Objective To compare the licit and illicit drug using patterns of heterosexual and non-heterosexual women in Australia.

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1 16/06/05 1 The association between drug use and sexual orientation in young women Lynne Hillier PhD, 1,3 Richard de Visser PhD, 1 Anne Kavanagh PhD, 1 Ruth McNair 2 (MBBS, DRACOG, DA(UK), FRACGP, FACRRM) 1 - Australian Research Centre in Sex, Health & Society, La Trobe University 2 - Department of General Practice, University of Melbourne 3 - To whom correspondence should be addressed at: Australian Research Centre in Sex, Health & Society, 1 st Floor, 215 Franklin St, Melbourne VIC 3000, Australia Objective To compare the licit and illicit drug using patterns of heterosexual and non-heterosexual women in Australia. Design - Cross-sectional analysis of first follow-up survey of national longitudinal study of young Australian women aged 22 to 27 years. Setting Self-administered survey of women in the general population. Subjects 9260 women, aged 22 to 27 years, of whom 8409 were heterosexual and 797 were non-heterosexual. Outcome measures - Use of licit drugs (tobacco and alcohol) and illicit drugs (marijuana, amphetamines, LSD, ecstasy/designer drugs, tranquilisers, natural hallucinogens, cocaine, inhalants, heroin, or barbiturates) - ever and in the 12 months prior to completing the survey. Results After adjusting for age, region of residence, and father's occupation, non-heterosexual women were more likely to be current smokers (OR 3.18, 95% CI ); consume alcohol at high risk levels (OR 2.50, 95% CI ); have used illicit drugs the last year (OR 5.50, 95% CI ); and, to have injected illicit drugs (OR 12.26, 95% CI ). Use of marijuana, amphetamines, LSD, ecstasy/designer drugs, tranquilisers, natural hallucinogens, cocaine, inhalants and barbituates were elevated in non-heterosexual women and these effects remained even after adjusting for age, region of residence and father's occupation. Conclusions Elevated drug use may be a response to homophobia. This suggests a need for support and counseling and action towards social change to make the community safer for young lesbians and bisexual women. Higher levels of drug use may also reflect normalisation of drug

2 use in gay and lesbian communities. This suggests a need for interventions to minimise potential harms related to drug use among young lesbians and bisexual women. 16/06/05 2

3 16/06/05 3 Recreational drug use is an important determinant of health status. 1 Although women in general are known not to be high drug users 16,17, nonheterosexual women appear to use recreational drugs at higher rates than their heterosexual peers. Large population-based studies have rarely assessed sexual orientation, limiting the capacity to make comparisons between the health of heterosexual and non-heterosexual women. 2 The studies that have made these comparisons indicate that lesbians and bisexual women have higher rates of tobacco use and alcohol consumption, and are more likely to have used illicit drugs. 3-8 Studies of young people in Australia reveal elevated levels of marijuana use and injecting drug use among non-heterosexual young women. 9,10 Higher levels of injecting drug use among women who have sex with women may increase their risk of becoming infected with HIV, Hepatitis C, or other blood-borne viruses. 4 Although recreational drug use appears to be more prevalent among non-heterosexual women, most research has used non-representative samples, which reduces the generalisability of study findings. This paper presents a comparison of patterns of recreational drug use among a representative sample of heterosexual and non-heterosexual young women in Australia. Methods Study population The Australian Longitudinal Study of Women s Health involves three cohorts of women - aged 18-23, 45-50, or at initial recruitment who complete a self-administered questionnaire every 3 years. The survey methodology has been described elsewhere. 11 Women were randomly selected from the Medicare database, which includes all Australian citizens and permanent residents. Women living in non-urban areas were over-sampled. The response rate for young women at stage one was 41%, and the retention rate for stage two was 71%. This paper uses data from the second survey of 9,683 young women, who were aged when contacted in This paper focuses on the 9,260 women who provided information about their sexual identity. Measures Women indicated which of the following five categories best described their sexual identity: exclusively heterosexual, mainly heterosexual, bisexual, mainly homosexual (lesbian), or exclusively homosexual (lesbian). Overall, 91.4% were exclusively heterosexual, 8.6% were not exclusively heterosexual and 1.0% were predominantly or exclusively homosexual. This distribution is similar to other surveys of representative samples. 12 The outcomes of interest to this paper relate to recreational drug use. Tobacco smoking status was measured as a 3-level variable: never smoked / former smoker / current smoker. Respondents reports of (a) how many days per week they usually drink alcohol, and (b) how many alcoholic

4 16/06/05 4 drinks they usually have on a drinking day were combined to distinguish between four categories of alcohol consumption: no risk (never or rarely drink) / low risk ( 14 drinks/week) and no binge drinking / low risk ( 14 drinks/week), with binges of 5 or more drinks at least weekly / and hazardous or harmful levels of consumption ( 15 drinks/week) regardless of binge drinking. 13 Respondents indicated whether (a) at any time, and (b) within the year prior to completing the survey, they had used marijuana, amphetamines, LSD, ecstasy/designer drugs, tranquilisers, natural hallucinogens, cocaine, inhalants, heroin, or barbiturates. New variables were created to identify respondents who had used illicit drugs (a) ever, and (b) in the year prior to completing the survey. Use of marijuana was not included in these measures as the majority of women had used marijuana (58%), whereas a minority had used each of the other drugs. Respondents indicated whether they had ever injected illicit drugs, and if so whether they had ever shared a needle. Data analysis Data were weighted to correct for over-sampling in non-metropolitan areas. The analyses compare exclusively heterosexual women to all other women. Analyses which distinguished between heterosexual, bisexual, and lesbian women revealed minimal differences between bisexual and lesbian women. Details of analyses comparing bisexual and lesbian women are available from the authors. Confounding variables Odds ratios were adjusted for three confounding variables: age, father s occupation, and region of residence. Father s occupation was used as a measure of social class because it was likely to better reflect social class than a woman s own occupation - only 52.1% of respondents were working full-time, 28.4% were studying, and 25.4% lived with their parents. The Australian Standard Classification of Occupations 14 was collapsed into a 3-level variable to distinguish between managerial/professional, white-collar, and blue-collar occupations. Region of residence was coded as urban, regional, or remote according to the Accessibility/Remoteness Index of Australia. 15 Results Table 1 displays the association between sexual attraction and recreational drug use. Lesbians and bisexual women were significantly more likely than heterosexual women to have ever smoked, to be current smokers, and to report risky levels of alcohol consumption. Just under half of the non-heterosexual women were current smokers, and 45.6% reported risky alcohol consumption. Table 1

5 16/06/05 5 Non-heterosexual women were significantly more likely than heterosexual women to report use of marijuana and other illicit drugs, and significantly more likely to have injected drugs. These significant differences held after adjusting for age, region of residence, and father s occupation. The vast majority of non-heterosexual women had used marijuana at least once, and 54.6% had done so in the year prior to completing the survey. Over half of the non-heterosexual women had ever used other illicit drugs, and 40.7% had done so in the last year. One in ten non-heterosexual women had injected illicit drugs, and one-third of these women had shared a needle. Table 2 displays patterns of use of illicit drugs other than marijuana. For every one of the drugs listed, bisexual women and lesbians were significantly more likely to report use ever, and in the year prior to being interviewed. This result held when the data were adjusted for the confounding variables. Forty-one percent of non-heterosexual women had ever used amphetamines, ecstasy/designer drugs, or LSD compared with 10% of heterosexual women. These were also the drugs most likely to have been used in the recent past, with 29.4% of non-heterosexual women using ecstasy in the last year. Lifetime experience of heroin use was reported by 7.2% of non-heterosexual women, and 0.7% of heterosexual women and 2.6% of non-heterosexual women had used heroin in the last year compared with 0.2% of heterosexual women. Table 2 Discussion This study demonstrates convincingly that young Australian bisexual and lesbian women are more likely than heterosexual women to use licit and illicit recreational drugs. The overall distributions of responses for variables measuring cigarette smoking, alcohol consumption, and illicit drug use match what one would expect from surveys of the general population. 16,17 What is important about these results, however, is that lesbians and bisexual women reported significantly higher levels of drug consumption across all types of drugs - from cigarettes and alcohol, to commonly used illicit drugs such as marijuana and ecstasy, and 'harder' drugs such as heroin - whether the time-frame was the women s lifetimes or the last year. These young women do not use drugs in a social vacuum. Elevated levels of drug use may be related to the homophobic abuse experienced by many lesbians and bisexual women. 9,18 Drug use may be an, albeit short lived, panacea for feelings of isolation and alienation. 19 It is also important to note that recreational drug use may be normalised within gay and lesbian communites. 20,21 Thus, the elevated patterns of drug use found in this study may be the result of individual experiences (i.e. discrimination) and/or sub-cultural experiences (i.e. normalisation of recreational drug use). Further work is needed to better ascertain the reasons for higher levels of recreational drug use among non-heterosexual women.

6 16/06/05 6 To the extent that drug use is a response to personal experiences of discrimination, there may be a need for accessible support and counselling services so that young women do not respond to sexuality-based discrimination by engaging in potentially harmful patterns of drug use. At the broader cultural level there is a need to work towards a society which accepts sexual diversity. To the extent that drug use occurs in subcultures in which recreational drug use is normalised, there is a need to ensure that young women who choose to use drugs can do so in ways that do not compromise their safety or health. The results of this study suggest that there may be a need for specific interventions among young lesbians and bisexual women. Although women in general are less likely than men to use drugs, and may not be a high-priority target for drug education, non-heterosexual young women report levels of illicit drug use at least as high as those of young men. 16,17 There may be a particular need for health education relating to injecting drug use and the risk of transmission of HIV, Hepatitis C, and other blood-borne viruses. There are some limitations to the data presented in this paper. First, not all women who completed the survey provided information about their sexual identity. Second, the survey only included one measure of sexual orientation, making it impossible to examine the degree of correspondence between sexual identity, sexual attraction and sexual experience. In addition, not all respondents answered all questions about drug use. Fortunately, there was little missing data, and it would be unlikely to affect the strength of the associations reported in this paper. We don't expect differential bias in response rate by sexual orientation. The data reported in this article are from the youngest of three cohorts in the Women s Health Australia study. The longitudinal design of the study will enable an assessment of whether bisexual and lesbian women continue their patterns of higher drug use across their lifespan. Acknowledgments Thanks are due to Bin Tong for preliminary data analysis. The Australian Longitudinal Study on Women's Health is funded by the Commonwealth Department of Health and Ageing and conducted by the Universities of Newcastle and Queensland, Australia. Additional funding for the analyses presented here was provided by Women s Health Victoria and the Tasmanian Department of Human Services. Competing interests None References 1 Marmot M, Wilkinson RG. Social determinants of health. Oxford: Oxford University Press, Roberts J. Lesbian health research: a review and recommendations for future research. Women s Health Care Int 2001; 22:

7 16/06/ Abbott L. The use of alcohol by lesbians. A review and research agenda. Substance Use and Misuse 1998; 33: Bradford J, Ryan C & Rothblum E. National Lesbian Health Care Survey: Implications for mental health care. J Consult Clin Psychol 1994; 62: Fethers K, Marks C, Mindel A & Estcourt C. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Inf 2000; 76: Gruskin E, Hart S, Gordon N & Ackerson L. Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organisation. Am J Public Health 2001; 91: Murnane A, Smith A, Crompton L, Snow P & Munro G. Beyond perceptions: A report on alcohol and other drug use among gay lesbian, bisexual and queer communities. Melbourne: Australian Drug Foundation, Welch S, Howden-Chapman P & Collings S. Survey of drug and alcohol use by lesbian women in New Zealand. Addictive Behav 1998; 23: Hillier L, Dempsey D, Harrison L, et al. Writing themselves in: A national report on the sexuality, health and well-being of same sex attracted young people. Carlton: National Centre in HIV Social Research, Smith A, Lindsay J, Rosenthal D. Same sex attraction, drug injection and binge drinking among Australian adolescents: results of a national survey. Aust NZ J Public Health 1999; 23: Brown W, Bryson L, Byles J, et al. Women s Health Australia: recruitment for a national longitudinal cohort study. Women and Health 1998; 28: Hubert M, Bajos N & Sandfort T (Eds.) Sexual behaviour and HIV/AIDS in Europe. London: UCL Press, National Health and Medical Research Council. Australian drinking guidelines. Canberra: National Health and Medical Research Council, Australian Bureau of Statistics. Australian Standard Classification of Occupations. Canberra: Australian Bureau of Statistics, Department of Health and Aged Care. Measuring remoteness: Accessibility/ Remoteness Index of Australia. Canberra: Department of Health and Aged Care, Australian Institute of Health & Welfare Australia s young people. Canberra: AIHW, Australian Institute of Health & Welfare Australia s Health Canberra: AIHW, Hershberger S & D Augelli A. The impact of victimisation on the mental health and suicidality of lesbian, gay and bisexual youths. Developmental Psychol 1995; 31: Jordan K. Substance abuse among gay lesbian, bisexual, transgender, and questioning adolescents. School Psychol Rev 2000; 29: Parks C. Lesbian social drinking: the role of alcohol in growing up and living as a lesbian. Contemporary Drug Problems 1999; 26: Richters J, Bergin S, Lubowitz S & Prestage G. Women in contact with Sydney s gay and lesbian community: Sexual identity, practice, and HIV risks. AIDS Care 2002; 14:

8 16/06/05 8 Table 1 Frequencies, unadjusted odds ratios, adjusted odds ratios for drug use among bisexual women and lesbians drug heterosexual bisexual + lesbian unadjusted OR (95% CI) adjusted* OR (95% CI) Smoking status never smoked 60.8% 37.0% former smoker 14.2% 17.4% 2.02 ( ) 2.15 ( ) current smoker 25.0% 45.6% 2.99 ( ) 3.18 ( ) n = 8,284 n = 755 Alcohol consumption no risk 36.7% 23.9% low risk - no bingeing 31.5% 30.6% 1.49 ( ) 1.33 ( ) low risk - with bingeing 27.9% 38.6% 2.13 ( ) 2.01 ( ) risky 3.9% 7.0% 2.75 ( ) 2.50 ( ) n = 8,419 n = 796 Used marijuana ever 54.8% 84.6% 4.55 ( ) 4.42 ( ) last year 21.5% 58.2% 5.09 ( ) 4.68 ( ) Used illicit drugs** ever 22.4% 61.2% 5.46 ( ) 5.31 ( ) last year 10.2% 40.7% 6.03 ( ) 5.50 ( ) Injected illicit drugs ever 1.2% 10.8% 9.70 ( ) ( ) n = 8,409 n = 797 Shared a needle ever 19.6% 32.0% 1.83 ( ) 1.63 ( ) n = 110 n = 85 * - adjusted for age, region of residence, and father s occupation, ** - illicit drugs other than marijuana

9 16/06/05 9 Table 2 Frequencies, unadjusted odds ratios, adjusted odds ratios for use of specific drugs bisexual + lesbian unadjusted OR (95% CI) adjusted* OR (95% CI) drug heterosexual Amphetamines ever 13.9% 44.3% 4.93 ( ) 4.79 ( ) last year 6.6% 28.7% 5.66 ( ) 5.08 ( ) Ecstasy / designer drugs ever 12.2% 41.7% 5.14 ( ) 4.95 ( ) last year 7.5% 29.4% 5.14 ( ) 4.75 ( ) LSD ever 11.7% 40.4% 5.10 ( ) 4.94 ( ) last year 2.2% 13.0% 6.75 ( ) 6.92 ( ) Cocaine ever 4.8% 19.6% 4.84 ( ) 4.75 ( ) last year 2.2% 9.6% 4.71 ( ) 4.37 ( ) Natural hallucinogens ever 4.0% 16.5% 4.77 ( ) 4.14 ( ) last year 0.4% 5.4% ( ) ( ) Tranquillisers ever 3.9% 17.2% 5.18 ( ) 5.53 ( ) last year 1.4% 7.1% 5.35 ( ) 5.79 ( ) Inhalants ever 1.2% 8.6% 7.57 ( ) 8.14 ( ) last year 0.1% 2.0% ( ) ( ) Heroin ever 0.7% 7.2% ( ) ( ) last year 0.2% 2.6% ( ) ( ) Barbiturates ever 0.3% 2.2% 6.75 ( ) 7.65 ( ) last year 0.1% 0.5% 9.32 ( ) ( ) n = 8,409 n = 797 * - adjusted for age, region of residence, and father s occupation