American youth who identify as gay or bisexual have been more likely to engage in underage alcohol use and binge drinking in the past decade compared to their heterosexual peers, partially as a result of stress from stigma, prejudice and discrimination, a new study found.

Using data gathered from more than 200,000 high school students in the U.S., a team of researchers explored the associations between sexual identity, sexual behavior and alcohol use in a study published in Alcohol and Alcoholism on Dec. 9. 

Lead author Gregory Phillips II, a professor of medical social sciences at Northwestern University, told The Academic Times that within sexual orientation, an individual’s identity, attraction and behavior can be very different. But it’s rare for research to account for the differences.

Phillips and his team pooled data between 2009–2017 from the Youth Risk Behavior Survey, which is run by the Centers for Disease Control and Prevention to monitor health-related behaviors among youth in grades 9-12. 

In the study, the researchers analyzed associations between sexual identity, sexual behavior and alcohol use outcomes, including age at first drink, binge drinking and current drinking. The authors noted that other studies have found that sexual minority youth are 190% more likely to use substances including alcohol than their heterosexual peers. 

This increased use has primarily been attributed to what psychologists refer to as minority stress, which includes stigma, prejudice and discrimination that contribute to hostile environments for those who hold minority identities. These environments subsequently lead to mental health issues and risk behaviors as coping mechanisms, including alcohol use, according to the current study.

In his data analysis, Phillips found that teens whose behavior did not align with “stereotypical” beliefs regarding sexual identity and behavior alignment had higher levels of current drinking and were more likely to have had their first drink before the age of 13. 

“Sexual identity and sexual behavior, especially among adolescents, are complex and multilayered constructs, and exploration and experimentation are normal parts of the process of sexual development for many youths,” Phillips wrote. “It is, therefore, common for youth to report a sexual identity which may not perfectly align with stereotypical expectations of one’s sexual behavior … However, an individual may be stigmatized if their sexual behavior does not perfectly align with social expectations, therefore creating distress and possibly leading to increased levels of alcohol consumption.”

And youth whose behavior and identity are perceived by others as being “nonaligned” can experience ostracization and shame, which can lead to increased alcohol use as an attempt to cope, the study said.

“Researchers, policymakers and teachers should take care not to reinforce that identity and behavior must be ‘aligned,’ but rather work to communicate the complex and multifaceted nature of sexuality,” Phillips said in the study.

Individual males who reported having sex with other males and females who reported having sex with both males and females were “significantly more likely” to have consumed alcohol in the last 30 days.

All sexual minority males and females were also significantly more likely than their heterosexual peers to have had their first drink prior to age 13. And all males and females who reported bisexual behavior were significantly more likely to have engaged in binge drinking.

Bisexual individuals had higher odds of alcohol use, even compared to the other sexual minority groups. Phillips theorized that this could be a result of bisexual populations feeling ostracized by both heterosexual and sexual minority communities and feeling socially isolated and marginalized, which leads to more alcohol use.

“We’re able to see these associations and say that sexual identity, sexual behavior and the combination of them are associated with alcohol use behaviors in certain groups of adolescence, which hasn’t really been done before,” Phillips said.

The results highlight the need to incorporate multiple methods of sexual orientation measurement into future substance-use research, according to the study, because analyzing alcohol use disparities only by one dimension of sexual orientation may result in critical disparities being obscured. Too often, research and intervention programs focus on sexual identity while failing to consider sexual behavior, Phillips said, which can exclude populations who could benefit from targeted intervention.

Phillips suggested that a more in-depth, intersectional approach to how race and ethnicity impact alcohol use outcomes should be explored in future research, especially in young people who hold multiple marginalized identities.

“It is essential to know how different dimensions of sexual orientation operate together to influence alcohol use patterns in order to understand who is most at risk and develop policy and interventions accordingly,” Phillips said in the study.

The Youth Risk Behavior Survey did not include questions about gender identity until 2017, so the researchers only referred to “male” or “female” participants in the paper. But they suggested that future analyses should include gender identity.

Phillips’ research was funded by a grant from the National Institute on Alcohol Abuse and Alcoholism, as well as a grant from the National Heart, Lung, and Blood Institute.

The study, “Differential Alcohol Use Disparities by Sexual Identity and Behavior Among High School Students,” was published in Alcohol and Alcoholism on Dec. 9. Gregory Phillips II of Northwestern University was the lead author. Xinzi Wang, Megan M. Ruprecht, Dylan Felt, David McCuskey, Reno Stephens, Esrea Perez-Bill and Lauren B. Beach, all of Northwestern University, served as co-authors.