Testing Substance Use as a Mediator of Structural Stigma-Cardiovascular Health Associations in a Large Sample of Gay Men and Lesbian Women

Compared to heterosexual individuals, gay men and lesbian women experience multiple health inequities, including higher prevalence of substance use and cardiovascular disease (CVD). Gay men and lesbian women also face structural stigma, including laws that fail to protect or actively discriminate against them. These phenomena can be understood by considering two theories previously tested among gay men and lesbian women: minority stress and cognitive escape. Minority stress theory suggests being stigmatized for one's minority identity relates to negative health sequelae, while cognitive escape theory suggests escape-related behaviors may mediate links between chronic stress exposure and health. Using 2017 Behavioral Risk Factor Surveillance System data, we ran binary logistic regressions to test models in which binge drinking and cigarette smoking independently mediated links between structural stigma and health among gay men and lesbian women. Structural stigma was operationalized at the U.S. state level as number of sexual orientation anti-discrimination laws. Health was operationalized as presence of any CVD. Models were tested in an aggregated sample, and also in subsamples by sex. In bivariate and component-path analyses, structural stigma predicted smoking across samples. Structural stigma-binge drinking associations were more salient among lesbian women compared to gay men. Per Sobel test results, smoking mediated associations between structural stigma and CVD in the gay men sample, suggesting gay men may smoke to escape from structural stigma, with negative implications for cardiovascular health.