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. Author manuscript; available in PMC: 2026 Mar 2.
Published in final edited form as: Am J Psychiatry. 2026 Feb 18;183(7):472–481. doi: 10.1176/appi.ajp.20250206

Substance Use Patterns Across the Sexual Identity Spectrum Among U.S. Individuals

Kevin H Yang 1, Letitia A Mueller 1, Benjamin H Han 2, Joseph J Palamar 3
PMCID: PMC12949925  NIHMSID: NIHMS2149867  PMID: 41703691

Abstract

Objective:

The authors sought to examine substance use patterns across the sexual identity spectrum, particularly among individuals who describe their sexual identity using different terms or express uncertainty about their orientation—groups that remain poorly understood beyond lesbian, gay, or bisexual (LGB) categories.

Methods:

Using data from the 2023 National Survey on Drug Use and Health among individuals ≥12 years of age (N=52,525), the authors examined past-year substance use across five sexual identity groups: heterosexual, gay/lesbian, bisexual, those using a different term to describe their sexual identity, and those unsure of their identity. Associations were examined between sexual identity (overall and disaggregated by sex using sex-specific heterosexual reference groups) and past-year use of cannabis, hallucinogens, cocaine, inhalants, methamphetamine, and misuse of prescription opioids, tranquilizers/sedatives, and stimulants.

Results:

Substance use was higher across all other sexual identity groups compared with heterosexual individuals. Bisexual and gay/lesbian individuals showed elevated odds across most substances examined, particularly inhalants, hallucinogens, and cannabis. Both individuals using different terms and those unsure of their sexual identity showed elevated odds for inhalants, hallucinogens, cannabis, and prescription tranquilizer/sedative misuse, with those using different terms additionally showing elevated odds for prescription stimulant misuse. In sex-disaggregated analyses, both males and females showed elevated odds across multiple substances, with females generally showing elevations across a greater number of substances, although some estimates for males were suppressed due to small sample sizes.

Conclusions:

These findings extend our understanding of substance use beyond LGB categories, revealing nuanced patterns among emerging identity groups, underscoring the importance of targeted screening and prevention strategies.

Substance use disparities among non-heterosexual groups in the United States have been consistently documented, particularly among individuals identifying as lesbian, gay, or bisexual (LGB) (1–8). These populations often experience elevated rates of substance use compared to their heterosexual peers, a phenomenon commonly attributed to identity-related stress, societal disenfranchisement, perceived stigma, discrimination, lower levels of family support, increased isolation, and adverse societal experiences (9–11). However, existing research has largely neglected the nuanced experiences of individuals who describe their sexual identity using terms outside LGB categories or who remain unsure of their orientation. Despite emerging evidence suggesting heterogeneity in substance use behaviors and associated risk factors among different sexual orientation groups (12–14), information on individuals beyond LGB identities is poorly understood, particularly at the national level. Recent research indicates an expanding range of sexual identity expressions, particularly among younger populations, with increasing numbers of individuals identifying beyond LGB categories, such as queer, pansexual, asexual, or omnisexual, among others (15, 16). Understanding substance use patterns across these emerging sexual identity categories is crucial for clinical practice and public health intervention, as different subgroups may require distinct prevention and treatment approaches.

Our current understanding of substance use patterns across the sexual identity spectrum has been limited by several key factors. First, nationally representative data capturing the full spectrum of sexual identities has been scarce. Previous research using the National Survey on Drug Use and Health (NSDUH) has focused exclusively on LGB populations, as the survey’s sexual identity question prior to 2023 only included responses for heterosexual, gay/lesbian, and bisexual orientations, limiting analysis of individuals who identify differently or are unsure of their orientation. Beyond NSDUH, research on substance use among non-heterosexual populations has often relied on convenience samples from various settings, including community organizations and clinical populations (17–20). While venue-specific studies, such as those sampling nightclub attendees or social media users (21–23), have provided valuable insights into specific contexts, their limited generalizability highlights the importance of nationally representative data. Although the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) included an option of “not sure” for sexual identity (7, 8), this survey was last conducted in 2012–2013. Second, previous versions of the NSDUH only included “don’t know” and “refused” options beyond LGB categories—responses that many researchers omitted from analysis (2–6), thereby missing potentially important variation in substance use patterns. Third, the understanding of adolescent substance use patterns across sexual identities has been limited by survey design constraints, as most national surveys, including NSDUH prior to 2023, only collected sexual identity data from adult respondents. This data limitation is particularly significant given that adolescence represents a critical period for substance use initiation and development of use patterns (24). Additionally, non-heterosexual youths often report earlier onset and higher rates of substance use compared to their heterosexual peers (25–27).

The 2023 NSDUH represents a significant advancement in addressing these limitations through two key changes: 1) the addition of expanded sexual identity categories, including “I use a different term” and “I am not sure,” and 2) the extension of these sexual identity questions to adolescent respondents. These changes provide an opportunity to examine updated substance use patterns across a broader spectrum of sexual identities and age groups than previously possible in nationally representative data. Therefore, this study provides the first comprehensive examination of substance use patterns across the sexual identity spectrum among individuals age 12 and older, addressing gaps in our understanding of emerging sexual identity categories and providing insights to inform targeted prevention and intervention strategies for various sexual orientation groups.

METHODS

Data Source

We analyzed data from the 2023 National Survey on Drug Use and Health (NSDUH) among individuals age 12 and older (N=52,525). The NSDUH is a nationally representative annual cross-sectional survey of noninstitutionalized individuals in the United States. The analysis was limited to 2023, which was the first year that sexual identity questions were expanded to be more inclusive and included adolescents. The survey is based on a multistage area probability sample for each of the 50 states and the District of Columbia. Multimodal data collection, with a mixture of in-person and online, was used in the 2023 NSDUH. The weighted interview response rate for the 2023 NSDUH was 50.5%, with 36.1% of interviews completed online and 63.9% completed in person.

Measures

Sexual identity was assessed via the question “Which one of the following do you consider yourself to be?”, with responses including “heterosexual, that is, straight,” “gay or lesbian,” “bisexual,” “I use a different term,” and “I am not sure about my sexual identity.” We excluded other response categories, including “I do not know what this question is asking,” “don’t know,” “bad data,” “refused,” and “blank.”

Past-year substance use was assessed for multiple substances, including cannabis, hallucinogens, cocaine, inhalants, methamphetamine, and misuse of prescription opioids, tranquilizers/sedatives, and stimulants. Hallucinogens were defined by NSDUH to include lysergic acid diethylamide (LSD), phencyclidine (PCP), peyote, mescaline, psilocybin, 3,4-methylenedioxymethamphetamine (MDMA/Ecstasy), ketamine, dimethyltryptamine (DMT), alpha-methyltryptamine (AMT), 5-MeO-DIPT (“foxy methoxy” or “foxy”), and Salvia divinorum. Misuse was defined as using in any way not directed by a physician, including use without a prescription or use in greater amounts, more often, or longer than instructed (28).

Demographic characteristics included age (12–17, 18–25, 26–34, ≥35 years), sex at birth (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, non-Hispanic other, Hispanic), education (less than high school, high school, some college/associate’s degree, college degree or higher), and annual family income (<$20,000, $20,000–$49,999, $50,000–$74,999, ≥$75,000). The education variable was included only for adults age 18 or older.

Statistical Analysis

First, we estimated past-year prevalence of use for each substance according to each sexual identity category overall and disaggregated by sex. Next, Rao-Scott chi-square tests examined bivariable associations between sexual identity and substance use. To prevent family-wise error, we implemented a Bonferroni correction by dividing alpha (0.05) by 8 (the number of substances examined), resulting in an alpha of 0.006 for bivariable tests and multivariable models. Finally, we fitted two sets of multivariable logistic regression models to estimate adjusted odds ratios for each substance: one examining associations between sexual identity and substance use overall, and another examining these associations disaggregated by sex (e.g., male heterosexual, female heterosexual, male gay, female lesbian), with heterosexual males serving as the reference group for comparisons among males, and heterosexual females for comparisons among females. Both models adjusted for age, race/ethnicity, education, and annual family income. Models included indicators for “missing” education among adolescents to prevent case-wise deletion. Estimates with unweighted sample sizes <10 were suppressed due to concerns about statistical reliability. All analyses were conducted using Stata SE 17 (StataCorp, College Station, TX), and weights accounted for the complex survey design, nonresponse, selection probability, and population distribution. This secondary analysis was exempt from review at the New York University Langone Medical Center’s Institutional Review Board.

RESULTS

Prevalence of Substance Use by Sexual Identity

An estimated 89.2% of individuals identified as heterosexual, 2.5% as gay/lesbian, 5.1% as bisexual, 1.6% using different terms, and 1.6% not sure about their identity. Table 1 presents prevalence estimates of use for each substance according to sexual identity group, overall and disaggregated by sex (unweighted sample sizes are presented in the online supplement). Overall, the prevalence of each substance was consistently elevated among all non-heterosexual groups compared to heterosexual individuals (all p values <0.001). Notable prevalence estimates include cannabis use among bisexual individuals (48.0%), hallucinogen use among those using different terms (13.6%), cocaine use among gay/lesbian and bisexual individuals (both 4.3%), inhalant use among gay/lesbian individuals (8.4%), and methamphetamine use among those using different terms (2.6%). For prescription drug misuse, notable prevalence estimates include opioid misuse among bisexual individuals and those using different terms (both 4.9%), tranquilizer/sedative misuse among gay/lesbian individuals (6.0%), and stimulant misuse among bisexual individuals (5.0%).

TABLE 1.

Prevalence of past-year substance use according to sexual identitya

Cannabis Hallucinogens Cocaine Inhalants Methamphetamine Prescription opioid misuse Prescription tranquilizer/sedative misuse Prescription stimulant misuse
Sexual identity and sex % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI
Overall sample
22.4 21.7, 23.1 3.2 2.9, 3.5 1.8 1.6, 2.0 1.0 0.8, 1.1 0.9 0.7, 1.1 3.0 2.7, 3.3 1.7 1.5, 2.0 1.4 1.3, 1.6
Full sample
Heterosexual 20.1 19.4, 20.8 2.4 2.2, 2.7 1.5 1.3, 1.8 0.5 0.4, 0.6 0.8 0.6, 1.0 2.9 2.5, 3.2 1.4 1.2, 1.7 1.2 1.0, 1.3
Gay/lesbian 38.2 34.1, 42.3 7.0 5.2, 9.5 4.3 2.8, 6.6 8.4 5.8, 12.0 2.3 1.3, 4.2 3.7 2.3, 6.0 6.0 3.5, 10.0 2.7 1.6, 4.4
Bisexual 48.0 45.8, 50.2 9.7 8.4, 11.0 4.3 3.5, 5.4 3.5 2.6, 4.7 1.9 1.4, 2.7 4.9 4.0, 6.1 4.3 3.3, 5.6 5.0 4.1, 6.2
Different term 37.8 33.1, 42.8 13.6 9.9, 18.6 3.7 2.0, 6.8 3.7 2.3, 5.8 2.6 1.3, 5.1 4.9 3.1, 7.5 2.7 1.4, 5.1 4.0 2.4, 6.4
Not sure 29.5 24.9, 34.6 7.8 5.0, 11.8 2.7 1.4, 5.3 3.1 1.6, 6.0 1.0 0.4, 2.4 1.6 0.9, 2.8 2.3 1.4, 3.8 0.8 0.4, 1.7
Sex, disaggregated
Heterosexual, male 23.4 22.4, 24.5 3.3 3.0, 3.8 2.1 1.8, 2.5 0.7 0.5, 0.9 1.0 0.8, 1.3 3.1 2.7, 3.5 1.4 1.2, 1.7 1.4 1.2, 1.6
Heterosexual, female 16.6 15.8, 17.4 1.5 1.3, 1.8 0.9 0.7, 1.2 0.3 0.2, 0.4 0.5 0.4, 0.7 2.6 2.3, 3.1 1.5 1.2, 1.8 0.9 0.8, 1.1
Gay, male 36.8 30.9, 43.2 9.8 6.7, 14.1 5.5 3.2, 9.2 13.3 9.2, 19.0 3.7 1.9, 6.9 4.1 2.1, 7.8 6.5 3.2, 13.0 3.5 1.8, 6.5
Lesbian, female 39.9 34.8, 45.2 3.4 2.1, 5.6 2.8 1.6, 4.7 1.9 1.0, 3.4 — — 3.2 2.0, 5.1 5.3 2.5, 11.1 1.6 0.9, 2.8
Bisexual, male 43.2 37.9, 48.7 8.0 5.7, 11.2 4.4 2.5, 7.6 6.5 3.8, 11.0 1.5 0.5, 4.3 2.7 1.6, 4.5 5.0 2.4, 10.0 4.5 2.8, 7.1
Bisexual, female 49.7 47.1, 52.3 10.2 8.7, 12.0 4.3 3.3, 5.6 2.5 1.8, 3.4 2.0 1.4, 3.0 5.7 4.4, 7.3 4.0 3.1, 5.2 5.2 3.9, 6.9
Different term, male 44.1 33.9, 54.8 15.8 9.2, 25.8 4.7 2.0, 11.1 5.2 2.4, 11.2 — — 3.6 1.4, 9.4 — — — —
Different term, female 35.2 29.8, 41.0 12.7 8.9, 17.7 3.3 1.6, 6.6 3.0 1.7, 5.4 — — 5.4 3.3, 8.6 2.5 1.3, 4.8 4.9 2.9, 7.9
Not sure, male 32.8 23.3, 44.1 13.1 6.7, 24.0 4.6 1.7, 11.7 — — — — 2.2 0.9, 5.4 — — — —
Not sure, female 28.0 22.9, 33.9 5.4 3.7, 7.8 1.9 0.7, 4.8 2.9 1.5, 5.8 — — 1.3 0.6, 2.9 2.4 1.3, 4.3 0.6 0.2, 1.5
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a

All prevalence estimates are weighted to account for the National Survey on Drug Use and Health complex survey design. “Different term” refers to respondents who used a term other than heterosexual, straight, gay, lesbian, or bisexual to describe their sexual identity. “Not sure” refers to respondents who were uncertain about their sexual identity. Estimates with unweighted N<10 were suppressed to ensure statistical reliability and are denoted with a dash. All p values for bivariable tests were <0.001.

Multivariable Associations by Sexual Identity

Figure 1 presents overall associations by sexual identity from multivariable models, and Table 2 presents associations both overall and disaggregated by sex. Compared to heterosexual individuals, bisexual individuals had significantly elevated odds across all substances examined, with the strongest associations observed for inhalants (adjusted odds ratio [aOR]=3.75, 95% CI=3.03, 4.65), hallucinogens (aOR=3.22, 95% CI=2.84, 3.64), cannabis (aOR=3.07, 95% CI=2.86, 3.29), and methamphetamine (aOR=2.63, 95% CI=1.96, 3.54). Compared to heterosexual individuals, gay/lesbian individuals showed elevated odds for all substances examined except prescription opioid misuse, with particularly strong associations for inhalants (aOR=9.67, 95% CI=7.78, 12.02), methamphetamine (aOR=3.20, 95% CI=2.18, 4.70), and prescription tranquilizer/sedative misuse (aOR=3.05, 95% CI=2.34, 3.97).

FIGURE 1. Forest plots of past-year substance use by sexual identitya.

FIGURE 1.

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a Adjusted odds ratios with 95% confidence intervals for past-year substance use by sexual identity among U.S. individuals ≥12 years of age from the 2023 National Survey on Drug Use and Health (N=52,525), with heterosexual individuals as the reference group for all substances. Models were adjusted for age, race/ethnicity, education, and annual family income. The x-axis is displayed on a logarithmic scale. “Different term” refers to respondents who used a term other than heterosexual, straight, gay, lesbian, or bisexual to describe their sexual identity. “Not sure” refers to respondents who were uncertain about their sexual identity. For inhalants among gay/lesbian individuals, the arrow indicates that the upper 95% confidence interval extends beyond the displayed x-axis range, to 12.02.

TABLE 2.

Multivariable associations between sexual identity and past-year substance usea

Cannabis Hallucinogens Cocaine Inhalants Methamphetamine Prescription opioid misuse Prescription tranquilizer/sedative misuse Prescription stimulant misuse
Sexual identity and sex aOR 95% CI aOR 95% CI aOR 95% CI aOR 95% CI aOR 95% CI aOR 95% CI aOR 95% CI aOR 95% CI
Overall model (reference: heterosexual)
Gay/lesbian 2.32c 2.08, 2.58 2.07c 1.69, 2.53 1.94c 1.47, 2.57 9.67c 7.78, 12.02 3.20c 2.18, 4.70 1.45 1.11, 1.90 3.05c 2.34, 3.97 1.63b 1.21, 2.21
Bisexual 3.07c 2.86, 3.29 3.22c 2.84, 3.64 2.31c 1.92, 2.78 3.75c 3.03, 4.65 2.63c 1.96, 3.54 1.83c 1.56, 2.14 2.44c 2.01, 2.97 2.39c 2.00, 2.85
Different term 2.09c 1.85, 2.36 3.22c 2.64, 3.95 1.61 1.12, 2.30 4.19c 3.04, 5.77 1.65 0.89, 3.06 1.49 1.11, 2.01 2.15c 1.52, 3.03 1.75b 1.26, 2.43
Not sure 1.60c 1.41, 1.81 2.23c 1.77, 2.82 1.40 0.93, 2.09 2.92c 2.09, 4.06 2.05 1.13, 3.72 0.88 0.61, 1.26 1.87b 1.29, 2.72 0.99 0.65, 1.51
Males (reference: heterosexual males)
Gay 1.85c 1.58, 2.16 1.97c 1.51, 2.57 1.92c 1.33, 2.75 14.49c 11.20, 18.75 4.77c 3.05, 7.47 1.21 0.79, 1.84 3.71c 2.58, 5.32 1.71 1.14, 2.55
Bisexual 2.11c 1.83, 2.43 2.20c 1.75, 2.77 1.87c 1.32, 2.64 3.67c 2.61, 5.15 1.69 0.88, 3.26 1.52 1.09, 2.13 2.41c 1.61, 3.60 2.17c 1.57, 3.02
Different term 1.64c 1.29, 2.09 2.17c 1.48, 3.19 1.41 0.74, 2.69 3.86c 2.25, 6.61 — — 1.28 0.71, 2.29 — — — —
Not sure 1.19 0.94, 1.50 1.86b 1.27, 2.72 1.33 0.70, 2.53 — — — — 0.92 0.49, 1.74 — — — —
Females (reference: heterosexual females)
Lesbian 2.79c 2.41, 3.22 2.32c 1.69, 3.17 1.97b 1.27, 3.06 3.30c 2.08, 5.26 — — 1.69b 1.19, 2.39 2.45c 1.66, 3.62 1.54 0.97, 2.45
Bisexual 3.45c 3.18, 3.74 4.02c 3.44, 4.69 2.41c 1.92, 3.02 3.17c 2.39, 4.21 2.69c 1.90, 3.81 1.96c 1.62, 2.36 2.40c 1.91, 3.01 2.47c 1.99, 3.07
Different term 2.27c 1.97, 2.62 4.10c 3.21, 5.24 1.63 1.05, 2.54 3.62c 2.41, 5.44 — — 1.58 1.11, 2.24 2.16c 1.45, 3.20 2.11c 1.46, 3.06
Not sure 1.78c 1.54, 2.06 2.68c 1.99, 3.60 1.40 0.84, 2.36 2.96c 1.98, 4.42 — — 0.85 0.54, 1.33 1.98b 1.30, 3.03 1.05 0.63, 1.76
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a

Models were adjusted for age, sex (overall model only), race/ethnicity, education, and annual family income. A Bonferroni-corrected alpha of 0.006 (0.05/8 substances) was used to determine statistical significance. “Different term” refers to respondents who used a term other than heterosexual, straight, gay, lesbian, or bisexual to describe their sexual identity. “Not sure” refers to respondents who were uncertain about their sexual identity. Estimates with unweighted N<10 were suppressed to ensure statistical reliability and are denoted with a dash. aOR=adjusted odds ratio.

b

p<0.006.

c

p<0.001.

Compared to heterosexual individuals, those who used a different term to describe their sexual identity had elevated odds for five of eight substances examined, with the strongest associations for inhalants (aOR=4.19, 95% CI=3.04, 5.77), hallucinogens (aOR=3.22, 95% CI=2.64, 3.95), and prescription tranquilizer/sedative misuse (aOR=2.15, 95% CI=1.52, 3.03). Among individuals who were unsure of their identity, significant associations were found for four of eight substances examined, with particularly strong associations for inhalants (aOR=2.92, 95% CI=2.09, 4.06), hallucinogens (aOR=2.23, 95% CI=1.77, 2.82), and prescription tranquilizer/sedative misuse (aOR=1.87, 95% CI=1.29, 2.72).

Sex-Disaggregated Analyses

Sex-disaggregated associations for males are presented in Table 2 and Figure 2. Compared to heterosexual males, gay males showed elevated odds for six of eight substances examined, with particularly strong associations for inhalants (aOR=14.49, 95% CI=11.20, 18.75), methamphetamine (aOR=4.77, 95% CI=3.05, 7.47), and prescription tranquilizer/sedative misuse (aOR=3.71, 95% CI=2.58, 5.32). Similarly, bisexual males also had elevated odds for six of eight substances examined, with the strongest associations for inhalants (aOR=3.67, 95% CI=2.61, 5.15), prescription tranquilizer/sedative misuse (aOR=2.41, 95% CI=1.61, 3.60), and hallucinogens (aOR=2.20, 95% CI=1.75, 2.77). Males who used different terms showed elevated odds for inhalants (aOR=3.86, 95% CI=2.25, 6.61), hallucinogens (aOR=2.17, 95% CI=1.48, 3.19), and cannabis (aOR=1.64, 95% CI=1.29, 2.09), and males who were unsure of their identity showed elevated odds for hallucinogens (aOR=1.86, 95% CI=1.27, 2.72), with several estimates for both groups suppressed due to small sample sizes.

FIGURE 2. Forest plots of past-year substance use by sexual identity among malesa.

FIGURE 2.

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a Adjusted odds ratios with 95% confidence intervals for past-year substance use by sexual identity among U.S. males ≥12 years of age from the 2023 National Survey on Drug Use and Health, with heterosexual males as the reference group for all substances. Models were adjusted for age, race/ethnicity, education, and annual family income. The x-axis is displayed on a logarithmic scale. “Different term” refers to respondents who used a term other than heterosexual, straight, gay, lesbian, or bisexual to describe their sexual identity. “Not sure” refers to respondents who were uncertain about their sexual identity. Estimates with unweighted N<10 were suppressed to ensure statistical reliability and are not displayed.

Sex-disaggregated associations for females are presented in Table 2 and Figure 3. Compared to heterosexual females, lesbian females showed elevated odds for six of eight substances examined, with the strongest associations for inhalants (aOR=3.30, 95% CI=2.08, 5.26), cannabis (aOR=2.79, 95% CI=2.41, 3.22), and prescription tranquilizer/sedative misuse (aOR=2.45, 95% CI=1.66, 3.62). Bisexual females had elevated odds for all eight substances examined, with the strongest associations for hallucinogens (aOR=4.02, 95% CI=3.44, 4.69), cannabis (aOR=3.45, 95% CI=3.18, 3.74), and inhalants (aOR=3.17, 95% CI=2.39, 4.21). Females who used different terms showed elevated odds for five of eight substances examined (with methamphetamine suppressed due to small sample sizes), including hallucinogens (aOR=4.10, 95% CI=3.21, 5.24), inhalants (aOR=3.62, 95% CI=2.41, 5.44), cannabis (aOR=2.27, 95% CI=1.97, 2.62), prescription tranquilizer/sedative misuse (aOR=2.16, 95% CI=1.45, 3.20), and prescription stimulant misuse (aOR=2.11, 95% CI=1.46, 3.06). Females unsure of their identity showed elevated odds for four of eight substances examined (with methamphetamine suppressed due to small sample sizes), including inhalants (aOR=2.96, 95% CI=1.98, 4.42), hallucinogens (aOR=2.68, 95% CI=1.99, 3.60), prescription tranquilizer/sedative misuse (aOR=1.98, 95% CI=1.30, 3.03), and cannabis (aOR=1.78, 95% CI=1.54, 2.06).

FIGURE 3. Forest plots of past-year substance use by sexual identity among femalesa.

FIGURE 3.

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a Adjusted odds ratios with 95% confidence intervals for past-year substance use by sexual identity among U.S. females ≥12 years of age from the 2023 National Survey on Drug Use and Health, with heterosexual females as the reference group for all substances. Models were adjusted for age, race/ethnicity, education, and annual family income. The x-axis is displayed on a logarithmic scale. “Different term” refers to respondents who used a term other than heterosexual, straight, gay, lesbian, or bisexual to describe their sexual identity. “Not sure” refers to respondents who were uncertain about their sexual identity. Estimates with unweighted N<10 were suppressed to ensure statistical reliability and are not displayed.

DISCUSSION

This study provides a comprehensive examination of substance use patterns across an expanded spectrum of sexual identities in a nationally representative sample, addressing a gap in understanding disparities among sexual identity groups beyond LGB categories. Consistent with previous research (2–6, 8, 23, 29–31), we observed elevated substance use prevalence among non-heterosexual individuals compared to heterosexual individuals, with bisexual individuals exhibiting elevated odds of use across all substances, especially inhalants, hallucinogens, and cannabis. Similarly, gay/lesbian individuals demonstrated heightened odds for numerous substances, with the highest odds for inhalants, methamphetamine, and prescription tranquilizer/sedative misuse. Sex-disaggregated analyses revealed that bisexual and gay/lesbian individuals of both sexes showed elevated odds across multiple substances when compared to their sex-specific heterosexual counterparts. Our analysis also produced novel findings on the associations between substance use and emerging sexual identities such as “I use a different term” and “I am not sure,” which demonstrated nuanced substance use patterns with elevated odds across multiple substances, both overall and disaggregated by sex. These findings not only expand our understanding of substance use disparities but also highlight the importance of including broader sexual identity categories in surveys to capture the full spectrum of use patterns and underscore the need for further research examining risk factors and mechanisms underlying these associations to inform targeted screening and intervention strategies.

Among individuals who used different terms to describe their sexual identity, we observed distinctly elevated use patterns across multiple substances. In the overall model, individuals using different terms showed elevated odds for inhalants, hallucinogens, cannabis, and prescription tranquilizer/sedative and stimulant misuse compared to heterosexual individuals. Sex-disaggregated analyses revealed largely consistent patterns, with both males and females showing elevated odds for hallucinogens, inhalants, and cannabis when compared to their sex-specific heterosexual counterparts. However, some sex-specific differences emerged: Females who used different terms additionally demonstrated elevated odds for prescription tranquilizer/sedative and stimulant misuse, and several estimates for males were suppressed due to small sample sizes. To our knowledge, these substance use patterns among individuals who use different terms to describe their sexual identity have not been previously reported.

These observed patterns of substance use among individuals using different terms to describe their sexual identity may reflect differences in social contexts, such as participation in nightlife or use for sexual functioning, as well as coping mechanisms for stressors related to identity expression (21, 32, 33). Individuals who use alternative terms may feel disconnected from both LGB communities and broader societal norms, contributing to heightened stress and substance use as a coping strategy (9, 34). Additionally, the preference for using alternative identity labels may signal a higher degree of self-exploration or nonconformity, which may be associated with increased experimentation with substances (16). Further research is needed to explore these dynamics in emerging sexual identities.

Individuals who were unsure of their sexual identity also showed substance use patterns distinct from their heterosexual peers. In the overall model, individuals unsure of their identity showed elevated odds for inhalants, hallucinogens, cannabis, and prescription tranquilizer/sedative misuse compared to heterosexual individuals. Sex-disaggregated analyses revealed some common patterns, with both males and females showing elevated odds for hallucinogens compared to their sex-specific heterosexual counterparts. Notable sex-specific differences were observed: Females unsure of their sexual identity showed elevated odds for cannabis, inhalants, and prescription tranquilizer/sedative misuse—patterns that were not observed for males compared to their sex-specific heterosexual counterparts. For inhalants and prescription tranquilizer/sedative misuse, however, data for males were suppressed due to small sample sizes, preventing direct comparison.

The substance use patterns among individuals unsure of their sexual identity may reflect multiple factors. These individuals may experience unique difficulties accessing support systems or resources and may face perceived stigma associated with such identities (9). The process of identity questioning may create psychological distress, potentially leading to substance use as a coping mechanism. However, substance use patterns may also reflect participation in specific social contexts, preferences for certain drug effects, or involvement in particular venues or communities where substance use is more common. The observed sex differences, particularly females’ elevated odds across multiple substances, may reflect gender-specific coping strategies, differential access to substances, or varying social contexts, although further research is needed to understand these patterns given our limited data for males due to small sample sizes. Our findings highlight the importance of considering identity uncertainty as a distinct risk category rather than excluding these individuals from analyses or combining them with “other” groups. By recognizing the unique experiences of individuals who are unsure of their sexual identity, we can develop more nuanced and targeted public health strategies that address the complex interplay of identity exploration and substance use patterns. Future research should continue to examine these emerging identity categories, focusing on understanding the specific mechanisms, social contexts, and other factors that contribute to substance use among individuals navigating sexual identity uncertainty.

Of note, hallucinogens showed elevated odds across all sexual minority groups compared to heterosexual individuals, with particularly notable elevations among individuals who used different terms to describe their sexual identity and those who were unsure of their identity, and especially among females using different terms. The elevated odds of hallucinogen use among individuals using different terms and those unsure of their identity may suggest involvement in specific social scenes or networks where these substances are more prevalent (21). Additionally, hallucinogen use may reflect self-exploration, altered states of consciousness, and social bonding—experiences that may align with periods of identity questioning and exploration of identities beyond LGB categories (35). While hallucinogen use may initially be pursued for these purposes, research suggests that these substances may be associated with worsened mental health symptoms (36–38). Because our NSDUH-defined hallucinogen category encompasses diverse substances—including LSD, psilocybin, ketamine, MDMA, and others, which have distinct pharmacological profiles and use contexts (39)—future research should examine specific hallucinogen subtypes among sexual minority populations once larger samples are available, especially given ongoing shifts in hallucinogen decriminalization policies and increasing therapeutic research applications.

Elevated odds of inhalants, cannabis, and prescription tranquilizer/sedative misuse were observed across all sexual identity groups compared to heterosexual individuals, including those using different terms and those unsure of their identity. Across sexual minority populations, cannabis and prescription tranquilizer/sedative misuse may serve as coping mechanisms for minority stress, perceived stigma, discrimination, and identity-related challenges (40, 41), although both are associated with various physical and psychosocial adverse effects (42, 43). Similarly, inhalant use showed elevated odds across all sexual identity groups compared to heterosexual individuals and is associated with neurological damage and respiratory complications (44). However, it should be noted that inhalants encompass a heterogeneous category including volatile solvents, aerosols, and alkyl nitrites (“poppers”), each with distinct use contexts and health risks (45, 46). The elevated prevalence of these substances across sexual minority populations, particularly among understudied sexual identity groups, warrants increased clinical attention and screening.

Several limitations should be considered in the context of our findings. First, measures of sexual identity and substance use are self-reported and may be subject to social desirability or recall bias. Second, the cross-sectional nature of NSDUH prevents causal or temporal inferences regarding the relationship between sexual identity and substance use patterns. Third, we were unable to incorporate earlier versions of the NSDUH, as expanded sexual identity categories were added to the most recent (2023) survey, limiting our ability to examine trends over time. Fourth, the relatively recent addition of these categories may have limited our ability to detect significant associations for certain substances due to small sample sizes in several categories, and our analyses were further limited by small cell sizes for certain sexual identity and substance combinations in sex-disaggregated models, requiring suppression of some estimates. Future research using subsequent waves of NSDUH data with these expanded sexual identity categories will allow for larger samples to confirm our findings. Related to these sample size constraints, we were unable to examine substance use disorders among emerging sexual identity categories. While previous research has documented elevated substance use disorder diagnoses among sexual and gender minority populations (14, 47–49), future studies with larger samples should examine whether similar patterns exist for individuals using different identity terms or who are unsure of their identity. Fifth, some substance categories (e.g., hallucinogens, inhalants) encompassed a wide variety of substances with different pharmacological effects, use contexts, and risk profiles, which may obscure substance-specific patterns within these broader categories. Sixth, as the NSDUH only samples noninstitutionalized individuals, our findings may not capture substance use patterns among particularly vulnerable populations, such as those experiencing homelessness. Finally, NSDUH lacks data on confounding factors, such as adverse life experiences and sexual assault, which may influence substance use patterns.

CONCLUSIONS

This cross-sectional study provides novel insights into substance use patterns across an expanded spectrum of sexual identities, revealing important variations in risk among individuals who use different terms to describe their identity or are unsure about their orientation. Our findings underscore the heterogeneity of substance use behaviors across sexual identity groups and highlight the importance of considering emerging identity categories in substance use research and intervention development. Clinicians should consider sexual identity as a relevant component of comprehensive health assessment to better identify potential risks for substance use, while ensuring that these discussions are conducted in a supportive, nonstigmatizing, and patient-centered manner. This is particularly important given evidence that non-heterosexual populations have lower perceived risk of illicit drug use and face unique challenges to accessing substance use treatment (50, 51). Public health interventions should be designed to address the unique social contexts and stressors associated with different sexual identity expressions. Future research should continue to examine these expanded sexual identity categories, particularly focusing on understanding the mechanisms underlying these disparities and developing targeted prevention strategies.

Supplementary Material

supplemental table

Acknowledgments

This research was supported by NIDA grants K23DA043651 (principal investigator, Dr. Han), R21DA058404 (principal investigator, Dr. Han), and R21DA060362 (principal investigator, Dr. Palamar). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. This work was also supported in part by the UC San Diego Sam and Rose Stein Institute for Research on Aging.

Dr. Palamar has received personal fees from the Washington-Baltimore High Intensity Drug Trafficking Area program, Elsevier, Wiley, Rutgers University, Arizona State University, Dartmouth University, the University of Southern California, Queensland University, the National Network of Public Health Institutes, and Alta Mira Recovery programs, and he has received nonfinancial support from NIH/NIDA, University of Florida, Rx Summit, the Cape Cod Symposium on Addiction Disorders, and the Reagan-Udall Foundation for the FDA. The other authors report no financial relationships with commercial interests.

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Supplementary Materials

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