{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T23:17:37Z","timestamp":1764890257788,"version":"3.46.0"},"reference-count":53,"publisher":"BMJ","issue":"10","license":[{"start":{"date-parts":[[2025,10,24]],"date-time":"2025-10-24T00:00:00Z","timestamp":1761264000000},"content-version":"unspecified","delay-in-days":23,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100008091","name":"University of Rochester","doi-asserted-by":"publisher","award":["n\/a"],"award-info":[{"award-number":["n\/a"]}],"id":[{"id":"10.13039\/100008091","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,10,3]]},"published-print":{"date-parts":[[2025,10]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Our study aims to investigate the associations between sexual minority stressors, resilience factors and substance misuse outcomes, using an intersectional framework to examine heterogeneities across sexual minority populations (SMPs) in the United States of America (USA). We hypothesised that stressors would be positively associated with substance use, and that resilience factors would be negatively associated, with these associations varying across intersectional strata.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>The current study employed a secondary data analysis strategy to analyse cross-sectional data using Bayesian hierarchical modelling and Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Data were obtained from the Generation Study Wave 1 (data collected from 2016 to 2018), a nationally representative cohort of SMPs in the USA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>The study included 1518 participants aged 18\u201359. Combinations of education, birth sex, sexual orientation, income and race\/ethnicity defined intersectional strata. Participants were selected based on self-reported demographic and behavioural data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcome measures<\/jats:title>\n                    <jats:p>Primary outcomes were the risks of alcohol use and drug use, measured using validated scales (AUDIT (Alcohol Use Disorders Identification Test) and DUDIT (Drug Use Disorders Identification Test)). Explanatory variables included resilience factors (social support, life satisfaction, social well-being and community connectedness) and sexual minority stressors (everyday discrimination, perceived stigma, healthcare stereotype threat and internalised homophobia).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In descriptive analyses, group differences on psychosocial scales were small to modest, with higher everyday discrimination in lower-income and Black participants. In Bayesian regressions, everyday discrimination was the strongest positive correlate of both alcohol and drug use, whereas perceived stigma was inversely associated. In MAIHDA models, demographic factors were associated with higher AUDIT among males and those with college-or-more education, and with higher DUDIT among low-income participants; relative to bisexual participants, gay (AUDIT) and lesbian (DUDIT) groups had lower scores. The strata-level variance component was small in null models and approached zero after adjusting for demographics and psychosocial factors, indicating that disparities are primarily driven by differential exposure to these factors rather than unexplained heterogeneity between strata.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>While minority stressors and resilience factors are salient predictors of substance use among SMPs, their effects are consistent across diverse intersectional identities. The application of MAIHDA demonstrates that substance use disparities are better explained by the main effects of demographics and psychosocial experiences than by the unique combination of identities. This highlights the importance of universal interventions in reducing discrimination and enhancing resilience across the entire SMP population.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-099457","type":"journal-article","created":{"date-parts":[[2025,10,24]],"date-time":"2025-10-24T07:35:16Z","timestamp":1761291316000},"page":"e099457","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Intersectional associations between minority stressors, resilience and substance misuse in the United States sexual minority populations: a cross-sectional MAIHDA analysis of the generation study"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8771-561X","authenticated-orcid":false,"given":"Chen","family":"Zhang","sequence":"first","affiliation":[{"name":"School of Nursing, University of Rochester, Rochester, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wonkyung","family":"Kniffen","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1834-1834","authenticated-orcid":false,"given":"Shan","family":"Qiao","sequence":"additional","affiliation":[{"name":"University of South Carolina, Columbia, South Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yu","family":"Liu","sequence":"additional","affiliation":[{"name":"School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,10,23]]},"reference":[{"key":"2025120415075665000_15.10.e099457.1","unstructured":"SAMHSA . Results from the 2013 National survey on drug use and health: summary of National findings: DHHS. 2014."},{"key":"2025120415075665000_15.10.e099457.2","unstructured":"SAMHSA . Center for behavioral health statistics and quality, national survey on drug use and health, 2022. 2023. Available: https:\/\/www.samhsa.gov\/data\/data-we-collect\/nsduh-national-survey-drug-use-and-health"},{"key":"2025120415075665000_15.10.e099457.3","doi-asserted-by":"publisher","DOI":"10.1089\/lgbt.2019.0352"},{"key":"2025120415075665000_15.10.e099457.4","doi-asserted-by":"publisher","DOI":"10.2307\/2137286"},{"key":"2025120415075665000_15.10.e099457.5","doi-asserted-by":"crossref","first-page":"3125","DOI":"10.1080\/00918369.2022.2087481","article-title":"Anticipated Sexual Minority Stress and Mental Health after the 2016 Presidential Election: Examining a Psychological Mediation Framework","volume":"70","author":"Brooks","year":"2023","journal-title":"J Homosex"},{"key":"2025120415075665000_15.10.e099457.6","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0250500","article-title":"Longitudinal effects of gender minority stressors on substance use and related risk and protective factors among gender minority adolescents","volume":"16","author":"Katz-Wise","year":"2021","journal-title":"PLoS One"},{"key":"2025120415075665000_15.10.e099457.7","doi-asserted-by":"crossref","unstructured":"Ungar M . Resilience and culture: the diversity of protective processes and positive adaptation. In: Youth resilience and culture: commonalities and complexities. 2015: 37\u201348.","DOI":"10.1007\/978-94-017-9415-2_3"},{"key":"2025120415075665000_15.10.e099457.8","doi-asserted-by":"publisher","DOI":"10.1089\/apc.2013.0330"},{"key":"2025120415075665000_15.10.e099457.9","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1037\/fsh0000859","article-title":"Applying an intersectionality framework to health services research","volume":"41","author":"Motley","year":"2023","journal-title":"Fam Syst Health"},{"key":"2025120415075665000_15.10.e099457.10","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2017.02.029"},{"key":"2025120415075665000_15.10.e099457.11","doi-asserted-by":"crossref","DOI":"10.1186\/s12916-018-1246-9","article-title":"Challenges and opportunities in examining and addressing intersectional stigma and health","volume":"17","author":"Turan","year":"2019","journal-title":"BMC Med"},{"key":"2025120415075665000_15.10.e099457.12","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1017\/S1742058X13000349","article-title":"INTERSECTIONALITY: Mapping the Movements of a Theory","volume":"10","author":"Carbado","year":"2013","journal-title":"Du Bois Rev"},{"key":"2025120415075665000_15.10.e099457.13","first-page":"139","article-title":"Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine","volume":"1989","author":"Crenshaw","year":"1989","journal-title":"Univ Chic Leg Forum"},{"key":"2025120415075665000_15.10.e099457.14","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-019-6430-0","article-title":"Mental health and substance use among women and men at the intersections of identities and experiences of discrimination: insights from the intersectionality framework","volume":"19","author":"Vu","year":"2019","journal-title":"BMC Public Health"},{"key":"2025120415075665000_15.10.e099457.15","doi-asserted-by":"crossref","first-page":"104612","DOI":"10.1016\/j.drugpo.2024.104612","article-title":"The intersection of substance use stigma and anti-Black racial stigma: A scoping review","volume":"133","author":"Ghonasgi","year":"2024","journal-title":"Int J Drug Policy"},{"key":"2025120415075665000_15.10.e099457.16","doi-asserted-by":"crossref","first-page":"109384","DOI":"10.1016\/j.drugalcdep.2022.109384","article-title":"Discrimination and alcohol problems among heavy drinking HIV-positive men who have sex with men: The buffering effect of a brief Motivational Intervention to reduce alcohol use","volume":"233","author":"Guy","year":"2022","journal-title":"Drug Alcohol Depend"},{"key":"2025120415075665000_15.10.e099457.17","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1016\/j.socscimed.2019.01.017","article-title":"Modeling the intersectionality of processes in the social production of health inequalities","volume":"226","author":"Evans","year":"2019","journal-title":"Soc Sci Med"},{"key":"2025120415075665000_15.10.e099457.18","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-021-11449-6","article-title":"Applying Intersectionality in designing and implementing health interventions: a scoping review","volume":"21","author":"Ghasemi","year":"2021","journal-title":"BMC Public Health"},{"key":"2025120415075665000_15.10.e099457.19","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2020.113559"},{"key":"2025120415075665000_15.10.e099457.20","unstructured":"Meyer IH . Data from: generations: a study of the life and health of LGB people in a Changing society, United States, 2016\u20132019, version V2. Inter-university Consortium for Political and Social Research (ICPSR), 2023. Available: https:\/\/doi.org\/10.3886\/ICPSR37166.v2"},{"key":"2025120415075665000_15.10.e099457.21","doi-asserted-by":"crossref","first-page":"107619","DOI":"10.1016\/j.drugalcdep.2019.107619","article-title":"Sexual orientation and gender identity disparities in substance use disorders during young adulthood in a United States longitudinal cohort","volume":"205","author":"Jun","year":"2019","journal-title":"Drug Alcohol Depend"},{"key":"2025120415075665000_15.10.e099457.22","doi-asserted-by":"crossref","first-page":"179","DOI":"10.15288\/jsad.2014.75.179","article-title":"Intersecting identities and substance use problems: sexual orientation, gender, race, and lifetime substance use problems","volume":"75","author":"Mereish","year":"2014","journal-title":"J Stud Alcohol Drugs"},{"key":"2025120415075665000_15.10.e099457.23","doi-asserted-by":"crossref","DOI":"10.1186\/s40359-023-01352-7","article-title":"Risk factors of substance use treatment gaps among a nationally representative sample of black American adults in relation to sexual minority status and health insurance coverage","volume":"12","author":"Rice","year":"2024","journal-title":"BMC Psychol"},{"key":"2025120415075665000_15.10.e099457.24","doi-asserted-by":"crossref","first-page":"790","DOI":"10.1037\/a0035499","article-title":"Sexual-orientation disparities in substance use in emerging adults: a function of stress and attachment paradigms","volume":"28","author":"Rosario","year":"2014","journal-title":"Psychol Addict Behav"},{"key":"2025120415075665000_15.10.e099457.25","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1089\/lgbt.2019.0066","article-title":"Substance Use Among a National Sample of Sexual and Gender Minority Adolescents: Intersections of Sex Assigned at Birth and Gender Identity","volume":"7","author":"Watson","year":"2020","journal-title":"LGBT Health"},{"key":"2025120415075665000_15.10.e099457.26","unstructured":"Chang W , McMahon J , Qiao S , et al . Discrimination, stress, and unhealthy alcohol and substance use among ethnoracial minority gay, bisexual, and other men who have sex with men. Rochester, NY: School of Nursing, University of Rochester, 2025."},{"key":"2025120415075665000_15.10.e099457.27","unstructured":"Zhang C , Chang W , Tang Y , et al . Resilience, stressors, and intersectionality: understanding alcohol and drug use disparities among sexual minority populations. 6th National Big Data Health Science Conference, Columbia, SC, USA; 2025"},{"key":"2025120415075665000_15.10.e099457.28","doi-asserted-by":"publisher","DOI":"10.1146\/annurev-clinpsy-081219-120307"},{"key":"2025120415075665000_15.10.e099457.29","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.socscimed.2018.11.036","article-title":"Adding interactions to models of intersectional health inequalities: Comparing multilevel and conventional methods","volume":"221","author":"Evans","year":"2019","journal-title":"Soc Sci Med"},{"key":"2025120415075665000_15.10.e099457.30","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2017.11.011"},{"key":"2025120415075665000_15.10.e099457.31","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0296657","article-title":"Understanding intersectional inequality in access to primary care providers using multilevel analysis of individual heterogeneity and discriminatory accuracy","volume":"19","author":"He","year":"2024","journal-title":"PLoS One"},{"key":"2025120415075665000_15.10.e099457.32","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2017.12.026"},{"key":"2025120415075665000_15.10.e099457.33","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1016\/j.socscimed.2017.02.040","article-title":"An intersectional approach to multilevel analysis of individual heterogeneity (MAIH) and discriminatory accuracy","volume":"178","author":"Wemrell","year":"2017","journal-title":"Soc Sci Med"},{"key":"2025120415075665000_15.10.e099457.34","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwu108"},{"key":"2025120415075665000_15.10.e099457.35","doi-asserted-by":"crossref","first-page":"783","DOI":"10.2147\/CLEP.S247368","article-title":"Geographical and sociodemographic differences in discontinuation of medication for Chronic Obstructive Pulmonary Disease - A Cross-Classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)","volume":"12","author":"Khalaf","year":"2020","journal-title":"Clin Epidemiol"},{"key":"2025120415075665000_15.10.e099457.36","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0220322","article-title":"Precision public health: Mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)","volume":"14","author":"Persmark","year":"2019","journal-title":"PLoS One"},{"key":"2025120415075665000_15.10.e099457.37","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.158.16.1789"},{"key":"2025120415075665000_15.10.e099457.38","doi-asserted-by":"publisher","DOI":"10.1080\/00952990.2018.1456545"},{"key":"2025120415075665000_15.10.e099457.39","doi-asserted-by":"publisher","DOI":"10.1111\/j.1530-0277.2002.tb02534.x"},{"key":"2025120415075665000_15.10.e099457.40","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.jsat.2015.01.008","article-title":"The Psychometric Properties of the Drug Use Disorders Identification Test (DUDIT): A Review of Recent Research","volume":"53","author":"Hildebrand","year":"2015","journal-title":"J Subst Abuse Treat"},{"key":"2025120415075665000_15.10.e099457.41","doi-asserted-by":"crossref","first-page":"1168","DOI":"10.1080\/10826084.2023.2212038","article-title":"Change in Drug Use Disorders Identification Test \u2013 Consumption (DUDIT-C) with Telehealth Treatment Compared to in-Person Treatment","volume":"58","author":"Neufeld","year":"2023","journal-title":"Subst Use Misuse"},{"key":"2025120415075665000_15.10.e099457.42","doi-asserted-by":"publisher","DOI":"10.1207\/s15327752jpa5503&4_17"},{"key":"2025120415075665000_15.10.e099457.43","doi-asserted-by":"publisher","DOI":"10.1207\/s15327752jpa4901_13"},{"key":"2025120415075665000_15.10.e099457.44","doi-asserted-by":"publisher","DOI":"10.2307\/2787065"},{"key":"2025120415075665000_15.10.e099457.45","doi-asserted-by":"publisher","DOI":"10.1080\/00224499.2011.565427"},{"key":"2025120415075665000_15.10.e099457.46","doi-asserted-by":"publisher","DOI":"10.1177\/135910539700200305"},{"key":"2025120415075665000_15.10.e099457.47","doi-asserted-by":"publisher","DOI":"10.1037\/0033-2909.129.5.674"},{"key":"2025120415075665000_15.10.e099457.48","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1007\/978-0-387-09556-1_4","article-title":"Sexual stigma and sexual prejudice in the United States: a conceptual framework","volume":"54","author":"Herek","year":"2009","journal-title":"Nebr Symp Motiv"},{"key":"2025120415075665000_15.10.e099457.49","doi-asserted-by":"publisher","DOI":"10.1111\/josi.12228"},{"key":"2025120415075665000_15.10.e099457.50","doi-asserted-by":"crossref","first-page":"558","DOI":"10.1080\/00918369.2013.760304","article-title":"Psychometrics of an internalized homophobia instrument for men","volume":"60","author":"Theodore","year":"2013","journal-title":"J Homosex"},{"key":"2025120415075665000_15.10.e099457.51","doi-asserted-by":"crossref","unstructured":"Kruschke JK . Doing bayesian data analysis a tutorial with R, JAGS, and Stan. London, UK: Elsevier, 2015.","DOI":"10.1016\/B978-0-12-405888-0.00008-8"},{"key":"2025120415075665000_15.10.e099457.52","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2012.301069"},{"key":"2025120415075665000_15.10.e099457.53","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1016\/j.drugalcdep.2016.02.022","article-title":"Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors","volume":"161","author":"Coulter","year":"2016","journal-title":"Drug Alcohol Depend"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-099457","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T23:13:30Z","timestamp":1764890010000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-099457"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10]]},"references-count":53,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,10,23]]},"published-print":{"date-parts":[[2025,10]]}},"alternative-id":["10.1136\/bmjopen-2025-099457"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-099457","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"type":"print","value":"2044-6055"},{"type":"electronic","value":"2044-6055"}],"subject":[],"published":{"date-parts":[[2025,10]]}}}