Testing Substance Use as a Mediator of Structural Stigma-Cardiovascular Health Associations in a Large Sample of Gay Men and Lesbian Women

Abstract

Compared to heterosexual individuals, gay men and lesbian women experience multiple health inequities, including higher prevalence of substance use and cardiovascular disease (CVD). Gay men and lesbian women also face structural stigma, including laws that fail to protect or actively discriminate against them. These phenomena can be understood by considering two theories previously tested among gay men and lesbian women: minority stress and cognitive escape. Minority stress theory suggests being stigmatized for one's minority identity relates to negative health sequelae, while cognitive escape theory suggests escape-related behaviors may mediate links between chronic stress exposure and health. Using 2017 Behavioral Risk Factor Surveillance System data, we ran binary logistic regressions to test models in which binge drinking and cigarette smoking independently mediated links between structural stigma and health among gay men and lesbian women. Structural stigma was operationalized at the U.S. state level as number of sexual orientation anti-discrimination laws. Health was operationalized as presence of any CVD. Models were tested in an aggregated sample, and also in subsamples by sex. In bivariate and component-path analyses, structural stigma predicted smoking across samples. Structural stigma-binge drinking associations were more salient among lesbian women compared to gay men. Per Sobel test results, smoking mediated associations between structural stigma and CVD in the gay men sample, suggesting gay men may smoke to escape from structural stigma, with negative implications for cardiovascular health.

Structural stigma and alcohol use among sexual and gender minority adults: A systematic review

“…Subgroup differences in the positive association between structural stigma and poor alcohol-related outcomes among sexual minority people are consistent with prior research documenting variation in alcohol outcomes by sexual identity and gender. In general, associations between structural stigma and alcohol use were stronger among SMW than among SMM ( Greene et al., 2020 , 2021 ; Manser and Du Bois, 2021 ); this is unsurprising given previous findings that alcohol-use disparities are more pronounced among SMW than SMM ( Hughes et al., 2016 , 2020 ; McCabe et al., 2019 ). Further, findings of stronger associations between structural stigma and alcohol use among bisexual women than lesbian women ( Drabble et al., 2022 ; Greene et al., 2020 , 2021 ) are in line with previous findings that bisexual women experience worse alcohol-related outcomes than lesbian women ( Hughes et al., 2020 ; Schuler and Collins, 2020 ).…”

“…In another study using the same dataset, there were no significant associations between sexual identity, alcohol policy environment, presence of inclusive statutes, and binge drinking among men ( Greene et al., 2021 ). Similarly, in a subsample from a national study, structural stigma was not associated with binge drinking among gay men ( Manser and Du Bois, 2021 ).…”

“…(2021) found that in states with inclusive statutes, a stricter alcohol policy environment was associated with lower odds of binge drinking among women, but there was no association in states without inclusive statutes, suggesting that stricter alcohol policies may be protective against binge drinking among women, but only in LGBTQ+ inclusive policy environments ( Greene et al., 2021 ). Similarly, in a subsample from a national study, structural stigma was positively associated with binge drinking among lesbian women ( Manser and Du Bois, 2021 ).…”

“…(2021) Yes No Yes Yes Yes Yes Yes Yes 7/8 Hatzenbuehler et al. (2010) Yes Yes Yes Yes Yes Yes Yes Yes 8/8 Manser and Du Bois (2021) Yes Yes Yes Yes Yes Yes Yes Yes 8/8 Pachankis et al. (2014) Yes Yes Yes Yes Yes Yes No Yes 7/8 Note .…”