Recovery among sexual minorities in the united states population: Prevalence, characteristics, quality of life and functioning compared with heterosexual majority
Introduction
Alcohol and other drug (AOD) disorders are a major public health concern in most middle- and high-income countries globally, conferring a prodigious burden of disease, injury, premature mortality, and economic costs (NIDA, 2020, SAMHSA, 2019, WHO, 2018). Sexual minorities [SMs], including adults who identify as lesbian, gay, or bisexual, are overrepresented among the AOD disorder population and suffer higher rates of mental health morbidity and comorbidity (Cochran et al., 2003, Lee et al., 2015). Compared to heterosexuals, SMs are between 50% and 250% more likely to report a psychiatric disorder (Kerridge et al., 2017).
Compared to the majority heterosexual population, SMs report hazardous drinking (Hughes, 2011, Hughes et al., 2014) and experience AOD disorders at significantly higher rates (Boyd et al., 2019, Chaudhry and Reisner, 2019, Cochran et al., 2003, Duncan et al., 2019, Grella et al., 2011, Hughes et al., 2010, Kecojevic et al., 2017, Kecojevic et al., 2012, Kerridge et al., 2017, McCabe et al., 2010, McCabe et al., 2009, McCabe et al., 2019, Mereish and Bradford, 2014, Rosario et al., 2014, Schuler et al., 2018, Valentino, 2020), and are approximately two times more likely to report any past year alcohol use disorder (AUD) or drug use disorder (DUD) (SM AUD, 21.5% and heterosexual AUD, 12.8%; SM DUD, 7.7% and heterosexual DUD, 3.8%; (Boyd et al., 2019)). Also, in terms of severity of disorder, 7.2% of SMs report severe AUD in the past-year, compared to only 2.9% of heterosexuals (Boyd et al., 2019). This increased prevalence of AOD disorders appears to be the case regardless of age—SMs show an approximate doubling of risk compared to heterosexuals in every age group (Han et al., 2020, Peralta et al., 2019).
Conceptually, the increased risk for AOD disorders and other psychiatric disorders encountered by SMs might be explained by epigenetic stress and coping theories (e.g., (Folkman and Moskowitz, 2000; Gottlieb, 2007; Lazarus, 2000)). Minority stress, for example, which refers to the unique, chronic interpersonal stressors that SMs face, including stigma, discrimination, and prejudice (Meyer, 2003), may serve as an epigenetic factor triggering onset of other substance use and mental health conditions. At the same time, SM may also have access to fewer social-psychological resources which could help to buffer against these increased stressors (e.g., social support; (Bryan et al., 2017; Gilbert and Zemore, 2016; Lee et al., 2016; Lehavot and Simoni, 2011; McCabe et al., 2010; McCabe et al., 2019; Slater et al., 2017; Vu et al., 2019)). Research has also documented greater rates of unemployment and homelessness among SM individuals stemming from discriminatory practices (Mallory and Sears, 2015).
Due to SMs being a uniquely high-risk population for AOD and related mental health problems, SMs have been shown to utilize more treatment services to resolve an AOD problem compared to heterosexuals (Grella et al., 2011, Grella et al., 2009, Hughes, 2011, McCabe et al., 2013; US Department of Health and Human Services, 2018). Allen and Mowbray (2016) found about 24% of gay and lesbian individuals with an AUD and 29% of bisexual individuals with an AUD sought treatment compared to about 14% of heterosexual individuals with an AUD (Allen and Mowbray, 2016).
In spite of higher treatment utilization, SMs also report more barriers to treatment compared to heterosexuals. Bisexual individuals, for example, have been shown to be substantially more likely to endorse barriers, such as, “Did not think anyone could help,” when compared to heterosexual individuals (about 50% and 13%; respectively, (Allen and Mowbray, 2016)). Furthermore, SMs struggle finding treatment services that cater to their unique needs (Hughes, 2011), as very few SM-specific treatment programs exist (Mericle et al., 2018). Additional barriers are fears of discrimination (Jeong et al., 2016), stigma (Jeong et al., 2016), harassment (Brown et al., 2016), and being misunderstood (Brown et al., 2016). Therefore, even though SMs utilize treatment services at higher rates, a significant portion of SMs may delay seeking needed treatment (Allen and Mowbray, 2016, Corliss et al., 2006).
There is emerging literature on AOD disorder treatment amongst SMs, yet little is known about characteristics of recovering SMs. Also, while SMs are known to experience more treatment barriers, greater knowledge regarding SMs’ well-being and functioning across the recovery continuum would help inform SM-tailored services and policies. Such knowledge includes how SMs compare with the heterosexual majority in terms of AOD use and mental health histories, services used, recovery pathways followed, comfort in disclosing a history of an AOD problem, and quality of life (QOL) and psychological functioning. Research on such trajectories among those with significant AOD histories is emerging (Earnshaw et al., 2019, Kelly et al., 2017, Kelly et al., 2018), but little is known regarding the SM population, in particular, and how SMs compare to heterosexuals in terms of their characteristics, clinical histories, and well-being in recovery.
The current study uses a nationally representative sample of US adults who have successfully resolved a significant AOD problem (National Recovery Study; Kelly et al., 2017) to address these knowledge gaps for SMs, in part, by comparing their characteristics and experiences to those of their heterosexual counterparts. Specifically, the current study attempts to answer three main research questions: 1. What is the prevalence of SMs among those in the US population who have resolved a significant AOD problem; 2. How are SM and heterosexual individuals similar or different in terms of their demographics, clinical histories, and problem resolution pathways; and 3. To what extent do SM and heterosexual individuals differ in terms of QOL and psychological functioning and well-being outcomes following AOD problem resolution, and what factors in particular might explain any observed disparities. Greater knowledge regarding how SMs experience the recovery process compared to the majority heterosexual population could inform and enhance more targeted strategies and services to better meet the AOD recovery needs of this high-risk population.
Section snippets
Sample and procedure
Data for the current study comes from the National Recovery Study (NRS), described in more detail elsewhere (Earnshaw et al., 2019, Kelly et al., 2017, Kelly et al., 2018). In short, the NRS is a nationally representative sample of US adults (18 + years) who have resolved a significant AOD problem. Participants answered “yes” to the screener question “Did you used to have a problem with drugs or alcohol, but no longer do?” Data was collected using the survey company GfK via their KnowledgePanel
Prevalence of SM individuals among those in the US population who have resolved a significant AOD problem
The proportion of the sample that identified as SM (lesbian, gay, or bisexual) was 11.7% (Table 1). The SM group included n = 17 individuals who self-identified as “Something else” other than heterosexual or lesbian, gay, or bisexual.
Differences between SM and heterosexual groups in terms of their demographics, clinical histories, and problem resolution pathways
SM participants were less likely to be employed relative to heterosexual participants (OR=0.64; 95% CI: 0.43, 0.96). SM participants were more likely than heterosexual participants to have a co-occurring psychiatric disorder (OR=2.24; 95% CI: 1.49, 3.37) and arrest
Discussion
This investigation estimated the national prevalence of SMs in recovery and compared SM and heterosexual individuals on socio-demographic, clinical, and service use characteristics as well as indices of QOL, functioning, and well-being. The prevalence of SM individuals in recovery translates into approximately 2.6 million adults in the US general population. Compared to heterosexual individuals, SM individuals differed on several socio-demographic and clinical/legal factors. Notably, the SM
Role of Funding Source
This work was supported by Massachusetts General Hospital Recovery Research Institute (No: RRI081715N) and NIAAA (K24AA022136; K23AA025707).
Contributors
Amanda Haik and John Kelly conceptualized and wrote the first draft of the manuscript. Claire Greene conducted the data analyses. Brandon Bergman and Alexandra Abry helped with manuscript drafting and revisions. All authors have been personally and actively involved in substantive work leading to the report and will hold themselves jointly and individually responsible for its content. All authors have approved the final version of this manuscript version to be published.
Declarations of interests
None.
Conflict of Interest
No conflict declared.
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