Many young people who identify as Lesbian, Gay, Bisexual (LGB), other sexual or gender minority (for example Queer, Transgender or Intersex), or report being attracted to same- or both-gender partners, have poorer health than their peers who identify as heterosexual, cisgender or as exclusively attracted to members of the opposite gender [1
]. The studies show a large variation in the use of (biological) sex or (socially constructed) gender. They also employ various sexual identity terms or classify youth based on other dimensions of sexual orientation, such as gender of sexual or love partner(s). In this study, we use the term ‘gender’ to describe whether the respondents identified themselves as boys or girls. The ‘sexual minority youth’ (SMY) term is used, as this is the most inclusive, unless we refer to studies that used more specific terminology (such as LGB).
Extensive research indicates that SMY are more likely to engage in substance use [3
]. However, the validity of the evidence is limited by the fact that most investigations have been conducted in North America. There are just a few sporadic observations from other countries, and cross-cultural comparisons are largely missing. This study aimed to describe and compare substance use frequency across patterns of romantic attraction, in nationally representative samples of 15-year-old adolescents from eight European countries and regions with various geographical location, history, and levels of tolerance towards sexual minorities.
1.1. Tobacco Use
While LGB youths appear to start smoking at a later age than the general population, compared to their heterosexual peers they are significantly more likely to use various (and multiple) tobacco products, as well as to report smoking in the past month, or being current smokers [5
]. Smoking patterns were influenced by sexual identity, gender, race or ethnicity, and their interactions [8
]. In some studies, significant differences were found between sexual minority girls and boys, or bisexual youths and those identifying as lesbian or gay. Such findings indicate the importance of mapping the relative risk of SMY boys and girls separately.
Cross-sectional and longitudinal studies have concluded that psychological distress in SMY was associated with smoking [11
]. Sexual minority adolescents were significantly more likely to report smoking in the past year compared to heterosexual youth in a large-sample U.S. national prospective cohort study, after adjusting for gender, age, race/ethnicity, and family income. However, SMY youth living in states where the social environment was less stigmatizing toward LGB people had a significantly lower relative risk for smoking than those who lived in a state imposing stronger structural stigma. The stigmatizing environment did not have a differential effect on heterosexual youth [13
]. This indicates that besides micro-environmental influences, macro-level societal indicators may also be associated with substance use in SMY. Therefore, it is important to investigate cross-cultural variations in the associations between sexual minority status and substance use or other risk behaviors, ideally including sexual minority young people from various countries and cultures.
1.2. Alcohol Consumption and Drunkenness
Sexual minority adolescents are more likely than heterosexual youth to drink alcohol and get drunk [3
]. LGB young people report earlier alcohol initiation and sharper drinking trajectories into adulthood than heterosexual youth [15
]. The experience of sexual minority belonging in adolescence may shape alcohol-related behaviors in later age [16
]. Some argue that consuming any amount of alcohol and excessive drinking (i.e., heavy episodic drinking) may diverge, for instance for cultural reasons [17
], therefore they should be examined separately.
While there was a general decline in adolescent alcohol use in the United States and Europe over the last decade [18
], the alcohol-related disparities between heterosexual and SMY have remained stable or even widened [19
]. More recent findings demonstrate that pluri-sexual males (having both-gender sexual partners or identifying as bisexual) have higher risk for earlier onset and persistent use of alcohol than those with monosexual behavior (having exclusively opposite- or same-gender partners) or identifying as heterosexual or gay [20
1.4. Minority and Romantic Stress: Explanation for Different Types and Combinations of Substance Use?
In addition to the single substance studies cited above, there is a large corpus of evidence on multiple or poly-substance use and the association with mental health outcomes in SMY. These studies examine alcohol, tobacco and cannabis or other drugs [20
], alcohol and cigarettes [28
], drugs and alcohol [29
], tobacco, methamphetamine use and suicidal ideation [31
], or meta-analyses where different types of substance use were pooled [3
In a systematic review of 18 studies [3
], it was found that LGB youth were around three times more likely, compared to their heterosexual peers, to be involved in any type of substance use. The effects were larger in bisexual compared to lesbian/gay young people, and in females compared to males. When one large-effect size study was removed from the pool, no significant differences were observed between studies conducted in the United States or elsewhere, which suggests that the disparity may be universal across different countries and cultures. Another systematic review of 12 studies revealed that the strongest risk factors for substance use (smoking cigarettes, consuming alcohol, cannabis, cocaine and ecstasy) in SMY were LGB-related or general victimization, lack of supportive environments, psychological stress, internalizing/externalizing behaviors, negative responses to coming out, and housing status [4
The disparities between SMY and heterosexual youth’s substance use can be explained by the minority stress theory which argues that experiences of discrimination, victimization, and stigma are prevalent due to a pervasive homophobic culture [32
]. The existing literature points out that sexual orientation-based bullying and harassment at school contributes to SMY disparities in all forms of substance use. Hatzenbuehler’s [34
] extension of minority stress suggests that due to stigmatization, sexual (and gender) minority individuals experience chronic stress, which in the long term may lead to deficits in emotion regulation and negative affect. To cope with these, sexual minority individuals may turn to alcohol (and other substance) use [4
Consistent with the ecological framework provided by minority stress theory, it is important to examine factors that may predict substance use, particularly societal attitudes and policies regarding sexual minority communities and individuals. Although attitudes toward sexual minorities also are changing in several parts of the world, there are still many countries with strong anti-LGB policies or cultural norms. The negative effects of stigma and discrimination on sexual minority individuals’ health, including minority stress, depression, and fear of seeking help are well-documented. However, most of the evidence is from North America [36
]. The question remains whether these findings can be generalized to other countries and cultures (i.e., in the European region), given the large variation in societal attitudes, tolerance and acceptance towards gender and sexual minority individuals and issues within Europe [37
The countries involved in our study represent large variation both geographically (from Iceland to North Macedonia), historically (from traditionally Capitalist countries such as Belgium, England, France and Switzerland to post-Communist countries as Bulgaria and Hungary), and in terms of tolerance towards sexual minorities. The latter can be demonstrated by the International Lesbian Gay, Bisexual, Trans and Intersex Association’s (https://www.ilga-europe.org/rainboweurope
) Rainbow Score, a composite measure reflecting the legal situation and acceptance of gender and sexual minorities in different countries, ranging from 0 (gross violations of human rights) to 100 (full respect of human rights, full equality between sexual and gender minority and heterosexual and cisgender individuals). In the eight countries or regions involved in the present study, the Rainbow Score in 2014, when the data were collected, ranged from 13% in North Macedonia to 82% in the United Kingdom [39
In a nine-country investigation of substance use in 16–35-year-old LGB and heterosexual individuals, Demant and colleagues [40
] argue that cross-cultural comparisons in this area are important because cultural norms and attitudes towards both substances and sexual minority identities show considerable variations across countries with liberal versus more conservative policies and regulations. Until such studies are replicated, we cannot conclude that higher frequency of substance use in SMY is a universal phenomenon. Therefore, in this study we aimed to explore the associations between SMY and different substance use behaviors across different European countries and regions.
Another potential explanation, partly overlapping with the minority stress model, is that love, irrespective of the gender of the partner(s) with whom a young person is in love with, may be associated with stress on its own. Indeed, a cross-cultural study conducted in 17 countries found that adolescents experienced stress related the romantic relationships, especially in Mid- and South-European countries. Overall, around 20% of the adolescents used externalizing coping strategies, such as alcohol and drug use, to cope with these stressors [41
]. This prompts the notion that maybe not just same-or both-gender attracted adolescents may be at elevated risk of substance use, but anyone
who are in love may be at higher risk than those who are not being in love.
1.5. Dimensions of Sexual Orientation
The number of young people with same-gender attractions far exceeds those who engage in same-gender sexual behavior or who identify as lesbian, gay or bisexual. This is consistent with findings from large-scale nationally representative studies with adults, where the proportion of individuals with same- or both-gender attraction was much larger than those who identified as LGB [42
]. A population-based study in the United Kingdom demonstrated substantial diversity between identity, behavior and attraction in sexual minority adults [43
]. Studies have also varied on how they categorized SMY (identity, behavior or attraction), and whether they separated mono- and plurisexual youth. In one study, respondents as young as 9–10 years old were asked whether they consider themselves to be lesbian, gay or bisexual [44
]. While acknowledging the importance of all dimensions of sexual orientation, we argue that asking whether adolescents are attracted to girls, boys or both-gender partners may be easier for young people to answer, be more accurate, and can be used to subsequently categorize SMY based on same- or both-gender romantic attraction. This approach may be developmentally more appropriate than employing the identity labels of sexual orientation [45
]. Relying on sexual identity as a classifier for SMY may ‘mask’ or eliminate those young people who are still exploring their sexuality, have same- or both-gender attraction, but do not identify as LGB.
Health disparities in SMY can be found when respondents are classified by same- or both-gender romantic attraction. In a nationally representative study of U.S. adolescents [46
], boys romantically attracted to both-gender partners smoked more cigarettes, were more likely to have consumed alcohol while being alone, to have been drunk, and to use illegal drugs (including cannabis) compared to those who had been attracted to the opposite gender. Girls attracted to their same- or both-gender peers were more likely to smoke cigarettes, have been drunk, and have used cannabis or other drugs compared to opposite-gender attracted females. However, their conclusion was that SMY or certain subgroups within this category had a greater risk of substance use than heterosexually identifying or exclusively opposite-gender attracted youth. Therefore, in the current study we anticipate finding significant gender differences in the associations being investigated.
Another U.S. adolescent study demonstrated that sexual identity (i.e., defining oneself as LGB) and sexual behavior (i.e., having exclusively same- or both-gender partners) explained unique and significant sources of variability in tobacco and methamphetamine use and suicidal ideation [31
]. In another investigation, same- and both-sex romantic attraction and romantic relationship status were associated with various risk behaviors such as the number of cigarettes smoked in the past month, being drunk in the past year, and cannabis or other drug use [46
]. When adolescents were categorized into SMY based not on their identity but either on a history of same-gender attraction or sexual behavior, a sharper increase was observed in their cigarette and cannabis use than in those adolescents with heterosexual identity (or opposite-gender attraction or behavior) [47
]. These findings demonstrate that apart from identity, other dimensions of sexual orientation (i.e., behavior or romantic attraction) may also be associated with higher incidence of risk behaviors.
Based on these considerations and empirical evidence, in the present study, romantic attraction will be used to classify sexual minority adolescents and separate adolescents reporting being in love with any gender partners from those who have not been in love.
1.6. Aims of the Present Study
We aimed to describe and compare substance use frequency across patterns of romantic attraction, in nationally representative samples of 15-year-old adolescents from eight European countries and regions.
Romantic attraction was operationalized by an item on whether the respondent had already been in love, and if yes, whether the partner who they felt love for was a girl(s), boy(s), or both- a boy and a girl [45
]. This approach is in line with the notion that romantic attraction and love are conditional to each other [48
]. The responses, combined with the gender of the respondent, enabled us to categorize opposite-, same-, or both-gender attracted respondents, those who have not been attracted to anyone, or who have not responded to the love item. Contrary to most studies that concentrate on those with any type of attraction or sexual identity, we also measured the prevalence of substance use in those who reported not having been in love or who did not respond to this item. Based on previous findings from the literature, we hypothesized that same- and both-gender attracted young people will have significantly higher odds of cigarette smoking, drinking alcohol, being drunk, and cannabis use than their opposite-gender attracted peers or those who reported not having been in love. Our other hypothesis is that those young people who report being in love (with any gender partners) will have higher odds of substance use than those who have not been in love. We anticipated that despite cultural differences in the prevalence of these risk behaviors, higher incidence of substance use will be found in same- and both-gender attracted young people (and those who report being in love) across different countries and regions. Given the differences between sexual minority boys and girls found in many studies, analyses were stratified for gender.
An additional aim was to assess involvement of SMY in multiple risk behaviors (any two or all three of cigarette smoking, alcohol consumption, or cannabis use in the last 30 days). We hypothesized that youth reporting attraction to same- or both-gender partners will be more likely to be involved in using more than one type of substances than those who are exclusively attracted to opposite-gender partners or reported not having been in love.