Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Apr 1.
Published in final edited form as: Behav Res Ther. 2018 Dec 24;115:55–63. doi: 10.1016/j.brat.2018.12.012

Sexual Orientation and Sex-Related Substance Use: The Unexplored Role of Bisexuality

Tenille C Taggart 1, Craig Rodriguez-Seijas 1, Christina Dyar 2, Jennifer C Elliott 3,4, Ronald G Thompson Jr 5, Deborah S Hasin 3,4,6, Nicholas R Eaton 1
PMCID: PMC6409130  NIHMSID: NIHMS1517476  PMID: 30594299

Abstract

Using alcohol and drugs in sexual contexts is associated with negative health consequences, including increased risk for HIV/STIs, sexual victimization, unplanned pregnancies, and overdose. Evidence suggests millions of adults regularly use alcohol in sexual contexts, thus increasing their risk for these consequences. However, no nationally representative estimates exist for rates of regular alcohol and/or drug use in sexual contexts. Additionally, previous studies suggest sexual minority individuals are more likely to use substances in sexual contexts than heterosexuals; however, none of these studies examined for multiple dimensions or subgroups of sexual orientation. Thus, using two distinct datasets—one large, nationally representative sample (N = 17,491) and an Internet-collected convenience sample (N = 1,001)—we explored the associations between sexual orientation (dimensions and subgroups) and rates of regular sex-related alcohol and/or drug use in American adults. Results showed that sexual minority individuals were significantly more likely to report regularly using substances in sexual contexts compared to heterosexuals; however, results varied based on dimension of sexual orientation and by sex. Across both samples, bisexual individuals exhibited the highest rates of regular sex-related substance use. Findings suggest that sexual minorities, and bisexual individuals in particular, may be at increased risk for regular sex-related substance use and its associated negative health consequences. Future research should include nuanced and multidimensional assessments of sexual orientation to investigate sex-related alcohol and/or drug use and its associated risks, as well as examine the potential direct and indirect pathways by which these disparities may be conferred.

Keywords: substance use, sexual orientation, sexual minorities, bisexual, risky sexual behaviors

Introduction

Using alcohol and drugs in sexual contexts is associated with many risky sexual behaviors, such as having more unplanned sex (Cooper, 2002), more sex partners (Caldeira et al., 2009; Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson, 2004), and reduced likelihood of engaging in safer sexual behaviors like condom use (Caldeira et al., 2009; Colfax et al., 2005; Leigh, Ames, & Stacy, 2008; Purcell, Parsons, Halkitis, Mizuno, & Woods, 2001). It is also associated with increased risk for HIV/STI infection (Mansergh et al., 2008; Shuper, Joharchi, Monti, Loutfy, & Rehm, 2017; Shuper et al., 2010), sexual victimization (Bryan et al., 2016; Mohler-Kuo, Dowdall, Koss, & Wechsler, 2004), unintended pregnancy (Naimi, Lipscomb, Brewer, & Gilbert, 2003; Reardon, Coleman, & Cougle, 2004), and drug-related mortality (Hockenhull, Murphy, & Paterson, 2017). Several studies suggest that adults regularly use drugs in sexual contexts (Calsyn et al., 2010; Colfax et al., 2005; Colfax et al., 2004) at rates similar to those of alcohol (4.3 million American adults; Eaton, Thompson, et al., 2015). However, no nationally representative estimates exist regarding the prevalence of regular sex-related drug use or regular sex-related alcohol and drug (i.e., substance) use. Given associations with multiple detrimental social and health outcomes, regular alcohol and/or drug use in sexual contexts signifies an important public health concern that warrants further investigation.

Sex-Related Substance Use and Sexual Orientation

Growing evidence indicates significant sexual orientation-related mental and physical health disparities exist among sexual minority individuals (e.g., those who identify as lesbian, gay, or bisexual; report same-sex attractions; and/or engage in same-sex sexual behavior) compared to heterosexuals. For instance, compared to heterosexuals, sexual minorities have two to three times the risk for mood and anxiety disorders (e.g., major depressive disorder, generalized anxiety disorder; Cochran & Mays, 2000; Cochran, Sullivan, & Mays, 2003; Meyer, 2003; Ross et al., 2018), and two to nearly five times the risk for physical health conditions (e.g., liver disease, high blood pressure, cardiovascular disease; Dyar et al., 2018; Institute of Medicine, 2011). Additionally, sexual minority men and women have, at most, 17 and 12.4 times the risk for problematic substance use compared to heterosexual individuals (Drabble, Midanik, & Trocki, 2005; McCabe, Hughes, Bostwick, West, & Boyd, 2009; Pachankis, Hatzenbuehler, & Starks, 2014). Although rates of substance use (e.g., amyl nitrates [poppers], methamphetamine, gamma-hydroxybutyrate [GHB], mephedrome [bath salts]) in sexual contexts among sexual minorities are high, most studies have failed to compare rates for sexual minority and heterosexual individuals (Colfax et al., 2004; Diaz, Ayala, & Bein, 2004; Harawa et al., 2008; Hirshfield et al., 2004; Koblin et al., 2006; Mansergh et al., 2008; Purcell et al., 2001). The few extant comparisons suggest that sexual minority individuals are more likely to use substances in sexual contexts relative to heterosexuals (Gordon et al., 2017; Zellner et al., 2009). However, such evidence remains preliminary and has not utilized nationally representative data.

Dichotomizing sexual orientation (non-heterosexuals vs heterosexuals) in extant literature has obscured the extent to which rates of regular substance use in sexual contexts may differ by sexual orientation subgroup (e.g., lesbian/gay, bisexual, heterosexual). Such analytic treatment obscures potentially nuanced differences in health outcomes between sexual minority subgroups. For example, research that dichotomizes sexual orientation has shown that sexual minorities experience increased risk for psychiatric and alcohol/substance use disorders relative to heterosexuals (Cochran et al., 2003; Meyer, 2003). However, when stratified by sexual minority subgroup (e.g., gay/lesbian vs. bisexual), bisexual individuals are most at-risk for disorders relative to gay/lesbian and heterosexual individuals (Bostwick, Boyd, Hughes, & McCabe, 2010; McCabe et al., 2009).

Additionally, sexual orientation represents a multidimensional construct made up of at least three components (i.e., identity, attraction, and behavior; Sexual Minority Assessment Research Team, 2009). Previous research has shown that each dimension differentially predicts meaningful substance use outcomes (Brewster & Tillman, 2012; McCabe, Hughes, Bostwick, & Boyd, 2005; McCabe et al., 2009). For instance, evidence suggests that attraction and behavior might be more important than identity when predicting risk for problematic substance use by sexual orientation (e.g., Brewster & Tillman, 2012). Despite these findings, no studies have examined dimensions of sexual orientation, other than identity (Gilbert, Trocki, & Drabble, 2015), in relation to the regular use of substances in sexual contexts. This represents a notable gap in the literature.

Given differential risk for important health outcomes for subgroups of sexual minorities (Bostwick et al., 2010; McCabe et al., 2009)—as well as the public health (Institute of Medicine, 2011) and research (Eaton, Thompson Jr, & Hasin, 2015) importance of understanding the associations between multidimensional assessments of sexual orientation and health risk behaviors—such nuanced investigations are warranted.

The Current Study

Using two datasets, the current study examined the associations between multidimensional facets of sexual orientation (i.e., identity, attractions, behaviors) and the regular use of alcohol and drugs in sexual contexts. First, we expanded upon previous investigations of sexual orientation identity and regular sex-related alcohol use (Gilbert & Trocki, 2015) and, using the same nationally representative sample of U.S. adults (N = 17,491), compared the odds of regular alcohol use in sexual contexts by sexual orientation identity. Regular sex-related drug use was not assessed in the NESARC and thus was not analyzed in the current study. Next, using an Internet-collected convenience sample (N = 1,001), we examined the odds of reporting regular substance (alcohol and/or drug) use in sexual contexts by dimensions of sexual orientation (i.e., identity, attractions, behaviors) and sexual orientation subgroups (i.e., lesbian/gay, bisexual, heterosexual). We addressed the following research questions: (1) What are the rates of regular sex-related alcohol use by sexual orientation subgroups in a large, nationally representative sample of American adults?; (2) How do rates of regular sex-related substance use differ across dimensions of sexual orientation?; and (3) How do rates of regular sex-related alcohol use in the large, nationally representative sample compare to rates of regular sex-related substance use in the Internet-collected sample?

Method

Participants

Nationally representative sample.

Data were from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; see Grant et al., 2009), which comprised two waves: Wave 1 (N = 43,093; fielded 2001-2002 with 81% response rate of eligible participants), and a Wave 2 reassessment of Wave 1 participants (N = 34,653; fielded 2004-2005 with 86.7% response rate of eligible participants and a cumulative response rate of 70.2%). Regular sex-related alcohol use was only assessed in Wave 2; thus, only Wave 2 data were used in the present study. Further, we restricted our data to a subsample of sexually active drinkers (n = 17,491), defined as those participants who had sex and consumed alcohol in the past year (Eaton, Thompson, et al., 2015; Rodriguez-Seijas, Arfer, Thompson, Hasin, & Eaton, 2017). Participant ages ranged from 20 to >90 years and were 58% female. Participants self-identified race/ethnicity, including: non-Hispanic White (70.9%), Hispanic/Latino (11.6%), non-Hispanic Black (11.1%), Asian/Pacific Islander (4.3%), and Native American (2.2%). NESARC data were weighted to represent the age, racial/ethnic, and gender distributions of the adult United States population based on the 2000 Census. NESARC research protocol, including informed consent, received full ethical review and approval from the Census Bureau and Office of Management and Budget.

Internet sample.

Data were from a sample of 1,001 individuals who completed an Internet survey about sexuality on Amazon Mechanical Turk (MTurk) in 2014. Mturk is a data collection website where Internet users volunteer to participate in online tasks and in exchange are compensated with a small monetary award ($2 for the current study). Mturk participants tend to pay better attention to quality assurance manipulations than college subject pool participants (Hauser & Schwarz, 2016), which were utilized in the current study, indicating that Mturk participants provide high quality data, including in the current sample. Previous research has found Mturk samples to provide data comparable in quality to those using more traditional data collection methods (e.g., paper and pencil; laboratory sessions), and Mturk samples also tend to be more demographically diverse (Buhrmester, Kwang, & Gosling, 2011; Gosling, Vazire, Srivastava, & John, 2004). This study was approved by the Stony Brook University Institutional Review Board.

Given small cell sizes when stratifying by sex and sex-related substance use, only cisgender (i.e., non-transgender) individuals were included in analyses. That is, individuals who did not identify as either cisgender male or cisgender female (n = 12) were excluded from the current analyses. After quality control exclusion rules were applied1, an analytic sample of N = 936 (49% female) was analyzed. Participants’ ages ranged from 18 to 82 years (median = 31). Participants could choose more than one race/ethnicity category, which we reflected here, and self-identified as 80% White, 10% Black, 8% Asian, 6% Hispanic, and 2% Native American.

Measures

Regular sex-related alcohol use.

In the NESARC, drinking before sex was assessed with the question: “During the past year, how often did you drink alcohol before having sex?”. Response options were on a 5-point Likert-type scale, including “never” (1), “rarely” (2), “sometimes” (3), “most of the time” (4), and “always” (5). In the Internet sample, drinking before sex was assessed with the question: “How often do you use alcohol shortly before having sex?” Response options were on a 5-point Likert-type scale, including “never” (1), “rarely” (2), “sometimes” (3), “usually” (4), and “always” (5). In accordance with previous research which established an empirical cut-point for regular sex-related alcohol use (Eaton, Thompson, et al., 2015; Thompson, Eaton, Hu, Grant, & Hasin, 2014), responses were dichotomized to reflect regular (i.e., responses more frequent than sometimes) versus normative (i.e., responses sometimes, rarely, and never) alcohol use before sexual activity, yielding 615 (1.8%) regular sex-related alcohol users in the NESARC sample and 43 (4.6%) in the Internet sample.

Regular sex-related drug use.

Regular sex-related drug use was not assessed in the NESARC. In the Internet sample, sex-related drug use was assessed with the item: “How often do you use drugs (not including caffeine, alcohol, or a medication prescribed to you, but including cannabis, cocaine, methamphetamine, poppers, etc.) shortly before or during sex?” Response options were on a 5-point Likert-type scale, including “never” (1), “rarely” (2), “sometimes” (3), “usually” (4), and “always” (5). Responses were similarly dichotomized to reflect regular versus normative substance use before sex, yielding 47 (5.1%) regular sex-related drug users.

Regular sex-related substance use.

Internet sample participants who endorsed regular sex-related alcohol and/or drug use were collapsed into a superordinate sex-related substance use category for further analysis. This yielded a total of 83 regular sex-related substance users (8.9%). Endorsement rates of sex-related substance use for both samples are presented by sexual orientation and sex in Table 1.

Table 1.

Regular Sex-related Alcohol and Drug Use Endorsement Rates (n [%]) by Sexual Orientation and Sex in the NESARC and Internet Samples.

Sexual Orientation Regular Sex-related Alcohol Use Regular Sex-related Drug Use
NESARC Internet Internet
Men (n = 8,699) Women (n = 8,792) Men (n = 465) Women (n = 459) Men (n = 465) Women (n = 459)
Heterosexual 394 (4.64) 195 (2.28) 22 (5.56) 11 (3.34) 16 (4.01) 13 (3.99)
Gay/Lesbian 10 (7.94) 1 (1.00) 5(15.15) 3 (3.49) 4 (12.50) 10 (11.24)
Bisexual 3 (6.98) 8 (8.16) 1 (5.26) 1 (4.76) 1 (5.00) 2 (8.00)
Open in a new tab

Note. The NESARC only assessed sex-related alcohol use. The Internet sample assessed both sex-related alcohol and drug use.

Sexual orientation.

The NESARC sexual orientation measures reported herein are based exclusively on Wave 2 data.

Identity.

In the analytic sample of the NESARC, participants self-identified as heterosexual (n = 17,054; 97.5%), gay/lesbian (n = 227; 1.3%), and bisexual (n = 141; 0.8%). The remainder identified as unsure (n = 62; 0.4%) or was unknown (n = 9; 0.0%) and were excluded from analyses due to empty bivariate cells. Sexual orientation frequencies in the analytic sample were similar to those in the total sample of the NESARC at Wave 2 (heterosexual: n = 33,598, 97.0%; gay/lesbian: n = 335, 1.0%; bisexual: n = 242, 0.7%). In the Internet sample, participants self-identified as heterosexual (n = 737; 78.7%), bisexual (n = 126; 13.5%), and lesbian/gay (n = 43; 4.6%). The remainder (n = 30; 3.2%) self-identified as asexual, unsure, or provided a free response (e.g., pansexual) and were excluded from analyses due to empty bivariate cells.

Attractions.

Although NESARC participants provided information on sexual attractions and behaviors, significant differences in timeframes and response options prevented making meaningful comparisons across samples and thus were not included in the present analyses. In the Internet sample, participants reported the extent to which they experienced feelings of sexual attraction to (1) men and (2) women, separately, on a 5-point Likert scale (1 = “not at all sexually attracted”, 2 = “a little sexually attracted”, 3 = “somewhat sexually attracted”, 4 = “a good deal sexually attracted”, 5 = “very sexually attracted”). For the purpose of the current study, we maintained the continuous coding, but responses were recoded such that the two attractions items reflected the extent to which each participant was sexually attracted to individuals of the (1) same or (2) opposite sex of the participant.

Behaviors.

In the Internet sample, participants were asked to report the number of times that they engaged in sexual activity with (1) men and (2) women, separately, in the last twelve months. For the purpose of the current study, we maintained the continuous coding, but responses were recoded to reflect the number of times the participant engaged in sexual activity with individuals who were of the (1) same or (2) opposite sex of the respondent.

Statistical Analyses

Analyses were conducted using Mplus version 8 (Muthén & Muthén, 1998-2017). All analyses of NESARC data incorporated the NESARC’s complex design features (i.e., sample weights, primary sampling units, and stratification variables). First, in the NESARC sample, we examined the odds of reporting regular sex-related alcohol use for: (1) lesbian/gay and (2) bisexual versus heterosexual (reference group) participants using logistic regression. Using only the Internet sample, we examined the odds of reporting regular sex-related substance use—defined as reporting regularly engaging in sex-related alcohol and/or drug use—by sexual orientation identity (i.e., lesbian/gay and bisexual vs. heterosexual) using logistic regression. We further examined the associations between (1) attractions to, and (2) sexual behaviors with, members of the same- and opposite-sex and sex-related substance use. All analyses utilized logistic regression for the dichotomous sex-related substance use outcome (i.e., regular vs. normative use), a maximum likelihood estimator with robust standard errors, and were stratified by sex. Sexual attraction and behavior variables were mean centered. Of note, pairwise comparisons of sexual minority individuals by sex (e.g., gay men vs. bisexual men; gay men vs. lesbian women) were not possible due to small sample sizes of sexual minority men and women.

Results

Odds ratios (ORs) of regular sex-related alcohol use by sexual orientation utilizing the NESARC sample are presented in Table 2. ORs of regular sex-related substance use by sexual orientation, sexual attractions, and past year sexual behaviors utilizing the Internet sample are presented in Table 3. Visual depictions of the differences in endorsement rates for regular sex-related alcohol and drug use in the Internet sample are presented in Figures 1 and 2, respectively.

Table 2.

Odds Ratios (ORs) of Regular Sex-related Alcohol Use by Sexual Orientation and Sex in the NESARC Sample.

Sexual Orientation Regular Sex-related Alcohol Use
Men Women
β OR β OR
Gay/Lesbian 0.04 3.22 0.08* 3.79
Bisexual 0.06* 2.51 −0.06 0.35
Open in a new tab

Note. Heterosexuals served as the reference group for all comparisons.

*

p < .05.

Table 3.

Odds Ratios (OR) for Regular Sex-Related Substance, Alcohol, and Drug Use, by Sexual Orientation Dimension and Sex in the Internet Sample

Sexual Orientation Dimension Substance Use
 Alcohol Use
 Drug Use
Men Women Men Women Men Women
β OR β OR β OR β OR β OR β OR
Identity
 Gay/Lesbian 0.02 1.21 0.10 2.29 −0.06 0.94 0.37 1.45 0.23 1.26 0.93 2.53
 Bisexual 0.15* 2.88 0.19* 2.45 1.11* 3.04 0.04 1.05 1.23* 3.42 1.11* 3.05
Attractions
 Opposite-Sex Attractions 0.05 1.14 0.13 1.25 0.01 1.01 0.38 1.47 0.33 1.39 0.15 1.16
 Same-Sex Attractions 0.28*** 1.58 0.30*** 1.49 0.36* 1.44 0.20 1.22 0.55** 1.73 0.41** 1.51
Behaviors
 PY Opposite-Sex Behavior 0.24*** 1.42 0.22* 1.53 0.37** 1.45 0.56** 1.76 0.31* 1.36 0.38* 1.46
 PY Same-Sex Behavior 0.13* 1.38 0.24*** 2.27 0.35* 1.42 0.34 1.40 0.29 1.34 0.84*** 2.32
Open in a new tab

Note. PY = past year. Heterosexuals served as the reference groups for all comparisons of sexual orientation identity. ORs for attractions and behaviors should be interpreted as the odds of reporting regular sex-related substance use for a 1-unit increase in attractions/behaviors.

***

p < .001.

**

p < .01.

*

p < .05.

Figure 1.

Figure 1.

Open in a new tab

Regular sex-related alcohol use endorsement rates by sexual orientation and sex in the Internet sample.

Figure 2.

Figure 2.

Open in a new tab

Regular sex-related drug use endorsement rates by sexual orientation and sex in the Internet sample.

Identity: Nationally Representative Sample

Women.

Lesbian women were more likely to report regular sex-related alcohol use (OR = 3.79, p < .01) compared to heterosexual women. Conversely, bisexual women did not differ from heterosexual women in rates of reporting regular sex-related alcohol use, although their unadjusted rates were markedly higher than those for lesbian and heterosexual women.

Men.

Bisexual men were significantly more likely to report regular sex-related alcohol use than heterosexual men (OR = 2.51, p < .05), whereas gay men did not significantly differ from heterosexuals.

Identity: Internet Sample

Women.

Compared to heterosexual women, lesbian and bisexual women were not more likely to report regular sex-related alcohol use. Bisexual women were more likely to report regular sex-related drug use compared to heterosexual women (OR = 3.05, p < .01), whereas lesbian women did not differ from heterosexual women. Bisexual women were more likely to report regular sex-related substance use relative to heterosexual women (OR = 2.45, p < .05); lesbian women did not differ from heterosexual women.

Men.

Compared to heterosexual men, bisexual men were more likely to report regular sex-related alcohol (OR = 3.04, p < .05) and drug (OR = 3.42, p < .05) use. Gay and heterosexual men did not differ in rates of regular sex-related alcohol or drug use. Bisexual men were more likely to report regular sex-related substance use (OR = 2.88, p < .05) relative to heterosexual men, whereas gay men did not differ from heterosexual men.

Attractions: Internet Sample

Women.

Women who reported higher levels of same-sex attractions were more likely to report regular sex-related drug (OR = 1.51, p < .01) and substance (OR = 1.49, p < .001) use, but not regular sex-related alcohol use. Women who reported higher levels of opposite-sex attractions were not associated with regular sex-related alcohol, drug, or substance use.

Men.

Men who reported higher levels of same-sex attractions were more likely to report regular sex-related alcohol (OR = 1.44, p < .05), drug (OR = 1.73, p < .01), and substance use (OR = 1.58, p < .01). Conversely, men who reported higher levels of opposite-sex attractions were not associated with regular sex-related alcohol, drug, or substance use.

Behaviors: Internet Sample

Women.

Women who reported higher levels of past year opposite-sex sexual behaviors were more likely to report regular sex-related alcohol use (OR = 1.76, p < .01). Women who reported higher levels of past year opposite-sex sexual behaviors (OR = 1.46, p < .05) and same-sex sexual behaviors (OR = 2.32, p < .001) were more likely to report regular sex-related drug use. Women who reported higher levels of past year opposite-sex sexual behaviors (OR = 1.53, p < .01) and same-sex sexual behaviors (OR = 2.27, p < .001) were more likely to report regular sex-related substance use.

Men.

Men who reported higher levels of past year opposite-sex sexual behaviors (OR =1.45, p < .01) and same-sex sexual behaviors (OR = 1.42, p < .05) were more likely to report regular sex-related alcohol use. Men who reported higher levels of past year opposite-sex sexual behaviors were more likely to report regular sex-related drug use (OR = 1.36, p < .05). Men who reported higher levels of past year opposite-sex sexual behaviors (OR = 1.42, p < .001) and same-sex sexual behaviors (OR = 1.38, p < .05) were more likely to report engaging in regular sex-related substance use.

Discussion

We explored associations between sexual orientation and sex-related substance use, implementing a nuanced examination of how the odds of reporting regular sex-related alcohol and drug use differ—when compared to heterosexuals—as a function of sexual minority subgroup. These results correspond with previously reported findings of increased risk for regular sex-related alcohol use among sexual minority individuals compared to heterosexuals (Gilbert et al., 2015), and further expanded upon these findings by showing that, across both a nationally representative and Internet sample, results differ by sexual minority subgroup and dimension of sexual orientation. These findings underscore the importance of utilizing nuanced conceptualization of sexual minority status in public health research to better understand the negative psychosocial health outcomes and the potential pathways by which they may be conferred among sexual minority populations.

The Importance of Attending to Nuances within Sexual Minority Populations

Our results illustrate the importance of the conceptualization of sexual orientation used in sexual orientation-related psychosocial health outcomes. Analyzing sexual orientation dichotomously (sexual minority vs. heterosexual) may obscure important differences between gay/lesbian and bisexual persons compared to heterosexuals. In the present study, bisexual men and women drove the effects in sexual minorities’ increased odds of reporting regular sex-related alcohol and drug use compared to heterosexuals. Failure to account for these differences can lead to erroneous assumptions about the health of sexual minority individuals. Indeed, emerging research examining within-group differences in sexual minority populations has revealed that bisexual individuals are at elevated risk for myriad mental and physical health conditions. For instance, bisexuals were 1.44 and 2. 4 times more likely to report depression compared to lesbian/gay and heterosexual participants, respectively, and were 1.6 and 3.3 times more likely to report current anxiety compared to lesbian/gay and heterosexual participants. Bisexual women demonstrate similar differential findings for risk of physical health conditions, such as arthritis, cardiovascular disease, gastrointestinal conditions, and liver disease, relative to other sexual minority subgroups (Dyar et al., 2018).

Unique Stressors Faced by Bisexual Individuals

Understanding factors related to elevated negative psychosocial health outcomes among bisexual populations is important. Bisexual individuals experience unique stressors related to their sexual orientation from both heterosexual and sexual minority communities (Bostwick & Hequembourg, 2014; Dodge et al., 2016; Hayfield, Clarke, & Halliwell, 2014). Examples of negative stereotypes that persist about bisexual individuals include the beliefs that bisexuals are sexually adventurous, promiscuous, obsessed with sex, desire multiple sex partners as well as group sex activities, and suffer from STIs (Brewster & Moradi, 2010; Friedman et al., 2014). Although sexual minority acceptance is on the rise (Gallup, 2015), a recent study revealed that a majority of U.S. adults either explicitly agree with, or fail to reject, these negative bisexual stereotypes (Dodge et al., 2016). Bisexual individuals notice this, with most reporting weekly negative experiences of being stereotyped as highly sexual or likely to have an STI (Dyar & London, 2018).

Considering these stereotypes and their prevalence, sexual contexts may elicit concerns about rejection by sexual partners or sexual coercion for some bisexual individuals. Many heterosexual and sexual minority individuals, including other bisexuals, express an unwillingnes to engage romantically or sexually with bisexual persons (Feinstein, Dyar, Bhatia, Latack, & Davila, 2014; Li, Dobinson, Scheim, & Ross, 2013). Bisexual individuals’ awareness of this increases their concerns about rejection from potential and actual romantic and sexual partners (Bostwick & Hequembourg, 2014; Hayfield et al., 2014; Hequembourg & Brallier, 2009; Li et al., 2013), and sensitivity to rejection based on one’s sexual orientation is associated with higher rates of risky sexual behaviors (Pachankis et al., 2015; Rendina et al., 2017; Wang & Pachankis, 2016) and substance use (Pachankis et al., 2014). Additionally, bisexual women frequently repon feeling pressured to engage in sex and other sexual activities, such as having sex with multiple partners, with which they are uncomfortable or do not wish to participate (Hequembourg & Brallier, 2009; Kelley et al., 2018; Li et al., 2013), and subsequently report using alcohol to cope with these negative sexual experiences (Hauser & Schwarz, 2016). Furthermore, bisexual individuals have also commonly experienced other types of victimization, including childhood sexual abuse and adult sexual assault (Conron, Mimiaga, & Landers, 2010; Rothman, Exner, & Baughman, 2011; Walters, Chen, & Breiding, 2013)—all of which are associated with higher risk for sex-related substance use (Arreola, Neilands, & Diaz, 2009; Brennan, Hellerstedt, Ross, & Welles, 2007; Lloyd & Operario, 2012; Paul, Catania, Pollack, & Stall, 2001). Therefore, concerns about rejection and the potential for sexual coercion and victimization may increase the likelihood of engaging in sex-related substance use among bisexual individuals as a means of coping with these stressors.

Contending with the negative stereotypes about bisexuality might also lead to internalized binegativity among bisexual individuals, providing another explanation of elevations in sex-related substance use among bisexuals. Internalizing negative societal messages about one’s sexual minority status is positively associated with risky sexual behaviors (Smith, Mohr, & Ross, 2018) and substance use problems (Brubaker, Garrett, & Dew, 2009; Green & Feinstein, 2012; Pachankis et al., 2014), as well as sex-related substance use (Bruce, Ramirez-Valles, & Campbell, 2008). Substance use during sex can serve to reduce internalized negativity, ease anxiety about social rejection, and overcome sexual inhibitions arising from internalized negativity (Kashubeck-West & Szymanski, 2008; Pachankis, 2014; Pollard, Nadarzynski, & Llewellyn, 2018). Notably, bisexual individuals tend to have higher levels of internalized negativity than lesbian/gay individuals (Balsam & Mohr, 2007; Dyar, Feinstein, & London, 2015). Taken together, the unique stressors faced by bisexual individuals may drive differences in sex-related substance use, as well as other psychosocial health disparities. Future research should examine potential mechanisms and pathways that may help to explain bisexuals’ higher rates of regular sex-related substance use.

Multidimensional Nature of Sexual Orientation

While most studies of health outcomes among sexual minority populations rely on respondents’ reports of sexual orientation identity, we expanded upon previous findings to show that same-sex attractions and behaviors are also related to increased odds of reporting regular sex-related substance use. Findings highlight that attending to the multiple dimensions of sexual orientation bears important implications. Individuals commonly have same-sex sexual attractions and/or engage in same-sex sexual behaviors without identifying as lesbian, gay, or bisexual (Laumann, 1994). Nonetheless, these individuals may not be immune to the unique psychosocial stressors faced by sexual minority communities. Indeed, according to our findings, increased reported same-sex attraction—for both men and women—is associated with higher likelihood of engaging in one risky sexual behavior (sex-related substance use). When it comes to behavior, greater relative sexual behavior—regardless of the sex one’s sexual partner—is associated with higher odds of reporting regular sex-related substance use. Further research into the mechanisms associated with sexual attraction and behavior, and risky sexual practices remains warranted.

Limitations and Future Research

This study is not without limitations. First, the Internet sample had comparatively small numbers of sexual minority individuals compared to the NESARC; and second, the Internet sample was one of convenience and was not population-based, thus limiting generalizability. That said, our ability to compare and contrast findings for regular sex-related alcohol use between the NESARC and Internet sample somewhat ameliorates these concerns, highlighting in the comparisons that sexual orientation subgroups evinced similar patterns among the men. Nevertheless, no data exist documenting sex-related drug and/or substance use at the population level, preventing us from testing this construct in the NESARC. Taken together, our results investigated a critical area of sexual orientation-related disparities research. Future research should expand upon our findings to assess sex-related substance use using large, population-based samples that include more individuals identifying as non-heterosexual across dimensions of sexual orientation.

Third, although we examined differences in sex-related alcohol and drug use separately within the Internet sample, these results must be considered preliminary. Due to the small number of sexual minority individuals reporting regular sex-related alcohol and drug use—particularly among gay men and lesbian women—these findings require replication with larger sample sizes before generalizations about population health can be made. Also due to small sample sizes of sexual minority men and women, the current study did not compare differences in rates of sex-related alcohol and drug use among sexual minority subgroups (e.g., bisexual men vs. bisexual women; gay men vs. bisexual men). Future research would benefit from exploring the differences potential differences in frequency of regular sex-related substance use within sexual minority populations.

Finally, extant literature has failed to assess important correlates regarding sex-related substance use, including amount and number of specific substances consumed, negative consequences, such as failure to practice safer sex (e.g., condom use), increased HIV/STI risk, and unwanted pregnancies, as well as participants’ motivations and expectancies for engaging in sex-related substance use (e.g., coincidentally drank a glass of wine at dinner before sex vs. drank a bottle of wine to feel comfortable having sex). Previous evidence has shown that enhancement and coping motives of substance use are associated with distinct behavioral patterns and outcomes (Carpenter & Hasin, 1998; Cooper, Frone, Russell, & Mudar, 1995). For instance, coping expectancies of substance use, such as for relief or self-inflation, are positively associated with consumption levels, problems related to substance use, and substance dependence (Buckner, 2013; Carpenter & Hasin, 1998; DeMartini & Carey, 2011; Lac & Brack, 2018). Given sexual minority individuals are already at higher risk for problematic alcohol and substance use (Drabble et al., 2005; McCabe et al., 2009; Pachankis et al., 2014), it is essential that future research assess individuals’ sexual orientation, the level and number of substances consumed, and motivations for engaging in substance use when examining sex-related substance use.

Conclusion

Sex-related substance use is associated with a host of detrimental outcomes. Nonetheless, millions of American adults regularly engage in sex-related alcohol use, thus increasing their risk, yet no nationally representative data exist regarding rates of regular sex-related alcohol and/or drug use. Additionally, previous studies suggest sexual minority individuals use substances in sexual contexts at higher rates than heterosexuals, however, none have included dimensions or subgroups of sexual orientation. Our study indicates that bisexual men and women were more likely to regularly use substances in sexual contexts than heterosexual men and women. These findings highlight a critical area on which to focus public health efforts and also illustrate the importance of including nuanced and multidimensional assessments of sexual orientation when investigating sexual orientation-related psychosocial health disparities. Future research should examine the possibility that unique stressors faced by bisexual individuals may interact synergistically to compromise their health.

Highlights.

  • Rates of regularly using substances in sexual contexts differ by sexual orientation

  • Sexual minorities are more likely to regularly use substances in sexual contexts

  • Bisexuals reported the highest rates of regular substance use in sexual contexts

  • Findings indicate a critical area on which to focus public health efforts

  • Future research should include nuanced assessments of sexual orientation

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. However, this work was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) under grants R01AA023163 and K23AA023753, and the National Science Foundation (NSF) under grant 2016226314. The content is solely the responsibility of the authors and does not necessarily reflect the official views of the NIAAA, NIH, or NSF. The authors thank Kodi Arfer for his help with collecting the Internet data.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

1

We used three methods to ensure quality of the data and derive an analytic sample. First, we removed subjects who completed the task in fewer than seven minutes (n = 46), which was suggestive of careless responding (median completion time = 13 minutes). Second, we repeated two items (about appealingness of two sexual behaviors; not included in the current study) scored on a seven-point Likert-type scale throughout the survey, and we removed participants whose responses to both item pairs differed by three or more scale points (n = 5), consistent with Tellegen’s variable response inconsistency (VRIN) used in other measures (e.g., the Minnesota Multiphasic Personality Inventory-2 [MMPI-2]; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; the Multidimensional Personality Questionnaire [MPQ]; Tellegen & Waller, 2008) to minimize inconsistent and random responding (see Tellegen, 1988). Third, participants were queried at the end of the study about the degree of honesty with which they responded to items, noting that this would not impact payment, and we removed any participants who reported being “somewhat honest” or less (n = 20). Due to small cell sizes, individuals who were asexual, unsure, or provided a free response were excluded from the analytic sample. Some participants met more than one exclusion criterion.

Declarations of interest: none.

References

  1. Arreola SG, Neilands TB, & Díaz R (2009). Childhood sexual abuse and the sociocultural context of sexual risk among adult Latino gay and bisexual men. American Journal of Public Health, 99(Suppl 2), S432–S438. doi: 10.2105/AJPH.2008.138925 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Balsam KF, & Mohr JJ (2007). Adaptation to sexual orientation stigma: A comparison of bisexual and lesbian/gay adults. Journal of Counseling Psychology, 54(3), 306–319. doi: 10.1037/0022-0167.54.3.306 [DOI] [Google Scholar]
  3. Bostwick WB, Boyd CJ, Hughes TL, & McCabe SE (2010). Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. American Journal of Public Health, 100(3), 468–475. doi: 10.2105/AJPH.2008.152942 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bostwick WB, & Hequembourg A (2014). ‘Just a little hint’: Bisexual-specific microaggressions and their connection to epistemic injustices. Culture, Health & Sexuality, 16(5), 488–503. doi: 10.1080/13691058.2014.889754 [DOI] [PubMed] [Google Scholar]
  5. Brennan DJ, Hellerstedt WL, Ross MW, & Welles SL (2007). History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men. American Journal of Public Health, 97(6), 1107–1112. doi: 10.2105/ajph.2005.071423 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Brewster KL, & Tillman KH (2012). Sexual orientation and substance use among adolescents and young adults. American Journal of Public Health, 102(6), 1168–1176. doi: 10.2105/AJPH.2011.300261 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brewster ME, & Moradi B (2010). Perceived experiences of anti-bisexual prejudice: Instrument development and evaluation. Journal of Counseling Psychology, 57(4), 451–468. doi: 10.1037/a0021116 [DOI] [Google Scholar]
  8. Brubaker MD, Garrett MT, & Dew BJ (2009). Examining the relationship between internalized heterosexism and substance abuse among lesbian, gay, and bisexual individuals: A critical review. Journal of LGBT Issues in Counseling, 3(1), 62–89. doi: 10.1080/15538600902754494 [DOI] [Google Scholar]
  9. Bruce D, Ramirez-Valles J, & Campbell RT (2008). Stigmatization, substance use, and sexual risk behavior among Latino gay and bisexual men and transgender persons. Journal of Drug Issues, 38(1), 235–260. doi: 10.1177/002204260803800111 [DOI] [Google Scholar]
  10. Bryan AEB, Norris J, Abdallah DA, Stappenbeck CA, Morrison DM, Davis KC, . Zawacki T. (2016). Longitudinal change in women’s sexual victimization experiences as a function of alcohol consumption and sexual victimization history: A latent transition analysis. Psychology of Violence, 6(2), 271–279. doi: 10.1037/a0039411 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Buckner JD (2013). College cannabis use: The unique roles of social norms, motives, and expectancies. Journal of Studies on Alcohol and Drugs, 74(5), 720–726. doi: 10.15288/jsad.2013.74.720 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Buhrmester M, Kwang T, & Gosling SD (2011). Amazon’s Mechanical Turk a new source of inexpensive, yet high-quality, data? Perspectives on Psychological Science, 6(1), 3–5. [DOI] [PubMed] [Google Scholar]
  13. Butcher JN, Dahlstrom W, Graham J, Tellegen A, & Kaemmer B (1989). MMPI-2: Manual for administration and scoring. In: Minneapolis: University of Minnesota Press. [Google Scholar]
  14. Caldeira KM, Arria AM, O’Grady KE, Zarate EM, Vincent KB, & Wish ED (2009). Prospective associations between alcohol and drug consumption and risky sex among female college students. Journal of Alcohol and Drug Education, 53(2), 71–92. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806636/ [PMC free article] [PubMed] [Google Scholar]
  15. Calsyn DA, Cousins SJ, Hatch-Maillette MA, Forcehimes A, Mandler R, Doyle SR, & Woody G (2010). Sex under the influence of drugs or alcohol: Common for men in substance abuse treatment and associated with high-risk sexual behavior. American Journal on Addictions, 19(2), 119–127. doi: 10.1111/j.1521-0391.2009.00022.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Carpenter KM, & Hasin DS (1998). Reasons for drinking alcohol: Relationships with DSM-IV alcohol diagnoses and alcohol consumption in a community sample. Psychology of Addictive Behaviors, 12(3), 168–184. doi: 10.1037/0893-164X.12.3.168 [DOI] [Google Scholar]
  17. Cochran SD, & Mays VM (2000). Relation between psychiatric syndromes and behaviorally defined sexual orientation in a sample of the US population. American Journal of Epidemiology, 151(5), 516–523. doi: 10.1093/oxfordjournals.aje.a010238 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Cochran SD, Sullivan JG, & Mays VM (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71(1), 53–61. doi: 10.1037/0022-006X.71.1.53 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Colfax G, Coates TJ, Husnik MJ, Huang Y, Buchbinder S, Koblin B, … Vittinghoff E (2005). Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. Journal of Urban Health, 82(1), i62. doi: 10.1093/jurban/jti025 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Colfax G, Vittinghoff E, Husnik MJ, McKirnan D, Buchbinder S, Koblin B, … Team ES (2004). Substance use and sexual risk: A participant- and episode-level analysis among a cohort of men who have sex with men. American Journal of Epidemiology, 159(10), 1002–1012. doi: 10.1093/aje/kwh135 [DOI] [PubMed] [Google Scholar]
  21. Conron KJ, Mimiaga MJ, & Landers SJ (2010). A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health, 100(10), 1953–1960. doi: 10.2105/AJPH.2009.174169 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Cooper ML (2002). Alcohol use and risky sexual behavior among college students and youth: Evaluating the evidence. Journal of Studies on Alcohol, Supplement(s14), 101–117. doi: 10.15288/jsas.2002.s14.101 [DOI] [PubMed] [Google Scholar]
  23. Cooper ML, Frone MR, Russell M, & Mudar P (1995). Drinking to regulate positive and negative emotions: A motivational model of alcohol use. Journal of Personality and Social Psychology, 69(5), 990–1005. doi: 10.1037/0022-3514.69.5.990 [DOI] [PubMed] [Google Scholar]
  24. DeMartini KS, & Carey KB (2011). The role of anxiety sensitivity and drinking motives in predicting alcohol use: A critical review. Clinical Psychology Review, 31(1), 169–177. doi: 10.1016/j.cpr.2010.10.001 [DOI] [PubMed] [Google Scholar]
  25. Diaz RM, Ayala G, & Bein E (2004). Sexual risk as an outcome of social oppression: Data from a probability sample of Latino gay men in three U.S. Cities. Cultural Diversity & Ethnic Minority Psychology, 10(3), 255–267. doi: 10.1037/1099-9809.10.3.255 [DOI] [PubMed] [Google Scholar]
  26. Dodge B, Herbenick D, Friedman MR, Schick V, Fu T-C, Bostwick W, … Sandfort TGM (2016). Attitudes toward bisexual men and women among a nationally representative probability sample of adults in the United States. PloS One, 11(10), e0164430. doi: 10.1371/journal.pone.0164430 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Drabble L, Midanik LT, & Trocki K (2005). Reports of alcohol consumption and alcohol-related problems among homosexual, bisexual and heterosexual respondents: Results from the 2000 National Alcohol Survey. Journal of Studies on Alcohol, 66(1), 111–120. doi: 10.15288/jsa.2005.66.111 [DOI] [PubMed] [Google Scholar]
  28. Dyar C, Feinstein BA, & London B (2015). Mediators of differences between lesbians and bisexual women in sexual identity and minority stress. Psychology of Sexual Orientation and Gender Diversity, 2(1), 43–51. doi: 10.1037/sgd0000090 [DOI] [Google Scholar]
  29. Dyar C, & London B (2018). Longitudinal examination of a bisexual-specific minority stress process among bisexual cisgender women. Psychology of Women Quarterly, 42(3), 342–360. doi: 10.1177/0361684318768233 [DOI] [Google Scholar]
  30. Dyar C, Taggart TC, Rodriguez-Seijas C, Thompson RG, Elliott JC, Hasin DS, & Eaton NR (2018). Physical health disparities across dimensions of sexual orientation, race/ethnicity, and sex: Evidence for increased risk among bisexual adults. Archives of Sexual Behavior. doi: 10.1007/s10508-018-1169-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Eaton NR, Thompson RG Jr, & Hasin DS (2015). Letter to the editor: Toward a broader understanding of LGBT sex-related substance use. American Journal of Public Health, 105(12), e1–e2. doi: 10.2105/ajph.2015.302906 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Eaton NR, Thompson RG Jr., Hu MC, Goldstein RB, Saha TD, & Hasin DS (2015). Regularly drinking alcohol before sexual activity in a nationally representative sample: Prevalence, sociodemographics, and associations with psychiatric and substance use disorders. American Journal of Public Health, 105(7), 1387–1393. doi: 10.2105/AJPH.2015.302556 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Feinstein BA, Dyar C, Bhatia V, Latack JA, & Davila J (2014). Willingness to engage in romantic and sexual activities with bisexual partners: Gender and sexual orientation differences. Psychology of Sexual Orientation and Gender Diversity, 1(3), 255–262. doi: 10.1037/sgd0000047 [DOI] [Google Scholar]
  34. Friedman MR, Dodge B, Schick V, Herbenick D, Hubach R, Bowling J, … Reece M (2014). From bias to bisexual health disparities: Attitudes toward bisexual men and women in the United States. LGBT Health, 1(4), 309–318. doi: 10.1089/lgbt.2014.0005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Gallup. (2015). Gay and lesbian rights 2015. Retrieved from http://www.gallup.com/poll/1651/gay-lesbian-rights.aspx [Google Scholar]
  36. Gilbert PA, Trocki KF, & Drabble L (2015). Regular presex drinking: The importance of considering sexual orientation. American Journal of Public Health, 105(12), e1. doi: 10.2105/ajph.2015.302880 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Gordon KS, Edelman EJ, Justice AC, Fiellin DA, Akgün K, Crystal S, … Bryant KJ (2017). Minority men who have sex with men demonstrate increased risk for HIV transmission. AIDS and Behavior, 21(5), 1497–1510. doi: 10.1007/s10461-016-1590-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Gosling SD, Vazire S, Srivastava S, & John OP (2004). Should we trust web-based studies? A comparative analysis of six preconceptions about internet questionnaires. American Psychologist, 59(2), 93–104. doi: 10.1037/0003-066X.59.2.93 [DOI] [PubMed] [Google Scholar]
  39. Grant BF, Goldstein RB, Chou SP, Huang B, Stinson FS, Dawson DA, … Compton WM (2009). Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: Results from the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Molecular Psychiatry, 14(11), 1051–1066. doi: 10.1038/mp.2008.41 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Green KE, & Feinstein BA (2012). Substance use in lesbian, gay, and bisexual populations: An update on empirical research and implications for treatment. Psychology of Addictive Behaviors, 26(2), 265–278. doi: 10.1037/a0025424 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Harawa NT, Williams JK, Ramamurthi HC, Manago C, Avina S, & Jones M (2008). Sexual behavior, sexual identity, and substance abuse among low-income bisexual and non-gay-identifying African American men who have sex with men. Archives of Sexual Behavior, 37(5), 748–762. doi: 10.1007/s10508-008-9361-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Hauser DJ, & Schwarz N (2016). Attentive turkers: Mturk participants perform better on online attention checks than do subject pool participants. Behavior Research Methods, 48(1), 400–407. doi: 10.3758/s13428-015-0578-z [DOI] [PubMed] [Google Scholar]
  43. Hayfield N, Clarke V, & Halliwell E (2014). Bisexual women’s understandings of social marginalisation: ‘The heterosexuals don’t understand us but nor do the lesbians’. Feminism & Psychology, 24(3), 352–372. doi: 10.1177/0959353514539651 [DOI] [Google Scholar]
  44. Hequembourg AL, & Brallier SA (2009). An exploration of sexual minority stress across the lines of gender and sexual identity. Journal of Homosexuality, 56(3), 273–298. doi: 10.1080/00918360902728517 [DOI] [PubMed] [Google Scholar]
  45. Hirshfield S, Remien RH, Humberstone M, Walavalkar I, & Chiasson MA (2004). Substance use and high-risk sex among men who have sex with men: A national online study in the USA. Aids Care-Psychological and Socio-Medical Aspects of Aids/Hiv, 16(8), 1036–1047. doi: 10.1080/09540120412331292525 [DOI] [PubMed] [Google Scholar]
  46. Hockenhull J, Murphy KG, & Paterson S (2017). An observed rise in γ-hydroxybutyrateassociated deaths in london: Evidence to suggest a possible link with concomitant rise in chemsex. Forensic Science International, 270, 93–97. doi: 10.1016/j.forsciint.2016.11.039 [DOI] [PubMed] [Google Scholar]
  47. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press. [PubMed] [Google Scholar]
  48. Kashubeck-West S, & Szymanski DM (2008). Risky sexual behavior in gay and bisexual men:Internalized heterosexism, sensation seeking, and substance use. The Counseling Psychologist, 36(4), 595–614. doi: 10.1177/0011000007309633 [DOI] [Google Scholar]
  49. Kelley ML, Ehlke SJ, Lewis RJ, Braitman AL, Bostwick W, Heron KE, & Lau-Barraco C (2018). Sexual coercion, drinking to cope motives, and alcohol-related consequences among self-identified bisexual women. Substance Use and Misuse, 53(7), 1146–1157. doi: 10.1080/10826084.2017.1400565 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Koblin BA, Husnik MJ, Colfax G, Huang YJ, Madison M, Mayer K, … Buchbinder S. (2006). Risk factors for HIV infection among men who have sex with men. AIDS, 20(5), 731–739. doi: 10.1097/01.aids.0000216374.61442.55 [DOI] [PubMed] [Google Scholar]
  51. Lac A, & Brack N (2018). Alcohol expectancies longitudinally predict drinking and the alcohol myopia effects of relief, self-inflation, and excess. Addictive Behaviors, 77, 172–179. doi: 10.1016/j.addbeh.2017.10.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Laumann EO (1994). The social organization of sexuality: Sexual practices in the United States: University of Chicago Press. [Google Scholar]
  53. Leigh BC, Ames SL, & Stacy AW (2008). Alcohol, drugs, and condom use among drug offenders: An event-based analysis. Drug and Alcohol Dependence, 93(1–2), 38–42. doi: 10.1016/j.drugalcdep.2007.08.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Li T, Dobinson C, Scheim AI, & Ross LE (2013). Unique issues bisexual people face in intimate relationships: A descriptive exploration of lived experience. Journal of Gay & Lesbian Mental Health, 17(1), 21–39. doi: 10.1080/19359705.2012.723607 [DOI] [Google Scholar]
  55. Lloyd S, & Operario D (2012). HIV risk among men who have sex with men who have experienced childhood sexual abuse: Systematic review and meta-analysis. AIDS Education and Prevention, 24(3), 228–241. doi: 10.1521/aeap.2012.24.3.228 [DOI] [PubMed] [Google Scholar]
  56. Mansergh G, Flores S, Koblin B, Hudson S, McKirnan D, & Colfax GN (2008). Alcohol and drug use in the context of anal sex and other factors associated with sexually transmitted infections: Results from a multi-city study of high-risk men who have sex with men in the USA. Sexually Transmitted Infections, 84(6), 509–511. doi: 10.1136/sti.2008.031807 [DOI] [PubMed] [Google Scholar]
  57. McCabe SE, Hughes TL, Bostwick W, & Boyd CJ (2005). Assessment of difference in dimensions of sexual orientation: Implications for substance use research in a college-age population. Journal of Studies on Alcohol, 66(5), 620–629. doi: 10.15288/jsa.2005.66.620 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. McCabe SE, Hughes TL, Bostwick WB, West BT, & Boyd CJ (2009). Sexual orientation, substance use behaviors and substance dependence in the United States. Addiction, 104(8), 1333–1345. doi: 10.1111/j.1360-0443.2009.02596.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Meyer IH (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. doi: 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Mohler-Kuo M, Dowdall GW, Koss MP, & Wechsler H (2004). Correlates of rape while intoxicated in a national sample of college women. Journal of Studies on Alcohol, 65(1), 37–45. doi: 10.15288/jsa.2004.65.37 [DOI] [PubMed] [Google Scholar]
  61. Muthén LK, & Muthén BO (1998-2017). Mplus user’s guide (Eighth ed.). Los Angeles, CA: Muthén & Muthén. [Google Scholar]
  62. Naimi TS, Lipscomb LE, Brewer RD, & Gilbert BC (2003). Binge drinking in the preconception period and the risk of unintended pregnancy: Implications for women and their children. Pediatrics, 111(Supplement 1), 1136–1141. Retrieved from http://pediatrics.aappublications.org/content/pediatrics/111/Supplement_1/1136.full.pdf [PubMed] [Google Scholar]
  63. Pachankis JE (2014). Uncovering clinical principles and techniques to address minority stress, mental health, and related health risks among gay and bisexual men. Clinical Psychology: Science and Practice, 21(4), 313–330. doi: 10.1111/cpsp.12078 [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Pachankis JE, Hatzenbuehler ML, & Starks TJ (2014). The influence of structural stigma and rejection sensitivity on young sexual minority men’s daily tobacco and alcohol use. Social Science and Medicine, 103, 67–75. doi: 10.1016/j.socscimed.2013.10.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Pachankis JE, Rendina HJ, Restar A, Ventuneac A, Grov C, & Parsons JT (2015). A minority stress-emotion regulation model of sexual compulsivity among highly sexually active gay and bisexual men. Health Psychology, 34(8), 829–840. doi: 10.1037/hea0000180 [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Paul JP, Catania J, Pollack L, & Stall R (2001). Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect, 25(4), 557–584. doi: 10.1016/S0145-2134(01)00226-5 [DOI] [PubMed] [Google Scholar]
  67. Pollard A, Nadarzynski T, & Llewellyn C (2018). Syndemics of stigma, minority-stress, maladaptive coping, risk environments and littoral spaces among men who have sex with men using chemsex. Culture, Health & Sexuality, 20(4), 411–427. doi: 10.1080/13691058.2017.1350751 [DOI] [PubMed] [Google Scholar]
  68. Purcell DW, Parsons JT, Halkitis PN, Mizuno Y, & Woods WJ (2001). Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men. Journal of Substance Abuse, 13(1), 185–200. doi: 10.1016/S0899-3289(01)00072-4 [DOI] [PubMed] [Google Scholar]
  69. Reardon DC, Coleman PK, & Cougle JR (2004). Substance use associated with unintended pregnancy outcomes in the national longitudinal survey of youth. The American Journal of Drug and Alcohol Abuse, 30(2), 369–383. doi: 10.1081/ADA-120037383 [DOI] [PubMed] [Google Scholar]
  70. Rendina HJ, Gamarel KE, Pachankis JE, Ventuneac A, Grov C, & Parsons JT (2017). Extending the minority stress model to incorporate HIV-positive gay and bisexual men’s experiences: A longitudinal examination of mental health and sexual risk behavior. Annals of Behavioral Medicine, 51(2), 147–158. doi: 10.1007/s12160-016-9822-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. Rodriguez-Seijas C, Arfer KB, Thompson RG, Hasin DS, & Eaton NR (2017). Sex-related substance use and the externalizing spectrum. Drug and Alcohol Dependence, 174, 39–46. doi: 10.1016/j.drugalcdep.2017.01.008 [DOI] [PubMed] [Google Scholar]
  72. Ross LE, Salway T, Tarasoff LA, MacKay JM, Hawkins BW, & Fehr CP (2018). Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and heterosexual individuals: A systematic review and meta-analysis. Journal of Sex Research, 55(4–5), 435–456. doi: 10.1080/00224499.2017.1387755 [DOI] [PubMed] [Google Scholar]
  73. Rothman EF, Exner D, & Baughman A (2011). The prevalence of sexual assault against people who identify as gay, lesbian or bisexual in the United States: A systematic review. Trauma, violence & abuse, 12(2), 55–66. doi: 10.1177/1524838010390707 [DOI] [PMC free article] [PubMed] [Google Scholar]
  74. Sexual Minority Assessment Research Team. (2009). Best practices for asking questions about sexual orientation on surveys. The Williams Institute. Retrieved from http://williamsinstitute.law.ucla.edu/wp-content/uploads/SMART-FINAL-Nov-2009.pdf [Google Scholar]
  75. Shuper PA, Joharchi N, Monti PM, Loutfy M, & Rehm J (2017). Acute alcohol consumption directly increases HIV transmission risk: A randomized controlled experiment. Journal of Acquired Immune Deficiency Syndromes, 76(5), 493–500. doi: 10.1097/qai.0000000000001549 [DOI] [PMC free article] [PubMed] [Google Scholar]
  76. Shuper PA, Neuman M, Kanteres F, Baliunas D, Joharchi N, & Rehm J (2010). Causal considerations on alcohol and HIV/AIDS – a systematic review. Alcohol and Alcoholism, 45(2), 159–166. doi: 10.1093/alcalc/agp091 [DOI] [PubMed] [Google Scholar]
  77. Smith NG, Mohr JJ, & Ross LE (2018). The role of bisexual-specific minority stressors in sexual compulsivity among bisexual men. Sexual and Relationship Therapy, 33(1–2), 81–96. doi: 10.1080/14681994.2017.1386301 [DOI] [Google Scholar]
  78. Tellegen A (1988). The analysis of consistency in personality-assessment. Journal of Personality, 56(3), 621–661. doi: 10.1111/j.1467-6494.1988.tb00905.x [DOI] [Google Scholar]
  79. Tellegen A, & Waller NG (2008). Exploring personality through test construction: Development of the multidimensional personality questionnaire. In The SAGE handbook of personality theory and assessment, vol 2: Personality measurement and testing (pp. 261–292). Thousand Oaks, CA, US: Sage Publications, Inc. [Google Scholar]
  80. Thompson RG Jr., Eaton NR, Hu MC, Grant BF, & Hasin DS (2014). Regularly drinking alcohol before sex in the United States: Effects of relationship status and alcohol use disorders. Drug and Alcohol Dependence, 141, 167–170. doi: 10.1016/j.drugalcdep.2014.05.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  81. Walters ML, Chen J, & Breiding MJ (2013). National intimate partner and sexual violence survey (NISVS): 2010 findings on victimization by sexual orientation. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. [Google Scholar]
  82. Wang KT, & Pachankis J (2016). Gay-related rejection sensitivity as a risk factor for condomless sex. AIDS and Behavior, 20(4), 763–767. doi: 10.1007/s10461-015-1224-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  83. Zellner JA, Martinez-Donate AP, Sanudo F, Fernandez-Cerdeno A, Sipan CL, Hovell MF, & Carrillo H (2009). The interaction of sexual identity with sexual behavior and its influence on HIV risk among Latino men: Results of a community survey in northern San Diego county, California. American Journal of Public Health, 99(1), 125–132. doi: 10.2105/AJPH.2007.129809 [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES