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.

OBJECTIVES: 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. DESIGN: 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). SETTING: Data were obtained from the Generation Study Wave 1 (data collected from 2016 to 2018), a nationally representative cohort of SMPs in the USA. PARTICIPANTS: The study included 1518 participants aged 18-59. 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. PRIMARY AND SECONDARY OUTCOME MEASURES: 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). RESULTS: 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. CONCLUSIONS: 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.