Exploring Social and Structural Determinants of Substance Use Among Sexual and Gender Minority Adults in the United States.

PurposeTo identify key social and structural factors associated with hazardous alcohol and problematic drug use among sexual and gender minority (SGM) adults.MethodsWe conducted a cross-sectional secondary analysis of 2016 to 2019 data from the Generations Study, a probability sample of 1518 SGM adults. Hazardous alcohol and problematic drug use were measured using the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) and Drug Use Disorder Identification Test (DUDIT). Candidate predictors included sociodemographic characteristics, minority stressors, adverse childhood experiences, health indicators, and social support. Interpretable machine-learning models with SHapley Additive exPlanations characterized multilevel correlates of 3-level risk categories.ResultsHazardous alcohol use was linked to past smoking, lower social support, cancer history, housing instability, and identity-related stressors. Problematic drug use was linked to conversion-therapy exposure, housing discrimination, legal encounters, and mental-health indicators; prediction was more accurate for drug- than alcohol-use risk.ConclusionStructural vulnerability, discrimination, and identity-related stressors emerged as intervention targets to reduce substance-use disparities in SGM adults.