Abstract
Purpose
We tested three competing models about whether gender- and sexuality-based harassment at school have non-independent, additive, or interactive effects on adolescents’ electronic cigarette use (i.e., vaping), cigarette smoking, alcohol use, and heavy episodic drinking (HED). We also tested whether harassment mediated substance use disparities between lesbian, gay, bisexual, transgender (LGBT) adolescents and their cisgender heterosexual peers.
Methods
We analyzed cross-sectional data from the 2013–2014 California Healthy Kids Survey, including 316,766 students in grades 7, 9, and 11 from over 1,500 middle and high schools. We used logistic regression models and interaction terms to estimate associations of past-year gender- and sexuality-based harassment at school on past-month substance use, and the Karlson-Holm-Breen method to test whether harassment mediated LGBT disparities in substance use.
Results
Vaping, smoking, drinking, HED, and gender- and sexuality-based harassment were higher for transgender adolescents versus cisgender males and females, and for adolescents who were lesbian, gay, or bisexual only versus heterosexual only. Gender- and sexuality-based harassment were independently associated with greater odds of using each substance in every grade. These two types of harassment had positive interactions with each other for vaping in grade 11, smoking in grade 11, and HED in grades 9 and 11. Gender- and sexuality-based harassment significantly mediated many of the LGBT disparities in substance use.
Conclusions
Gender- and sexuality-based harassment at school independently or interactively produced LGBT disparities in substance use. Reducing these types of discrimination in schools will likely mitigate these disparities.
Keywords: Lesbian, gay, bisexual, and transgender, harassment, electronic cigarette use, cigarette use, alcohol use
INTRODUCTION
Lesbian, gay, and bisexual (LGB) adolescents are more likely than heterosexuals to smoke cigarettes,1–3 drink alcohol,3–6 and engage in heavy episodic drinking (HED).3–6 LGB adolescents have 123–323% higher odds of lifetime cigarette and alcohol use than heterosexuals.3 These disparities are larger for females than males, and for younger versus older adolescents.1–5 Scant research has examined differences in substance use behaviors between transgender and cisgender adolescents,7 but existing research suggests transgender youth have 18–72% higher odds of lifetime alcohol and cigarette use than cisgender adolescents.8,9 Less research has examined how these transgender–cisgender disparities differ by age/grade and sexual identity; however, this kind of intersectionality research10 was deemed a priority by the Institute of Medicine.7 Additionally, few studies have examined gender and sexual identity disparities in electronic cigarette use (i.e., vaping),11,12 despite vaping being more prevalent among adolescents than conventional cigarette smoking.13 Though the negative effects of adolescent smoking and alcohol use are well established,14,15 the effects of vaping are nascent. Nonetheless, vaping has been associated with nicotine dependence,16 poisonings,17 and inhalation of metals and toxins,18 thereby warranting vaping prevention during adolescence.
Minority stress theory19 posits LGB and transgender (LGBT) adolescents experience an excess burden of discrimination and victimization related to their sexual- and gender-minority statuses, which can lead them to cope by using substances. Victimization is more prevalent among LGBT versus cisgender heterosexual adolescents.8,20–23 Sexual identity disparities in peer victimization are larger for females than males, and for younger versus older ages,24,25 but little is known about whether transgender disparities in victimization vary by sexual identity or age/grade. Nevertheless, experiencing any form of victimization places adolescents at greater risk for several health risk behaviors, including smoking and drinking,26 and victimization has been shown to mediate LGBT disparities in smoking and drinking.8 Notably, discriminatory types of victimization—such as gender- and sexuality-based harassment—are more strongly associated with substance use than non-biased victimization,27 but rarely28 have they been tested as mediators of LGBT disparities in adolescent substance use. Furthermore, few studies have examined the predictors of vaping,29 including harassment.30
Moreover, few studies have examined how multiple types of discrimination—especially gender- and sexuality-based harassment—work in concert to influence adolescents’ use of substances. Multiple forms of harassment may influence health in three distinct ways.31,32 In non-independent models (e.g., prominence or inurement models31,32), the combined effect of multiple types of discrimination on health is not worse than the effects of just one form. In additive models, each type of discrimination produces independent effects on health, and, when both are present, their combined effect is equal to the sum of their independent effects. In interactive models (e.g., synergistic or exacerbation models31,32), the combined effect of multiple types of discrimination produce greater effects on health than simply adding together the independent effects of each type of discrimination. Research on discrimination among adolescents has found evidence of non-independent models for suicidal ideation,31 marijuana use,31 and HED31; additive models for depressive symptoms,23,31 psychological distress,33 self-rated health23; and interactive models have yet to be found. Research has primarily examined sexuality- and race-based discrimination, limiting knowledge about the effects of gender- and sexuality-based harassment on substance use among adolescents. Multicollinearity and lack of statistical power are common statistical problems in conducting research on multiple types of discrimination,31 but these problems are mitigated when analyzing data from large samples.
We analyzed data from Californian adolescents in grades 7, 9, and 11 to investigate gender and sexual identity disparities in gender- and sexuality-based harassment at school, as well as past-month vaping, smoking, drinking, and HED. We examined how these disparities varied across grades, and how sexual identity disparities differed by gender within grades. We explored whether gender- and sexuality-based harassment have non-independent, additive, or interactive effects on substance use, and tested the mediational effects of these types of harassment in producing gender and sexual identity disparities in substance use. We hypothesized substance use and harassment at school would be higher among LGB versus heterosexual adolescents, and transgender versus cisgender adolescents. We hypothesized sexual identity disparities would be larger for younger versus older adolescents, and for cisgender females versus cisgender males. Since scant research has tested the combined effects of gender- and sexuality-based harassment on substance use, we did not have a priori hypotheses about these associations. We hypothesized gender- and sexuality-based harassment would mediate gender and sexual identity disparities in substance use.
METHODS
Study Design
We analyzed cross-sectional data from the 2013–2014 California Healthy Kids Survey (CHKS), administered to students in grades 7, 9, and 11. The sample included 439,743 students attending 1,584 middle and high schools in California. Average school response rates were 77.0%, 67.0%, and 56.2% for grades 7, 9, and 11, respectively. Schools notified parents about the survey and offered them the opportunity to grant or withhold consent for their child(ren)—using either passive or active parental consent. Eligible students voluntarily completed anonymous confidential surveys, either online or using paper surveys depending on their school’s administration method. Sampling frames were diverse across schools and developed in collaboration with WestEd.34 Generally, census-sampling was employed in schools with ≤900 students per grade, and randomly selected classrooms were sampled in schools with >900 students per grade. The University of Pittsburgh Institutional Review Board deemed the current study exempt.
Measures
Our primary independent variables were gender and sexual identity. The following question measured LGBT status: “Which of the following best describes you?” Response options included: heterosexual (straight); gay or lesbian or bisexual; transgender; not sure; and decline to respond. Because surveys instructed participants to “mark all that apply,” we created 4 sexual identity groups based only on the first 2 response options. The 4 sexual identity groups were: lesbian, gay, or bisexual (LGB) only; heterosexual only; both heterosexual and LGB; and neither heterosexual nor LGB (participants who did not select either option). We removed participants who selected “decline to state” (n=31,637) or “not sure” (n=23,121) because we could not discern whether this corresponded with their gender or sexual identity. We created a three-category measure of gender by coding participants who selected “transgender” as transgender adolescents, and those who did not select this option were coded as cisgender males or cisgender females based on their responses to the following question: “What is your sex? Male or Female.”
Our hypothesized mediators were sexuality- and gender-based harassment. We used the term harassment because the victimization was directly tied to being a (real or perceived) member of a social group. First, the survey provided the definition: “You were bullied if you were shoved, hit, threatened, called mean names, teased, or had other unpleasant physical or verbal things done to you repeatedly or in a severe way. It is not bullying when two students of about the same strength quarrel or fight.” Participants were then asked: “During the past 12 months, how many times on school property were you harassed or bullied for any of the following reasons…”: (1) “because you are gay or lesbian or someone thought you were”; and (2) “your gender (being male or female).” Response options for each item included: 0 times; 1 time; 2 to 3 times; 4 or more times. We dichotomously coded each item as any versus none based on low prevalence and prior research.27
Our dependent variables were vaping, smoking, drinking, and HED, measured with the following items, “During the past 30 days, on how many days did you use…”: (1) “an electronic cigarette or any other nicotine delivery device”; (2) “cigarettes”; (3) “one drink of alcohol”; and (4) “five or more drinking of alcohol in a row, that is, within a couple of hours.” Response options included 0, 1, 2, 3–9, 10–19, and 20–30 days. We dichotomously coded each substance use item as any versus none because each variable was zero-inflated and failed to have Gaussian or Poisson distributions. (We conducted sensitivity analyses with alternative cutoffs [e.g., <2 versus ≥2 times], which yielded similar results.)
Demographic covariates included grade, race/ethnicity (Hispanic/Latino; White; Black, Asian or Pacific Islander; and other), and parents’ education. The following item assessed parents’ highest education level: “What is the highest level of education your parents completed? (Mark the educational level of the parent who went the furthest in school.)” Response options included: did not finish high school; graduated from high school; attended college but did not complete four-year degree; graduated from college; and don’t know.
Analyses
We conducted analyses in Stata version 14 (College Station, TX). After removing 12.5% of participants who checked “decline to state” or “unsure” for the gender and sexual identity item, 384,985 students in grades 7, 9, and 11 completed surveys. Per recommendations,35 we removed 2.7% of participants who selected “only some of them” or “hardly any” when responding to the question: “How many questions in this survey did you answer honestly?” Among the remaining participants, the proportion of missingness was highest for gender and sexual identity (11.0%) followed by gender- and sexuality-based harassment (5.7% for each). Of the participants who responded to at least one substance use question, 84.5% had complete data for all independent variables, mediators, and covariates, creating an analytic sample of 316,766 participants. We allowed sample sizes to vary for each substance use variable, and the samples had similar characteristics. Data were not missing completely at random: compared with participants missing gender and sexual identity data, participants included in our analytic sample were less likely to report vaping, smoking, HED, and gender- and sexuality-biased harassment, but more likely to report alcohol use. We chose not to impute missing data because missingness was largest for our primary independent variables.
We tested the bivariate associations between independent variables, mediators, and dependent variables using Rao-Scott chi-square tests to account for the clustering of students within schools. In all multivariable models, we controlled for demographic covariates using logistic regression with cluster-robust standard errors to adjust for the nesting of students within schools and provide precise estimations (comparable to multilevel modeling) when the number of clusters is plentiful.36
We used the same model building processes to examine the gender and sexual identity disparities in harassment and substance use. We initially examined the main effects of gender and sexual identity on harassment and substance use, followed by a model with grade-by-gender and grade-by-sexual-identity interaction terms. Subsequently, we stratified analyses by grade to illuminate the main effects of sexual and gender identity within each grade. We then added gender-by-sexual-identity interaction terms. To illuminate these intersectional disparities, we created a categorical variable for each sexual-identity-by-gender subgroup (with heterosexual only cisgender males as the referent).
To test the non-independent and additive models of harassment on substance use, we entered the two types of harassment as separate dichotomous variables into the model. To test the interactive harassment model, we added the interaction term for the 2 dichotomous harassment variables. To test whether harassment mediated LGBT disparities in substance use, we used the Karlson-Holm-Breen method, which provides the proportion of reduction in the effect of the primary independent variable caused by the mediators, as well as a p-value for the indirect effects.37
RESULTS
In total, 51.1% of participants were cisgender females, 48.2% were cisgender males, and 0.7% were transgender (Table 1). Overall, 94.4% of participants were heterosexual only, %4.6 were LGB only, 0.5% reported being both heterosexual and LGB, and 0.4% reported being neither (which is only comprised of transgender adolescents per the nature of the variable).
Table 1.
Sample Characteristics of the Total Sample and by Gender and Sexual Identity: California Healthy Kids Survey, California, 2013–2014
| Total sample (N=316,766) |
Gender | Sexual Identity | ||||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| Cisgender males (n=152,564) |
Cisgender females (n=161,833) |
Transgender (n=2,369) |
Heterosexual only (n=298,921) |
LGB only (n=14,726) |
Both heterosex ual and LGB (n=1,699) |
Neither heterosexual nor LGB (n=1,420) |
||
|
|
|
|
||||||
| % | % | % | % | % | % | % | ||
| Sexual Identity | ||||||||
| Heterosexual only | 94.4 | 96.9 | 93.2 | 10.9 | 100.0 | 0.0 | 0.0 | 0.0 |
| LGB only | 4.6 | 2.8 | 6.2 | 20.1 | 0.0 | 100.0 | 0.0 | 0.0 |
| Both heterosexual and LGB | 0.5 | 0.3 | 0.6 | 9.1 | 0.0 | 0.0 | 100.0 | 0.0 |
| Neither heterosexual nor LGB | 0.4 | 0.0 | 0.0 | 59.9 | 0.0 | 0.0 | 0.0 | 100.0 |
| Gender | ||||||||
| Cisgender males | 48.2 | 100.0 | 0.0 | 0.0 | 49.5 | 28.7 | 29.2 | 0.0 |
| Cisgender females | 51.1 | 0.0 | 100.0 | 0.0 | 50.5 | 68.1 | 58.1 | 0.0 |
| Transgender | 0.7 | 0.0 | 0.0 | 100.0 | 0.1 | 3.2 | 12.7 | 100.0 |
| Grade | ||||||||
| 7th | 26.9 | 27.2 | 26.8 | 23.3 | 27.5 | 16.8 | 26.1 | 21.5 |
| 9th | 37.8 | 37.6 | 37.9 | 41.3 | 37.6 | 41.4 | 37.5 | 42.4 |
| 11th | 35.3 | 35.3 | 35.3 | 35.5 | 35.0 | 41.9 | 36.4 | 36.1 |
| Race/Ethnicity | ||||||||
| Hispanic/Latino | 48.6 | 47.4 | 49.7 | 48.9 | 48.4 | 52.3 | 51.4 | 51.5 |
| White, non-Hispanic/Latino | 23.3 | 23.6 | 23.0 | 21.7 | 23.5 | 20.4 | 18.4 | 18.4 |
| Asian or Pacific Islander, non-Hispanic/Latino | 13.6 | 14.0 | 13.5 | 10.1 | 14.0 | 8.8 | 11.4 | 10.8 |
| Black, non-Hispanic/Latino | 3.5 | 3.7 | 3.3 | 7.0 | 3.4 | 4.8 | 4.5 | 8.2 |
| Other, non-Hispanic/Latino | 10.9 | 11.3 | 10.5 | 12.2 | 10.7 | 13.7 | 14.4 | 11.1 |
| Parent’s Highest Education Level | ||||||||
| Less than high school degree | 13.2 | 11.5 | 14.8 | 18.6 | 13.0 | 17.4 | 15.9 | 20.1 |
| High school degree | 15.7 | 15.6 | 15.9 | 14.9 | 15.6 | 17.9 | 17.1 | 16.7 |
| Attended some college | 13.1 | 12.2 | 14.0 | 12.7 | 13.0 | 15.5 | 14.9 | 11.8 |
| College degree | 40.8 | 42.0 | 39.7 | 34.9 | 41.3 | 32.2 | 34.7 | 31.3 |
| Don’t know | 17.1 | 18.7 | 15.7 | 18.9 | 17.1 | 17.0 | 17.4 | 20.1 |
Note. LGB = lesbian, gay, or bisexual. Gender and sexual orientation were significantly associated with all covariates (all p-values<0.001).
Harassment Disparities
From grades 7 to 11, gender-based harassment decreased from 7.3% to 6.5%, and sexuality-based harassment decreased from 9.5% to 6.3% (Table 2). Across all grades, gender- and sexuality-based harassment were higher among transgender adolescents than cisgender males and cisgender females, and among LGB only adolescents versus heterosexual only adolescents.
Table 2.
Differences by and Interactions of Gender and Sexual Identity on Gender- and Sexuality-based Harassment, Stratified by Grade: California Healthy Kids Survey, California, 2013–2014
| Gender-based Harassment at School in Past Year | Sexuality-based Harassment at School in Past Year | |||||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Prevalence | Main Effects | Interactions | Prevalence | Main Effects | Interactions | |
|
|
|
|||||
| % | AOR (95% CI) | AOR (95% CI) | % | AOR (95% CI) | AOR (95% CI) | |
| GRADE 7 | ||||||
| Total | 7.3 | 9.5 | ||||
| Gender | ||||||
| Cisgender male | 5.4 | 1.00 (referent) | 1.00 (referent) | 9.7 | 1.00 (referent) | 1.00 (referent) |
| Cisgender female | 8.7 | 1.59 (1.50, 1.69) | 1.66 (1.56, 1.76) | 8.9 | 0.78 (0.74, 0.83) | 0.74 (0.70, 0.78) |
| Transgender | 33.6 | 3.90 (2.84, 5.35) | 4.98 (2.80, 8.83) | 40.1 | 1.52 (1.09, 2.11) | 2.48 (1.40, 4.40) |
| Sexual Identity | ||||||
| Heterosexual only | 6.5 | 1.00 (referent) | 1.00 (referent) | 7.7 | 1.00 (referent) | 1.00 (referent) |
| LGB only | 26.6 | 4.57 (4.12, 5.07) | 6.60 (5.52, 7.89) | 58.8 | 17.53 (16.01, 19.20) | 11.97 (10.26, 13.97) |
| Both heterosexual and LGB | 21.9 | 3.22 (2.52, 4.11) | 3.82 (2.50, 5.84) | 40.1 | 7.50 (6.10, 9.21) | 5.06 (3.65, 7.01) |
| Neither heterosexual nor LGB | 30.5 | 2.09 (1.38, 3.16) | 1.68 (0.89, 3.17) | 33.4 | 3.51 (2.32, 5.29) | 2.09 (1.12, 3.90) |
| Gender × Sexual Identity Interactions | ||||||
| Cisgender female × LGB only | 0.60 (0.48, 0.74) | 1.78 (1.47, 2.15) | ||||
| Cisgender female × Both heterosexual and LGB | 0.80 (0.47, 1.37) | 2.14 (1.42, 3.21) | ||||
| Transgender × LGB only | 0.54 (0.26, 1.13) | 0.82 (0.40, 1.69) | ||||
| Transgender × Both heterosexual and LGB | 0.59 (0.24, 1.46) | 0.68 (0.30, 1.57) | ||||
| GRADE 9 | ||||||
| Total | 6.8 | 8.3 | ||||
| Gender | ||||||
| Cisgender male | 3.9 | 1.00 (referent) | 1.00 (referent) | 7.7 | 1.00 (referent) | 1.00 (referent) |
| Cisgender female | 9.1 | 2.23 (2.09, 2.38) | 2.47 (2.32, 2.64) | 8.3 | 0.79 (0.75, 0.82) | 0.80 (0.76, 0.84) |
| Transgender | 37.9 | 6.48 (5.14, 8.18) | 4.84 (2.84, 8.27) | 44.8 | 1.77 (1.38, 2.26) | 1.98 (1.11, 3.52) |
| Sexual Identity | ||||||
| Heterosexual only | 5.7 | 1.00 (referent) | 1.00 (referent) | 5.6 | 1.00 (referent) | 1.00 (referent) |
| LGB only | 22.8 | 4.07 (3.77, 4.40) | 7.67 (6.70, 8.77) | 52.2 | 18.90 (17.71, 20.16) | 20.70 (18.55, 23.11) |
| Both heterosexual and LGB | 19.9 | 2.97 (2.41, 3.66) | 4.31 (2.80, 6.64) | 33.3 | 7.98 (6.72, 9.47) | 6.21 (4.59, 8.40) |
| Neither heterosexual nor LGB | 36.5 | 2.42 (1.82, 3.23) | 3.48 (1.97, 6.13) | 42.2 | 6.24 (4.63, 8.41) | 5.61 (3.06, 10.29) |
| Gender × Sexual Identity Interactions | ||||||
| Cisgender female × LGB only | 0.43 (0.37, 0.50) | 0.88 (0.77, 0.99) | ||||
| Cisgender female × Both heterosexual and LGB | 0.59 (0.36, 0.99) | 1.42 (0.98, 2.06) | ||||
| Transgender × LGB only | 0.82 (0.44, 1.52) | 0.81 (0.41, 1.60) | ||||
| Transgender × Both heterosexual and LGB | 1.09 (0.46, 2.60) | 1.13 (0.51, 2.52) | ||||
| GRADE 11 | ||||||
| Total | 6.5 | 6.3 | ||||
| Gender | ||||||
| Cisgender male | 3.5 | 1.00 (referent) | 1.00 (referent) | 6.1 | 1.00 (referent) | 1.00 (referent) |
| Cisgender female | 8.7 | 2.50 (2.33, 2.68) | 2.79 (2.60, 2.99) | 5.9 | 0.70 (0.66, 0.74) | 0.75 (0.70, 0.80) |
| Transgender | 44.3 | 9.51 (7.48, 12.10) | 7.63 (4.36, 13.37) | 48.1 | 2.62 (2.01, 3.42) | 7.36 (4.28, 12.67) |
| Sexual Identity | ||||||
| Heterosexual only | 5.5 | 1.00 (referent) | 1.00 (referent) | 3.9 | 1.00 (referent) | 1.00 (referent) |
| LGB only | 18.7 | 3.26 (3.03, 3.51) | 6.08 (5.31, 6.97) | 42.4 | 18.93 (17.71, 20.23) | 22.50 (20.28, 24.96) |
| Both heterosexual and LGB | 18.3 | 2.58 (2.07, 3.23) | 4.25 (2.68, 6.73) | 26.5 | 8.01 (6.60, 9.72) | 8.97 (6.44, 12.49) |
| Neither heterosexual nor LGB | 44.8 | 2.63 (1.95, 3.55) | 3.53 (1.95, 6.38) | 45.8 | 6.78 (4.93, 9.31) | 2.49 (1.42, 4.36) |
| Gender × Sexual Identity Interactions | ||||||
| Cisgender female × LGB only | 0.43 (0.37, 0.51) | 0.77 (0.67, 0.87) | ||||
| Cisgender female × Both heterosexual and LGB | 0.53 (0.31, 0.90) | 0.85 (0.56, 1.29) | ||||
| Transgender × LGB only | 0.81 (0.43, 1.51) | 0.24 (0.13, 0.45) | ||||
| Transgender × Both heterosexual and LGB | 0.78 (0.34, 1.77) | 0.29 (0.13, 0.63) | ||||
Note. Boldface indicates statistical significance (p<0.05). LGB = lesbian, gay, or bisexual; AOR = adjusted odds ratio; CI = confidence interval; All models were estimated using logistic regression, adjusting for race/ethnicity, parent education, and school clustering (using cluster-robust standard errors).
Grade Interactions
Controlling for demographics, gender- and sexuality-based harassment disparities were larger in higher grades for transgender adolescents compared with cisgender males (p<0.001). Gender-based harassment disparities were smaller in higher grades for LGB only compared with heterosexual only adolescents (p<0.001), but sexuality-based harassment disparities by sexual identity did not differ across grades (p=0.20).
Main Effects
In each grade, transgender adolescents had significantly higher odds of gender- and sexuality-based harassment compared with cisgender males and cisgender females (Table 2). LGB only adolescents had higher odds of gender- and sexuality-based harassment compared with heterosexual only adolescents.
Gender-by-Sexual-Identity Interactions
Disparities for LGB only versus heterosexual only adolescents in gender- and sexuality-based harassment were smaller for cisgender females compared with cisgender males in grades 9 and 11 (Table 2). In grade 7, these findings were similar for gender-based harassment, but odds of sexuality-based harassment for LGB only versus heterosexual only adolescents were larger for cisgender females than cisgender males.
Substance Use Disparities
Vaping, smoking, drinking, and HED increased from grades 7–11 (Table 3). In each grade, all substance use prevalence rates were higher among transgender adolescents than cisgender males and cisgender females, and among LGB only versus heterosexual only adolescents.
Table 3.
Differences by and Interactions of Gender and Sexual Identity on Substance Use, Stratified by Grade: California Healthy Kids Survey, California, 2013–2014
| Electronic Cigarette Use | Cigarette Smoking | Alcohol Use | Heavy Episodic Drinking | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
|||||||||
| Prev- alence |
Main Effects |
Interactions | Prev- alence |
Main Effects |
Interactions | Prevalence | Main Effects | Interactions | Prev- alence |
Main Effects |
Interactions | |
|
|
|
|
|
|||||||||
| % | AOR (95% CI) | AOR (95% CI) | % | AOR (95% CI) | AOR (95% CI) | % | AOR (95% CI) | AOR (95% CI) | % | AOR (95% CI) | AOR (95% CI) | |
| GRADE 7 | ||||||||||||
| Total | 6.9 | 2.3 | 7.6 | 2.9 | ||||||||
| Gender | ||||||||||||
| Cisgender male | 6.6 | 1.00 (referent) | 1.00 (referent) | 2.2 | 1.00 (referent) | 1.00 (referent) | 6.6 | 1.00 (referent) | 1.00 (referent) | 2.6 | 1.00 (referent) | 1.00 (referent) |
| Cisgender female | 6.8 | 0.91 (0.86, 0.97) | 0.89 (0.83, 0.94) | 2.2 | 0.84 (0.76, 0.92) | 0.86 (0.77, 0.95) | 8.2 | 1.13 (1.07, 1.20) | 1.12 (1.06, 1.19) | 2.8 | 0.92 (0.85, 1.01) | 0.94 (0.85, 1.03) |
| Transgender | 30.4 | 2.90 (2.10, 3.99) | 3.38 (1.97, 5.80) | 25.8 | 5.82 (4.13, 8.19) | 4.77 (2.22, 10.23) | 34.3 | 3.53 (2.57, 4.85) | 3.36 (1.91, 5.91) | 26.7 | 4.62 (3.31, 6.46) | 1.54 (0.49, 4.84) |
| Sexual Identity | ||||||||||||
| Heterosexual only | 6.2 | 1.00 (referent) | 1.00 (referent) | 1.8 | 1.00 (referent) | 1.00 (referent) | 6.8 | 1.00 (referent) | 1.00 (referent) | 2.3 | 1.00 (referent) | 1.00 (referent) |
| LGB only | 24.8 | 4.55 (4.08, 5.08) | 3.56 (2.87, 4.42) | 14.9 | 7.99 (6.90, 9.24) | 9.01 (7.15, 11.35) | 28.3 | 4.72 (4.27, 5.22) | 4.68 (3.86, 5.66) | 17.1 | 7.51 (6.60, 8.55) | 8.19 (6.48, 10.36) |
| Both heterosexual and LGB | 20.6 | 3.22 (2.51, 4.14) | 3.13 (2.03, 4.82) | 10.5 | 4.09 (2.91, 5.75) | 4.03 (2.25, 7.23) | 22.3 | 3.17 (2.48, 4.06) | 1.94 (1.17, 3.23) | 13.1 | 4.60 (3.46, 6.13) | 3.56 (2.04, 6.22) |
| Neither heterosexual nor LGB | 29.0 | 1.94 (1.29, 2.91) | 1.64 (0.90, 3.00) | 22.3 | 2.24 (1.47, 3.42) | 2.77 (1.24, 6.18) | 31.6 | 1.83 (1.21, 2.77) | 1.92 (1.03, 3.56) | 24.8 | 2.73 (1.78, 4.19) | 8.26 (2.53, 26.96) |
| Gender × Sexual Identity Interactions | ||||||||||||
| Cisgender female × LGB only | 1.42 (1.11, 1.81) | 0.81 (0.62, 1.07) | 1.01 (0.81, 1.26) | 0.86 (0.66, 1.14) | ||||||||
| Cisgender female × Both heterosexual and LGB | 1.11 (0.63, 1.93) | 1.16 (0.55, 2.44) | 2.11 (1.16, 3.81) | 1.37 (0.69, 2.71) | ||||||||
| Transgender × LGB only | 1.07 (0.51, 2.25) | 1.26 (0.51, 3.12) | 1.07 (0.52, 2.21) | 3.16 (0.94, 10.61) | ||||||||
| Transgender × Both heterosexual and LGB | 0.89 (0.83, 0.94) | 0.86 (0.77, 0.95) | 1.12 (1.06, 1.19) | 0.94 (0.85, 1.03) | ||||||||
| GRADE 9 | ||||||||||||
| Total | 12.1 | 4.1 | 17.5 | 8.6 | ||||||||
| Gender | ||||||||||||
| Cisgender male | 12.3 | 1.00 (referent) | 1.00 (referent) | 4.0 | 1.00 (referent) | 1.00 (referent) | 14.3 | 1.00 (referent) | 1.00 (referent) | 7.5 | 1.00 (referent) | 1.00 (referent) |
| Cisgender female | 11.5 | 0.84 (0.81, 0.88) | 0.82 (0.79, 0.86) | 3.8 | 0.79 (0.74, 0.84) | 0.76 (0.71, 0.82) | 20.1 | 1.39 (1.34, 1.44) | 1.38 (1.33, 1.43) | 9.2 | 1.12 (1.07, 1.17) | 1.11 (1.06, 1.17) |
| Transgender | 37.1 | 1.67 (1.34, 2.08) | 1.61 (1.01, 2.58) | 28.6 | 2.54 (1.98, 3.26) | 1.59 (0.69, 3.68) | 42.2 | 2.00 (1.59, 2.51) | 1.80 (1.15, 2.84) | 35.4 | 2.15 (1.69, 2.73) | 2.31 (1.34, 3.98) |
| Sexual Identity | ||||||||||||
| Heterosexual only | 11.1 | 1.00 (referent) | 1.00 (referent) | 3.3 | 1.00 (referent) | 1.00 (referent) | 16.2 | 1.00 (referent) | 1.00 (referent) | 7.7 | 1.00 (referent) | 1.00 (referent) |
| LGB only | 25.8 | 2.65 (2.48, 2.83) | 2.18 (1.93, 2.46) | 15.5 | 5.06 (4.65, 5.50) | 4.23 (3.63, 4.93) | 35.9 | 2.49 (2.35, 2.65) | 2.28 (2.02, 2.57) | 21.8 | 2.98 (2.78, 3.19) | 2.97 (2.59, 3.40) |
| Both heterosexual and LGB | 28.5 | 2.92 (2.43, 3.52) | 2.08 (1.46, 2.98) | 14.2 | 4.13 (3.28, 5.20) | 4.44 (2.79, 7.07) | 35.4 | 2.44 (2.06, 2.88) | 2.03 (1.39, 2.96) | 23.9 | 3.26 (2.67, 3.96) | 2.78 (1.82, 4.25) |
| Neither heterosexual nor LGB | 29.9 | 2.86 (2.14, 3.84) | 2.93 (1.77, 4.86) | 30.5 | 4.36 (3.20, 5.93) | 6.84 (2.89, 16.21) | 44.2 | 2.42 (1.81, 3.25) | 2.67 (1.64, 4.35) | 39.7 | 3.89 (2.89, 5.23) | 3.61 (2.06, 6.35) |
| Gender × Sexual Identity Interactions | ||||||||||||
| Cisgender female × LGB only | 1.32 (1.15, 1.52) | 1.31 (1.09, 1.57) | 1.13 (0.98, 1.29) | 1.01 (0.86, 1.19) | ||||||||
| Cisgender female × Both heterosexual and LGB | 1.55 (1.02, 2.34) | 0.74 (0.41, 1.34) | 1.29 (0.85, 1.96) | 1.19 (0.74, 1.91) | ||||||||
| Transgender × LGB only | 1.16 (0.64, 2.12) | 1.70 (0.68, 4.25) | 1.27 (0.72, 2.23) | 0.85 (0.44, 1.65) | ||||||||
| Transgender × Both heterosexual and LGB | 0.82 (0.79, 0.86) | 0.76 (0.71, 0.82) | 1.38 (1.33, 1.43) | 1.11 (1.06, 1.17) | ||||||||
| GRADE 11 | ||||||||||||
| Total | 14.7 | 7.4 | 28.1 | 17.1 | ||||||||
| Gender | ||||||||||||
| Cisgender male | 16.4 | 1.00 (referent) | 1.00 (referent) | 8.5 | 1.00 (referent) | 1.00 (referent) | 26.6 | 1.00 (referent) | 1.00 (referent) | 17.7 | 1.00 (referent) | 1.00 (referent) |
| Cisgender female | 12.6 | 0.70 (0.67, 0.73) | 0.67 (0.64, 0.70) | 6.0 | 0.63 (0.60, 0.66) | 0.58 (0.55, 0.62) | 29.2 | 1.09 (1.06, 1.13) | 1.08 (1.04, 1.11) | 16.2 | 0.86 (0.83, 0.89) | 0.84 (0.81, 0.87) |
| Transgender | 42.5 | 1.47 (1.15, 1.88) | 2.14 (1.29, 3.55) | 37.4 | 1.92 (1.48, 2.49) | 2.65 (1.48, 4.76) | 50.6 | 1.31 (1.02, 1.67) | 2.19 (1.41, 3.41) | 43.4 | 1.72 (1.35, 2.20) | 2.23 (1.39, 3.58) |
| Sexual Identity | ||||||||||||
| Heterosexual only | 13.9 | 1.00 (referent) | 1.00 (referent) | 6.5 | 1.00 (referent) | 1.00 (referent) | 27.2 | 1.00 (referent) | 1.00 (referent) | 16.3 | 1.00 (referent) | 1.00 (referent) |
| LGB only | 24.4 | 2.05 (1.93, 2.19) | 1.58 (1.41, 1.77) | 19.0 | 3.45 (3.19, 3.72) | 2.43 (2.16, 2.74) | 40.0 | 1.70 (1.60, 1.81) | 1.53 (1.39, 1.68) | 26.3 | 1.80 (1.68, 1.93) | 1.48 (1.32, 1.66) |
| Both heterosexual and LGB | 28.0 | 2.36 (1.98, 2.82) | 1.26 (0.86, 1.85) | 18.4 | 3.01 (2.45, 3.69) | 1.47 (0.94, 2.30) | 42.5 | 1.90 (1.61, 2.23) | 1.15 (0.83, 1.59) | 30.1 | 2.08 (1.74, 2.48) | 1.03 (0.69, 1.54) |
| Neither heterosexual nor LGB | 47.4 | 3.24 (2.39, 4.38) | 2.19 (1.30, 3.70) | 41.1 | 4.20 (3.13, 5.63) | 2.96 (1.65, 5.30) | 55.2 | 2.66 (1.96, 3.62) | 1.58 (0.99, 2.52) | 46.5 | 2.48 (1.82, 3.37) | 1.89 (1.15, 3.11) |
| Gender × Sexual Identity Interactions | ||||||||||||
| Cisgender female × LGB only | 1.53 (1.33, 1.75) | 1.77 (1.53, 2.05) | 1.19 (1.06, 1.34) | 1.35 (1.18, 1.55) | ||||||||
| Cisgender female × Both heterosexual and LGB | 2.26 (1.43, 3.57) | 2.63 (1.53, 4.54) | 1.86 (1.26, 2.75) | 2.41 (1.51, 3.84) | ||||||||
| Transgender × LGB only | 0.62 (0.33, 1.15) | 0.80 (0.41, 1.55) | 0.43 (0.25, 0.75) | 0.68 (0.38, 1.21) | ||||||||
| Transgender × Both heterosexual and LGB | 0.67 (0.64, 0.70) | 0.58 (0.55, 0.62) | 1.08 (1.04, 1.11) | 0.84 (0.81, 0.87) | ||||||||
Note. Boldface indicates statistical significance (p<0.05). LGB = lesbian, gay, or bisexual; AOR = adjusted odds ratio; CI = confidence interval; All models were estimated using logistic regression, adjusting for race/ethnicity, parent education, and school clustering (using cluster-robust standard errors).
Grade Interactions
In multivariable models, all substance use disparities were larger in lower grades for transgender adolescents versus cisgender males (p-values<0.001), and for LGB only versus heterosexual only adolescents (p-values<0.001).
Main Effects
In every grade, the odds of each substance use behavior were higher for transgender adolescents versus cisgender males, and for LGB only adolescents versus heterosexual only adolescents (Table 3).
Gender-by-Sexual-Identity Interactions
Disparities for LGB only versus heterosexual only adolescents were larger among cisgender females than cisgender males for: vaping in all grades; smoking in grades 9 and 11; and alcohol use and HED in grade 11 (Table 3). Disparities for both heterosexual and LGB adolescents versus heterosexual only adolescents were larger among cisgender females than cisgender males for: vaping in grades 9 and 11; smoking and HED in grade 11; and alcohol use in grades 7 and 11. Disparities for both heterosexual and LGB adolescents versus heterosexual only adolescents were smaller among transgender adolescents than cisgender males for: vaping and smoking in all grades and HED in grade 11; but they were larger for drinking in all grades and HED in grade 9. Table 4, Step 1 shows the specific disparities for each sexual-identity-by-gender subgroup on substance use.
Table 4.
Gender and Sexual Identity Differences in Substance Use and the Mediating Effects of Gender- and Sexuality-based Harassment: California Healthy Kids Survey, California, 2013–2014
| Electronic Cigarette Use | Cigarette Use | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| Prev- alence |
Step 1. Base Model |
Step 2. Harassme nt Main Effects Model |
Step 3. Harassme nt Interaction Model |
Step 4. Proportion of Exposure Effect Explained by Harassment |
Prev- alence |
Step 1. Base Model |
Step 2. Harassme nt Main Effects Model |
Step 3. Harassme nt Interaction Model |
Step 4. Proportion of Exposure Effect Explained by Harassment |
|
|
|
|
|||||||||
| % | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | %a (pb) | % | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | %a (pb) | |
| GRADE 7 | ||||||||||
| Sexual Identity and Gender Subgroups | ||||||||||
| Heterosexual only cisgender male | 6.3 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 | 1.9 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 |
| Heterosexual only cisgender female | 6.0 | 0.89 (0.83, 0.94) | 0.88 (0.83, 0.94) | 0.88 (0.83, 0.94) | −1.2 (0.989) | 1.7 | 0.86 (0.77, 0.95) | 0.85 (0.77, 0.94) | 0.85 (0.77, 0.94) | −5.0 (0.960) |
| Heterosexual only transgender | 19.5 | 3.38 (1.97, 5.80) | 2.85 (1.63, 4.98) | 2.85 (1.63, 4.97) | 12.3 (0.178) | 9.1 | 4.77 (2.22, 10.23) | 3.57 (1.55, 8.21) | 3.58 (1.55, 8.22) | 14.3 (0.166) |
| LGB only cisgender male | 19.5 | 3.56 (2.87, 4.42) | 2.36 (1.90, 2.94) | 2.36 (1.90, 2.94) | 31.1 (<0.001) | 15.2 | 9.01 (7.15, 11.35) | 5.10 (3.97, 6.53) | 5.10 (3.97, 6.54) | 24.2 (0.001) |
| LGB only cisgender female | 26.1 | 4.49 (3.95, 5.10) | 2.89 (2.51, 3.32) | 2.88 (2.50, 3.32) | 28.9 (<0.001) | 12.7 | 6.30 (5.26, 7.55) | 3.37 (2.75, 4.12) | 3.37 (2.75, 4.12) | 32.1 (<0.001) |
| LGB only transgender | 40.7 | 12.85 (8.15, 20.28) | 6.94 (4.30, 11.19) | 6.98 (4.33, 11.25) | 24.1 (<0.001) | 47.6 | 54.16 (34.25, 85.62) | 24.74 (14.78, 41.42) | 24.74 (14.77, 41.42) | 20.7 (<0.001) |
| Both heterosexual and LGB cisgender male | 17.9 | 3.13 (2.03, 4.82) | 2.49 (1.62, 3.83) | 2.49 (1.62, 3.83) | 18.4 (0.059) | 7.5 | 4.03 (2.25, 7.23) | 2.75 (1.53, 4.94) | 2.75 (1.53, 4.94) | 22.2 (0.060) |
| Both heterosexual and LGB cisgender female | 19.2 | 3.07 (2.17, 4.35) | 2.25 (1.57, 3.23) | 2.25 (1.56, 3.23) | 27.6 (0.005) | 8.2 | 4.01 (2.48, 6.47) | 2.54 (1.55, 4.17) | 2.54 (1.55, 4.17) | 30.7 (0.007) |
| Both heterosexual and LGB transgender | 33.3 | 8.18 (4.51, 14.84) | 5.45 (3.04, 9.77) | 5.46 (3.05, 9.80) | 18.7 (<0.001) | 27.1 | 20.28 (11.29, 36.43) | 11.12 (6.35, 19.47) | 11.12 (6.35, 19.47) | 18.7 (<0.001) |
| Neither heterosexual nor LGB transgender | 29.0 | 5.56 (4.23, 7.32) | 4.13 (3.17, 5.39) | 4.14 (3.17, 5.40) | 16.5 (0.011) | 22.3 | 13.19 (9.91, 17.56) | 8.44 (6.26, 11.37) | 8.44 (6.26, 11.37) | 15.6 (0.010) |
| Gender-based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.65 (1.50, 1.81) | 1.71 (1.49, 1.95) | 2.26 (2.00, 2.56) | 2.23 (1.84, 2.69) | ||||||
| Sexuality- based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.90 (1.74, 2.07) | 1.93 (1.74, 2.15) | 2.20 (1.92, 2.52) | 2.18 (1.85, 2.57) | ||||||
| Interaction between Gender-based and Sexuality-based Harassment at School | 0.93 (0.76, 1.13) | 1.03 (0.79, 1.35) | ||||||||
| GRADE 9 | ||||||||||
| Sexual Identity and Gender Subgroups | ||||||||||
| Heterosexual only cisgender male | 11.9 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 | 3.6 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 |
| Heterosexual only cisgender female | 10.3 | 0.82 (0.79, 0.86) | 0.80 (0.77, 0.84) | 0.80 (0.77, 0.84) | −10.1 (0.786) | 2.9 | 0.76 (0.71, 0.82) | 0.73 (0.68, 0.78) | 0.73 (0.68, 0.79) | −11.0 (0.796) |
| Heterosexual only transgender | 18.6 | 1.61 (1.01, 2.58) | 1.46 (0.91, 2.34) | 1.45 (0.91, 2.33) | 18.0 (0.270) | 5.9 | 1.59 (0.69, 3.68) | 1.27 (0.56, 2.90) | 1.27 (0.56, 2.89) | 36.0 (0.270) |
| LGB only cisgender male | 23.4 | 2.18 (1.93, 2.46) | 1.58 (1.40, 1.80) | 1.59 (1.40, 1.80) | 39.3 (<0.001) | 14.3 | 4.23 (3.63, 4.93) | 2.42 (2.04, 2.86) | 2.44 (2.06, 2.89) | 35.8 (<0.001) |
| LGB only cisgender female | 26.3 | 2.37 (2.20, 2.56) | 1.78 (1.64, 1.93) | 1.78 (1.64, 1.94) | 32.0 (<0.001) | 15.2 | 4.21 (3.80, 4.66) | 2.53 (2.25, 2.85) | 2.54 (2.26, 2.86) | 32.5 (<0.001) |
| LGB only transgender | 35.8 | 4.09 (3.02, 5.53) | 2.41 (1.74, 3.34) | 2.40 (1.73, 3.33) | 36.8 (<0.001) | 31.4 | 11.45 (8.52, 15.39) | 4.80 (3.39, 6.80) | 4.76 (3.35, 6.77) | 34.7 (<0.001) |
| Both heterosexual and LGB cisgender male | 22.5 | 2.08 (1.46, 2.98) | 1.79 (1.25, 2.56) | 1.79 (1.25, 2.56) | 19.2 (0.065) | 15.0 | 4.44 (2.79, 7.07) | 3.35 (2.07, 5.43) | 3.36 (2.07, 5.45) | 16.4 (0.052) |
| Both heterosexual and LGB cisgender female | 28.0 | 2.65 (2.11, 3.33) | 2.18 (1.72, 2.78) | 2.18 (1.72, 2.78) | 18.8 (0.016) | 9.4 | 2.51 (1.76, 3.59) | 1.70 (1.17, 2.48) | 1.71 (1.17, 2.49) | 35.9 (0.015) |
| Both heterosexual and LGB transgender | 43.0 | 5.76 (3.68, 8.99) | 3.96 (2.54, 6.18) | 3.94 (2.53, 6.15) | 21.4 (<0.001) | 36.7 | 15.86 (10.00, 25.17) | 8.32 (5.11, 13.55) | 8.23 (5.05, 13.42) | 22.9 (<0.001) |
| Neither heterosexual nor LGB transgender | 39.9 | 4.72 (3.91, 5.70) | 3.42 (2.84, 4.11) | 3.41 (2.83, 4.11) | 20.6 (<0.001) | 30.5 | 10.89 (8.98, 13.21) | 6.19 (5.02, 7.63) | 6.18 (5.00, 7.62) | 22.3 (<0.001) |
| Gender-based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.72 (1.61, 1.83) | 1.68 (1.55, 1.83) | 2.36 (2.14, 2.60) | 2.18 (1.90, 2.50) | ||||||
| Sexuality- based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.48 (1.39, 1.59) | 1.46 (1.36, 1.58) | 1.95 (1.75, 2.16) | 1.86 (1.65, 2.10) | ||||||
| Interaction between Gender-based and Sexuality-based Harassment at School | 1.05 (0.92, 1.19) | 1.16 (0.96, 1.41) | ||||||||
| GRADE 11 | ||||||||||
| Sexual Identity and Gender Subgroups | ||||||||||
| Heterosexual only cisgender male | 16.1 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 3 | 8.1 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 3 |
| Heterosexual only cisgender female | 11.6 | 0.67 (0.64, 0.70) | 0.65 (0.63, 0.68) | 0.66 (0.63, 0.69) | −4.2 (0.840) | 4.9 | 0.58 (0.55, 0.62) | 0.57 (0.53, 0.60) | 0.57 (0.54, 0.60) | −3.2 (0.867) |
| Heterosexual only transgender | 29.1 | 2.14 (1.29, 3.55) | 1.79 (1.09, 2.95) | 1.79 (1.08, 2.95) | 22.5 (0.044) | 19.0 | 2.65 (1.48, 4.76) | 2.07 (1.18, 3.61) | 2.07 (1.18, 3.62) | 22.9 (0.041) |
| LGB only cisgender male | 23.6 | 1.58 (1.41, 1.77) | 1.20 (1.07, 1.34) | 1.22 (1.09, 1.37) | 54.2 (0.006) | 17.8 | 2.43 (2.16, 2.74) | 1.64 (1.45, 1.87) | 1.69 (1.48, 1.92) | 38.0 (0.003) |
| LGB only cisgender female | 24.6 | 1.62 (1.50, 1.75) | 1.27 (1.17, 1.39) | 1.28 (1.18, 1.40) | 45.3 (0.014) | 18.9 | 2.51 (2.29, 2.77) | 1.80 (1.62, 2.00) | 1.83 (1.64, 2.03) | 31.3 (0.010) |
| LGB only transgender | 30.2 | 2.08 (1.49, 2.90) | 1.20 (0.85, 1.70) | 1.15 (0.81, 1.63) | 79.9 (<0.001) | 33.1 | 5.14 (3.71, 7.12) | 2.52 (1.79, 3.54) | 2.43 (1.72, 3.42) | 44.2 (<0.001) |
| Both heterosexual and LGB cisgender male | 19.2 | 1.26 (0.86, 1.85) | 1.06 (0.72, 1.57) | 1.07 (0.72, 1.59) | 66.0 (0.106) | 11.2 | 1.47 (0.94, 2.30) | 1.15 (0.73, 1.82) | 1.17 (0.74, 1.85) | 53.1 (0.093) |
| Both heterosexual and LGB cisgender female | 27.4 | 1.91 (1.51, 2.42) | 1.64 (1.28, 2.10) | 1.66 (1.29, 2.12) | 20.3 (0.126) | 17.1 | 2.26 (1.71, 2.98) | 1.82 (1.36, 2.44) | 1.85 (1.38, 2.48) | 21.1 (0.120) |
| Both heterosexual and LGB transgender | 51.3 | 5.23 (3.25, 8.42) | 3.59 (2.20, 5.85) | 3.49 (2.13, 5.71) | 25.0 (<0.001) | 41.3 | 7.47 (4.69, 11.89) | 4.53 (2.78, 7.36) | 4.40 (2.68, 7.21) | 25.8 (<0.001) |
| Neither heterosexual nor LGB transgender | 47.4 | 4.69 (3.92, 5.60) | 3.20 (2.67, 3.84) | 3.13 (2.60, 3.76) | 26.4 (<0.001) | 41.1 | 7.84 (6.51, 9.44) | 4.74 (3.91, 5.74) | 4.65 (3.83, 5.64) | 25.1 (<0.001) |
| Gender-based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.67 (1.57, 1.79) | 1.52 (1.40, 1.65) | 1.84 (1.70, 2.00) | 1.59 (1.43, 1.78) | ||||||
| Sexuality- based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.52 (1.41, 1.63) | 1.38 (1.26, 1.52) | 1.80 (1.64, 1.98) | 1.62 (1.43, 1.82) | ||||||
| Interaction between Gender-based and Sexuality-based Harassment at School | 1.32 (1.15, 1.52) | 1.40 (1.18, 1.66) | ||||||||
| Alcohol Use | Heavy Episodic Drinking | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| Prevalence | Step 1. Base Model | Step 2. Harassment Main Effects Model | Step 3. Harassment Interaction Model | Step 4. Proportion of Exposure Effect Explained by Harassment | Prevalence | Step 1. Base Model | Step 2. Harassment Main Effects Model | Step 3. Harassment Interaction Model | Step 4. Proportion of Exposure Effect Explained by Harassment | |
|
|
|
|||||||||
| % | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | %a (pb) | % | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | %a (pb) | |
| GRADE 7 | ||||||||||
| Sexual Identity and Gender Subgroups | ||||||||||
| Heterosexual only cisgender male | 6.3 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 | 2.3 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 |
| Heterosexual only cisgender female | 7.3 | 1.12 (1.06, 1.19) | 1.12 (1.05, 1.19) | 1.12 (1.05, 1.19) | 1.3 (0.989) | 2.3 | 0.94 (0.85, 1.03) | 0.92 (0.84, 1.02) | 0.92 (0.84, 1.02) | −16.9 (0.934) |
| Heterosexual only transgender | 19.5 | 3.36 (1.91, 5.91) | 2.82 (1.55, 5.12) | 2.81 (1.55, 5.10) | 13.0 (0.178) | 3.9 | 1.54 (0.49, 4.84) | 1.14 (0.35, 3.72) | 1.14 (0.35, 3.72) | 60.4 (0.155) |
| LGB only cisgender male | 23.8 | 4.68 (3.86, 5.66) | 3.07 (2.52, 3.73) | 3.06 (2.52, 3.72) | 26.6 (<0.001) | 16.3 | 8.19 (6.48, 10.36) | 5.01 (3.93, 6.40) | 5.01 (3.93, 6.40) | 22.0 (0.001) |
| LGB only cisgender female | 28.8 | 5.32 (4.75, 5.97) | 3.36 (2.95, 3.82) | 3.34 (2.94, 3.80) | 27.2 (<0.001) | 15.7 | 6.63 (5.70, 7.72) | 3.87 (3.27, 4.59) | 3.87 (3.27, 4.59) | 27.0 (<0.001) |
| LGB only transgender | 49.1 | 16.89 (10.79, 26.45) | 9.11 (5.72, 14.51) | 9.21 (5.79, 14.66) | 22.7 (<0.001) | 43.5 | 39.79 (25.36, 62.41) | 19.15 (11.84, 30.97) | 19.14 (11.83, 30.97) | 20.5 (<0.001) |
| Both heterosexual and LGB cisgender male | 11.7 | 1.94 (1.17, 3.23) | 1.49 (0.90, 2.46) | 1.49 (0.90, 2.47) | 35.1 (0.061) | 8.0 | 3.56 (2.04, 6.22) | 2.58 (1.47, 4.52) | 2.58 (1.47, 4.52) | 20.8 (0.075) |
| Both heterosexual and LGB cisgender female | 25.2 | 4.60 (3.35, 6.32) | 3.34 (2.39, 4.65) | 3.33 (2.39, 4.64) | 21.0 (0.005) | 10.9 | 4.57 (3.02, 6.92) | 3.12 (2.03, 4.79) | 3.12 (2.03, 4.79) | 24.3 (0.010) |
| Both heterosexual and LGB transgender | 40.7 | 11.25 (6.52, 19.41) | 7.51 (4.48, 12.57) | 7.54 (4.50, 12.62) | 17.3 (<0.001) | 35.0 | 25.29 (14.62, 43.77) | 15.51 (9.24, 26.04) | 15.51 (9.24, 26.04) | 15.3 (<0.001) |
| Neither heterosexual nor LGB transgender | 31.6 | 6.44 (5.00, 8.29) | 4.70 (3.67, 6.03) | 4.72 (3.68, 6.05) | 16.3 (0.009) | 24.8 | 12.68 (9.49, 16.96) | 8.49 (6.37, 11.32) | 8.49 (6.37, 11.32) | 14.6 (0.009) |
| Gender-based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.70 (1.55, 1.86) | 1.84 (1.64, 2.06) | 2.29 (2.03, 2.58) | 2.28 (1.93, 2.68) | ||||||
| Sexuality-based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.96 (1.80, 2.13) | 2.04 (1.86, 2.24) | 1.90 (1.68, 2.14) | 1.89 (1.65, 2.17) | ||||||
| Interaction between Gender-based and Sexuality-based Harassment at School | 0.84 (0.71, 1.00) | 1.01 (0.80, 1.27) | ||||||||
| GRADE 9 | ||||||||||
| Sexual Identity and Gender Subgroups | ||||||||||
| Heterosexual only cisgender male | 13.9 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 | 7.2 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 3 |
| Heterosexual only cisgender female | 18.5 | 1.38 (1.33, 1.43) | 1.35 (1.30, 1.41) | 1.36 (1.30, 1.41) | 5.6 (0.790) | 8.1 | 1.11 (1.06, 1.17) | 1.08 (1.03, 1.13) | 1.09 (1.04, 1.14) | 19.8 (0.819) |
| Heterosexual only transgender | 23.5 | 1.80 (1.15, 2.84) | 1.66 (1.06, 2.59) | 1.66 (1.06, 2.59) | 12.7 (0.274) | 15.8 | 2.31 (1.34, 3.98) | 2.05 (1.20, 3.51) | 2.04 (1.19, 3.49) | 12.0 (0.278) |
| LGB only cisgender male | 27.5 | 2.28 (2.02, 2.57) | 1.71 (1.51, 1.94) | 1.72 (1.51, 1.95) | 33.7 (<0.001) | 19.1 | 2.97 (2.59, 3.40) | 2.11 (1.83, 2.44) | 2.15 (1.85, 2.49) | 27.6 (0.001) |
| LGB only cisgender female | 38.6 | 3.54 (3.30, 3.80) | 2.76 (2.56, 2.98) | 2.77 (2.57, 2.99) | 19.5 (<0.001) | 22.4 | 3.34 (3.07, 3.64) | 2.45 (2.23, 2.68) | 2.47 (2.25, 2.71) | 23.3 (0.002) |
| LGB only transgender | 45.9 | 5.23 (3.85, 7.10) | 3.30 (2.39, 4.56) | 3.27 (2.36, 4.53) | 27.9 (<0.001) | 31.6 | 5.86 (4.31, 7.96) | 3.27 (2.34, 4.59) | 3.18 (2.26, 4.49) | 33.2 (<0.001) |
| Both heterosexual and LGB cisgender male | 25.2 | 2.03 (1.39, 2.96) | 1.78 (1.21, 2.61) | 1.78 (1.21, 2.61) | 17.8 (0.066) | 18.1 | 2.78 (1.82, 4.25) | 2.34 (1.52, 3.58) | 2.34 (1.53, 3.59) | 14.8 (0.100) |
| Both heterosexual and LGB cisgender female | 38.3 | 3.62 (2.95, 4.43) | 3.06 (2.49, 3.76) | 3.06 (2.49, 3.76) | 12.9 (0.015) | 23.5 | 3.68 (2.92, 4.64) | 2.97 (2.33, 3.77) | 2.98 (2.33, 3.79) | 14.8 (0.035) |
| Both heterosexual and LGB transgender | 41.8 | 4.65 (2.96, 7.30) | 3.30 (2.11, 5.14) | 3.26 (2.09, 5.10) | 22.5 (<0.001) | 37.5 | 8.17 (5.16, 12.92) | 5.33 (3.39, 8.38) | 5.16 (3.28, 8.14) | 21.5 (<0.001) |
| Neither heterosexual nor LGB transgender | 44.2 | 4.81 (4.02, 5.76) | 3.61 (3.02, 4.32) | 3.60 (3.01, 4.30) | 18.3 (<0.001) | 39.7 | 8.35 (6.95, 10.02) | 5.84 (4.86, 7.01) | 5.78 (4.81, 6.95) | 17.1 (<0.001) |
| Gender-based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.62 (1.52, 1.72) | 1.57 (1.46, 1.69) | 1.91 (1.78, 2.05) | 1.66 (1.51, 1.83) | ||||||
| Sexuality- based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.44 (1.36, 1.52) | 1.41 (1.32, 1.50) | 1.48 (1.37, 1.60) | 1.34 (1.22, | ||||||
| Interaction between Gender-based and Sexuality-based Harassment at School | 1.08 (0.96, 1.22) | 1.38 (1.19, 1.61) | ||||||||
| GRADE 11 | ||||||||||
| Sexual Identity and Gender Subgroups | ||||||||||
| Heterosexual only cisgender male | 26.3 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 2 | 17.4 | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | Step 1 versus 3 |
| Heterosexual only cisgender female | 28.0 | 1.08 (1.04, 1.11) | 1.06 (1.03, 1.10) | 1.06 (1.03, 1.10) | 19.1 (0.771) | 15.2 | 0.84 (0.81, 0.87) | 0.82 (0.79, 0.85) | 0.82 (0.79, 0.85) | −8.5 (0.825) |
| Heterosexual only transgender | 44.2 | 2.19 (1.41, 3.41) | 1.98 (1.27, 3.08) | 1.98 (1.27, 3.08) | 13.1 (0.036) | 32.1 | 2.23 (1.39, 3.58) | 1.96 (1.23, 3.13) | 1.96 (1.22, 3.13) | 16.3 (0.060) |
| LGB only cisgender male | 35.5 | 1.53 (1.39, 1.68) | 1.31 (1.19, 1.44) | 1.31 (1.19, 1.45) | 36.2 (0.002) | 24.0 | 1.48 (1.32, 1.66) | 1.22 (1.09, 1.36) | 1.25 (1.12, 1.40) | 41.5 (0.026) |
| LGB only cisgender female | 42.2 | 1.97 (1.83, 2.11) | 1.72 (1.60, 1.85) | 1.73 (1.60, 1.86) | 19.4 (0.008) | 27.0 | 1.68 (1.55, 1.82) | 1.41 (1.30, 1.54) | 1.43 (1.31, 1.55) | 29.9 (0.030) |
| LGB only transgender | 36.3 | 1.44 (1.03, 2.02) | 1.04 (0.74, 1.46) | 1.03 (0.73, 1.44) | 89.2 (<0.001) | 34.5 | 2.24 (1.59, 3.16) | 1.47 (1.04, 2.09) | 1.40 (0.99, 2.00) | 56.8 (<0.001) |
| Both heterosexual and LGB cisgender male | 28.6 | 1.15 (0.83, 1.59) | 1.05 (0.75, 1.45) | 1.05 (0.76, 1.45) | 65.9 (0.076) | 17.7 | 1.03 (0.69, 1.54) | 0.91 (0.61, 1.37) | 0.92 (0.62, 1.38) | 646.1 (0.172) |
| Both heterosexual and LGB cisgender female | 45.6 | 2.30 (1.86, 2.84) | 2.12 (1.71, 2.62) | 2.12 (1.72, 2.63) | 9.9 (0.089) | 30.9 | 2.08 (1.65, 2.63) | 1.86 (1.47, 2.36) | 1.88 (1.48, 2.39) | 13.1 (0.169) |
| Both heterosexual and LGB transgender | 58.7 | 3.89 (2.41, 6.27) | 3.10 (1.93, 4.99) | 3.07 (1.90, 4.95) | 17.2 (<0.001) | 54.0 | 5.48 (3.47, 8.68) | 4.09 (2.58, 6.48) | 3.95 (2.48, 6.29) | 19.8 (<0.001) |
| Neither heterosexual nor LGB transgender | 55.2 | 3.47 (2.88, 4.16) | 2.75 (2.29, 3.30) | 2.73 (2.27, 3.27) | 19.1 (<0.001) | 46.5 | 4.21 (3.50, 5.07) | 3.12 (2.59, 3.77) | 3.03 (2.51, 3.67) | 22.9 (<0.001) |
| Gender-based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.40 (1.33, 1.49) | 1.37 (1.28, 1.47) | 1.57 (1.48, 1.68) | 1.42 (1.31, 1.54) | ||||||
| Sexuality- based Harassment at School | ||||||||||
| None | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | 1.00 (referent) | ||||||
| Any | 1.27 (1.20, 1.34) | 1.24 (1.15, 1.33) | 1.32 (1.23, 1.41) | 1.18 (1.08, 1.29) | ||||||
| Interaction between Gender-based and Sexuality-based Harassment at School | 1.08 (0.95, 1.23) | 1.37 (1.19, 1.59) | ||||||||
Note. Boldface indicates statistical significance (p<0.05). LGB = lesbian, gay, or bisexual; AOR = adjusted odds ratio; CI = confidence interval; Models in Steps 1, 2, and 3 were estimated using logistic regression, adjusting for race/ethnicity, grade in School, parent education, and School clustering (using cluster-robust standard errors). a Proportion of reduction in effects comparing Steps 1 and 2; b p-values for the indirect effects are for Step 1 compared to Step 2 if interaction effect were non-significant or for Step 1 compared to Step 3 if interaction effects were significant (the specified model is noted in the column).
Note. Boldface indicates statistical significance (p<0.05). LGB = lesbian, gay, or bisexual; AOR = adjusted odds ratio; CI = confidence interval; Models in Steps 1, 2, and 3 were estimated using logistic regression, adjusting for race/ethnicity, grade in School, parent education, and School clustering (using cluster-robust standard errors). a Proportion of reduction in effects comparing Steps 1 and 2; b p-values for the indirect effects are for Step 1 compared to Step 2 if interaction effect were non-significant or for Step 1 compared to Step 3 if interaction effects were significant (the specified model is noted in the column).
Harassment–Substance Use Associations
Adolescents who reported gender- or sexuality-based harassment were more likely than those who did not experience these types of harassment to engage in each substance use behavior (Table 4; p-values<0.001). In multivariable models, each type of harassment was independently associated with higher odds of each substance use behavior in every grade—confirming additive models (Step 2). When testing the interaction effects of harassment on substance use, we found positive significant interactions between gender- and sexuality-based harassment for vaping in grade 11, smoking in grade 11, and HED in grades 9 and 11 (Step 3). Gender- and sexuality-based harassment significantly mediated most of the gender and sexual identity disparities in substance use (Step 4). When significant, gender- and sexuality-based harassment explained 12.9–89.2% of the disparities in substance use.
DISCUSSION
We examined LGBT disparities in substance use—including vaping—and the interactive and mediational effects of gender- and sexuality-based harassment at school on substance use. Therefore, our paper addressed research recommendations put forth by the Institute of Medicine report7—examining disparities for transgender populations, using intersectionality to examine LGBT health disparities, and identifying social influences contributing to these disparities.
We found evidence of interactive and additive models—but not non-independent models—for gender- and sexuality-based harassment on substance use. Interactive models were detected for vaping, smoking, and HED in certain grades. For these behaviors, gender- and sexuality-based harassment were independently associated with use, and they also interacted to produce effects significantly greater than simply adding their independent effects together. Evidence of interaction models is new to the literature on discrimination among adolescents, and the explanations for our findings likely relate to psychological, developmental, and social processes. Psychologically, coping with a single stressor (e.g., gender-based harassment) may deplete adolescents’ energy reserves, making it more challenging for adolescents to deal with additional stressors (e.g., sexuality-based harassment)38 and magnifying adolescents’ use of substances to cope. Developmentally, adolescence is a period of identity formation, and having multiple identity-related stressors may interrupt healthy identity formation for LGBT youth, causing them to use substances in an exacerbated fashion. Socially, LGBT people may face discrimination from low-substance-using peers, causing them to have a greater number of high-substance-using peers39 and more permissive substance-use norms,28 thereby exacerbating their substance use. Contrastingly, for any alcohol use in every grade and each substance use behavior in grade 7, we found gender- and sexuality-based harassment were only additive. This might be because: having less than 5 drinks in one occasion is normative for adolescents; and in younger grades, harassment is more common and substances may be less accessible. Future research can investigate mechanisms that additively or synergistically link multiple types of harassment with substance use.
Second, LGBT adolescents have greater odds of substance use than cisgender heterosexuals, and there were significant interactions between grade, gender, and sexual identity. While we confirmed previous literature on sexual identity disparities in smoking and drinking,1–6,8 our study provides novel insights about disparities for transgender populations and about vaping as a health disparity for LGBT adolescents.11,12 Because electronic cigarettes are relatively new, our findings suggest LGBT adolescents are more vulnerable than cisgender heterosexuals to using emerging substances in the future, calling for ongoing surveillance of gender and sexual identity differences in use of emerging substances. Though the transgender-by-LGB-only interaction was not significant for any substances, the main effects were large for transgender and LGB only; the nonsignificant interaction suggests the combined effect was not greater than additive.
Third, we found that gender- and sexuality-based harassment mediate substance use disparities for most LGBT subgroups. Mediation only failed to reach significance among the smallest subgroups (e.g., heterosexual only transgender adolescents), likely due to limited statistical power. Our study highlights how discriminatory victimization may be a culprit contributing to LGBT disparities in substance use. This finding held true for electronic cigarette use, confirming harassment as a correlate of vaping.
Our findings can inform future epidemiologic and intervention research. Mediation can be more robustly tested in longitudinal studies, and harassment may be a moderator of LGBT disparities in substance use. Though our research examined the intersections of multiple identities and multiple forms of harassment on substance use, research can also examine how other social identities (e.g., race/ethnicity, disability status) and forms of harassment (e.g., race/ethnicity- and disability-based harassment) intersect to produce substance use disparities. Future research can examine how additional social ecological factors (e.g., LGBT school climate6) impact harassment and substance use. Given that gender- and sexuality-based harassment were either additive or interactive on substance use, interventions reducing biased-based harassment at school might be a key tool to reduce LGBT disparities in substance use. Preventing harassment for youth will likely yield great public health impact, as harassment during childhood and adolescence has deleterious health effects later in life.40 For students already exposed to harassment or substance use, effective treatment programs are critical. However, there are few interventions for reducing harassment and substance use among LGBT youth,7 but are necessary to achieve LGBT health equity.
Limitations and Strengths
Cross-sectional data may bias mediation estimates and cannot confirm causality or temporality between harassment and substance use, despite our strong theoretical foundation.19 Items were self-reported, and their psychometric properties are unknown. Given the sexual/gender identity item, we cannot compare lesbian/gay versus bisexual, know why participants selected both heterosexual and LGB, discern the current gender identity versus natal sex among transgender participants, differentiate whether transgender youth are on the transmasculine or transfeminine spectrums. This item also blends sexual and gender identity and omits some gender and sexual identities (e.g., non-binary, queer). No measures were included for sexual behavior, sexual attraction, or gender expression, which might yield different results, since gender and sexual identity are developmental processes that younger adolescents might not have completed. Biased-based harassment was evaluated based on participants’ perceptions, and attributions of harassment may be imprecise. Because the harassment items provided examples not inclusive of all LGBT youth (e.g., bisexuals, transgender people), harassment may be underreported among excluded groups. Bias-based harassment only measured school-related experiences, excluding harassment in other contexts (e.g., home). Additionally, participants who perceive discriminatory harassment may be more likely to report substance use, but we cannot be certain. Substance use was dichotomized as any versus none, which obscures differences in frequency. CHKS data are not weighted, therefore the prevalence may not be representative of Californian adolescents. Our findings may be biased if nonresponse was differentially related to gender, sexual identity, harassment, and substance use variables; however, the extent of this bias is unknown. Finally, we did not examine intersections with race/ethnicity.
Nevertheless, our study had several strengths. CHKS measured explicit types of discriminatory harassment and novel forms of substance use. We analyzed data from a large sample, allowing for investigation of interactions between multiple identities and types of harassment as well as disparities for transgender youth. The sample also included participants in 7th grade, while most studies of LGBT adolescents include only high-school-aged participants.
Conclusions
LGBT adolescents are more likely to use substances—including electronic cigarettes—than cisgender heterosexuals. Depending on the grade and substance, gender- and sexuality-based harassment have additive or synergistic associations with vaping, smoking, drinking, and HED. Many of the gender and sexual identity disparities in substance use are mediated by gender- and sexuality-based harassment at school. Only by designing interventions that effectively reduce anti-LGBT harassment or mitigate their deleterious effects will we eliminate LGBT disparities in substance use.
IMPLICATIONS AND CONTRIBUTIONS.
Gender- and sexuality-based harassment have additive or interactive effects on adolescents’ electronic cigarette use, cigarette smoking, alcohol use, and heavy episodic drinking depending on the substance and the adolescents’ grade. Gender- and sexuality-based harassment at school mediate many of the substance use disparities for lesbian, gay, bisexual, and transgender adolescents.
Acknowledgments
We want to thank WestEd for designing and organizing the California Health Kids Survey, and we extend our gratitude to school staff, parents, and young people who participated in the survey. This research and the first author was supported by the National Institute on Drug Abuse (F31DA037647) and the National Center for Advancing Translational Sciences (TL1TR001858) of the National Institutes of Health. The funding agencies had no involvement in the study design, analysis or interpretation of data, the writing of the report, or the decision to submit for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Preliminary findings were presented at the 2016 conference of the Society for Research on Adolescence. The authors have no conflicts of interest to disclose.
ABBREVIATIONS
- CHKS
California Healthy Kids Survey
- HED
heavy episodic drinking
- LGB
lesbian, gay, or bisexual
- LGBT
lesbian, gay, bisexual, and transgender
Footnotes
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References
- 1.Corliss HL, Wadler BM, Jun H-J, et al. Sexual-orientation disparities in cigarette smoking in a longitudinal cohort study of adolescents. Nicotine Tob Res. 2012 doi: 10.1093/ntr/nts114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Corliss HL, Rosario M, Birkett MA, Newcomb ME, Buchting FO, Matthews AK. Sexual orientation disparities in adolescent cigarette smoking: Intersections with race/ethnicity, gender, and age. Am J Public Health. 2014;104(6):1137–1147. doi: 10.2105/AJPH.2013.301819. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Marshal MP, Friedman MS, Stall R, et al. Sexual orientation and adolescent substance use: A meta-analysis and methodological review*. Addiction. 2008;103(4):546–556. doi: 10.1111/j.1360-0443.2008.02149.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Talley AE, Hughes TL, Aranda F, Birkett M, Marshal MP. Exploring alcohol-use behaviors among heterosexual and sexual minority adolescents: Intersections with sex, age, and race/ethnicity. Am J Public Health. 2014;104(2):295–303. doi: 10.2105/AJPH.2013.301627. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Corliss HL, Rosario M, Wypij D, Fisher LB, Austin SB. Sexual orientation disparities in longitudinal alcohol use patterns among adolescents: findings from the Growing Up Today Study. Arch Pediatr Adolesc Med. 2008;162(11):1071. doi: 10.1001/archpedi.162.11.1071. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Coulter RWS, Birkett M, Corliss HL, Hatzenbuehler ML, Mustanski B, Stall RD. Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors. Drug Alcohol Depend. 2016;161:340–347. doi: 10.1016/j.drugalcdep.2016.02.022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, D.C: National Academies Press; 2011. [PubMed] [Google Scholar]
- 8.Reisner SL, Greytak EA, Parsons JT, Ybarra ML. Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity. J Sex Res. 2014;52(3):243–256. doi: 10.1080/00224499.2014.886321. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.De Pedro KT, Gilreath TD, Jackson C, Esqueda MC. Substance use among transgender students in California public middle and high schools. J Sch Health. 2017;87(5):303–309. doi: 10.1111/josh.12499. [DOI] [PubMed] [Google Scholar]
- 10.Crenshaw K. Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 1991;43(6):1241–1299. [Google Scholar]
- 11.Goldbach JT, Mereish EH, Burgess C. Sexual orientation disparities in the use of emerging drugs. Subst Use Misuse. 2016:1–7. doi: 10.1080/10826084.2016.1223691. [DOI] [PubMed] [Google Scholar]
- 12.Dai H. Tobacco product use among lesbian, gay, and bisexual adolescents. Pediatrics. 2017;139(4):e20163276. doi: 10.1542/peds.2016-3276. [DOI] [PubMed] [Google Scholar]
- 13.Arrazola RA, Singh T, Corey CG, et al. Tobacco use among middle and high school students—United States, 2011–2014. Morbidity and Mortality Weekly Report. 2015;64(14):381–385. [PMC free article] [PubMed] [Google Scholar]
- 14.US Department of Health and Human Services. Preventing tobacco use among youth and young adults: A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. p. 3. [Google Scholar]
- 15.Squeglia LM, Jacobus J, Tapert SF. The influence of substance use on adolescent brain development. Clin EEG Neurosci. 2009;40(1):31–38. doi: 10.1177/155005940904000110. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Etter J-F, Eissenberg T. Dependence levels in users of electronic cigarettes, nicotine gums and tobacco cigarettes. Drug Alcohol Depend. 2015;147:68–75. doi: 10.1016/j.drugalcdep.2014.12.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Chatham-Stephens K, Law R, Taylor E, et al. Notes from the field: calls to poison centers for exposures to electronic cigarettes--United States, September 2010–February 2014. Morbidity and Mortality Weekly Report. 2014;63(13):292–293. [PMC free article] [PubMed] [Google Scholar]
- 18.Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014;23(2):133–139. doi: 10.1136/tobaccocontrol-2012-050859. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674. doi: 10.1037/0033-2909.129.5.674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kessel Schneider S, O’Donnell L, Stueve A, Coulter RWS. Cyberbullying, school bullying, and psychological distress: A regional census of high school students. Am J Public Health. 2012;102(1):171–177. doi: 10.2105/AJPH.2011.300308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Coulter RWS, Herrick AL, Friedman MR, Stall RD. Sexual-orientation differences in positive youth development: The mediational role of bullying victimization. Am J Public Health. 2016;106(4):691–697. doi: 10.2105/AJPH.2015.303005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Collier KL, van Beusekom G, Bos HM, Sandfort TG. Sexual orientation and gender identity/expression related peer victimization in adolescence: A systematic review of associated psychosocial and health outcomes. J Sex Res. 2013;50(3–4):299–317. doi: 10.1080/00224499.2012.750639. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Grollman EA. Multiple forms of perceived discrimination and health among adolescents and young adults. J Health Soc Behav. 2012;53(2):199–214. doi: 10.1177/0022146512444289. [DOI] [PubMed] [Google Scholar]
- 24.Friedman MS, Marshal MP, Guadamuz TE, et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am J Public Health. 2011;101(8):1481. doi: 10.2105/AJPH.2009.190009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Russell ST, Everett BG, Rosario M, Birkett M. Indicators of victimization and sexual orientation among adolescents: Analyses from Youth Risk Behavior Surveys. Am J Public Health. 2014;104(2):255–261. doi: 10.2105/AJPH.2013.301493. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Hertz MF, Everett Jones S, Barrios L, David-Ferdon C, Holt M. Association between bullying victimization and health risk behaviors among high school students in the United States. J Sch Health. 2015;85(12):833–842. doi: 10.1111/josh.12339. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Russell ST, Sinclair KO, Poteat VP, Koenig BW. Adolescent health and harassment based on discriminatory bias. Am J Public Health. 2012;102(3):493–495. doi: 10.2105/AJPH.2011.300430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Mereish EH, Goldbach JT, Burgess C, DiBello AM. Sexual orientation, minority stress, social norms, and substance use among racially diverse adolescents. Drug Alcohol Depend. 2017;178:49–56. doi: 10.1016/j.drugalcdep.2017.04.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Cho JH, Shin E, Moon S-S. Electronic-cigarette smoking experience among adolescents. J Adolesc Health. 2011;49(5):542–546. doi: 10.1016/j.jadohealth.2011.08.001. [DOI] [PubMed] [Google Scholar]
- 30.Johnson M, Pennington N. Adolescent use of electronic cigarettes: An emergent health concern for pediatric nurses. J Pediatr Nurs. 2015;30(4):611–615. doi: 10.1016/j.pedn.2014.11.006. [DOI] [PubMed] [Google Scholar]
- 31.Thoma BC, Huebner DM. Health consequences of racist and antigay discrimination for multiple minority adolescents. Cultural Diversity and Ethnic Minority Psychology. 2013;19(4):404–413. doi: 10.1037/a0031739. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Raver JL, Nishii LH. Once, twice, or three times as harmful? Ethnic harassment, gender harassment, and generalized workplace harassment. J Appl Psychol. 2010;95(2):236–254. doi: 10.1037/a0018377. [DOI] [PubMed] [Google Scholar]
- 33.Diaz RM, Ayala G, Bein E, Henne J, Marin BV. The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities. Am J Public Health. 2001;91(6):927–932. doi: 10.2105/ajph.91.6.927. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.WestEd. [Accessed Nov 1, 2016];California Healthy Kids Survey: Administration instructions for schools using active consent. 2016 Available at: http://chks.wested.org/wp-content/uploads/all-instructions-active_paper.docx.
- 35.Furlong MJ, Fullchange A, Dowdy E. Effects of mischievous responding on universal mental health screening: I love rum raisin ice cream, really I do! Sch Psychol Q. 2016 doi: 10.1037/spq0000168. [DOI] [PubMed] [Google Scholar]
- 36.Arceneaux K, Nickerson DW. Modeling certainty with clustered data: A comparison of methods. Political Analysis. 2009;17(2):177–190. [Google Scholar]
- 37.Kohler U, Karlson KB, Holm A. Comparing coefficients of nested nonlinear probability models. Stata Journal. 2011;11(3):420–438. [Google Scholar]
- 38.Robert G, Hockey J. Compensatory control in the regulation of human performance under stress and high workload: A cognitive-energetical framework. Biol Psychol Bull. 1997;45(1):73–93. doi: 10.1016/s0301-0511(96)05223-4. [DOI] [PubMed] [Google Scholar]
- 39.Hatzenbuehler ML, McLaughlin KA, Xuan Z. Social networks and sexual orientation disparities in tobacco and alcohol use. Journal of Studies on Alcohol And Drugs. 2015;76(1):117–126. [PMC free article] [PubMed] [Google Scholar]
- 40.Kim MJ, Catalano RF, Haggerty KP, Abbott RD. Bullying at elementary school and problem behaviour in young adulthood: A study of bullying, violence and substance use from age 11 to age 21. Criminal Behaviour and Mental Health. 2011;21(2):136–144. doi: 10.1002/cbm.804. [DOI] [PMC free article] [PubMed] [Google Scholar]