Abstract
Background and Aims:
Sexual minority (SM) populations experience higher rates of substance use disorder (SUD) associated with increased sexual orientation-related stress. Social support may moderate the impact of stress on SUD among SM adults. This study assessed associations between social support and DSM-5 SUD by sex and sexual minority identity.
Design:
Cross-sectional study using data from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III).
Setting and participants:
A nationally representative cross-sectional sample of adults (n=36,309) in the United States.
Measurements:
SUD were defined based on the DSM-5 criteria for alcohol use (AUD), tobacco use (TUD) and drug use (DUD) disorders. Structural social support was measured as the type and frequency of kin and non-kin contact, and functional social support was measured by the Social Provision Scale.
Findings:
SM adults had higher odds of all SUD compared to heterosexual adults (AUD: 1.56, 95%CI 1.28–1.84; TUD: 1.51, 95%CI 1.23–1.85; DUD: 1.52, 95%CI 0.41–0.63); SM women experienced the highest proportion of all SUD (AUD: 27.1%, TUD: 29.1%, DUD: 10.9%). Type of social support was differentially associated with SUD by sex and sexual identity status. Higher social provision was associated with lower rates of AUD (adjOR 0.77, 95%CI 0.71–0.84), TUD (adjOR 0.75, 95%CI 0.69–0.80) and DUD (adjOR 0.56, 95%CI 0.49–0.64). Marriage was associated with lower SUD among heterosexual men (AUD: adjOR 0.50, 95%CI 0.43–0.58); TUD: adjOR 0.60, 95%CI 0.52–0.70; DUD: adjOR 0.50, 95%CI 0.37–0.69) and women (AUD: adjOR 0.64, 95%CI 0.53–0.77; TUD: 0.0.58, 95%CI 0.51–0.67; DUD: adjOR 0.52, 95%CI 0.37–0.71). Compared to heterosexual adults, SM women with at least one child under the age of 18 had higher odds of TUD (adjOR 1.99, 95%CI 1.33–2.99). SM-related discrimination was not associated with SUD among some SM subgroups, but discrimination among male heterosexually-identifying individuals reporting same-sex attraction or behavior was associated AUD (adjOR 4.61, 95%CI 1.62–13.14)
Conclusions:
In the U.S. there are significant associations between functional support (quality or provision of support) and structural support (type and frequency of social networks) and substance use disorder (SUD) which differ by sex and sexual identity status.
Keywords: substance use disorder, sexual orientation, social support, alcohol, tobacco
INTRODUCTION
Sexual minorities (SM), individuals who have sexual identity, orientation or behavior different than the majority population (e.g. gay, lesbian, bisexual), experience a higher prevalence of substance use disorders (SUD). Studies across the globe have found greater alcohol (AUD), tobacco (TUD), and drug (DUD) use disorders among SM compared to heterosexual adults.(1–4) However, SUD are not homogenous across SM populations, and differences exist between male and female SM.(3) Although TUD is higher among all SM adults compared to heterosexual adults (5, 6), SM women are more likely than SM men to use tobacco products.(7, 8) Studies also have found AUD to be significantly higher among SM individuals.(1, 8–10) Higher burden of stressors experienced by SM, including discrimination and stigma, are associated with substance use.(11–15) This relationship between stressors and substance use is consistent with Meyer’s Minority Stress Model that posits unique SM-related stressors are associated with poor mental health outcomes, including SUD.(16) Substance use associated with SM-related stress varies by sex and sexual identity, (11, 17) potentially the result of stressor severity or differential coping and resilience mechanisms.(13, 17, 18)
Social support is a moderator of stress in the Minority Stress Model and a protective factor against poor mental health outcomes, including SUD.(16, 19–21) Social support, defined as perceived and actual support received through social ties, includes four primary domains: emotional, instrumental, informational and appraisal.(22) Emotional support is the expression of empathy, trust and love; instrumental support includes tangible support and services; informational support includes guidance and advice; appraisal support is information that guides self-evaluation.(22) Social support can be measured as structural support, the composition of the social network and frequency of contact, and as functional support, the quality or provision of support. Social support acts as a buffer to stress and is associated with lower victimization and higher resilience against SM-related discrimination.(23–26) However, while the relationship between social support and substance use has been extensively assessed among young SM (27–29), there has been less research on the impact of social support, and specifically structural and functional support, on SUD among SM adults.(30) Understanding external influences, including social relationships, on substance use among adults is critical to developing effective strategies for reducing SUD. Thus, we assessed associations between social support, including structural social support (type and frequency of social networks) and functional social support (perceived and enacted social provision), and three major groups of SUD (AUD, TUD, and DUD) by sex and sexual minority status.
METHODS
This study used NESARC-III data collected via in-person interviews from April 2012 through June 2013 among the general U.S. civilian noninstitutionalized population of individuals 18 years of age or older. The NESARC-III sample design, response rates, and weighting procedures have been described elsewhere.(1, 31) NESARC-III procedures were approved by an institutional review board (IRB), and this secondary data analysis was deemed exempt by the IRB at the first author’s institution.
The NESARC-III included reliable and validated measures that align with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DSM-5 (American Psychiatric Association, 2013) criteria for AUD, TUD, and DUD among self-identified heterosexual and SM (lesbian, gay, bisexual, and ‘not sure’) respondents.(32) using the National Institute on Alcohol Abuse and Alcoholism “Alcohol Use Disorder and Associated Disabilities Interview Schedule-5” (AUDADIS-5), a fully structured diagnostic interview that maps onto the 11 DSM-5 symptom criteria for alcohol, tobacco and drug use.(33)
Past-year AUD and TUD diagnosis was made for “any disorder,” defined as two or more symptoms based on the recommended approach in the DSM-5.(34, 35) A diagnosis for DUD was similar to AUD and TUD except multiple drug classes were included and required at least two symptoms from the same drug class (i.e., sedative/tranquilizer, cannabis, amphetamine, cocaine, non-heroin opioid, heroin, hallucinogen, club drugs, and solvents/inhalants). Test-retest reliability for DSM-5 AUD, TUD, and DUD diagnoses was fair and dimensional criteria scales were fair to excellent.(36–38)
Sociodemographic characteristics included age, self-reported sex (male and female), race/ethnicity, education level, income, employment status, U.S. region, and urbanicity. Sexual minority status was assessed by asking respondents to identify which of the following categories best described them: heterosexual, gay, lesbian, bisexual, or not sure. The NESARC-III also includes questions about sexual attraction and behavior, but for the purposes of the current study, sexual minority status is defined by sexual identity only (heretofore referred to as SM), and heterosexual-identifying respondents that reported same-sex behavior/attraction were defined as heterosexual. To retain a large enough sample size to stratify the analysis by sex, we dichotomized heterosexual and SM (combining gay or lesbian, bisexual, and ‘not sure’).
Structural support was measured as the frequency and type of past two-week social contact with kin and non-kin.(39) We used dichotomous measures (yes/no) to assess kin using marital status (i.e., married, cohabiting but not married, not married [widowed/divorced/separated/never married]), having at least one child under the age of 18, past two-week contact with parents, past two-week contact with grown children (18 or older), past two-week contact with spouses’ parents, and past two-week contact with other relatives. Non-kin contact was measured (continuously variables) as the number of past two-week contacts with ‘close friends’ and acquaintances (i.e., ‘fellow students’, ‘co-workers’, ‘neighbors’, ‘people from volunteer groups, and people from ‘other groups’).
Functional support was measured as the mean score from the Social Provision Scale, a 12-item scale that measured the four domains of social support (see the footnotes in Table 2 for the wording on each item).(40) The scale ranged from 1 to 4, with a 4 indicating the highest level of social provision. The social provision scale has excellent reliability based on data from the NESARC-III (Cronbach’s alphas = 0.83).
Table 2.
Social support/sexual orientation discrimination and past-year SUD by sex and sexual minority status (Source: NESARC-III)
| Men | Women | ||||
|---|---|---|---|---|---|
| Total (n=36309) |
Heterosexual(a) (n=15190) |
Sexual Minority(b) (n=534) |
Heterosexual(c) (n=19454) |
Sexual Minority(d) (n=817) |
|
| %/mean (SE) | %/mean (SE) | %/mean (SE) | %/mean (SE) | %/mean (SE) | |
| Marital status/Children | |||||
| Married | 51.2% (0.005) | 54.6% (0.006)b,c,d | 11.5% (0.022)a,c | 50.6% (0.005)a,b,d | 17.6% (0.005)a,c |
| Living With Someone as if married | 6.6% (0.001) | 6.8% (0.003)b,c,d | 16.2% (0.021)a,c | 5.8% (0.002)a,b,d | 16.0% (0.015)a,c |
| At least 1 child under the age of 18 | 27.3% (0.004) | 25.4% (0.006)b,c | 7.1% (0.018)a,c,d | 30.0% (0.0056)a,b | 23.9% (0.022)c |
| Contact with kin (2 weeks) | |||||
| Contact with grown children [18 years of age or older] (Yes) | 43.6% (0.004) | 39.6% (0.006)b,c,d | 12.4% (0.020)a,c | 49.3% (0.006)a,b,d | 14.3% (0.014)a,c |
| Contact with parents (Yes) | 61.5% (0.004) | 61.7% (0.005)d | 63.8% (0.026)d | 60.9% (0.004)d | 74.3% (0.020)a,b,c |
| Contact with spouses’ parents (Yes) | 26.8% (0.004) | 29.4% (0.005)b,c,d | 9.9% (0.017)a,c,d | 25.3% (0.004)a,b,d | 18.1% (0.019)a,b,c |
| Contact with other relatives (Yes) | 73.6% (0.004) | 69.3% (0.006)c | 64.5% (0.029)c | 78.1% (0.005)a,b,d | 71.8% (0.019)c |
| Number of contacts with non-kin (2 weeks) | |||||
| Close friends | 4.31 (0.044) | 4.49 (0.063)c,d | 4.47 (0.309) | 4.15 (0.053)a | 3.76 (0.156)a |
| Acquaintances (e.g., Fellow students, Co-workers…) | 6.07 (0.099) | 6.67 (0.154)c,d | 6.30 (0.770) | 5.55 (0.114)a | 4.87 (0.411)a |
| Social provision (past-year) | |||||
| Social provision | 3.50 (0.004) | 3.50 (0.005)b,d | 3.33 (0.032)a,c | 3.51 (0.005)b,d | 3.42 (0.023)a,c |
| Sexual orientation discrimination (past-year) | |||||
| Sexual minority discrimination | 0.010 (0.001) | 0.001 (0.001)b,d | 0.297 (0.028)a,c | 0.002 (0.001)b,d | 0.229 (0.018)a,c |
| Past-year SUD | |||||
| Alcohol use disorder (2+ symptoms) | 13.3% (0.002) | 16.8% (0.003)b,c,d | 27.2% (0.026)a,c | 9.3% (0.003)a,b,d | 27.1% (0.019)a,c |
| Tobacco use disorder (2+ symptoms) | 17.4% (0.004) | 19.6% (0.005)b,c,d | 28.5% (0.026)a,c | 14.6% (0.004)a,b,d | 29.1% (0.021)a,c |
| Drug use disorder (2+ symptoms) | 4.0% (0.001) | 4.9% (0.002)c,d | 8.1% (0.015)c | 2.7% (0.002)a,b,d | 10.9% (0.016)a,c |
Notes:
Sexual minority was defined as self-reported gay, lesbian, bisexual or ‘not sure’ identity. Heterosexual-identifying individuals with same-sex behavior or attraction were defined as heterosexual.
The 12 items for social support included the following: ‘would have a hard time finding someone to take a day trip with me’, ‘feel that there is no one to share worries and fears with’, ‘would be able to find someone to help with chores if sick’, ‘someone to turn to for advice on family problems’, ‘could easily find someone to go to movie on spur of the moment’, ‘someone I could turn to for personal problems’, ‘don’t often get invited to do things with others’, ‘would be difficult to find someone to watch house if out of town’, ‘could easily find lunch companion’, ‘someone would get me if stranded 10 miles from home’, ‘would be difficult to get advice from someone for a family crisis’, ‘would have a hard time finding someone to help me move’.
Sample sizes vary due to missing data. Unweighted sample sizes are provided. Percentages incorporate survey weights provided by the NESARC-III.
Results from binary logistic and bivariate regression models were used to determine if differences between heterosexual (men and women) and sexual minorities (men and women) were statistically significant at the 0.01 alpha level for
Heterosexual(a) men,
Sexual Minority(b)men,
Heterosexual(c) women, and
Sexual Minority(d) women
SM-related discrimination was based on the Experiences with Discrimination scale. (41, 42) Questions in the NESARC-III regarding SM-related discrimination were restricted to adults that self-identified as SM and heterosexual-identified adults that reported same-sex attraction or behavior. The scale measured six types of discrimination that respondents have experienced based on sexual minority status (obtaining health care, receiving health care, obtaining a job/applying to school/interacting with police, public locations, verbal or physical aggression) with responses ranging from “never” (0) to “very often” (4). The analyses coded heterosexually-identified individuals with concordant behavior and attraction responses as ‘never’ (0) given that these questions were not asked of these respondents due to the low possibility of being discriminated against based on their sexuality (i.e., concordant heterosexual identity, heterosexual behavior, and heterosexual attraction). Cronbach’s alpha for these six items within the analytic sample used of this study was equal to .893.
The data analysis was divided into three sections. First, differences (based on sex and sexual minority status) in social contacts, social provision, sexual orientation discrimination, and past-year SUD (i.e., AUD, TUD, and DUD) were assessed using either binary logistic or linear regression. Second, we used binary logistic regression to assess the association between SUD and social contacts/social provision/sexual orientation discrimination within the full sample controlling for sex, sexual minority status, and sociodemographic characteristics. Third, we stratified the binary logistic regression models assessing the association between SUD and social contacts/social provision/sexual orientation discrimination in order to examine differences in the associations between heterosexual men, SM men, heterosexual women, and SM women. To compare logit coefficients across models, we used the Z-test for the equality of coefficients (43) to test differences between the strength of the coefficients assessing different types of SUD between groups. This approach is similar to creating interaction terms with the added benefit of seeing specific associations that are unique within each of the stratified groups (i.e., heterosexual men, SM men, heterosexual women, SM women).
We used STATA 15.0 for all analyses (Version 15.0; StataCorp LP, College Station, Texas). The NESARC-III design included stratification and clustering of the target population. Analytic techniques were design-based, using sampling weights to calculate estimates of population parameters and specialized variance estimation techniques to accommodate the complex design features when estimating standard errors. All estimates provided here used these sampling weights. However, unweighted sample sizes are provided to show the actual number of respondents within each sub-population. Given the number of comparisons and analyses performed, we only considered values that reached an alpha level of 0.01 or lower to be indicative of statistical significance within the analyses. (44) Listwise deletion was used to handle any missing data within the analyses; only 4.1% of the sample had missing data on at least one of the items used in the current analyses (95.9% of the sample had complete information).
RESULTS
Among the 36,309 respondents, 15,724 (43.3%) were men and 20271 (55.8%) were women (Table 1). Respondents identifying as heterosexual made up most of the sample (N=34,644, 95.4%), and 1,351 (3.7%) identified as SM. Significant differences between heterosexual and SM males included age, education, income, employment, geographic region and urbanicity. Among women, significant differences between heterosexual and SM were found for age, race, education, income and urbanicity.
Table 1.
Demographics of United States adults by sex and sexual minority status (Source: NESARC-III)
| Men | Women | ||||
|---|---|---|---|---|---|
| Total (N=36309) % (n) |
Heterosexual (N=15190) % (n) |
Sexual Minority (N=534) % (n) |
Heterosexual (N=19454) % (n) |
Sexual Minority (N=817) % (n) |
|
| Age | |||||
| 18–34 | 30.2 (11755) | 30.9 (4962) | 38.1 (197) | 28.4 (6037) | 59.7 (481) |
| 35–54 | 35.7 (13150) | 36.2 (5572) | 35.5 (199) | 35.6 (7030) | 25.9 (231) |
| 55+ | 34.0 (11404) | 32.8 (4656) | 26.3 (138) | 35.9 (6387) | 14.4 (105) |
| Race | |||||
| White | 66.1 (19194) | 66.7 (8175) | 69.6 (318) | 66.0 (10173) | 62.0 (401) |
| Black | 11.8 (7766) | 11.0 (3035) | 10.2 (84) | 12.3 (4333) | 17.0 (230) |
| Hispanic | 14.7 (7037) | 15.2 (2959) | 14.5 (103) | 14.2 (3750) | 15.4 (152) |
| Other race | 7.3 (2312) | 7.1 (1021) | 5.8 (29) | 7.5 (1198) | 5.6 (34) |
| Education | |||||
| High school degree or less | 38.8 (15289) | 40.5 (6699) | 31.7 (159) | 37.3 (7958) | 40.1 (334) |
| Some college | 33.1 (12105) | 33.2 (4737) | 32.9 (201) | 34.7 (6755) | 37.6 (305) |
| College degree or higher | 28.1 (8915) | 28.3 (3754) | 35.5 (174) | 28.0 (4741) | 22.3 (178) |
| Personal Income (USD) | |||||
| $0-$24,999 | 52.3 (20094) | 42.0 (6964) | 52.2 (276) | 61.1 (12085) | 70.9 (577) |
| $25,000-$59,999 | 31.0 (11339) | 34.0 (5261) | 29.9 (174) | 28.7 (5646) | 20.0 (169) |
| $60,000+ | 16.7 (4876) | 24.0 (2965) | 17.9 (84) | 10.2 (1723) | 9.1 (71) |
| Employment | |||||
| Not employed full-time | 55.4 (20376) | 47.1 (7354) | 56.8 (298) | 62.8 (12020) | 64.0 (509) |
| Employed full-time (35+ hours) | 44.6 (15933) | 52.9 (7836) | 43.2 (236) | 37.2 (7434) | 36.0 (308) |
| US Region | |||||
| Northwest | 18.2 (5180) | 17.9 (2138) | 24.6 (97) | 18.3 (2764) | 21.0 (140) |
| Midwest | 21.5 (7566) | 21.7 (3229) | 19.3 (98) | 21.4 (4004) | 19.1 (164) |
| South | 37.1 (14532) | 36.8 (5915) | 29.6 (177) | 37.5 (8003) | 33.8 (297) |
| West | 23.2 (9031) | 23.6 (3908) | 26.5 (162) | 22.8 (4683) | 26.1 (216) |
| Urbanicity | |||||
| Suburban/Urban | 78.7 (30193) | 78.7 (12588) | 86.1 (480) | 78.1 (16116) | 87.7 (739) |
| Rural | 21.3 (6116) | 21.3 (2602) | 13.9 (54) | 21.9 (3338) | 12.3 (78) |
Notes:
Sexual minority was defined as self-reported gay, lesbian, bisexual or ‘not sure’ identity (Men: gay [n = 321, 1.7%], bisexual [n = 144, .8%%] or ‘not sure’ [n = 69, .4%]; Women: lesbian [n = 265, 1.2%], bisexual [n = 422, 1.8%] or ‘not sure’ [n = 130, .6%]). Heterosexual-identifying individuals with same-sex behavior or attraction were defined as heterosexual.
Sample sizes vary due to missing data. Unweighted sample sizes are provided. Percentages incorporate survey weights provided by the NESARC-III. Results from design-adjusted Rao-Scott chi-square tests are provided.
Bivariate differences between sex and sexual identity
Substantial variation was found by sex and sexual minority status with respect to the main independent (social contacts, social provision and sexual orientation discrimination) and dependent (AUD, TUD, DUD) variables (Table 2). The average social provision score was significantly higher for heterosexual men and women (3.50 and 3.51, respectively) when compared to their SM peers (3.33 and 3.42, respectively). The prevalence of past-year AUD and TUD were significantly higher for SM men (AUD = 27.2%; TUD = 28.5%) and women (AUD = 27.1%; TUD = 29.1%) when compared to their heterosexual peers (men: AUD = 16.8%, TUD = 19.6%; women: AUD = 9.3%, TUD = 14.6%).
Associations between SUD and social contact, social provision, and sexual orientation discrimination
Women had lower odds of indicating an AUD (AOR = 0.554, p<.001), TUD (AOR = 0.657, p<.001), and DUD (AOR = 0.536, p<.001) compared to men, while SM had higher odds of indicating an AUD (AOR = 1.535, p<.001), TUD (AOR = 1.512, p<.001), and DUD (AOR = 1.520, p<.001) compared to heterosexuals (Table 3). Several other measures assessing social contact and social provision were found to have a robust association across each of the substance use disorders. Respondents who were married had lower odds of AUD (AOR = 0.579, p<.001), TUD (AOR = 0.605, p<.001), and DUD (AOR = 0.507, p<.001) compared to unmarried respondents; cohabitation was associated with a higher odds of AUD and TUD compared to unmarried/non-cohabiting respondents. Higher average social provision scores were associated with lower odds of indicating an AUD (AOR = 0.771, p<.001), TUD (AOR = 0.747, p<.001), and DUD (AOR = 0.558, p<.001). Higher sexual orientation discrimination scores were only positively associated with past-year AUD (1.396, p<.01).
Table 3.
Substance use disorder (AUD) as a function of sex, sexual minority status, social support and sexual orientation discrimination (Source: NESARC-III)
| AUD 2+ (n=34,913) |
TUD 2+ (n=34,866) |
DUD 2+ (n=34,919) |
|
|---|---|---|---|
| AOR 95%CI | AOR 95%CI | AOR 95%CI | |
| Substance use disorder (2+ symptoms) | AUD 2+ | TUD 2+ | DUD 2+ |
| Sex | |||
| Men | Reference | Reference | Reference |
| Women | 0.554*** (0.510,0.601) | 0.657*** (0.609,0.709) | 0.536*** (0.457,0.628) |
| Sexual minority | |||
| Heterosexual | Reference | Reference | Reference |
| Sexual Minority | 1.535*** (1.278,1.844) | 1.512*** (1.234,1.854) | 1.520*** (1.139,2.028) |
| Marital status/Children | |||
| Not Married | Reference | Reference | Reference |
| Married | 0.579*** (0.520,0.645) | 0.605*** (0.554,0.662) | 0.507*** (0.409,0.629) |
| Living With Someone as if married | 1.251** (1.057,1.480) | 1.405*** (1.212,1.627) | 1.160 (0.890,1.512) |
| Does not have a child under the age of 18 | Reference | Reference | Reference |
| At least 1 child under the age of 18 | 0.825***(0.751,0.906) | 1.082 (0.981,1.192) | 0.847 (0.695,1.031) |
| Contact with kin (2 weeks) | |||
| No Contact with grown children[18 years of age or older] | Reference | Reference | Reference |
| Contact with grown children[18 years of age or older] | 0.900 (0.799,1.014) | 1.169** (1.051,1.299) | 1.193 (0.926,1.537) |
| No Contact with parent | Reference | Reference | Reference |
| Contact with parent | 1.159* (1.034,1.298) | 1.023 (0.941,1.112) | 1.005 (0.835,1.210) |
| No Contact with spouses’ parent | Reference | Reference | Reference |
| Contact with spouses’ parent | 0.924 (0.828,1.031) | 1.023 (0.917,1.143) | 0.857 (0.674,1.091) |
| No Contact with other relatives | Reference | Reference | Reference |
| Contact with other relatives | 0.853***(0.778,0.935) | 0.894* (0.820,0.976) | 0.886 (0.763,1.028) |
| Number of contacts with non-kin (2 weeks) | |||
| Close friends (continuous measure) | 1.014***(1.006,1.022) | 0.995 (0.986,1.005) | 1.000 (0.986,1.013) |
| Acquaintances (continuous measure) | 1.004* (1.000,1.008) | 0.991***(0.985,0.996) | 1.001 (0.993,1.009) |
| Social provision (past-year) | |||
| Social provision (continuous measure) | 0.771***(0.705,0.844) | 0.747***(0.694,0.804) | 0.558***(0.490,0.636) |
| Sexual orientation discrimination (past-year) | |||
| Sexual orientation discrimination (continuous measure) | 1.396**(1.106,1.760) | 1.277 (0.980,1.665) | 1.193 (0.832,1.711) |
Notes:
Sexual minority was defined as self-reported gay, lesbian, bisexual or ‘not sure’ identity. Heterosexual-identifying individuals with same-sex behavior or attraction were defined as heterosexual.
The zero-order correlations between AUD and TUD was .226 (p<.001). The zero-order correlation between AUD and DUD was .245 (p<.001). The zero order correlation between TUD and DUD was .215 (p<.001).
Sample sizes vary due to missing data. Unweighted sample sizes are provided. Analysis incorporates survey weights provided by the NESARC-III and control for age, race, level of education, personal income, employment status, US region, and urbanicity.
p < 0.05,
p < 0.01,
p < 0.001
Associations between SUD and social contact, social provision, and sexual orientation discrimination
Tables 4 through 6 show stratified results (by sex and sexual minority status) in associations between SUD and the main independent variables.. Examining Table 4, two statistically significant differences were found in the associations between AUD and the main independent variables across the stratified groups. First, there was a significantly stronger negative association (i.e., lower odds of indicating an AUD) between AUD and contact with spouses’ parent among heterosexual women compared to heterosexual men (heterosexual women: AOR = 0.738, p<.01; heterosexual men: AOR = 1.090, non-sig.; Z-score = 3.06, p<.01)[Z-scores not shown in tables]. Second, there was a significantly stronger positive association (i.e., higher odds on indicating and AUD) between AUD and sexual orientation discrimination among heterosexual men compared to SM women (heterosexual men: AOR = 4.608, p<.01; SM women: AOR = 1.121, non-sig.; Z-score = 2.49, p<.01).
Table 4.
Alcohol use disorder (AUD) as a function of social support and sexual orientation discrimination (Source: NESARC-III)
| Men | Women | |||
|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 4 | |
| Heterosexual(a) (n=14,662) |
Sexual Minority(b) (n=518) |
Heterosexual(c) (n=18,937) |
Sexual Minority(d) (n=796) |
|
| AOR 95%CI | AOR 95%CI | AOR 95%CI | AOR 95%CI | |
| Alcohol use disorder (2+ symptoms) | AUD 2+ | AUD 2+ | AUD 2+ | AUD 2+ |
| Marital status/Children | ||||
| Not Married | Reference | Reference | Reference | Reference |
| Married | 0.500*** (0.432,0.579) | 0.883 (0.237,3.287) | 0.637***(0.529,0.767) | 0.590 (0.210,1.660) |
| Living With Someone as if married | 1.060 (0.858,1.308) | 0.984 (0.415,2.332) | 1.581***(1.219,2.051) | 1.358 (0.709,2.601) |
| Does not have a child under the age of 18 | Reference | Reference | Reference | Reference |
| At least 1 child under the age of 18 | 0.853 (0.721,1.010) | 1.021 (0.311,3.350) | 0.747***(0.656,0.851) | 1.258 (0.808,1.957) |
| Contact with kin (2 weeks) | ||||
| No Contact with grown children[18 years of age or older] | Reference | Reference | Reference | Reference |
| Contact with grown children[18 years of age or older] | 0.906 (0.776,1.058) | 1.174 (0.434,3.176) | 0.855 (0.699,1.046) | 1.032 (0.521,2.043) |
| No Contact with parent | Reference | Reference | Reference | Reference |
| Contact with parent | 1.133 (0.967,1.327) | 1.199 (0.593,2.427) | 1.200 (0.971,1.482) | 0.818 (0.457,1.466) |
| No Contact with spouses’ parent | Reference | Reference | Reference | Reference |
| Contact with spouses’ parent | 1.090 (0.933,1.274)c | 0.739 (0.220,2.485) | 0.738** (0.605,0.900)a | 0.819 (0.406,1.650) |
| No Contact with other relatives | Reference | Reference | Reference | Reference |
| Contact with other relatives | 0.861* (0.759,0.977) | 0.871 (0.474,1.601) | 0.809** (0.703,0.932) | 1.029 (0.657,1.613) |
| Number of contacts with non-kin (2 weeks) | ||||
| Close friends (continuous measure) | 1.016** (1.000,1.026) | 1.060 (0.995,1.130) | 1.009 (0.995,1.024) | 0.974 (0.918,1.034) |
| Acquaintances (continuous measure) | 1.006* (1.001,1.011) | 1.007 (0.986,1.028) | 1.002 (0.994,1.009) | 0.984 (0.959,1.009) |
| Social provision (past-year) | ||||
| Social provision (continuous measure) | 0 .798***(0.702,0.906) | 0.532* (0.318,0.890) | 0.775*** (0.680,0.883) | 0.741 (0.507,1.083) |
| Sexual orientation discrimination (past-year) | ||||
| Sexual orientation discrimination (continuous measure) | 4.608**(1.615,13.14)d | 1.574 (0.992,2.498) | 1.147 (0.547,2.404) | 1.121 (0.744,1.688)a |
Notes:
Sexual minority was defined as self-reported gay, lesbian, bisexual or ‘not sure’ identity. Heterosexual-identifying individuals with same-sex behavior or attraction were defined as heterosexual.
Sample sizes vary due to missing data. Unweighted sample sizes are provided. Analysis incorporates survey weights provided by the NESARC-III and control for age, race, level of education, personal income, employment status, US region, and urbanicity.
p < 0.05,
p < 0.01,
p < 0.001
Significant differences between logit coefficients using the Z-test of equality at the 0.01 alpha level or lower when compared to
Heterosexual(a) men,
Sexual Minority(b) men,
Heterosexual(c) women, and
Sexual Minority(d) women.
Table 6.
Drug use disorder (DUD) as a function of social support and sexual orientation discrimination (Source: NESARC-III)
| Men | Women | |||
|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 4 | |
| Heterosexual(a) (n=14,668) |
Sexual Minority(b) (n=519) |
Heterosexual(c) (n=18,936) |
Sexual Minority(d) (n=795) |
|
| AOR 95%CI | AOR 95%CI | AOR 95%CI | AOR 95%CI | |
| Other drug use disorder (2+ symptoms) | DUD 2+ | DUD 2+ | DUD 2+ | DUD 2+ |
| Marital status/Children | ||||
| Not Married | Reference | Reference | Reference | Reference |
| Married | 0.504*** (0.369,0.689) | 0.605 (0.174,2.103) | 0.515***(0.372,0.712) | 0.404 (0.114,1.428) |
| Living With Someone as if married | 1.174 (0.795,1.733) | 0.527 (0.158,1.756) | 1.204 (0.821,1.765) | 0.729 (0.248,2.142) |
| Does not have a child under the age of 18 | Reference | Reference | Reference | Reference |
| At least 1 child under the age of 18 | 0.960 (0.713,1.292) | 0.879 (0.187,4.127) | 0.750* (0.582,0.966) | 0.643 (0.307,1.348) |
| Contact with kin (2 weeks) | ||||
| No Contact with grown children[18 years of age or older] | Reference | Reference | Reference | Reference |
| Contact with grown children[18 years of age or older] | 1.230 (0.913,1.657) | 0.411 (0.031,5.376) | 1.013 (0.698,1.470) | 2.173 (0.741,6.374) |
| No Contact with parent | Reference | Reference | Reference | Reference |
| Contact with parent | 1.080 (0.832,1.401) | 0.624 (0.253,1.540) | 0.951 (0.695,1.301) | 0.912 (0.443,1.877) |
| No Contact with spouses’ parent | Reference | Reference | Reference | Reference |
| Contact with spouses’ parent | 0.871 (0.594,1.277) | 2.638 (0.716,9.717) | 0.776 (0.559,1.077) | 0.874 (0.266,2.868) |
| No Contact with other relatives | Reference | Reference | Reference | Reference |
| Contact with other relatives | 0.799* (0.658,0.971) | 0.439* (0.226,0.853)c | 1.060 (0.833,1.349)b | 1.178 (0.638,2.175) |
| Number of contacts with non-kin (2 weeks) | ||||
| Close friends (continuous measure) | 1.005 (0.991,1.020) | 0.995 (0.918,1.078) | 0.989 (0.958,1.020) | 0.951 (0.868,1.041) |
| Acquaintances (continuous measure) | 1.004 (0.994,1.014) | 1.016 (0.989,1.043) | 0.994 (0.978,1.010) | 0.950 (0.892, 1.011) |
| Social provision (past-year) | ||||
| Social provision (continuous measure) | 0.639***(0.537,0.760)b,c | 1.651 (0.819,3.326)a, c | 0.413***(0.340,0.502)a,b | 0.732 (0.411,1.304) |
| Sexual orientation discrimination (past-year) | ||||
| Sexual orientation discrimination (continuous measure) | 1.684 (0.602,4.707) | 1.535 (0.982,2.399) | 1.880 (0.767,4.608) | 0.827 (0.446,1.531) |
Notes:
Sexual minority was defined as self-reported gay, lesbian, bisexual or ‘not sure’ identity. Heterosexual-identifying individuals with same-sex behavior or attraction were defined as heterosexual.
Sample sizes vary due to missing data. Unweighted sample sizes are provided. Analysis incorporates survey weights provided by the NESARC-III and control for age, race, level of education, personal income, employment status, US region, and urbanicity.
p < 0.05,
p < 0.01,
p < 0.001
Significant differences between logit coefficients using the Z-test of equality at the 0.01 alpha level or lower when compared to
Heterosexual(a) men,
Sexual Minority(b) men,
Heterosexual(c) women, and
Sexual Minority(d) women.
Table 5 shows the stratified results assessing past-year TUD. There was a significantly stronger positive association between TUD and having a child under the age of 18 among SM women compared to either heterosexual men or heterosexual women (SM women: AOR = 1.990, p<.001; heterosexual men: AOR = 1.064, non-sig.; heterosexual women: AOR = 1.029, non-sig.; Z-score = 2.90, p<.01 and Z-score = 3.07, p<.01, respectively). There was a significantly stronger positive association between TUD and having contact with grown children among heterosexual women compared to heterosexual men (heterosexual women: AOR = 1.397, p<.001; heterosexual men: AOR = 0.953, non-sig.; Z-score = 3.80, p<.001). There was also a significantly stronger positive association between TUD and number of close friends among SM men compared to heterosexual women (SM men: AOR = 1.062, p<.05; heterosexual women: AOR = 0.980, p<.05; Z-score = 2.56, p<.01). Finally, we found a significantly stronger negative association between TUD and number of acquaintances among heterosexual women compared to heterosexual men (heterosexual women: AOR = 0.979, p<.001; heterosexual men: AOR = 0.998, non-sig.; Z-score = 3.33, p<.001).
Table 5.
Tobacco use disorder (TUD) as a function of social support and sexual orientation discrimination (Source: NESARC-III)
| Men | Women | |||
|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 4 | |
| Heterosexual(a) (n=14,640) |
Sexual Minority(b) (n=518) |
Heterosexual(c) (n=18,913) |
Sexual Minority(d) (n=795) |
|
| AOR 95%CI | AOR 95%CI | AOR 95%CI | AOR 95%CI | |
| Tobacco use disorder (2+ symptoms) | TUD 2+ | TUD 2+ | TUD 2+ | TUD 2+ |
| Marital status/Children | ||||
| Not Married | Reference | Reference | Reference | Reference |
| Married | 0.603*** (0.521,0.699) | 1.635 (0.493,5.422) | 0.584***(0.507,0.671) | 0.425* (0.182,0.996) |
| Living With Someone as if married | 1.353** (1.100,1.665) | 1.114 (0.527,2.356) | 1.570***(1.241,1.985) | 0.847 (0.391,1.835) |
| Does not have a child under the age of 18 | Reference | Reference | Reference | Reference |
| At least 1 child under the age of 18 | 1.064 (0.932,1.213)d | 0.839 (0.324,2.175) | 1.029 (0.909,1.165)d | 1.990***(1.325,2.988)a, c |
| Contact with kin (2 weeks) | ||||
| No Contact with grown children[18 years of age or older] | Reference | Reference | Reference | Reference |
| Contact with grown children[18 years of age or older] | 0.953 (0.830,1.094)c | 0.982 (0.343,2.815) | 1.397***(1.210,1.612)a | 1.806 (0.843,3.870) |
| No Contact with parent | Reference | Reference | Reference | Reference |
| Contact with parent | 1.059 (0.917,1.223) | 0.680 (0.347,1.333) | 1.020 (0.906,1.148) | 0.873 (0.501,1.522) |
| No Contact with spouses’ parent | Reference | Reference | Reference | Reference |
| Contact with spouses’ parent | 1.065 (0.909,1.248) | 0.929 (0.255,3.377) | 0.940 (0.789,1.121) | 1.485 (0.629,3.504) |
| No Contact with other relatives | Reference | Reference | Reference | Reference |
| Contact with other relatives | 0.911 (0.817,1.016) | 0.897 (0.498,1.615) | 0.869* (0.756,0.999) | 0.821 (0.506,1.333) |
| Number of contacts with non-kin (2 weeks) | ||||
| Close friends (continuous measure) | 1.000 (0.989,1.012) | 1.062* (1.001,1.128)c | 0.980* (0.964,0.997)b | 0.996 (0.930,1.066) |
| Acquaintances (continuous measure) | 0.998 (0.992,1.004)c | 0.983 (0.959,1.008) | 0.979***(0.969,0.988)a | 0.961* (0.929,0.995) |
| Social provision (past-year) | ||||
| Social provision (continuous measure) | 0.831***(0.748,0.925)c | 0.651 (0.385,1.101) | 0.688*** (0.618,0.767)a | 0.915 (0.630,1.328) |
| Sexual orientation discrimination (past-year) | ||||
| Sexual orientation discrimination (continuous measure) | 1.738 (0.660,4.571) | 1.561*(1.028,2.370) | 1.974 (0.879,4.429) | 1.003 (0.664,1.514) |
Notes:
Sexual minority was defined as self-reported gay, lesbian, bisexual or ‘not sure’ identity. Heterosexual-identifying individuals with same-sex behavior or attraction were defined as heterosexual.
Sample sizes vary due to missing data. Unweighted sample sizes are provided. Analysis incorporates survey weights provided by the NESARC-III and control for age, race, level of education, personal income, employment status, US region, and urbanicity.
p < 0.05,
p < 0.01,
p < 0.001
Significant differences between logit coefficients using the Z-test of equality at the 0.01 alpha level or lower when compared to
Heterosexual(a) men,
Sexual Minority(b) men,
Heterosexual(c) women, and
Sexual Minority(d) women.
In the stratified results assessing DUD (Table 6), we found a significantly stronger negative association between DUD and social provision among heterosexual women compared to heterosexual men and SM men (heterosexual women: AOR = 0.413, p<.001; heterosexual men: AOR = 0.639, p<.001; SM men: AOR = 1.651, non-sig.; Z-score = 3.31, p<.001 and Z-score = 3.77, p<.001, respectively).
DISCUSSION
In this nationally representative cohort of U.S adults, we found that associations between social support and DSM-5 SUD differed by sex and sexual minority status and sex. Consistent with previous studies (1, 9, 10), SM individuals had higher past-year AUD, TUD, and DUD compared to heterosexual individuals. Specifically, SM men and women had significantly more AUD and TUD; SM women also had significantly higher DUD. Although social contacts were associated with SUD, types and frequency of contacts varied by drug class and sexual minority status. Social provision was associated with all types of SUD and was significantly lower among SM compared to heterosexuals. SM women reported lower social provision and fewest non-kin social contact, as well having the highest prevalence of SUD.
Measures of structural support, including frequency of kin and non-kin contacts, were inconsistently associated with SUD, sexual minority status, or sex. In general, populations with higher frequency of kin and non-kin contact had comparably lower SUD. However, differences in the number of social contacts did not necessarily impact odds of SUD. For example, SM women had the highest proportion of recent contact with parents, but this was not associated with increased risk for any substance use disorder. This suggests that frequency of contact alone may not be a sufficient predictor of SUD.
We found differences in SUD by sex and sexual minority status based on the type of social contact. Heterosexual men with higher number of contacts with close friends were significantly more likely to have AUD. This finding is similar to previous studies indicating larger social networks made up of heavy drinkers have been found to be associated with greater alcohol consumption and AUD among men.(45, 46) Being married was associated with all types of past-year SUD, consistent with the literature indicating marriage may provide additional social support for both men and women, with decreased substance use after marriage.(47–50) Reciprocally, individuals without SUD may be more able to participate in stable, functioning relationships.(49, 51) We did not find a similar relationship between marriage and SUD among SM populations, possibly due to a smaller percentage of married SM individuals in this cohort. The NESARC-III study was completed in 2013, prior to the 2015 Supreme Court decision to legalize same-sex marriage, and many states did not have marriage equality laws at the time of the survey. Although we did not find consistent patterns of associations between structural support and TUD and DUD among SM populations, previous research has found greater frequency of TUD and DUD among SM populations is attributed, in part, to higher prevalence of substance use and substance use acceptability in SM social networks, as well as increased perceived tolerant norms and availability of drugs.(29, 52, 53)
Higher functional support was associated with lower SUD, although varied sex and sexual minority status. Higher social provision was associated with lower odds of all SUD for both heterosexual men and women but not for SM adults. The null findings for the relationship between social provision and SUD among SM may be the result of a smaller sample size or that social provision was already significantly lower among SM. Functional social support indicates the quality of social support received which is important for approaches in decreasing SUD. Caring, positive relationships that include informational support and promotion of self-efficacy are linked to reduced substance use initiation (21, 54–56), and higher functional social support has been found to increase efficacy of substance use treatment interventions and identified as an indicator of entry and retention in treatment.(57–59) Due to the cross-sectional nature of our data, we are unable to determine whether higher social provision results in lower SUD or if the presence of SUD results in lower social provision due to loss of support resources related to substance use. However, our findings of a strong association between functional social support and SUD suggest that incorporating existing social support resources or enhancing provisions of support may increase effectiveness of prevention and treatment programs in reducing SUD.
The overall association between functional support and SUD, and the inconsistent relationship between structural support and SUD, suggests quality of relationships and social provision to be as important a consideration as composition and frequency of contact relative to substance use.(28, 60, 61) Additionally, while social support may function to moderate SUD, it is also probable that substance use may contribute to social dynamics that create shifts in relationships and social networks. Individuals with SUD are more likely to have relationships that include substance users, but individuals may also be selecting social relationships that affirm existing substance use.(62) Our findings are not able to tease out the temporal relationship between social support and SUD, but determining the specific role of social networks and support in substance use is important for interventions that integrate social support mechanisms in prevention and treatment. For example, Valente, et al found that a peer-influence substance use intervention in a school setting was mainly effective only for students with social networks that did not include substance users.(63) Effective strategies to incorporate social support may require assessing the functional support received and tailoring interventions based on social networks.
SM-related discrimination has been found to be associated with increased tobacco, alcohol, and drug use in SM populations (13, 17, 64, 65), although differentially associated with substance use across SM identities.(8, 13, 66) We found that while SM-related discrimination was significantly higher among SM, discrimination was not significantly associated with SUD among SM-identifying individuals. However, SM-related discrimination was significantly associated with AUD among heterosexual-identifying men who reported same-sex attraction/behavior. In a previous NESARC-III analysis, McCabe et. al. found significant associations between sexual identity/attraction discordance and TUD, although the relationship between discordant identity/attraction and AUD and DUD have been mixed in other studies.(67, 68) Discordance between identity and attraction may be due to identity concealment and fear of disclosure associated with experiences of discrimination that may increase risk for SUD.
The present study is not without limitations. First, the NESARC-III is a cross-sectional study, and experiences of social support and discrimination are dynamic. Longitudinal studies would be more informative in establishing causation with SUD. Second, we did not examine differences between social support and SUD within specific sexual identity population (i.e. bisexual, ‘not sure’). Individuals that identify as ‘not sure’ may lack community connectedness and social support that warrants further exploration.(15) Third, are possible other explanatory factors that were not considered in our analysis, including age, polysubstance use and gender identity (NESARC-III did not capture gender identity- e.g. trans-, cis-gender). Finally, we assessed functional and structural social support as separate mechanisms for SUD and did not look at the interaction of social provision with frequency of contacts or social networks. The NESARC-III data are limited for this type of assessment, and future studies should consider the quality of social support in the context of composition of social networks.
To our knowledge, this is the first assessment of social support and SUD by sex and sexual minority status from a nationally representative sample of U.S. adults. We found social support to be differentially associated with SUD among by sex and sexual minority status. Higher social provision was generally associated with lower SUD, suggesting that functional support may be a more important avenue for developing strategies to reduce SUD. Understanding differences by sex and sexual minority status in how social support influences SUD is important in developing targeted strategies for substance use prevention and treatment for diverse populations. Marriage was associated with lower SUD among heterosexuals, and future research should revisit this relationship among SM populations in light of marriage equality. Our findings are consistent with constructs of the Minority Stress Model, but additional research on social composition and relationship quality by specific populations of SMs may further tease out the influence of social support and discrimination on substance use behaviors that can inform future research and development of strategies for substance use prevention. Of particular relevance for intervention development is assessing how social networks are formed in the context of substance use and how social provisions of support are related to SUD in order to incorporate social support into effective prevention and treatment.
Acknowledgements:
The development of this manuscript was support by National Institute Health research grants R01DA043696 and R01036541 from the National Institute on Drug Abuse, R01AA025684 from the National Institute on Alcohol Abuse and Alcoholism, and R01CA212517 from the National Cancer Institute. This manuscript was prepared using a limited access dataset obtained from the National Institute on Alcohol Abuse and Alcoholism. The funders had not role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse, the National Cancer Institute, the National Institute on Alcohol Abuse and Alcoholism, NIH or the U.S. Government.
Footnotes
Declaration of Interest Statement: The authors of this manuscript do not have any financial disclosures to report.
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