Abstract
Most research on sexual orientation and alcohol use in the United States has found higher rates of alcohol use and abuse among gay men and lesbians. Studies from other countries have found smaller or no differences between sexual minority and heterosexual women and men. The present study used general population survey data from 14 countries to examine high-volume and risky single-occasion drinking by sexual orientation. Data from 248 gay men and lesbians and 3,720 heterosexuals were analyzed in a case-control design. In several countries partnered or recently partnered gay men and lesbians had no greater risk of heavy drinking or engaging in heavy drinking than heterosexual controls. Only lesbians in North America showed higher risk for both indicators. Future general population health research should include larger samples of gays and lesbians and use more comprehensive measures of sexual orientation for investigating the prevalence of health risk factors.
Keywords: homosexuality, alcohol drinking, risky drinking, international comparisons, gay, lesbian
Introduction
Research on sexual orientation and alcohol use has been conducted mostly in the United States (USA) where heavy drinking is perceived to be a serious problem among sexual minority men and women. Possible explanations for this apparent heightened risk are stress related to societal stigma and the reliance on bars or other heavy drinking venues as a primary outlet for socialization. Early USA studies found high rates of alcohol use and abuse among lesbians and gay men [1–3]. However, methodological limitations, such as small, homogeneous samples (which often overrepresented bar patrons) and lack of heterosexual comparison groups, raised questions about the validity of these findings.
Later USA research has found overall lower rates of heavy drinking than in earlier studies [4–8]. Nonetheless, these as well as results from more recent studies based on large general population samples [5, 6, 8–15] continue to indicate that, compared with heterosexuals, lesbians and gay men are likely to drink larger amounts and to report more alcohol-related problems. Moreover, these differences are substantially larger between sexual minority and heterosexual women than are differences between sexual minority and heterosexual men [5, 12, 13, 15].
Studies outside the USA include research in England and Wales [16, 17], Europe [18–21], Australia [22–24] and New Zealand [25]. Most of these have found smaller or no differences between sexual minority and heterosexual women and men. This is particularly true for men. However, in a recent meta-analysis (with 17 of the 25 studies coming from the US), King et al. [26] concluded that the risk of alcohol and other substance dependence in the past 12 months was 50% higher among gays, lesbians and bisexuals in general, with lesbian and bisexual women having an even greater risk.
Acceptance of homosexuality varies greatly internationally and is strongly linked to the centrality of religion and morality. According to the Pew Global Attitudes Project [27], African and Middle Eastern countries object most strongly to homosexuality, but there is far greater tolerance for it in Latin America including Mexico, Argentina, and Brazil. Opinion in Europe is split between West and East. Large majorities in every Western European nation surveyed say homosexuality should be accepted, whereas most Russians, Poles and Ukrainians disagree.
As of 2003 a slight majority of US Americans (51%) agreed that homosexuality should be accepted [27]. However, there is also large variation in attitudes within the country. A recent analysis of the relationship between state-level policies and psychiatric morbidity found that lesbians, gays and bisexuals (LGB) who live in states that do not have protective policies toward sexual minorities (i.e., laws against hate crimes, employment discrimination) have higher risks for alcohol, drug and mental health disorders than do those who live in states with protective policies [28].
Although many new studies employing representative probability samples have compared alcohol use between LGB and heterosexuals in the past 10 years, most knowledge is based on a preponderance of US research. In addition, most previous studies have shown inconclusive results regarding men. The present study extends the knowledge base by examining the prevalence of heavy-volume drinking and risky single-occasion drinking (RSOD) in 14 countries in Europe, Latin America and North America. We hypothesize that (1) gay men and lesbians will have higher rates of heavy drinking and RSOD than heterosexuals; additionally (2) based on the greater acceptance of homosexuality in Europe and Latin America we further hypothesize that these differences will be greatest in North America, followed by Latin America and Europe.
METHODS
Data and measures
The study used data from the project Gender, Alcohol, and Culture: An International Study (GENACIS) which has collected 45 surveys relating to alcohol use in the general population from more than 36 countries. Surveys from 14 of these countries collected comparable data on sexual orientation: Argentina (ARG), Brazil (BRA), Canada (CAN), Costa Rica (CRC), Czech Republic (CZE), Denmark (DEN), Great Britain (GBR), Isle of Man (IOM), New Zealand (NZL), Nicaragua (NCA), Spain (ESP), Sweden (SWE), Uruguay (URU), and the United States (USA). All surveys used in the present study were conducted between 2000 and 2007. Although the common GENACIS questionnaire was employed, and thus comparable measures were used, some differences across the surveys exist regarding sampling frame (regional vs. national), age range of samples (mostly 18+), and modes of administration. For more information about data collection and development of the GENACIS questionnaire, see Wilsnack et al.[29].
All relevant ethical guidelines for protection of human subjects were followed. Individual country surveys were reviewed according to procedures created to protect research participants in their countries. The overall GENACIS project was reviewed and approved by the Institutional Review Board of the University of North Dakota.
In this paper we focus on sexual orientation comparisons for two dichotomous drinking outcome variables: ”high-volume drinking” was coded according to the World Health Organization guidelines (WHO, 2000) if average consumption exceeded 20 grams pure alcohol per day for women and 30 grams for men; “risky single-occasion drinking” (RSOD) (also known as heavy episodic or binge drinking) was coded if monthly or more frequent episodes of consuming high quantities of alcohol were reported (most countries used a cut-off of 60 grams; exceptions were CAN (68g), SWE (72g), DEN (75g) and CZE (90g)). Three countries (IOM, ESP and UK) did not include a question concerning RSOD in their questionnaire.
The present analysis is based solely on respondents who had a romantic partner either currently or within the past 12 months. Respondents’ “sexual orientation” was then based on the romantic partner’s gender: for purposes of these analyses, participants with a partner of the same gender were considered as ‘probable’ gay or lesbian (GL) whereas participants with a partner of the opposite gender were considered heterosexual (H) and were used as the reference group. At the time of data collection (2000–2007), a few countries (e.g., Denmark, Sweden and Argentina) legally recognized civil partnerships and only very few provinces/states in Canada and the USA allowed same-gender marriages. Therefore respondents who reported being married were not asked about their romantic partner’s gender, but were directly coded as heterosexual. Respondents who were not married at the time of the study and did not report having been in a romantic relationship during the 12 months preceding the interview were not included in the present study.
Four demographic factors that have been shown to be associated with volume of alcohol consumption and frequency of RSOD were controlled for: gender, age (continuous variable), education (recoded into low, middle, and high education level according to a GENACIS adaptation of the ISCED-97[30]), and domicile (for most countries three categories, “rural” to “metropolitan,” were used; CRC and URU had only two categories; for BRA, CAN, GBR, and NCA no information about domicile was collected).
The full GENACIS samples for the 14 countries consist of 34,270 respondents; 71% (24,325) of them were currently or in the past year in a romantic relationship. In total 248 respondents were coded as GL. Together with 15 controls per case the sample analyzed in the present study consisted of 3,968 individuals.
Statistical analysis
Because the prevalence of gay or lesbian persons is relatively low as measured by general population surveys, we employed a case-control design in order to analyze the data as efficiently as possible. For each gay or lesbian respondent (“case”), 15 heterosexual respondents (“controls”) who also had been in a romantic relationship either currently or within the past 12 months were selected. These were exactly matched on country and gender, and propensity score matching on age, education and domicile was used through the matched-group-variable method [31, 32]. Conditional logistic regression models were used to regress alcohol consumption (high-volume drinking and RSOD) on sexual orientation stratified by country and gender. Because cases and controls were matched on age, education and domicile, these potentially confounding variables did not have to be adjusted for. Conditional logistic regression-fitted models are appropriate for the matching design in that they use the true conditional likelihood and not an approximation of it; parameters can be interpreted as those of a logistic regression [31]. Besides analyses stratified by country and gender, the models were estimated for the total sample and for pooled samples within regions (e.g., “Europe”). In these models countries were included as dummy-coded variables. In some countries the dependent variable was constant among GL, therefore these regression models could not be estimated for the specific country. For example, because all lesbians in the Czech Republic drank at low volume, the odds for this subsample cannot be estimated (numerator would be 0), and therefore also no ratio of the odds could be calculated. In such cases countries’ data could nonetheless be included in the pooled analyses for regions. Data preparation and analysis were carried out using the Stata 9.1 statistical software package [32].
Due to differences in sizes of matched case-samples across countries (ranging from n=64 in URU to n=1440 in CAN), the present study focused not only on the significance of findings, but also on general trends across surveys. In this way, we follow Rothman [33] who argues that if the same patterns of findings across different surveys can be demonstrated, even if findings are not significant for all countries, these provide stronger evidence than only reporting significant findings, which often depend on sample size.
RESULTS
Descriptive information by gender and region for the 14 countries is presented in Table 1. A total of 122 lesbians and 126 gay men were counted across the samples and compared with matched controls, totaling 1,830 heterosexual women and 1,890 heterosexual men. Among the total of all countries, a lower percentage of lesbians reported high-volume drinking and having engaged in RSOD. There was no difference in the total prevalence of high-volume drinking among men; gay men had a slightly higher prevalence of RSOD. However, these percentages varied by region and country. The prevalence of high-volume drinking was higher among GL in some European countries, North America and New Zealand, but generally not (with the exception of Uruguay) in Latin America. Due to the limited number of country surveys measuring RSOD in Europe and its low frequency in Latin America, no identifiable geographic pattern was discernable. In North America GL had higher rates of RSOD, whereas in New Zealand higher rates were found only among lesbians.
Table 1.
Description of sample, high-volume drinking and risky single-occasion drinking
| women | men | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| sample | high-volume | RSOD | sample | high-volume | RSOD | |||||||
| nL | nH matched | %L | %H matched | %L | %H matched | nG | nH matched | %G | %H matched | %G | %H matched | |
| Europe | ||||||||||||
| Czech Republic | 4 | 60 | .00 | .05 | .00 | .07 | 8 | 120 | .00 | .29 | .00 | .29 |
| Denmark | 3 | 45 | .33 | .11 | .67 | .16 | 3 | 45 | .33 | .36 | .33 | .58 |
| Isle of Man | 5 | 75 | .20 | .09 | ---a) | ---a) | 1 | 15 | .00 | .27 | ---a) | ---a) |
| Spain | 9 | 135 | .00 | .07 | ---a) | ---a) | 8 | 120 | .13 | .12 | ---a) | ---a) |
| Sweden | 2 | 30 | .00 | .00 | .00 | .00 | 2 | 30 | .50 | .10 | .50 | .43 |
| UK | 18 | 270 | .11 | .11 | ---a) | ---a) | 14 | 210 | .36 | .17 | ---a) | ---a) |
| North America | ||||||||||||
| Canada | 39 | 585 | .18 | .08 | .15 | .14 | 51 | 765 | .10 | .10 | .37 | .31 |
| USA | 12 | 180 | .25 | .04 | .56 | .10 | ---b) | ---b) | ---b) | ---b) | ---b) | ---b) |
| Latin America | ||||||||||||
| Argentina | 1 | 15 | .00 | .00 | 1.00 | .00 | 3 | 45 | .00 | .11 | .33 | .27 |
| Brazil | 2 | 30 | .00 | .00 | .00 | .00 | 3 | 45 | .00 | .18 | .00 | .11 |
| Costa Rica | 6 | 90 | .00 | .01 | .00 | .04 | 12 | 180 | .08 | .06 | .17 | .14 |
| Nicaragua | 11 | 165 | .00 | .05 | .18 | .07 | 12 | 180 | .00 | .06 | .08 | .24 |
| Uruguay | 1 | 15 | 1.00 | .07 | 1.00 | .00 | 3 | 45 | .33 | .16 | .33 | .27 |
| Australasia | ||||||||||||
| New Zealand | 9 | 135 | .11 | .04 | .33 | .14 | 6 | 90 | .33 | .17 | .33 | .39 |
| total | ||||||||||||
| all countries | 122 | 1830 | .13 | .07 | .23 | .11 | 126 | 1890 | .13 | .13 | .27 | .29 |
Remarks: G,L = gay men/lesbian in a romantic relationship, H = heterosexual men/women in a romantic relationship, matched = subsample of heterosexual women/men matched on age, education and domicile, f = female, m = male; in SWE respondents co-habiting with their partner, have not been asked about their romantic partner’s gender and were not included in the analysis,
= no question about RSOD was included in the questionnaire,
=USA-sample does not include male participants.
Table 2 shows the odds ratios for GL to be high-volume drinkers as estimated in the gender-specific, conditional logistic regression models. In Europe there is no significant difference in high-volume drinking between lesbians and heterosexual women. The same is true among men; however, gay men in Great Britain showed a borderline tendency to be high-volume drinkers. Among women in North America lesbians had a significantly greater likelihood of being heavy-volume drinkers; this was not the case among men. In Latin America the models could not be estimated for women because within the separate countries lesbians were either all non-heavy drinkers or all heavy drinkers. Only for Costa Rica and Uruguay could differences among men be examined, but these were not significant. Likewise in New Zealand the number of cases was too small to find significant differences, although the tendency was for higher risk among lesbians and gay men. In the total pooled sample, there was a statistically significant difference between lesbians and heterosexual women with regard to high-volume drinking. This was primarily due to differences found in the North American and New Zealand samples. Gay men showed no greater risk.
Table 2.
Estimated odds ratios for GL to be high-volume drinkers (20/30+g per day), (conditional logistic regression, reference = Hmatched)
| women | men | |||||
|---|---|---|---|---|---|---|
| OR | SE | p | OR | SE | p | |
| Europe | ||||||
| Czech Republic | ---a) | ---a) | ||||
| Denmark | 2.58 | 3.22 | .448 | .89 | 1.12 | .929 |
| Isle of Man | 4.42 | 6.36 | .303 | ---a) | ||
| Spain | ---a) | 1.04 | 1.15 | .968 | ||
| Sweden | ---a) | 5.92 | 8.40 | .210 | ||
| UK | 1.04 | .81 | .960 | 3.32 | 2.07 | .055+ |
| Europe (pooled) | 1.09 | .61 | .878 | 1.08 | .47 | .864 |
| North America | ||||||
| Canada | 2.81 | 1.27 | .022* | 1.03 | .51 | .950 |
| USA | 9.81 | 8.35 | .007** | ---c) | ||
| North America (pooled) | 3.57 | 1.39 | .001** | 1.03 | .51 | .950 |
| Latin America | ||||||
| Argentina | ---a) | ---a) | ||||
| Brazil | ---a) | ---a) | ||||
| Costa Rica | ---a) | .66 | .76 | .715 | ||
| Nicaragua | ---a) | ---a) | ||||
| Uruguay | ---b) | 2.75 | 3.99 | .485 | ||
| Latin America (pooled) | --- | --- | --- | .37 | .30 | .226 |
| Australasia | ||||||
| New Zealand | 2.29 | 2.57 | .462 | 6.44 | 7.03 | .088+ |
| all countries | ||||||
| total (pooled) | 2.21 | .65 | .008** | 1.03 | .29 | .924 |
Remarks: ”---” = model could not be estimated, as dependent variable for subgroup is constant or there are too few cases;
= all GL consume alcohol at a low risk level (≤20/30 g per day);
= all GL consume alcohol at a high risk level (>20/30 g per day);
= sample does not include male participants;
p ≤ 0.10,
p ≤ 0.05,
p ≤ 0.01
Results of logistic regression models for RSOD are presented for countries where this measure was included (Table 3). In Europe only models based on the pooled data sets can be interpreted reasonably, as sample sizes are very small or GL lack variance in RSOD. Although the effects are nonsignificant, they point towards an increased risk among lesbians and a somewhat lower risk for gay men compared to heterosexuals. In North America lesbians had a higher likelihood of RSOD than heterosexual women, especially in the US sample. Gay and heterosexual men in Canada did not differ on RSOD. In Latin America the lack of variance in RSOD among lesbians made country-specific and pooled estimates impossible. For Latin American men there were no statistically significant differences in RSOD by sexual orientation. Also in New Zealand differences by sexual orientation were not statistically significant. When pooling all countries, the difference in RSOD by sexual orientation among women persisted, carried mainly by the US sample; a similar, but nonsignificant effect could be consistently found in the other countries. However, the total pooled estimate for men and the lack of a consistent pattern across countries suggests there is no difference in risk of RSOD between gay and heterosexual men.
Table 3.
Estimated odds ratios for GL to be binge drinkers (RSOD), (conditional logistic regression, reference = Hmatched)
| women | men | |||||
|---|---|---|---|---|---|---|
| OR | SE | p | OR | SE | p | |
| Europe | ||||||
| Czech Republic | ---a) | ---a) | ||||
| Denmark | ---a) | .46 | .57 | .529 | ||
| Sweden | ---a) | 1.00 | 1.41 | 1.000 | ||
| Europe (pooled) | 4.49 | 4.39 | .125 | .29 | .23 | .122 |
| North America | ||||||
| Canada | 1.18 | .56 | .723 | 1.33 | .42 | .360 |
| USA | 23.64 | 26.81 | .005** | ---c) | ||
| North America (pooled) | 2.12 | .81 | .050+ | 1.33 | .42 | .360 |
| Latin America | ||||||
| Argentina | ---b) | 1.73 | 2.94 | .746 | ||
| Brazil | ---a) | ---a) | ||||
| Costa Rica | ---a) | .47 | .52 | .498 | ||
| Nicaragua | 2.98 | 2.59 | .208 | .25 | .28 | .206 |
| Uruguay | ---b) | 1.58 | 2.35 | .758 | ||
| Latin America (pooled) | 2.80 | 2.12 | .174 | .61 | .32 | .355 |
| Australasia | ||||||
| New Zealand | 2.89 | 2.12 | .148 | .37 | .48 | .440 |
| all countries | ||||||
| total (pooled) | 2.51 | .74 | .002** | .89 | .22 | .636 |
Remarks: ”---” = model could not be estimated, as dependent variable for subgroup is constant or there are too few cases;
= no GL is a ”risky single-occasion drinker”;
= all GL are ”risky single-occasion drinkers”;
= sample does not include male participants;
p ≤ 0.10,
p ≤ 0.05,
p ≤ 0.01
DISCUSSION
The current study examined whether, from an international perspective, lesbians and gay men are at greater risk for high-volume drinking and for risky single-occasion drinking compared with their heterosexual counterparts. In general there were few statistically significant differences in these drinking measures based on sexual orientation. Among the countries in the European region, gay men and heterosexual men tended to drink similarly. The same was true among European women for high-volume drinking, whereas there were too few cases of RSOD among lesbians for comparative purposes. In North America lesbians were significantly more likely to drink heavily and in a risky fashion compared to heterosexual women, whereas no differences were found among (Canadian) men. In Latin America lesbians had a low prevalence of high-volume drinking and too few cases of RSOD for comparisons. Latin American gay men showed no increased risk on either drinking measure. Finally, in New Zealand no statistically significant differences based on sexual orientation were evident. The total pooled results pointed to greater risk of high-volume drinking and RSOD only among lesbians in North America.
The outcomes of the study confirm limited previous international research on sexual orientation and drinking; namely, that previous concerns about heavy and high-risk drinking tend to be based more on lesbians’ experiences and on North American research. Studies from other countries have shown smaller differences and often no differences among men. Our new data from non-American countries support this general pattern.
These findings suggest that it might be time to revise general beliefs about excessive drinking among gay men and lesbians. Further, they indicate that levels and patterns of drinking among sexual minority groups vary substantially across regions of the world. If the hypothesis is correct that stressors associated with stigma and discrimination lead gay men and lesbians to drink more as a way of coping, then more tolerant public attitudes toward gay men and lesbians in Europe and Latin America are consistent with our results of no increased rates of heavy drinking among gays/lesbians in those regions.
Furthermore, our results showing heavier and riskier drinking among lesbians in North America, but not among North American gay men or among lesbians and gay men in other regions of the world, suggest that stressors related to minority sexual orientation may differentially affect women and men and that cultural attitudes and governmental policies may mitigate such stressors. As Hatzenbuehler and colleagues’ [28] results show for the US federal states, policies that protect sexual minorities, such as laws against hate crimes and employment discrimination are related to lower rates of alcohol, drug and mental health disorders. Lesbians are targets of discrimination on the basis of both their sexual orientation and their gender [34], and studies indicate that the health impact is magnified among sexual minority respondents reporting multiple forms of discrimination [35, 36]. Therefore it may be that multiple forms of discrimination have synergistic or additive effects and that lesbians in North America are more vulnerable because of their multiple marginalized statuses.
Study Limitations
There are several methodological limitations to the current study. First, the definition of gay/lesbian used in the study is very conservative. Sexual orientation was based only on the gender of the respondent’s current (or recent) romantic partner. Thus, only respondents who were in a romantic relationship (or in a recent relationship) were included in the study. Even after controlling for age, these respondents may differ significantly from respondents who are single. As is known from the general alcohol literature, individuals who are married are less likely to be heavy or problematic drinkers than those who are not married [37]. Thus, the study’s results may underestimate actual differences in the broader gay and lesbian population. Nonetheless, the findings are informative in that they are valid for those respondents who are in relationships or who have recently been in one. Second, the sizes of many gay/lesbian subsamples were too small to calculate reliable estimates. To overcome this limitation, researchers must either over-sample gay/lesbian respondents or draw a much larger overall study sample -- which is often cost-prohibitive. Although limited in the conclusions that can be drawn, the data were analyzed as efficiently as possible by selecting more “controls” per case and running analyses with pooled samples.
Conclusions
In several countries across Europe, Latin America, North America and Australasia partnered or recently partnered gay men and lesbians have no greater risk of being heavy drinkers or engaging in risky drinking than their heterosexual counterparts. Only lesbians in North America showed greater risk for high-volume drinking and risky single-occasion drinking. When possible, future general population alcohol research should strive to include larger samples of gay men and lesbians and more comprehensive measures of sexual orientation.
Acknowledgments
Preparation of this paper was supported by Grant Number R01AA015775 from the National Institute on Alcohol Abuse and Alcoholism/National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Alcohol Abuse and Alcoholism or the National Institutes of Health.
The data used in this paper are from the project, Gender, Alcohol and Culture: An International Study (GENACIS). GENACIS is a collaborative international project affiliated with the Kettil Bruun Society for Social and Epidemiological Research on Alcohol and coordinated by GENACIS partners from the University of North Dakota, Aarhus University, the Alcohol Research Group/Public Health Institute, the Centre for Addiction and Mental Health, the University of Melbourne, and the Swiss Institute for the Prevention of Alcohol and Drug Problems. Support for aspects of the project comes from the World Health Organization, the Quality of Life and Management of Living Resources Program of the European Commission (Concerted Action QLG4-CT-2001-0196), the U.S. National Institute on Alcohol Abuse and Alcoholism/National Institutes of Health (Grants R21 AA012941 and R01 AA015775), the German Federal Ministry of Health, the Pan American Health Organization, and Swiss national funds. Support for individual country surveys was provided by government agencies and other national sources.
The study leaders and funding sources for data sets used in this report are: Argentina, Myriam Munné, World Health Organization; Brazil, Florence Kerr-Correa, Foundation for the Support of Sao Paulo State Research (Fundação de Amparo a Pesquisa do Estado de São Paulo, FAPESP) (Grant 01/03150-6); Canada, Kathryn Graham, Canadian Institutes of Health Research (CIHR); Costa Rica, Julio Bejarano, World Health Organization; Czech Republic, Ladislav Csémy, Ministry of Health grant MZ23572; Denmark, Kim Bloomfield, Danish Medical Research Council and Danish Health Insurance Fund; Great Britain, Martin Plant and Moira Plant, Alcohol Education and Research Council, Amsterdam Group, University of West of England; Isle of Man, Martin Plant and Moira Plant, Isle of Man Medical Research Council and University of West of England; New Zealand, Jennie Connor, Otago University Research Grant; Nicaragua, Jose Trinidad Caldera, World Health Organization; Spain, Juan C. Valderrama, Dirección General de Atención a la Dependencia, Conselleria de Sanidad, Generalitat Valenciana; Comisionado do Plan de Galicia sobre Drogas, Conselleria de Sanidade, Xunta de Galicia; Dirección General de Drogodependencias y Servicios Sociales, Gobierno de Cantabria; Sweden, Karin Bergmark, Swedish Ministry of Social Affairs; United States of America, Sharon Wilsnack, National Institute on Alcohol Abuse and Alcoholism/National Institutes of Health (Grant R01 AA004610); Uruguay, Raquel Magri, World Health Organization.
References
- 1.Fifield LH, Latham JD, Phillips C. Alcoholism in the gay community: The price of alieniation, isolation and oppression. Los Angeles: Gay Community Services Center. (GENERIC); 1977. [Google Scholar]
- 2.Morales ES, Graves MA. Substance abuse: Patterns and barriers to treatment for gay men and lesbians in San Francisco. San Francisco: Department of Public Health; 1983. [Google Scholar]
- 3.Saghir MT, Robins E. Male and female homosexuality: A comprehensive investigation. Baltimore: Williams and Wilkins; 1973. [Google Scholar]
- 4.Bloomfield K. A comparison of alcohol consumption between lesbians and heterosexual women in an urban population. Drug Alcohol Depend. 1993;33(3):257–269. doi: 10.1016/0376-8716(93)90112-4. [DOI] [PubMed] [Google Scholar]
- 5.Gruskin EP, Gordon N. Gay/Lesbian sexual orientation increases risk for cigarette smoking and heavy drinking among members of a large Northern California health plan. BMC Public Health. 2006;6:241. doi: 10.1186/1471-2458-6-241. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hughes TL. Lesbians’ drinking patterns: beyond the data. Subst Use Misuse. 2003;38(11–13):1739–1758. doi: 10.1081/ja-120024239. [DOI] [PubMed] [Google Scholar]
- 7.McKirnan DJ, Peterson PL. Alcohol and drug use among homosexual men and women: epidemiology and population characteristics. Addict Behav. 1989;14(5):545–553. doi: 10.1016/0306-4603(89)90075-0. [DOI] [PubMed] [Google Scholar]
- 8.Skinner WF. The prevalence and demographic predictors of illicit and licit drug use among lesbians and gay men. Am J Public Health. 1994;84(8):1307–1310. doi: 10.2105/ajph.84.8.1307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Burgard SA, Cochran SD, Mays VM. Alcohol and tobacco use patterns among heterosexually and homosexually experienced California women. Drug Alcohol Depend. 2005;77(1):61–70. doi: 10.1016/j.drugalcdep.2004.07.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Case P, Austin SB, Hunter DJ, Manson JE, Malspeis S, Willett WC, Spiegelman D. Sexual orientation, health risk factors, and physical functioning in the Nurses’ Health Study II. J Womens Health (Larchmt) 2004;13(9):1033–1047. doi: 10.1089/jwh.2004.13.1033. [DOI] [PubMed] [Google Scholar]
- 11.Cochran SD, Mays VM, Sullivan JG. Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. J Consult Clin Psychol. 2003;71(1):53–61. doi: 10.1037//0022-006x.71.1.53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Drabble L, Midanik LT, Trocki K. Reports of alcohol consumption and alcohol-related problems among homosexual, bisexual and heterosexual respondents: results from the 2000 National Alcohol Survey. J Stud Alcohol. 2005;66(1):111–120. doi: 10.15288/jsa.2005.66.111. [DOI] [PubMed] [Google Scholar]
- 13.Gilman SE, Cochran SD, Mays VM, Hughes M, Ostrow D, Kessler RC. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. Am J Public Health. 2001;91(6):933–939. doi: 10.2105/ajph.91.6.933. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Wilsnack SC, Hughes TL, Johnson TP, Bostwick WB, Szalacha LA, Benson P, Aranda F, Kinnison KE. Drinking and drinking-related problems among heterosexual and sexual minority women. J Stud Alcohol Drugs. 2008;69(1):129–139. doi: 10.15288/jsad.2008.69.129. [DOI] [PubMed] [Google Scholar]
- 15.McCabe SE, Hughes TL, Bostwick WB, West BT, Boyd CJ. Sexual orientation, substance use behaviors and substance dependence in the United States. Addiction. 2009;104(8):1333–1345. doi: 10.1111/j.1360-0443.2009.02596.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.King M, McKeown E, Warner J, Ramsay A, Johnson K, Cort C, Wright L, Blizard R, Davidson O. Mental health and quality of life of gay men and lesbians in England and Wales: controlled, cross-sectional study. Br J Psychiatry. 2003;183:552–558. doi: 10.1192/bjp.183.6.552. [DOI] [PubMed] [Google Scholar]
- 17.Mercer CH, Bailey JV, Johnson AM, Erens B, Wellings K, Fenton KA, Copas AJ. Women who report having sex with women: British national probability data on prevalence, sexual behaviors, and health outcomes. Am J Public Health. 2007;97(6):1126–1133. doi: 10.2105/AJPH.2006.086439. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Bergmark KH. Drinking in the Swedish gay and lesbian community. Drug Alcohol Depend. 1999;56(2):133–143. doi: 10.1016/s0376-8716(99)00026-5. [DOI] [PubMed] [Google Scholar]
- 19.Sandfort TG, de Graaf R, Bijl RV, Schnabel P. Same-sex sexual behavior and psychiatric disorders: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) Arch Gen Psychiatry. 2001;58(1):85–91. doi: 10.1001/archpsyc.58.1.85. [DOI] [PubMed] [Google Scholar]
- 20.Sandfort TG, de Graaf R, Bijl RV. Same-sex sexuality and quality of life: findings from the Netherlands Mental Health Survey and Incidence Study. Arch Sex Behav. 2003;32(1):15–22. doi: 10.1023/a:1021885127560. [DOI] [PubMed] [Google Scholar]
- 21.Sandfort TG, Bakker F, Schellevis FG, Vanwesenbeeck I. Sexual orientation and mental and physical health status: findings from a Dutch population survey. Am J Public Health. 2006;96(6):1119–1125. doi: 10.2105/AJPH.2004.058891. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hillier L, DeVisser R, Kavanaugh A, NcNair R. The association between licit and illicit drug use and sexuality in young Australian women. MJA. 2003;179:326–327. doi: 10.5694/j.1326-5377.2003.tb05562.x. [DOI] [PubMed] [Google Scholar]
- 23.Hughes TL, Szalacha LA, McNair RP. Substance use and mental health disparities: Comparisons across sexual identity groups in a national sample of young Australian women. Soc Sci Med. 2010;71(4):824–831. doi: 10.1016/j.socscimed.2010.05.009. [DOI] [PubMed] [Google Scholar]
- 24.Jorm AF, Korten AE, Rodgers B, Jacomb PA, Christensen H. Sexual orientation and mental health: results from a community survey of young and middle-aged adults. Br J Psychiatry. 2002;180:423–427. doi: 10.1192/bjp.180.5.423. [DOI] [PubMed] [Google Scholar]
- 25.Welch S, Howden-Chapman P, Collings SC. Survey of drug and alcohol use by lesbian women in New Zealand. Addict Behav. 1998;23(4):543–548. doi: 10.1016/s0306-4603(98)00036-7. [DOI] [PubMed] [Google Scholar]
- 26.King M, Semlyen J, Tai SS, Killaspy H, Osborn D, Popelyuk D, Nazareth I. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8:70. doi: 10.1186/1471-244X-8-70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Pew Research Center. Views of a changing world 2003. 2003 http://pewglobal.org/2003/06/03/views-of-a-changing-world-2003/ 15-12-2009. (GENERIC) Ref Type: Electronic Citation.
- 28.Hatzenbuehler ML, Keyes KM, Hasin DS. State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. Am J Public Health. 2009;99(12):2275–2281. doi: 10.2105/AJPH.2008.153510. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wilsnack RW, Wilsnack SC, Kristjanson AF, Vogeltanz-Holm ND, Gmel G. Gender and alcohol consumption: patterns from the multinational GENACIS project. Addiction. 2009;104(9):1487–1500. doi: 10.1111/j.1360-0443.2009.02696.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Bloomfield K, Grittner U, Kramer S, Gmel G. Social inequalities in alcohol consumption and alcohol-related problems in the study countries of the EU concerted action “Gender, Culture and Alcohol Problems: A Multi-national Study”42. Alcohol and Alcoholism. 2006;41:i26–i36. doi: 10.1093/alcalc/agl073. [DOI] [PubMed] [Google Scholar]
- 31.Schlesselman J. Case-Control Studies: Design, Conduct, Analysis. New York: Oxford University Press; 1982. [Google Scholar]
- 32.StataCorp LP. Stata 91. 2005. (GENERIC) Ref Type: Computer Program. [Google Scholar]
- 33.Rothman K. Epidemiology -An Introduction. New York: Oxford University Press; 2002. [Google Scholar]
- 34.Bowleg L, Huang J, Brooks K, Black A, Burkholder G. Triple jeopardy and beyond: Multiple minority stress and resilience among Black lesbians. Journal of Lesbian Studies. 2003;7(4):87–108. doi: 10.1300/J155v07n04_06. [DOI] [PubMed] [Google Scholar]
- 35.McCabe SE, Bostwick WB, Hughes TL, West BT, Boyd CJ. The relationship between discrimination and substance use disorders among lesbian, gay and bisexual adults in the United States. Am J Public Health. 2010;100(10):1946–1952. doi: 10.2105/AJPH.2009.163147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Meyer IH, Schwartz S, Frost DM. Social patterning of stress and coping: Does disadvantaged status confer excess exposure and fewer coping resources? Soc Sci Med. 2008;67:368–379. doi: 10.1016/j.socscimed.2008.03.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Leonard K, Rothbard J. Alcohol and the marriage effect. J Stud Alcohol. 1999;Supplement 13:139–146. doi: 10.15288/jsas.1999.s13.139. [DOI] [PubMed] [Google Scholar]