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. Author manuscript; available in PMC: 2023 May 25.
Published in final edited form as: Subst Use Misuse. 2022 May 25;57(8):1313–1321. doi: 10.1080/10826084.2022.2079138

Sexual Orientation and Age of First Drug Use Among Adults in the United States

İbrahim Sönmez a, Joseph J Palamar b
PMCID: PMC9202448  NIHMSID: NIHMS1811117  PMID: 35614545

Abstract

Background:

Early onset of drug use could lead to long-term impairments, and research suggests that substance use and substance use disorders are more common among lesbian, gay, and bisexual (LGB) individuals. We sought to determine whether adults of different sexual identities were at differential risk for an earlier onset of drug use.

Methods:

We examined data from adults participating in the five waves (2015–2019) of the National Survey on Drug Use and Health, a nationally representative sample of noninstitutionalized adults in the United States. We determined whether current sexual identity was associated with retrospectively reported age of the first use of marijuana, cocaine, inhalants, ecstasy, and methamphetamine.

Results:

Compared to heterosexual individuals of the same sex, gay men had a later age of onset of use of all five drugs examined (marijuana, cocaine, inhalants, ecstasy, and methamphetamine) and bisexual men had a later onset of marijuana and inhalant use. Bisexual women had earlier age of onset for marijuana, cocaine, and ecstasy use. When examining early initiation (prior to age 15), both lesbian and bisexual women had greater odds of early initiation for marijuana, cocaine, and ecstasy; bisexual men had greater odds of early initiation for cocaine. Gay men had lower odds of initiation prior to age 15 for marijuana, inhalants, and methamphetamine.

Conclusions:

Current sexual identity is a correlate of earlier onset drug use. Longitudinal research is needed to further examine such associations as sexual identity can shift over time. Results are discussed in relation to prevention efforts aiming younger LGB persons.

Keywords: Age at the first drug use, club drugs, early substance use initiation, sexual orientation, LGB

Introduction

Early onset of drug use has been found to be predictive of elevated risk of several problems, such as substance use disorders (Grant & Dawson, 1997; Poudel & Gautam, 2017), conduct disorder during adolescence (Hser et al., 2003), risky sexual behaviors (Gordon et al., 2004), problems with school adjustment (Gordon et al., 2004), and school non-completion (Kelly et al., 2015). Further, it is well-documented that relative to their heterosexual counterparts, lesbian, gay, and bisexual (LGB) individuals tend to have higher prevalence of psychoactive drug use (Schuler et al., 2019) and are at almost at double the risk of developing substance use disorder (Kerridge et al., 2017). The difference between LGB and heterosexual individuals’ drug use prevalence appears to be more pronounced with respect to “club drug” use (Griffin et al., 2020; Kelly et al., 2006). Club drugs are commonly defined as ecstasy (MDMA, Molly), ketamine, gamma-hydroxybutyrate (GHB), methamphetamine (e.g., crystal meth), and powder cocaine (Griffin et al., 2020; Kelly et al., 2006; Lampinen et al., 2006; Le et al., 2020; Philbin et al., 2020; Tardelli et al., 2021). Yet, to our knowledge, no study has investigated the association between sexual orientation and age at the first drug use with a particular focus on club drugs. In this study, we focus on self-reported age of first use of the following drugs: marijuana, cocaine, inhalants, ecstasy, and methamphetamine.

Sexual minority status, such as identifying as LGB, could be a correlate of early onset drug use for several reasons. Minority stress theory has been put forward to explain this possible link to a certain extent. Minority stress theory suggests that LGB persons tend to experience elevated social stress because of perception of negative social attitudes toward their sexual identity (Meyer, 1995, 2003), and it grounds on a conceptualized continuum of minority stressors ranging from distal to proximal processes (Mongelli et al., 2019). While distal process commonly refers to experienced discrimination, being victims of prejudice events, and homophobia at the societal level, proximal processes refer to internalized homophobia, internalization, and endorsement of negative societal attitudes (Mongelli et al., 2019). Similarly, minority stressors posit structural stigma, where community-level negative attitudes are linked to individual-level outcomes (Hatzenbuehler & Link, 2014). For example, state-level protective policies for LGBT rights can contribute to eliminating sexual orientation disparities in dysthymia (Hatzenbuehler et al., 2009). Whether distal, proximal, or structural, minority stress has been postulated as an explanation of the LGB individuals’ high prevalence of the use of psychoactive drugs (Lea et al., 2014; Mongelli et al., 2019). A meta-analysis of 15 studies suggested that sexual minority stress indicators (e.g., perceived negative reactions to disclosure of sexual orientation) were associated with drug use among LGB individuals during adolescence (Goldbach et al., 2014). Likewise, different stereotypes held toward different sexual minority identities and experienced victimization by LGB people can lead to unique coping strategies (Hequembourg & Brallier, 2009) such as substance use (Boyle et al., 2017). Therefore, to a certain extent, minority stressors can explain the disparities in age at the first use of drugs.

Research suggests that compared to heterosexual individuals, LGB individuals are more likely to use “club drugs.” Results from the 2015 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of noninstitutionalized individuals in the United States, suggest that LGB adults were more likely to use drugs in the past year compared to heterosexual adults, with gay and bisexual men reporting higher prevalence of using inhalants (e.g., amyl nitrate) and methamphetamine in particular, and lesbian and bisexual women reporting higher prevalence of using ecstasy/MDMA (Medley et al., 2015). In another study, gay men who attend nightclubs were more likely to use club drugs including ecstasy, GHB, and methamphetamine (Griffin et al., 2020). Similarly, in a study among 3004 men who have sex with men in Sweden, it was found that club drug use was particularly prevalent among gay identified men, and among men that had more sexual partners and took more sexual risks (Petersson et al., 2016). Therefore, given its high prevalence, it is necessary to examine drug use among LGB identified individuals with a particular focus on club drugs.

It is also well-documented that bisexual individuals, especially bisexual women (Duncan et al., 2019; Parsons et al., 2006), are at an increased risk of various substance use behaviors (Demant et al., 2017; Duncan et al., 2019; Parsons et al., 2006; Roxburgh et al., 2016; Schuler et al., 2018, 2019). For example, the risk of both lifetime and recent use of marijuana (Schuler et al., 2019), hallucinogens (Schuler et al., 2019), inhalants (Le et al., 2020; Schuler et al., 2019), stimulants (Philbin et al., 2020), and other illegal drugs is elevated among bisexual women relative to heterosexual adults. Analysis of the 2015 Global Drug Survey also revealed that bisexual females had higher odds for lifetime use of all drugs queried (except for poppers), including MDMA, cocaine, and methamphetamine, compared to heterosexual females (Demant et al., 2017).

Research not only suggests that LGB individuals are more likely to use various drugs, but a number of studies have also documented that LGB individuals are at high risk of the earlier initiation of substances when compared to their heterosexual counterparts. For example, Schuler and Collins (2019) found that lesbian and bisexual women had elevated risk for early initiation of alcohol, which in turn had an effect on heavy episodic drinking and alcohol use disorder during adulthood. Similarly, Talley et al. (2019) found that lesbian and bisexual females were more likely to exhibit early use of alcohol and early and persistent use of marijuana and tobacco. In a study among 58,963 respondents from the Global Drug Survey, Demant et al. (2017) demonstrated that while bisexual and lesbian women had an earlier age of onset of drugs including MDMA, LSD, and ketamine, when compared to heterosexual females, gay males had an older age of onset for all substances considered when compared to heterosexual and bisexual males. Likewise, in a study of Roxburgh et al. (2016), LGB women initiated tobacco and alcohol use at an earlier age than heterosexual women while gay and bisexual men had an older age of onset for methamphetamine and hallucinogen use in comparison to that of heterosexual men.

Given the high prevalence of and documented risk of an earlier onset of drug use among LGB individuals and the risks and long-term impairments that can result from early onset of drug use, the aim of this study is to examine the association between the current sexual identity and age at the first drug use with a particular focus on drugs that are commonly used at nightclubs, including marijuana, cocaine, inhalants, ecstasy, and methamphetamine, using a nationally representative sample of noninstitutionalized adults in the United States. This focus is important to investigate because this information can inform prevention efforts targeting LGB youth and help determine groups within LGB communities who are at greater risk of an earlier onset of drug use.

Methods

Study population

We aggregated the most recent five waves of data from NSDUH (2015–2019, N = 282,768). Data are derived from nationally representative probability samples of populations living in households, noninstitutionalized group quarters, and shelters, obtained through four sampling stages (Center for Behavioral Health Statistics & Quality, 2020). We focused on adults (age ≥18) because only adults were asked about their sexual identity. These cross-sectional surveys were administered via computer-assisted interviewing conducted by an interviewer and audio computer-assisted self-interviewing. The weighted interview response rates were 69.7% (2015), 68.4% (2016), 67.1% (2017), 66.6% (2018), and 64.9% (2019).

Measures

Participants were asked about lifetime use of various drugs and drug classes. Those who reported a lifetime use of a particular drug, then were asked about their age at the first use of that drug. Participants typed in their age at the first use. In our analysis, we focused on the following drugs: marijuana, cocaine, inhalants (e.g., amyl nitrite (poppers), or nitrous oxide (whippets), gasoline or lighter fluid), ecstasy (MDMA, Molly), and methamphetamine.

With respect to sexual identity, participants were asked “which one of the following do you consider yourself to be?” and answer options were “heterosexual, “lesbian or gay,” and “bisexual.” Respondents who refused to answer (1.2%) or reported not knowing (0.6%) were excluded from the analysis. Based on the sexual orientation variable and the respondents’ reported sex, we created an updated sexual identity variable indicating both the reported sex and sexual orientation of respondents. Specifically, the categories of this variable are “heterosexual man,” “heterosexual woman,” “gay man,” bisexual man,” “lesbian woman,” and “bisexual woman.”

We included several control variables in consistency with previous literature, such as age, race/ethnicity, education level, income, marital status and several other demographic variables. We included the participants’ age at the time of the study as a categorical variable, with categories indicating ages 18–25, 26–34, 35–49, and 50 or older. Participants’ race/ethnicity was included as a recoded variable indicating non-Hispanic white, non-Hispanic black, Hispanic, and Asian or other race. Participants’ education level was included with values indicating less than high school, high school graduate, some college or the associate’s degree, and college graduate. Participants were also asked about their annual family income, and we included a recoded version of this variable with values indicating <$20,000, $20,000-$49,999, $50,000-$74,999, and ≥$75,000. Variable for the participants’ marital status was included with the following categories; ever married, separated, or divorced, and never married. Respondents’ insurance status (i.e., private insurance, Medicare, Medicaid, Champus/ChampusVA/Military, or other insurance) was included as the already imputed version in the NSDUH dataset. We included insurance status as a control variable because previous research suggests that insurance status is associated with illicit substance use including club drugs (Whittle et al., 2019) and with mental health treatment among adults with substance use disorder (Jones & McCance-Katz, 2019). Lastly, we included county metro/nonmetro status with a three-level variable indicating counties with more than a million people, 250,000 to a million people, and less than 250,000 people.

Statistical analysis

For descriptive purposes, we estimated the mean and median age at the first drug use overall and then by each sexual identity and sex group. Next, we estimated prevalence of lifetime use of each drug by each sexual identity and sex. Comparisons of use between each category were conducted using Rao-Scott chi-square. We then examined whether sexual identity was associated with self-reported age at the first drug use of each of the five drugs. We specified retrospectively reported age first use of each drug as the dependent variable in each model. Given that each distribution of discrete outcomes was negatively skewed, we used 10 separate sex-stratified generalized negative binomial regression models to estimate correlates of age of the first reported use. First, we examined bivariate models including only the outcome and the sexual identity variable to estimate unadjusted incidence rate ratios (IRRs). Then, we included all aforementioned demographic variables as covariates. These models were used to estimate adjusted IRRs (aIRRs). Next, we examined how current sexual identity was associated with early substance use initiation, which is defined as use prior to age 15, based on previous research (Ahuja et al., 2021; Trujillo et al., 2019). Logistic regression was used to estimate unadjusted and adjusted odds ratios (ORs) for such early initiation. Sample weights were utilized in all analyses which were provided by NSDUH to address unit- and individual-level non- response, complex survey design, selection probability, and population distribution. Data were analyzed using survey (“svy”) commands in Stata MP 13 (StataCorp, 2015). These secondary data analyses of de-identified data were exempt from review of the New York University Langone Medical Center institutional review board.

Results

Descriptive statistics are presented in Table 1. Most (95.2%) male participants identified as heterosexual, with 2.4% identifying as gay, and 2.4% identifying as bisexual. Similarly, 90.8% of women identified as heterosexual, 2.0% identified as lesbian, and 7.2% identified as bisexual. Table 2 presents estimated lifetime drug use prevalence according to sexual identity and sex. The estimated prevalence of lifetime use of the five drugs differed by sexual identity (p < .001). For all five drugs, gay men had the highest estimated prevalence of lifetime use of all groups. Among women, while heterosexual women had the lowest estimated lifetime use for all of the five drugs analyzed, bisexual women had the highest prevalence of estimated lifetime use. Table 3 presents estimated mean and median ages of the first drug use according to current sexual identity. Among individuals reporting lifetime use, inhalants tended to be used at the earliest age (mean age: 17.7) and methamphetamine tended to be used at the latest age (mean age: 22.1). Among all five drugs reported, bisexual women had the youngest mean age of onset, while gay men had the oldest mean age of onset compared to rest of the population.

Table 1.

Sample characteristics.

Men Women
% N % N
Sexual identity
Heterosexual 95.2 93,506 90.8 93,506
Gay/Lesbian 2.4 2,348 2.0 2,292
Bisexual 2.4 2,350 7.2 8,017
Education
Less than high school 14.3 14,242 11.9 13,613
High school 29.2 29,159 24.3 27,899
Some college 31.2 31,091 35.6 40,890
College 25.3 25,277 28.2 32,334
Income
<$20,000 17.7 17,661 22.0 25,273
$20,000–$49,999 30.6 30,479 31.8 36,467
$50,000–$74,999 16.0 16,006 15.3 17,509
≥$75,000 35.7 35,623 30.9 35,487
Race
White 60.6 60,618 59,3 68,306
Black 11.9 11,885 13,2 15,196
Hispanic 17.1 17,053 17,4 19,962
Asian/other 10.2 10,213 9,8 11,272
Age
18–25 33.8 33,739 31.5 36,177
26–34 20.3 20,219 20.7 23,797
35–49 25.8 25,740 26.9 30,826
50–64 11.6 11,605 11.9 13,608
65+ 8.5 8,466 9.00 10,328
Marital status
Ever married, Separated, or Widowed 51.5 51,360 58.0 66,549
Never married 48.5 48,409 42.0 48,187
Insurance
No 14.0 13,916 10.0 11,411
Yes 86.0 85,853 90.0 103,325
Metropolitan area
>1,000,000 45.1 44,955 45.1 51,763
250,000 – 1,000,000 35.3 35,213 35.4 40,568
<250,000 19.7 19,601 19.5 22,405
Survey year
2015 19.9 19,828 20.7 23,733
2016 19.9 19,853 19.9 22,772
2017 20.0 19,987 19.7 22,567
2018 20.2 20,169 19.9 22,857
2019 20.0 19,932 19.9 22,807
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Table 2.

Prevalence of lifetime drug use and the current sexual identity among adults in the United States, 2015–2019.

Global weighted % (95% CI) Heterosexual men weighted % (95% CI) Gay men weighted % (95% CI) Bisexual men weighted % (95% CI) Heterosexual women weighted % (95% CI) Lesbian women weighted % (95% CI) Bisexual women weighted % (95% CI)
Marijuana 48.5 (48.1–48.9) 52.6 (52.1–53.1) 71.8 (68.6–74.8) 60.2 (56.4–63.8) 42.4 (41.9–42.9) 69.6 (66.4–72.7) 71.6 (70.2–73.0)
Cocaine 16.3 (16.1–16.6) 19.9 (19.5–20.3) 32.8 (29.8–36.1) 26.9 (23.6–30.5) 11.9 (11.5–12.2) 22.4 (19.5–25.5) 26.0 (24.5–27.6)
Inhalants 9.3 (9.1–9.5) 11.4 (11.1–11.7) 41.3 (37.9–44.8) 24.6 (21.9–27.4) 5.9 (05.7–06.0) 15.4 (13.0–18.3) 17.5 (16.6–18.4)
Ecstasy 45.2 (44.6–45.9) 42.2 (41.4–43.3) 65.8 (59.7–71.5) 51.3 (46.3–56.2) 45.2 (44.0–46.4) 53.3 (45.7–60.9) 67.5 (64.6–70.3)
Methamphetamine 6.1 (5.9–06.2) 7.4 (7.1–07.6) 13.4 (11.3–15.8) 11.7 (9.52–14.3) 4.4 (4.2–04.5) 8.1 (06.5–09.9) 11.8 (10.8–12.9)
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Note: Differences among sexual orientations within each drug examined were all p < .001.

CI, Confidence interval.

Table 3.

Mean age at the first drug use according to the current sexual identity among adults in the United States, 2015–2019.

Total (N = 210,392) Mean (SD), Median Heterosexual men (N = 93,506) Mean (SD), Median Gay men (N = 2348) Mean (SD), Median Bisexual men (N = 2350) Mean (SD), Median Heterosexual women (N = 101,879) Mean (SD), Median Lesbian women (N = 2,292) Mean (SD), Median Bisexual Women (N = 8,017) Mean (SD), Median
Marijuana 18.2 (5.9), 17 17.8 (5.3), 17 20.0 (6.7), 17 18.1 (7.0), 18 18.8 (6.5), 17 18.4 (7.0), 17 17.0 (6.3), 16
Cocaine 21.7 (5.9), 20 21.6 (5.5), 20 23.0 (5.4), 21 22.1 (9.6), 22 21.9 (6.1), 20 21.7 (6.4), 20 20.1 (6.2), 19
Inhalants 17.7 (5.8), 16 17.5 (5.0), 17 21.8 (7.1), 17 19.1 (8.7), 21 17.5 (5.8), 18 17.7 (6.6), 17 16.6 (7.0), 16
Ecstasy 21.9 (6.3), 20 22.0 (6.0), 20 25.2 (7.0), 20 21.6 (5.8), 23 21.9 (6.6), 20 21.5 (6.8), 20 20.4 (5.9), 19
Methamphetamine 22.1 (7.6), 20 22.3 (7.2), 20 25.7 (8.3), 20 22.7 (8.1), 23 21.8 (7.7), 20 20.6 (8.4), 19 20.4 (7.6), 19
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SD, Standard deviation.

Table 4 presents the results of unadjusted and multivariable models according to the sexual identity and sex. IRRs in the unadjusted bivariate models suggest that gay men were more likely to report later initiation of marijuana, cocaine, ecstasy, and methamphetamine than heterosexual men, while bisexual women were more likely to report the earlier initiation of all drugs examined compared to heterosexual women. In multivariate models, compared to heterosexual men, gay men were more likely to report a later onset of initiation of marijuana (aIRR = 1.13, 95% CI: 1.10–1.15), cocaine (aIRR = 1.06, 95% CI: 1.03–1.09), inhalants (aIRR = 1.20, 95% CI: 1.15–1.25), ecstasy (aIRR = 1.08, 95% CI: 1.03–1.12), and methamphetamine (aIRR = 1.17, 95% CI: 1.09–1.26). Bisexual men were more likely to report a later onset of initiation of marijuana (aIRR = 1.04, 95% CI: 1.00–1.08) and inhalants (aIRR = 1.10, 95% CI: 1.02–1.18) in comparison to heterosexual men.

Table 4.

Associations between the current sexual identity and age at the first drug use among adults in the United States, 2015–2019.

Males Marijuana Cocaine Inhalants Ecstasy Methamphetamine
IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI
Heterosexual men 1.00 1.00 1.00 1.00 1.00
Gay men
Unadjusted 1.12 (1.09–1.15)c 1.01 (1.03–1.09)c 0.79 (0.55–1.14) 1.14 (1.08–1.21)c 1.15 (1.06–1.24)c
Adjusted 1.13 (1.10–1.15)c 1.06 (1.03–1.09)c 1.20 (1.15–1.25)c 1.08 (1.03–1.12)c 1.17 (1.09–1.26)c
Bisexual men
Unadjusted 1.01 (0.97–1.06) 1.02 (0.94–1.10) 0.79 (0.55–1.14) 0.98 (0.94–1.21) 1.01 (0.94–1.09)
Adjusted 1.04 (1.00–1.08)a 1.04 (0.97–1.10) 1.10 (1.02–1.18)b 1.01 (0.97–1.04) 1.04 (0.97–1.12)
Females Marijuana Cocaine Inhalants Ecstasy Methamphetamine
IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI
Heterosexual women 1.00 1.00 1.00 1.00 1.00
Lesbian women
Unadjusted 0.98 (0.95–1.01) 0.98 (0.94–1.03) 0.69 (0.44–1.10) 0.99 (0.94–1.03) 0.94 (0.84–1.04)
Adjusted 1.00 (0.97–1.04) 1.00 (0.96–1.03) 0.99 (0.93–1.06) 1.00 (0.95–1.05) 0.97 (0.89–1.06)
Bisexual women
Unadjusted 0.90 (0.89–0.91)c 0.91 (0.90–0.92)c 0.62 (0.47–1.10)c 0.93 (0.91–0.95)c 0.93 (0.90–0.96)c
Adjusted 0.97 (0.96–0.98)c 0.97 (0.96–0.99)c 1.00 (0.97–1.04) 0.98 (0.96–0.99)b 1.00 (0.96–1.04)
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Note: estimates are based from 10 separate sex-stratified models. Multivariable adjusted models are controlled for survey year, current age group, race/ethnicity, education, annual family income, marital status, insurance status, size of metropolitan area.

IRR, Incident Risk Ratio; CI, Confidence interval.

a

p < .05.

b

p < .01.

c

p < .001.

In comparison to heterosexual women, bisexual women were more likely to report an earlier onset of drug use for following drugs examined: marijuana (aIRR = 0.97, 95% CI: 0.96–0.98), cocaine (aIRR = 0.97, 95% CI: 0.96–0.99), and ecstasy (aIRR = 0.98, 95% CI: 0.96–1.00). We found no significant results for lesbian women regarding the earlier onset of drug use when compared to heterosexual women.

Table 5 presents associations between the current sexual identity and an early substance use initiation (≤14 years old). Results suggest that gay men had lower odds of reporting an early substance use initiation of marijuana, cocaine, inhalants, and methamphetamine, while bisexual men had higher odds of reporting an early substance use initiation of cocaine, in comparison to heterosexual men. Lesbian and bisexual women had higher odds of reporting an early substance use initiation of marijuana, cocaine, and ecstasy in comparison to heterosexual women. In the multivariate models, compared to heterosexual men, gay men had lower odds of reporting an early initiation of marijuana (aOR = 0.53, 95% CI: 0.43–0.66), inhalants (aOR= 0.58, 95% CI: 0.44–0.77), and methamphetamine (aOR = 0.22, 95% CI: 0.07–0.69). Bisexual men were more likely to report an early initiation of cocaine (aOR = 2.00, 95% CI: 1.10–3.62). Compared to heterosexual women, lesbian women were at higher odds of reporting an early substance use initiation of marijuana (aOR = 1.28, 95% CI: 1.08–1.46), cocaine (aOR = 1.89, 95% CI: 1.06–3.37), and ecstasy (aOR = 4.63, 95% CI: 2.06–10.39). Finally, bisexual women were more likely to report an early initiation of marijuana (aOR = 1.88, 95% CI: 1.72–2.05), cocaine (aOR= 2.02, 95% CI: 1.46–2.79), and ecstasy (aOR = 2.00, 95% CI: 1.32–3.02).

Table 5.

Associations between the current sexual identity and early substance use initiation among adults in the United States, 2015–2019.

Males Marijuana Cocaine Inhalants Ecstasy Methamphetamine
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Heterosexual men 1.00 1.00 1.00 1.00 1.00
Gay men
Unadjusted 0.51 (0.41–0.64)c 0.79 (0.38–1.61)c 0.52 (0.39–0.69)c 0.30 (0.08–1.10) 0.23 (0.07–0.71)a
Adjusted 0.53 (0.43–0.66)c 0.95 (0.45–2.04) 0.58 (0.44–0.77)c 0.47 (0.13–1.70) 0.22 (0.07–0.69)b
Bisexual men
Unadjusted 1.11 (0.88–1.40) 1.99 (1.11–3.55)a 1.15 (0.82–1.62) 1.15 (0.56–2.37) 1.30 (0.49–3.44)
Adjusted 1.01 (0.80–1.28) 2.00 (1.10–3.62)b 1.08 (0.78–1.51) 0.99 (0.47–2.07) 1.12 (0.42–3.00)
Females Marijuana Cocaine Inhalants Ecstasy Methamphetamine
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Heterosexual women 1.00 1.00 1.00 1.00 1.00
Lesbian Women
Unadjusted 1.32 (1.14–1.53)c 1.96 (1.05–3.63)b 1.20 (0.85–1.70) 4.93 (2.29–10.58)c 1.57 (0.82–2.99)
Adjusted 1.28 (1.08–1.46)c 1.89 (1.06–3.37)b 1.25 (0.89–1.76) 4.63 (2.06–10.39)c 1.50 (0.79–2.82)
Bisexual women
Unadjusted 2.34 (2.16–2.55)c 2.75 (1.99–3.79)c 1.45 (0.85–1.70) 2.80 (2.29–10.5)c 1.57 (1.12–2.99)a
Adjusted 1.88 (1.72–2.05)c 2.02 (1.46–2.79)c 1.24 (0.99–1.56) 2.00 (1.32–3.02)c 1.38 (0.96–1.99)
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Note. Early substance use initiation is defined as age at the first use before or when 14 years old. Estimates are based from 10 separate sex-stratified models. Multivariable adjusted models are controlled for survey year, current age group, race/ethnicity, education, annual family income, marital status, insurance status, size of metropolitan area.

OR, Odd Ratios; CI, confidence interval.

a

p < .05.

b

p < .01.

c

p < .001.

Discussion

Many studies suggest that prevalence of substance use is higher among LGB persons compared to heterosexual individuals (Caputi, 2018; Caputi et al., 2018; Kelly et al., 2006; Kerr et al., 2014; Parsons et al., 2006); however, research was needed to determine whether sexual identity is associated with retrospectively reported age at the first drug use. To our knowledge, this is the first study to examine the associations between sexual identity and age at the first use of marijuana, cocaine, inhalants, ecstasy, and methamphetamine among a nationally representative sample of noninstitutionalized adults in the United States.

Results suggest that bisexual women were more likely to have an earlier onset of use of marijuana, cocaine, and ecstasy when compared to heterosexual women. Similarly, we found that bisexual women were more likely than their heterosexual counterparts to report initiation prior to age 15 for marijuana, cocaine, and ecstasy. These findings add to the previously documented disparity in substance use, substance use disorder, and risk factors between bisexual and heterosexual women. For example, findings by Schuler et al. (2022) suggest that bisexual women were at greater risk of the use of inhalants, hallucinogen, methamphetamine, and cocaine in the past year when compared to heterosexual women. Similar results have been reported by Caputi (2018) in which adolescent bisexual females were at greater risk of lifetime illegal substance use when compared to adolescent heterosexual females.

The differences between bisexual and heterosexual women in the prevalence of an early substance use initiation could be explained by unique minority stressors experienced by bisexual women. According to the minority stress theory, LGB individuals often experience an elevated risk of social stress from the broader community (Meyer, 2003; Roxburgh et al., 2016). Additionally, bisexual individuals can experience negative attitudes toward their sexual identity from heterosexual and gay/lesbian individuals (Feinstein & Dyar, 2017), whether because of the belief that many bisexual individuals are promiscuous (Brewster & Moradi, 2010), or that bisexuality is not a legitimate identity (Feinstein & Dyar, 2017). These negative attitudes may render bisexual identity invisible to some others (Mohr et al., 2017; Schuler et al., 2018) and may contribute in explaining early drug onset between bisexual women and heterosexual women. Multiple minority stressors experienced by sexual minority women (Lehavot & Simoni, 2011), based on gender and sexual identity simultaneously, and may heighten risk for substance use initiation. Similar to bisexual women, our results show those lesbian women are at risk of early substance use initiation prior to age 15 when compared to heterosexual women. While lesbian women have shown the similar substance use profiles as heterosexual women in terms of age at the first use, they are also shown to be a high-risk group for early initiation. Therefore, our results highlight a need for the future research to examine how variability in bisexual and lesbian identity development for women, when compared to other sexual minority identities and sexes, predicts age at the first drug use and an early substance use initiation. Likewise, the future prevention efforts should consider targeting younger sexual minority women, in particular, as early substance use initiation is one of the common and main predictors of substance use disorders later in adulthood (Trujillo et al., 2019).

Gay men had the highest prevalence of lifetime use of each drug examined; however, we found that gay men were actually more likely to have a later onset of marijuana, ecstasy, cocaine, methamphetamine, and inhalant use when compared to heterosexual men. An abundance of literature suggests that gay men are more likely to use various club drugs in particular. For example, findings by Griffin et al. (2020) suggest that gay men were at higher risk for the use of ecstasy, GHB, and methamphetamine, when compared to heterosexual men. However, our results partly corroborate the findings of Roxburgh et al. (2016), that heterosexual men were more likely to initiate methamphetamine use at a significantly younger age when compared to gay and bisexual men.

These results together with our findings may possibly be driven, in part, by distinctive identity development of gay men during early adolescence. On the one hand, it is possible that gay men are able to develop a sense of community easier than bisexual women (Fingerhut et al., 2010; Herek, 2004). This phenomenon is similar to the earlier generations of gay men’s developed sense of community during the initial years of HIV epidemic which shapes the understanding of gay community among men today. As in Wilkinson et al.’s (2012) study, which showed that the elective relationships among gay men were associated with great loyalty, a desire to help, a readiness to listen, and commitment to the relationships, we suggest that developing a sense of community early on may also be a protective factor against early onset of substance use. On the other hand, studies suggest that club drug use is more common among men who identify as gay (Griffin et al., 2020), who have more sexual partners, and have who have recently visited gay venues or clubs (Petersson et al., 2016). Similarly, community attachment for gay men has been directly linked with substance use (Carpiano et al., 2011; Moody et al., 2018) while minority stressors, such as internalized homonegativity (Berg et al., 2013), can hinder the gay men’s connection to the gay community (Goldbach et al., 2015; Moody et al., 2018). However, they may actually initiate substance use later than heterosexual men, in part, due to connections with gay communities often not occurring until a later age. This could mean that gay men may not have particularly elevated substance use risk in early adolescence because they may develop this community connection by the time they are allowed to legally visit gay venues or clubs (e.g., reaching the age 21 which is the typical age requirement to enter such venues).

Bisexual men, similar to gay men, were more likely to report older age of first use of marijuana and inhalants. However, bisexual men were at greater risk of initiation of cocaine prior to age 15. This difference could be due to the similar social risk factors in adulthood but different risk profiles in adolescence experienced by gay and bisexual men. As abovementioned, unique minority stressors experienced by bisexual individuals can contribute to an early substance use initiation of bisexual men. Similarly, in adulthood, gay and bisexual men may have more similar types of gay community connection and attendance of the similar venues, which can influence the social risk factors of substance use. Further research is needed to better understand the relationship between age at the first drug use and drug use prevalence among gay and bisexual men, and the possible effect of gay community connection on this relationship.

The current findings have important implications for substance use prevention efforts especially targeting LGB individuals. In the recent poll of 15,349 adults living in the United States, it was shown that there are generational differences in identifying as lesbian, gay, bisexual, or trans (LGBT), and those who identified as something other than heterosexual was more prevalent in younger generations (Jones, 2021). According to the estimates, 15.9% of those who were born between 1997 and 2002 identified as LGBT, while only 9.1% of those who were born between 1981 and 1996 identified as LGBT. In addition to the pronounced generational differences, women (4.3%), more so than men (1.8%), were more likely to identify as bisexual. Given this reported prevalence and the particular risk of an earlier onset of drug use for bisexual and lesbian women, it is critical for prevention and harm reduction efforts to be targeted toward younger LGB individuals. Lastly, our results inform the future studies on the LGB population. As the previous research has shown, the intersection of LGB and racial/ethnic identity can influence disparities in substance use (Schuler et al., 2020); therefore, the future research is needed to focus on racial/ethnic identities of LGB individuals when examining early substance use initiation. Future studies should collect longitudinal data to further examine such associations as sexual identity can shift over time (Katz-Wise et al., 2017; Mock & Eibach, 2012). Similarly, the future research should focus on LBG identity development as a predictor of age at the first drug use to further explain the disparity across sexual identities.

Limitations

Our study has its limitations. Firstly, NSDUH is a self-reported survey and self-reported responses are susceptible to limited recall and social desirability bias. Secondly, another limitation to our study is that NSDUH does not ask whether the participants are transgender, which studies increasingly show that is a factor in determining health-related disparities. Thirdly, sexual orientation can shift over time and future studies should determine the associations between sexual orientation and age at the first drug use using longitudinal data. Similarly, the cross-sectional design of this study does not allow us to infer causality between variables. Finally, NSDUH only samples noninstitutionalized U.S. population and thus adults who live in long-term care, individuals experiencing homelessness, and incarcerated are underrepresented.

Conclusion

Bisexual and lesbian women are at heightened risk of having an early onset of use of substances when compared to heterosexual women. Similarly, bisexual men are at greater risk of substance use at a younger age than heterosexual men. These differences possibly exist due to unique minority stressed experienced by sexual minority individuals. These findings highlight the need to target younger LGB populations in prevention efforts.

Acknowledgments

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R01DA044207.

Footnotes

Disclosure statement

The authors have no other potential conflicts to declare.

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