Alcohol use among gender and sexual minorities: LGBT+ Drinkaware

Overview
This systematic scoping review uses the best available evidence (published and grey literature) to assess the prevalence of harmful drinking for LGBT+ people, causes and effects and related problems with reference to how alcohol use has changed over the life course, and at the intersections of age, ethnicity, gender and sexuality. Moreover, the review collates evidence on interventions and protective factors, to illustrate current practice in addressing the alcohol-related support needs of these communities in the UK.

Key questions
These are 1) What is the prevalence (measured between 2010-2021) of hazardous/harmful drinking among LGBT+ people in the UK? 2) How does alcohol use change among LGBT+ people in the UK throughout the life course? 3) What are the international interventions used between 2000-2021 to address alcohol-related support needs of LGBT+ communities?

Rationale
No recent comprehensive systematic scoping reviews exist to bring together relevant evidence on alcohol misuse for LGBT+ communities in the UK.

Methods
Two sets of inclusion criteria were developed. The first included published and grey literature available from 2010 on the prevalence of hazardous/harmful drinking among LGBT+ people in the UK and whether alcohol use changed through their life course. The second included published and grey literature from 2000 on any interventions used to address alcohol-related support needs of the LGBT+ communities in the UK and beyond. Database searches (and platforms) were performed in CINAHL (EBSCO), Central (Cochrane Library), Embase (OVID), MEDLINE (OVID), PsycINFO (EBSCO) and the Science Citation Index (Web of Science). Extensive searching of relevant charity websites, a private library of LGBT+ health research, citations from systematic and other reviews and relevant primary studies was made. Numerical and qualitative data was extracted from all relevant sources, with tables constructed from the data showing characteristics of included studies and their numerical results to enable comparison across studies. Risk of bias was by assessment of study design for prevalence studies and by CASP questionnaires for intervention studies. Two people conducted citation checking, data extraction and quality assessment (LZ and CM). Synthesis was through narrative description as meta-analysis was not appropriate.

Results
Question 1. What is the prevalence of hazardous/harmful drinking among gender and sexual minority communities in the UK?
Searches yielded 13 publications and 17 grey literature reports (29 studies in total). As alcohol misuse was reported in a wide variety of ways, no meta-analyses could be conducted, but in 19 studies of UK-based sexual orientation or LGBT+ populations compared to UK-based heterosexual populations, all had higher rates of alcohol use in sexual minority and LGBT+ populations compared to the heterosexual populations. From one study, rates in asexual people were lower than in allosexual people. No comparative trans/cisgender evidence was found but rates were apparently high when compared to average rates of drinking in the UK population. There was no information available on alcohol use in UK intersex people.

During the COVID-19 pandemic several UK LGBT+ charities enquired about alcohol use but there were no published studies on alcohol use in LGBT+ communities during this time. The relatively low quality data suggest more problems with alcohol misuse during the pandemic than beforehand. Where LGBT+ people reported increased alcohol use during lockdown, very few had access to alcohol use services during this period.

Question 2. How does alcohol use change among gender and sexual minorities in the UK throughout the life course?
Higher rates of excessive and regular alcohol use were found in younger LGB people and older LGB people, compared to their heterosexual peers. There is very little information regarding intersectional protected characteristics (such as age), and alcohol use. Evidence from before 2008 suggests that high rates of alcohol misuse have been prevalent in the LGB communities for many years with the worst drinking in women and in the younger age groups, but there is no early evidence on alcohol use in the trans, intersex or asexual communities in the UK.

There are a number of known risk factors or antecedents of alcohol misuse and dependence including: binge drinking; having at least one parent with alcoholism; having a mental health problem including anxiety, depression, and bipolar disorder; low self-esteem; stress; coming from a culture where alcohol abuse is comparatively common; and lack of family support in LGBT+ people. Whereas very limited evidence is available for LGBT+ people in the UK on how alcohol impacts rates of chronic illness, psychological or emotional problems, dementia, human papilloma virus (HPV)-based cancers, and HIV. There is very limited evidence that these conditions are more frequent in some LGBT+ people compared to heterosexual/cisgender people and how alcohol intake may impact these rates.

Question 3. Which international interventions have been used to address alcohol-related support needs of gender and sexual minority communities?
Searches yielded 24 publications and 5 grey literature reports (28 studies in total). There was some evidence on the effectiveness of various types of counselling specifically for alcohol misuse in sexual minorities, such as cognitive behavioural therapy combined with motivational interviewing, behavioural couple therapy, and modified behavioural self-control training. Several of these interventions showed some success. Interventions showing an awareness how, for some LGBT+ people, alcohol may be key to their socialisation, as well as interventions designed with involvement of LGBT+ people themselves as either practitioners or as peers, were perceived as more effective.

Although there are LGBT+ Alcoholics Anonymous (AA) meetings in the UK, there was no evidence found on the effectiveness of these. There was qualitative research on the experiences of UK people attending mainstream AA meetings. Some people from the USA found AA useful, particularly where they attended an LGBT+ AA meeting. The qualitative studies about UK LGBT+ people’s experiences of attending these services showed some difficulties, with people anticipating or experiencing homophobia, biphobia and transphobia or other problems in meetings. Also, some encountered presumptions that alcohol or mental difficulties were due to sexual orientation or gender identity, difficulties with the religious overtones, and feeling intimidated by mainstream services that added additional stress.

There were several studies on the effectiveness of interventions for general wellbeing that were evaluated in relation to LGBT+ people and measured alcohol use. Some of these were novel interventions or promising practices, such as a game-based intervention for young people, and the introduction of an anti-homophobia policy, both of which showed positive results, and some were more well-known interventions such as mindfulness and motivational enhancement. Some of these were successful in reducing alcohol consumption, particularly gay-straight alliances and anti-homophobia policies in schools, but some less so, such as mindfulness.

Protective factors against excessive alcohol use in LGBT+ people included social support, resilience and maintaining dignity, questioning social norms, having a supportive religious climate, and imagining a future without alcohol.

Conclusions
This systematic scoping review found good evidence to show that the prevalence of hazardous or harmful drinking amongst gender and sexual minority communities in the UK is higher than heterosexual and cisgender people across all ages and over a number of years, and that the COVID-19 pandemic may have made the situation worse. High alcohol intake can result in a number of physical and mental short- and longer-term problems and there is some evidence that these are more prevalent in LGBT+ people. Evidence suggests that mainstream counselling interventions may be effective in reducing harmful alcohol consumption, but very little of this research explores the experiences of trans, non-binary and intersex people. LGBT+ people encounter some difficulties with accessing mainstream programmes such as the AA, and that these could be more effectively tailored to address the specific needs of LGBT+ people. The ideal is for all service providers to ensure that alcohol services are LGBT+ inclusive, however where this is not attainable, services with a specific focus on LGBT+ communities are needed. Service providers should make every effort to foster an environment and treatment experience of affirmation and inclusivity by consulting with their local LGBT+ populations and by learning about LGBT+ people’s lives where underlying societal or structural factors may have increased reliance on alcohol. UK-based cohort studies of alcohol use and RCTs of alcohol misuse interventions should incorporate sexual orientation and gender identity measures into their data collection and report the results. With more robust reporting, the evidence generated could be used to inform future policy, practice and research to address the specific alcohol-related health needs of LGBT+ people with the aim to achieve greater health equity for these diverse communities.