Full length articleSexual orientation, minority stress, social norms, and substance use among racially diverse adolescents
Introduction
Numerous studies have found that sexual minority adolescents (SMA; e.g., lesbian, gay, bisexual) are at high risk of substance use and misuse. A meta-analysis found that SMA are 190% more likely to report a history of substance use compared to their heterosexual peers (Marshal et al., 2008). This disparity was recently highlighted by the Centers for Disease Control and Prevention, which found SMA at higher risk than their heterosexual counterparts of 11 of 13 tobacco use indicators and 18 of 19 alcohol and other drug use behaviors (Kann et al., 2016). Sexual orientation disparities in substance use are significant, especially because early age of onset is associated with an increased likelihood of addiction later in life (Grant et al., 2001). Moreover, research examining sexual minority substance use lacks racially and ethnically diverse samples (Institute of Medicine, 2011).
One prominent framework for understanding sexual orientation substance use disparities is minority stress theory (Meyer, 2003). This theory suggests that victimization, perceived and experienced discrimination, and internalized stigma related to their stigmatized sexual identity places SMA at risk of negative outcomes (Hatzenbuehler, 2009, Meyer, 2003), including substance use (Goldbach et al., 2014, Marshal et al., 2009). A recent meta-analysis by Goldbach et al. (2014) found that minority stressors, such as negative reactions to sexual orientation disclosure, sexual identity distress, internalized homophobia, and victimization, were positively correlated with substance use.
Although minority stress theory has been tested in numerous studies, including meta- analyses (Goldbach et al., 2014), it has been critiqued for a lack of attention to other factors that may influence the relationship between sexual identity and behavioral health outcomes. For example, Hatzenbuehler (2009) argued that while minority stressors lead to poor outcomes, factors such emotional dysregulation and maladaptive cognitive and coping processes should also be considered.
In the case of substance use, one factor independent of minority stress that has received little attention in the literature on SMA substance use disparities are social norms (Green and Feinstein, 2012). Social norms theory assumes that individuals incorrectly perceive that the attitudes, beliefs, and behaviors of others are different from their own and thus adjust their own behavior (Berkowitz, 2005). Both descriptive (i.e., perceptions of others’ behavior) and injunctive (i.e., perceptions of whether a behavior is approved by others) social norms exist (Cialdini, 2003 Prentice and Miller, 1996), and the effects of these norms on the use of alcohol, tobacco, and other drugs are well documented (Berkowitz, 2005, Perkins, 2003).
Although social norms are considered a key intervention point for reducing substance use during adolescence (Berkowitz, 2005) and social networks have been a hallmark of substance use prevention research for nearly 30 years (Dishion et al., 2012, Hawkins et al., 1992 Oetting and Beauvais, 1987), there is a dearth of literature applying social norms theory to understanding sexual orientation substance use disparities. We identified only one study among adolescents which found that SMA girls had more descriptive norms regarding tobacco use than heterosexual girls, but these norms did not significantly mediate the association between sexual orientation and tobacco use; sexual orientation differences in tobacco norms were not found for boys (Austin et al., 2004). Limitations of this work include it being outdated as the data were collected in 19991, and it did not examine injunctive norms or substances other than tobacco.
Research involving young and middle adults has documented that alcohol use social norms specific to sexual minority communities were associated with more alcohol use among sexual minorities (Hatzenbuehler et al., 2008, Trocki et al., 2005). Another study found that sexual minority adult women perceived sexual minority women to drink more than heterosexual women and that more descriptive social norms (i.e., norms related to women in general and those specific to sexual minority women) and alcohol use were positively associated with each other over time (Litt et al., 2015). Moreover, a recent study found that sexual minority adults misperceived their sexual minority peers to be more likely to use alcohol and drugs to cope with minority stress (i.e., 2016 Orlando nightclub shooting), considering only a small portion of the sample was likely to do so (Boyle et al., 2017). These studies underscore the importance of examining social norms in understanding substance use; however, they did not clearly delineate between descriptive and injunctive norms, test the effects of norms on multiple substances, or examine these norms specifically among adolescents or with racially diverse samples. Adolescence is a critical period for substance use initiation featuring unique developmental factors and during which peers and parental influences are important; therefore, more research is needed to understand sexual orientation differences in descriptive and injunctive norms among adolescents and test how these norms may account for disparities in substance use.
The present study explored factors that contribute to sexual orientation disparities in substance use among adolescents. In an effort to test both minority stress and social norms theories, we examined how homophobic bullying (i.e., one form of minority stress) and descriptive and injunctive social norms may account for sexual orientation disparities in substance use, namely tobacco, alcohol, marijuana, and prescription drugs. Specifically, we (a) examined sexual orientation differences in homophobic bullying and descriptive and injunctive social norms regarding friends and parents; and (b) tested the mediating effects of minority stress and social norms on the relationship between sexual orientation and use of four substances (Fig. 1). Consistent with the literature on minority stress (Meyer, 2003) and research documenting more descriptive substance use norms among SMA compared to heterosexual adolescents (Austin et al., 20014), we hypothesized that SMA will experience more homophobic bullying and have more descriptive substance use friend norms than heterosexual adolescents, and that both of these factors would contribute to sexual orientation disparities in use of tobacco, alcohol, marijuana, and prescription drugs among adolescents. We also hypothesized similar patterns for injunctive substance use norms for friends and parents; however, given the lack of literature on SMA injunctive norms, these were exploratory hypotheses.
Section snippets
Methods
Secondary analyses were conducted using a dataset collected from the Youth Development Survey (YDS), a comprehensive cross-sectional survey of the primary school district of a large county in North Carolina. The YDS was originally developed in 1972 and has been conducted every two to four years using random cluster sampling. The institutional review board-approved survey covers topics including school bonding, relationships, bullying, substance use, and mental health.
Correlations and basic comparisons
Table 1 presents associations between the substance use social norms variables and homophobic bullying as well as basic descriptives for these variables. We conducted a multivariate analysis of variance to test for sexual orientation, gender, and racial differences in homophobic bullying and the three social norms. Results indicated a statistically significant effect for sexual orientation, Wilks’s Λ = 0.89, F(4, 2305) = 69.78, p < 0.001, = 0.108, and race, Wilks’s Λ = 0.99, F(4, 2305) = 4.27, p < 0.01,
Discussion
Sexual orientation disparities in substance use have been widely documented among adolescents (Marshal et al., 2008). However, there is a dearth of research identifying factors that explain these disparities beyond minority stress (Meyer, 2003), especially studies using racially diverse samples of adolescents. To our knowledge, the present study was the first to examine and document that descriptive and injunctive norms, in conjunction with minority stress, are important factors in explaining
Conflict of interest
There are no conflicts of interest by any author.
Funding
Manuscript preparation was supported by the National Institutes of Health grants awarded to J. Goldbach (Eunice Kennedy Shriver National Institute of Child Health & Human Development; R21HD082813) and A. DiBello (National Institute of Alcohol Abuse and Alcoholism; T32-AA007459).
Contributors
E. H. Mereish conceptualized the project, conducted all analyses, and wrote most of the manuscript. J. T. Goldbach provided feedback on the analyses and wrote parts of the manuscript. C. Burgess and A. DiBello provided feedback on the results and drafts of the manuscript. All authors contributed to and have approved the final manuscript.
Acknowledgements
None.
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