives for cannabis use, and symptoms of anxiety and depression were consistently associated with perceptions of heavier cannabis use among SMW in concurrent analyses. However, these results were less consistently among SMGD individuals and in prospective analyses. This may suggest that the perceived acceptability of using cannabis to cope among SMW and SMGD individuals may contribute to perceptions of heavier cannabis use among these populations for individuals who experience more relevant stressors and use cannabis to cope. We posit two potential pathways through which this may occur. First, individuals who experience more stressors and use cannabis to cope may perceive norms regarding the acceptability of using to cope among sexual and gender minority people as being more relevant to themselves, resulting in perceptions that substance use is heavier among sexual and gender minority people for these individuals. Second, individuals who use cannabis to cope may be more likely to select friends who do as well. Given that using cannabis to cope is associated with heavier cannabis use (Bresin & Mekawi, 2019), this may mean that sexual and gender minority individuals who use to cope and experience more relevant stressors have a peer group that uses cannabis more heavily, which is then generalized to all sexual and gender minority people, resulting in perceptions that sexual and gender minority people use more heavily among this group. Both potential pathways should be examined in future research as should the effects of the perceived acceptability of using cannabis to cope. It is also possible that some of these variables may be concurrently associated with perceived cannabis norms as a result of their shared associations with individuals’ own substance use. Given that we found limited evidence that these factors prospectively predict changes in cannabis use norms, future research with more observations and longer periods between observations are also necessary to determine the directionality of these associations.

Clinical Implications

Study findings have potential implications for clinical treatment and intervention development given the efficacy of personalized normative feedback interventions in reducing alcohol use and related problems in the general population (Miller et al., 2013; Neighbors et al., 2004). To date, there is only one published personalized normative feedback intervention for alcohol among SMW. This intervention provides sexual identity specific personalized normative feedback and appears effective in reducing alcohol consumption and problems, particularly when information about norms related to drinking to cope is included (Boyle et al., 2022). The current study’s findings linking perceived drinking among SMW with SMW’s own alcohol problems aligns with the theorized mechanisms targeted by this intervention. Clinicians working with clients who are SMW may wish to utilize this intervention. As it remains unclear whether descriptive norms are prospectively associated with substance use among SMGD individuals, it is unclear whether such interventions would be effective in this population.

There are currently no interventions for cannabis use among SMW or gender diverse individuals. It is unclear if adapted personalized normative feedback interventions for cannabis would be effective because current evidence for the efficacy of such interventions in the general population is mixed. Some studies testing interventions that include personalized normative feedback components find no changes in cannabis consumption or consequences (Cunningham et al., 2021; Elliott et al., 2014); others find that consumption or consequences are only reduced for a subset of participants (e.g., only women or only those more ready for change; Lee, Neighbors, et al., 2010; Walukevich-Dienst et al., 2021; Walukevich-Dienst et al., 2019); and still other find decreases in consumption and consequences in the full sample (Blevins et al., 2018; Buckner et al., 2020; Copeland et al., 2017). Future research should continue to explore for whom and under what circumstances cannabis use interventions that incorporate personalized normative feedback are effective among the general population and among sexual and gender minority populations.

Limitations

The results of the current study should be considered in light of its limitations. First, only sexual minority cisgender women and gender diverse individuals assigned female at birth who used alcohol or cannabis regularly, lived in the US, and were between ages 18 and 25 were included in this study. As a result, it is unclear whether similar patterns will be found among sexual minority men, those assigned male at birth, sexual minority individuals who live outside the US, older individuals or adolescents, or those who use alcohol or cannabis less frequently. Second, the current study included only two observations, spaced one month apart, and therefore, this study may not have been long enough to detect the full span of effects of norms on use and vice versa. Third, this study only examined descriptive norms; future research should explore the roles of injunctive norms (i.e., others’ perceived approval of substance use). Fourth, revisions were made to the instructions for the AUDIT and CUDIT-R to fit the study timeframe (references to past 6 months were changed to past 30 days). This change in timeframe leads the mean AUDIT and CUDIT-R scores for these measures to be unable to be comparable to scores from other studies. To avoid making other changes to this measure, we retained the response options of the original measure, which includes response options of “never” and “monthly or less.” Given the revised one-month timeframe for these measures, these response options may have been difficult for participants to differentiate, and this should be considered as a limitation.

Conclusions

The current study advanced our understanding of the roles of descriptive norms in alcohol and cannabis use among SMW and SMGD individuals. Findings indicate that descriptive norms for SMW are most relevant for SMW. Little evidence was found for the reciprocal nature of these associations, with descriptive norms predicting subsequent changes in problems for SMW, but not vice versa. Further, this study found little evidence for prospective associations between descriptive norms and substance use among SMGD individuals, potentially as a result of the smaller sample for these analyses. These findings have potential implications for the adaptation of normative feedback interventions for SWM and SMGD individuals. Results also illuminate potential predictors of perceptions of heavier alcohol and cannabis use among SMW and SMGD individuals. Coping motives for alcohol use prospectively predicted increases in perceptions of heavy drinking among GD individuals, while elevated symptoms of depression prospectively predicted increases in perceptions of heavy cannabis use among SMW. This provides some evidence to support minority stress and coping factors as drivers of perceptions of heavy alcohol and cannabis use among sexual and gender minority individuals.

Public Health Significance Statement:

Results indicate that perceptions of heavy alcohol and cannabis use among lesbian, bisexual, and queer women may contribute to heavier alcohol and cannabis use and problems related to use among lesbian, bisexual, and queer women. Experiences of microaggressions, using cannabis to cope, and anxiety and depression may contribute to perceptions of heavier cannabis use among lesbian, bisexual, and queer women and gender diverse individuals.

Acknowledgements:

We would like to thank Shariell Crosby and Sophia Pirog for their invaluable work on this project. We also thank Project QuEST participants for their vital contributions to understanding substance use among sexual minority women and gender diverse individuals.

Role of Funding Sources

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number K01DA046716 (PI: Dyar) and Drs. Rhew and Lee’s time on this manuscript was supported by R01DA058642. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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