Abstract
Objectives:
In light of the opioid epidemic, it is essential to understand which subgroups of youth are at elevated risk for opioid use. Sexual minority groups have increased rates of substance use compared to heterosexual youth. Our study aims to examine the prevalence of both prescription opioid misuse and heroin use in adolescents. We then examine odds of prescription opioid misuse and heroin use adjusting for common covariates.
Methods:
Using 2017 Youth Risk Behavior Surveillance System data, we examined lifetime odds of prescription opioid misuse and heroin use among sexual minority youth as defined by sexual identity and sexual behavior. We used logistic regression adjusting for age, sex, and race.
Results:
28.5% of gay/lesbian and 25.1% of bisexual youth reported misuse compared to 12.5% of heterosexual youth. Nearly one in ten gay/lesbian youth reported a history of heroin use compared to 4.1% of bisexual and 1.1% of heterosexual young people. Among those who reported having a history of sexual contact, those with same sex contact and sexual contact with both sexes had elevated odds of lifetime heroin use compared to those with a history of opposite sex contact only (aOR: 3.77; 95% CI: 1.68, 8.44 and aOR: 7.44; 95% CI: 4.59, 12.06 respectively).
Conclusions:
We demonstrated preliminary evidence sexual minority youth have significant opioid-related health disparities with greater odds of lifetime prescription opioid misuse and heroin use. As early exposure to opioids is associated with greater risk for developing an opioid use disorder and increased opioid-morbidity and mortality, it is critical that providers recognize and incorporate the unique needs for sexual minority youth into traditional treatment and prevention models.
Keywords: Sexual and gender minorities, opioid-related disorders, healthcare disparities
Introduction
As one in ten young adult deaths are now attributable to opioid-related causes (Gomes et al., 2018), it is important to identify vulnerable youth at early stages of use. Sexual minority youth have higher rates of drug use compared to heterosexual youth, although most research focuses on tobacco, alcohol, and marijuana (Dermody, 2018). Many national surveys, such as Monitoring the Future (MTF), provide estimates on substance use among youth, but fail to ask about sexual identity or sexual behaviors (Johnston et al., 2019), limiting our ability to examine specific sub-populations that may be at elevated risk. Additionally, previous iterations of the Youth Risk Behavior Survey (YRBS) grouped together all prescription misuse (e.g. stimulants, opioids, tranquilizers) limiting our ability to understand opioid misuse specifically, which is the most common way youth initiate opioid use and can serve as a pathway to more severe opioid use (Lankenau et al., 2012). For example, analysis of 2015 YRBS data showed higher rates of prescription drug misuse among sexual minority adolescent females and gay and unsure males, but they were unable to isolate prescription opioids (Li et al., 2018). Misuse of stimulants or other drugs may be triggered by different emotions than sedating drugs like opioids.
Limited research on opioids suggests higher rates of heroin use in sexual minority youth (Newcomb et al., 2014; Caputi et al., 2018); however, these studies report on data that is now outdated, particularly in light of the exponential increases in opioid-related deaths seen among young people (Jalal et al., 2018) or do not adjust for common covariates (Kann et al., 2018). While the National Survey on Drug Use and Health (NSDUH) data reported higher unadjusted rates of past year prescription opioid misuse and heroin use among sexual minority young adults (ages 18 to 25) (SAMHSA, 2017) and Duncan, et al (2019) found prescription opioid-related disparities existed among sexual minority adults, analyses excluded youth.
To identify sub-populations of youth at elevated risk for future opioid-related morbidity and mortality, we examine adolescent disparities in lifetime odds of heroin and prescription opioid misuse by sexual minority status using YRBS data. We define sexual minority status broadly—using both sexual identity and sexual behavior—as people, particularly youth endorse sexual behaviors discordant with sexual identity (Fu, et al, 2019). Many previous studies included only sexual identity (Li et al., 2018), limiting the ability to understand the nuances of risk among sexual minority youth.
Methods
Study population
This is a secondary data analysis from the 2017 YRBS (n=14,765), a confidential, self-administered standardized survey administered to a nationally representative sample of high school students from grades 9–12. YRBS incorporates a three-stage cluster design to create a nationally representative sample. It was approved by Centers for Disease Control and Prevention Institutional Review Board (IRB) and the analysis of non-identifiable, publicly available data is deemed non-human subjects research by our IRB.
Study variables
Sexual identity was examined by asking: “Which of the following best describes you? Heterosexual (straight), gay or lesbian, bisexual, not sure” and was coded as heterosexual, gay/lesbian, bisexual, or unsure. Sexual behavior was based on respondent’s sex (male or female) and sex of the individual(s) with whom the respondent had sexual contact (options included “I have never had sexual contact,” “Females,” “Males,” and “Females and males”). Sexual contact was not defined in the survey. We used responses to questions on heroin and prescription opioid misuse. Specifically, these questions were: “During your life, how many times have you used heroin?” and “During your life, how many times have you taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told you to use it?” We dichotomized responses as “never used” or “any use.”
Data analysis
Survey weights were based on student sex, race/ethnicity, and grade account for nonresponse and oversampling of Black and Hispanic students. We used the Stata package svy (Statacorp, 2017) to account for complex survey design and survey weights. After adjusting for age, sex, and race/ethnicity, we examined the association between sexual identity or behavior (in separate models) with each opioid use outcome using logistic regression. As some responses to questions relevant to our analyses were missing, our models had sample sizes ranging from 11,774 to 13,811. We also examined models with sex-by-sexual-minority-status interaction terms, and these were not significant (available upon request), although we were underpowered to detect differences within these subgroups. We opted to not stratify by sex in our final analyses as it drastically reduced the sample size.
Results
Rates of prescription opioid use were highest among sexual minority youth: 12.5% of heterosexual youth report prescription opioid misuse versus 28.5% of gay/lesbian and 25.1% of bisexual youth (Table 1). Prescription opioid misuse was higher among those reporting same sex contact (24.4%) or contact with both sexes (38.0%) compared to opposite sex contact (19.3%) or no contact (8.0%). Heroin rates of use were highest among gay/lesbian youth (9.2%) followed by unsure youth (8.4%) and bisexual youth (4.1%) compared to heterosexual youth (1.1%).
Table 1:
Descriptive statistics (weighted) for national sample of youth from 2017 YRBSS.
| Sexual identitya | All (n = 14,108) |
Heterosexual (n = 12,012) |
Gay/lesbian (n = 357) |
Bisexual (n = 1,137) |
Not sure (n = 602) |
p-value |
|---|---|---|---|---|---|---|
| Age, mean (SD) | 16.02 (1.25) | 16.03 (1.24) | 16.04 (1.39) | 15.97 (1.23) | 15.90 (1.35) | 0.004 |
| Sex, n (%) | <0.001 | |||||
| Female | 7,211 (51.6) | 5,741 (48.1) | 190 (54.8) | 914 (82.1) | 366 (61.7) | |
| Male | 6,778 (48.5) | 6,195 (51.9) | 157 (45.2) | 199 (17.9) | 227 (38.3) | |
| Race/ethnicity, n (%) | 0.011 | |||||
| NH American Indian/Alaska Native | 133 (1.0) | 110 (0.9) | 4 (1.1) | 11 (1.0) | 8 (1.4) | |
| NH Asian/Pacific Islander | 787 (5.7) | 672 (5.7) | 15 (4.3) | 54 (4.8) | 46 (7.8) | |
| NH Black | 2,696 (19.3) | 2,235 (18.8) | 95 (27.1) | 246 (22.0) | 120 (20.2) | |
| NH White | 6,002 (43.1) | 5,160 (43.4) | 132 (37.6) | 467 (41.8) | 243 (41.0) | |
| Multiracial | 784 (5.6) | 657 (5.5) | 17 (4.8) | 85 (7.6) | 25 (4.2) | |
| Hispanic | 3,539 (25.4) | 3,045 (25.6) | 88 (25.1) | 255 (22.8) | 151 (25.5) | |
| Heroin use (ever),b n (%) | <0.001 | |||||
| Yes | 262 (1.9) | 135 (1.1) | 32 (9.2) | 46 (4.1) | 49 (8.4) | |
| No | 13,607 (98.1) | 11,686 (98.9) | 317 (90.8) | 1,069 (95.9) | 525 (91.6) | |
| Prescription opioid misuse (ever)c, n (%) | <0.001 | |||||
| Yes | 1,994 (14.2) | 1,499 (12.5) | 100 (28.5) | 284 (25.1) | 111 (18.6) | |
| Sexual behaviord | All (n = 12,121) |
None (n = 6,164) |
Opposite sex (n = 5,124) |
Same sex (n = 221) |
Both sexes (n = 612) |
p-value |
| Age, mean (SD) | 16.04 (1.24) | 15.72 (1.21) | 16.37 (1.18) | 16.15 (1.26) | 16.17 (1.25) | <0.001 |
| Female | 6,219 (51.5) | 3,250 (53.1) | 2,342 (45.7) | 142 (64.3) | 485 (81.1) | |
| Male | 5,848 (48.5) | 2,874 (46.9) | 2,782 (54.3) | 79 (35.8) | 113 (18.9) | |
| Race/ethnicity, n (%) | <0.001 | |||||
| NH American Indian/Alaska Native | 108 (0.9) | 50 (0.8) | 51 (1.0) | 1 (0.5) | 5 (0.8) | |
| NH Asian/Pacific Islander | 688 (5.7) | 483 (7.8) | 184 (3.6) | 12 (5.5) | 9 (1.5) | |
| NH Black | 2,144 (17.9) | 952 (15.7) | 988 (19.3) | 73 (33.3) | 131 (21.8) | |
| NH White | 5,213 (43.4) | 2,660 (43.8) | 2,210 (43.2) | 69 (31.5) | 274 (45.6) | |
| Multiracial | 661 (5.5) | 329 (5.4) | 279 (5.5) | 12 (5.5) | 41 (6.8) | |
| Hispanic | 3,194 (26.6) | 1,602 (26.4) | 1,399 (27.4) | 52 (23.7) | 141 (23.5) | |
| Heroin use (ever), n (%) | <0.001 | |||||
| Yes | 184 (1.6) | 53 (0.9) | 86 (1.7) | 13 (6.0) | 32 (5.3) | |
| No | 11,724 (98.5) | 6,005 (99.1) | 4,946 (98.3) | 204 (94.0) | 569 (94.7) | |
| Prescription opioid misuse (ever), n (%) | <0.001 | |||||
| Yes | 1,759 (15.6) | 489 (8.0) | 984 (19.3) | 54 (24.4) | 232 (38.0) | |
Sexual identity was coded as heterosexual, gay/lesbian, bisexual, or unsure.
We dichotomized heroin and prescription opioid misuse as any use versus never used.
Sexual behavior was based on respondent’s sex (male or female) and sex of the individual(s) with whom the respondent had sexual contact.
Sexual minority youth had greater adjusted odds of lifetime heroin use compared to heterosexual youth: gay/lesbian youth (aOR: 4.84; 95% CI: 2.42, 9.67), bisexual (aOR: 4.27, 95% CI: 2.39, 7.63), and unsure youth (aOR 8.20, 95% CI, 4.47, 15.02). Among those with a history of sexual contact, those with same sex and sexual contact with both sexes had elevated odds of lifetime heroin use compared to only heterosexual contact (aOR: 3.77; 95% CI: 1.68, 8.44 and aOR: 7.44; 95% CI: 4.59, 12.06 respectively).
Similar patterns were seen when examining lifetime prescription opioid misuse. There were increased adjusted odds of prescription opioid misuse among gay/lesbian (aOR: 1.96; 95% CI: 1.29, 2.96), bisexual (aOR: 2.27; 95% CI: 1.79, 2.88), and unsure youth (aOR: 1.44, 95% CI: 1.06, 1.94) compared to youth identified as heterosexual. Among youth with a history of sexual contact, those with contact with both sexes had statistically higher risk of lifetime prescription opioid misuse (aOR 2.62; 95% CI: 2.10, 3.25) compared to those with only heterosexual contact (Table 2).
Table 2.
Adjusted logistic regressiona analyses for lifetime history of heroin and prescription opioid misuse among national sample of youth surveyed by YRBSS 2017.
| Heroin used | Prescription opioid misused | |||
|---|---|---|---|---|
| Model 1a | Model 1b | Model 2a | Model 2b | |
| (n = 13,648) | (n = 11,774) | (n = 13,811) | (n = 11,935) | |
| OR [95% CI] | OR [95% CI] | OR [95% CI] | OR [95% CI] | |
| Sexual identityb | ||||
| Gay/lesbian | 4.84 [2.42, 9.67]*** | 1.96 [1.29, 2.96]** | ||
| Bisexual | 4.27 [2.39, 7.63]*** | 2.27 [1.79, 2.88]*** | ||
| Not sure | 8.20 [4.47, 15.02]*** | 1.44 [1.06, 1.94]* | ||
| Sexual behaviorc | ||||
| None | 0.24 [0.13, 0.45]*** | 0.27 [0.22, 0.33]*** | ||
| Same sex | 3.77 [1.68, 8.44]** | 1.22 [0.91, 1.63] | ||
| Both sexes | 7.44 [4.59, 12.06]*** | 2.62 [2.10, 3.25]*** | ||
| Missing outcome (n) | 385 | 385 | 255 | 255 |
| Missing sexual identity (n) | 657 | 657 | ||
| Missing sexual behavior (n) | 2,644 | 2,644 | ||
| Missing any other covariates (n) | 248 | 248 | 248 | 248 |
OR = odds ratio; CI = confidence interval
p < 0.001
p < 0.01
p < 0.05.
Adjusted for race/ethnicity, sex, and age.
Sexual identity was coded as heterosexual, gay/lesbian, bisexual, or unsure. Reference group was heterosexual.
Sexual behavior was based on respondent’s sex (male or female) and sex of the individual(s) with whom the respondent had sexual contact. Reference group is history of opposite sex contact.
We dichotomized heroin and prescription opioid misuse as any use versus never used.
Discussion
Our findings demonstrate preliminary evidence significant opioid-related disparities exist for sexual minority youth. As earlier exposure to opioids is associated with a greater risk for developing a later opioid use disorder, and prescription opioid misuse is a risk factor for later heroin use (Lankenau et al., 2012), the high rates of prescription opioid misuse among sexual minority youth are alarming warning signs of future opioid morbidity and mortality.
These preliminary findings support the urgent need for providers to explicitly address health risk behaviors in sexual minority youth and to understand the complex personal and social factors contributing to opioid-related disparities. As studies find discordance among sexual attraction, sexual identity and sexual behaviors, particularly in youth (Fu, et al; 2019; Pathela and Schillinger; 2010; Pathela, et al; 2006), healthcare providers should ask broadly about orientation or identity and sexual practices or behaviors at each preventive exam, as well as, when providing acute care and discussing substance use or sex behaviors. Sexual minority status may identify youth who are at-risk for additional psychosocial stress or discriminatory experiences, which may in turn contribute to first or ongoing substance use. For example, sexual minorities experience higher rates of stigma, violence, and discrimination leading to increased stress (Meyer 2003; Hsieh and Ruther, 2016). Opioid use in this population may serve as a surrogate for stress and act as a maladaptive coping behavior.
We found a greater prevalence of opioid use compared to other national surveys, such as MTF (lifetime prevalence by 12th grade: 0.80% heroin and 6% prescription opioid misuse) or NSDUH (<0.1% current heroin use and 3.65% for past year prescription opioid misuse among those under age 18 (Johnston et al., 2019; SAMHSA, 2017). While it is unclear why population estimates from YRBS are higher, this pattern has been consistently seen when comparing data using previous versions of the survey (Li et al., 2018). While YRBS may be an over-estimate of prescription opioid misuse compared to the true national prevalence, it may also reflect variations in how questions are asked. For example, MTF asks about opioid use “without a doctor telling you to use them” in contrast to YRBS, which asks about use “without a doctor’s prescription or differently than how a doctor told you to use it?” YRBS may better capture medications originally prescribed to young people by their own physician, which are then misused.
Odds of opioid use were particularly pronounced among those who reported having sexual contact with both sexes. While some of this risk may be related to having had more sexual experiences (as they are reporting at least two episodes of sexual contact with a same sex and an opposite sex partner) than those who reported only an opposite sex or same sex encounter (and number of sexual experiences in this young age group are surrogates of risky behaviors (Bauer and Brennan, 2013), individuals who identified as bisexual had high odds of lifetime opioid use, suggesting sexual minority status is a likely contributor. Although we did not compare the magnitude of odds ratios between bisexual or youth reporting sexual contact with both sexes to gay/lesbian youth or youth with only same sex, sexual contact, studies have demonstrated bisexual youth are at higher risk than other subpopulations of sexual minority youth of engaging in a number of high-risk behaviors (Caputi et al., 2017) suggesting unique factors influencing risk in this population. Research suggests that in addition to discrimination or victimization from heterosexual peers, gay/lesbian individuals may hold negative stereotypes of bisexual individuals and may propagate stigma and discrimination as “biphobia,” contributing to increased hostility and psychological distress among bisexual youth (Feinstein & Dyar, 2017; Friedman et al, 2014). There are also higher rates of victimization among bisexual identified individuals, including higher rates of rape, sexual abuse and other sexual violence (Katz-Wise and Hyde, 2012). Victimization has been found to account for some disparities in prescription drug misuse partially, although the relationship varies via sex (Li et al., 2018). Substance use may be a coping tool for bisexual youth experiencing more sexual trauma and victimization than even gay/lesbian peers.
There are a number of potential limitations with the study. YRBS relies upon self-reported data and so reported substance use or sexual minority status may not reflect true prevalence. While we conceptualize attraction, identity, and behavior as discrete activities, the YRBS data only asks about identity and behavior. We may miss identifying non-sexually active sexual minority youth who have same sex or both sex attraction, but do not identify as gay/lesbian or bisexual. We only analyze lifetime reports of opioid use and cannot identify those using regularly versus those with only incidental exposure, however, the morbidity associated with prescription opioid misuse or heroin use suggests any exposure may identify those at high risk for health-related consequences. Additionally, we are not able to examine gender identity or sex and how these might interact with sexual behavior or attraction. We are limited in our power to identify differences in behaviors among subpopulations of sexual minority young people (stratified by sex or gender) because of the limited sample size provided by just one year of YRBS data.
Conclusion
Despite this, our study finds preliminary evidence sexual minority youth experience significant opioid-related disparities compared to heterosexual youth. We need to identify and address the complex personal and social factors that likely contribute to opioid-related disparities in these sub-groups as part of treatment. To improve health outcomes, we need interventions that address and incorporate the unique needs of sexual minority youth into traditional treatment and prevention paradigms.
Acknowledgements
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors, however, Dr. Wilson was supported through a grant by NIH (NCATS KL2 TR001856).
Funding acknowledgements
Dr. Wilson was supported by NCATS KL2 TR001856.
Abbreviations:
- aOR
Adjusted odds ratio
- CI
Confidence Interval
- YRBSS
Youth Risk Behavior Surveillance System
Footnotes
Conflicts of interest: None to disclose for any author.
References
- 1.Gomes TM, Mamdani MM, Paterson JM, Juurlink DN. The burden of opioid-related mortality in the United States. JAMA Network Open 2018;1(2):e180217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Dermody SS. Risk of polysubstance use among sexual minority and heterosexual youth. Drug and Alcohol Dependence 2018;192:38–44. [DOI] [PubMed] [Google Scholar]
- 3.Johnston LD, Miech RA, O’Malley PM, Bachman JG, Schulenberg JE, & Patrick ME (2019). Monitoring the Future national survey results on drug use 1975–2018: Overview, key findings on adolescent drug use Ann Arbor: Institute for Social Research, University of Michigan. [Google Scholar]
- 4.Lankenau SE, Teti M, Silva K, Jackson Bloom J, Harocopos A, Treese M. Initiation into prescription opioid misuse amongst young injection drug users. Int J Drug Policy 2012;23(1):37–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Li DH, Turner BC, Mustanski B, Phillips GL. Sexual orientation disparities in prescription drug misuse among a nationally representative sample of adolescents: Prevalence and correlates. Addict Behav 2018;77:143–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Newcomb ME, Birkett M, Corliss HL, Mustanski M. Sexual orientation, gender, and racial differences in illicit drug use in a sample of US high school students. American Journal of Public Health 2014;104(2): 304–310. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Caputi TL, Smith LR, Strathdee SA, Ayers JW. Substance use among lesbian, gay, bisexual unsure adolescents in the United States, 2015. Am J Public Health 2018;108-1031–1034. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Changing dyandmics of the drug overdose epidemic in the United States from 1979 through 2016. Science 2018;361(6408): eaau1184. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance-United States, 2017. MMWR Surveill Summ 2018;67(No SS-8):1–114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health(HHS Publication No. SMA 17–5044) Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/. [Google Scholar]
- 11.Duncan DT, Zweig S, Hambrick HR, Palamar JJ. Sexual orietnation disiparities in prescription opioid misuse among U.S. adults. Am J Prev Med 2019. 56(1):17–26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Fu TC, Herbenick D, Dodge B, Owens C, Sanders SA, Reece M, Fortenberry JD. Relationships among sexual identity, sexual attraction and sexual behavior: results from a nationally representative probability sample of adults in the United States. Arch Sex Behav 2019;48(5):1483–1493. [DOI] [PubMed] [Google Scholar]
- 13.Pathela P and Schillinger JA. Sexual behaviors and sexual violence: adolescents with opposite-, same-, or both-sex partners. Pediatrics 2010; 126(5): 879–886. [DOI] [PubMed] [Google Scholar]
- 14.Pathela P, Hajat A, Schillinger J, et al. Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men. Ann Intern Med 2006;145:416–425. doi: 10.7326/0003-4819-145-6-200609190-00005 [DOI] [PubMed] [Google Scholar]
- 15.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003. September; 129(5):674–697. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Hsieh N and Ruther M. Sexual minority health and health risk factors: Intersection effects of gender, race, and sexual identity. Am J Prev Med 2016;60(6):746–755 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Johnston LD, Miech RA, O’Malley PM, Bachman JG, Schulenberg JE, & Patrick ME (2019). Monitoring the Future national survey results on drug use 1975–2018: Overview, key findings on adolescent drug use Ann Arbor: Institute for Social Research, University of Michigan. [Google Scholar]
- 18.Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health(HHS Publication No. SMA 17–5044) Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/. [Google Scholar]
- 19.Bauer GR, Brennan DJ. The problem with “behavioral bisexuality”: Assessing sexual orientation in survey research. Journal of Bisexuality 2013;13(2):148–165 [Google Scholar]
- 20.Caputi TL, Smith D, Ayers JW. Suicide risk behaviors among sexual minroity adolescents in the United States, 2015. JAMA 2017; 318 (23): 2349–2351. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Feinstein BA and Dyar C. Bisexuality, minority stress, and health. Curr Sex Health Rep 2017;March;9(1):42–49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Friedman MR, Dodge B, Schick V, et al. From bias to bisexual health disparities: Attitudes toward bisexual men and women in the United States. LGBT Health 2014;1:309–18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Katz-Wise SL and Hyde JS. Victimization experiences of lesbian, gay, and bisexual individuals: a meta-analysis. J Sex Res 2012; 48(2–3):142–67. [DOI] [PubMed] [Google Scholar]