Drug use and perceived social support in a sexual minority

Consumo de sustancias y apoyo social percibido por minoría sexual

ABSTRACT

Aim

To evaluate the perception of social support in a sexual minority and to associate it with the risk of drug addiction.

Method

Cross-sectional study, with 254 self-declared gay, bisexual, lesbian, or transsexual participants in the city of Fortaleza, between October and December 2019. Data analyzed by descriptive statistics and likelihood ratio tests.

Results

Most were satisfied with social support between low and medium (74.4%). The most commonly used drugs were alcohol (91.5%), tobacco (67.4%) and marijuana (66.9%). Assessing the risk of addiction, 28.7% scored it as low, 46.9% as moderate, and 9.8% as high risk. There was significance between satisfaction of social support and years of study.

Conclusion

We found a level of satisfaction between low and medium, and it was possible to report the most consumed drugs. There was no association between social support and drug use, although the weaknesses and strengths of social support have been highlighted.

Keywords
Sexual and gender minorities; Social support; Substance-related disorders

RESUMEN

Objetivo

Evaluar la percepción de apoyo social en una minoría sexual y asociarle con el riesgo de adicción a las drogas.

Método

Estudio transversal, con 254 participantes autodeclarados gay, bisexuales, lesbianas o transexuales en la ciudad de Fortaleza, entre octubre y diciembre de 2019. Datos analizados mediante estadística descriptiva y prueba de razón de verosimilitud.

Resultados

Satisfacción con el apoyo social entre baja y media (74,4%). Las drogas más consumidas fueron alcohol (91,5%), tabaco (67,4%) y marihuana (66,9%). En cuanto al riesgo de dependencia, 28,7% lo puntuó como bajo, 46,9% como moderado y 9,8% como riesgo alto. Hubo significación entre satisfacción con el apoyo social y años de estudio.

Conclusión

Encontramos nivel de satisfacción entre bajo y medio y fue posible reportar las drogas más consumidas. No se encontró asociación entre el apoyo social y el consumo de drogas, aunque se haya resaltado las debilidades y el potencial del apoyo social.

Palabras clave
Minorías sexuales y de género; Apoyo social; Trastornos relacionados con sustancias

RESUMO

Objetivo

Avaliar a percepção de suporte social em minoria sexual e associá-la com o risco de dependência de drogas.

Método

Estudo transversal, com 254 participantes autodeclarados gays, bissexuais, lésbicas ou transexuais na cidade de Fortaleza, entre outubro e dezembro de 2019. Dados analisados por estatística descritiva e teste de razão de verossimilhança.

Resultados

A maioria apresentou satisfação com suporte social entre baixa e média (74,4%). Acerca do uso de drogas, as mais utilizadas foram álcool (91,5%), tabaco (67,4%) e maconha (66,9%). Quanto ao risco de dependência, 28,7% pontuaram como baixo, 46,9% como moderado e 9,8% como alto. Houve significância entre satisfação do suporte social e anos de estudo.

Conclusão

Encontrou-se nível de satisfação entre baixo e médio e foi possível reportar as drogas mais consumidas. Não foi encontrada associação entre o suporte social e o consumo de drogas, embora as fragilidades e potencialidades do suporte social tenham sido evidenciadas.

Palavras-chave
Minorias sexuais e de gênero; Apoio social; Transtornos relacionados ao uso de substâncias

INTRODUCTION

Historically, the population of Lesbian, Gays, Bisexual, Transvestite, Transsexual and Transgender, Queer, Intersex, and Asexual people, among other possibilities of sexual orientation and/or identification and gender expression (LGBTQIA+), faces challenges that interfere in the guarantee of a full citizenship, with freedom, peace, and social justice1.

Brazil is still one of the most homophobic countries in the world, where one LGBTQIA+ person is murdered every 26 hours2. The LGBTQIA+ population has vulnerabilities and needs an adequate support network to deal with them, which may also happen place in health care, in order to achieve equity and social inclusion.

Nonetheless, it is valid to mention that the National Policy for Integral LGBT Health (PNSILGBT) is considered to be a milestone in regard to the health of the LGBTQIA+ population. This document, instituted by Decree 2.836/2011, aims to care for this population in an inclusive and egalitarian way, understanding that sexual diversity involves specific situations of health3.

Considering the particularities of the segments of this group, a Brazilian study which evaluated the use of psychoactive substances (PAS) in trans youth found that they mostly use these substances to relief stress and have fun. The main determinants for the drug use were instability at home and discrimination. The reports of feeling unsafe in public spaces have been directly related to higher drug use4.

That is, the anguish emerging from fear, prejudice, homophobia, and stigma may favor the abuse of alcohol and other drugs, which may lead to risky sexual behavior.

There are other elements associated with sexual orientation/gender expression and sexual identity, such as race/color, perception of risk for STIs, educational level, violence, and discrimination, even within one's own support network, all of which may be barriers against the access of the LGBTQIA+ population5. Among these barriers, the educational level stands out, since it is believed that individuals with more knowledge about the negative consequences of drug abuse may adopt damage control practices or not use these substances. However, the academic environment may favor the contact with legal and illegal substances, triggering the problematic use of drugs.

This context is associated to a loss of citizenship, that is, mainly, to violence and inequality in the access to the law and in the guarantee of one's rights. Therefore, in addition to collective efforts to develop and implement public policies, the family and other significant relationships have an important role in the social support network of this population, strengthening bonds of protection and support.

Social support is a product of social relations and of the perception of individuals about the quality, frequency, and suitability of the support they are offered, considering their needs6. Therefore, a negative perception of social support is one of the factors that affect the mental health of individuals, especially those who belong to social minorities, and can stimulate the use of PAS at any age, but, more strongly, during youth4.

Understanding the specificities related to the main vulnerabilities of the LGBTQIA+ population is an attitude that gives support to nursing care based on real needs, in addition to sensitizing professionals so they can overcome discrimination and stigma, which would lead to more inclusive care. Therefore, considering the importance of social relations and particular practices in the dynamics and quality of life of subjects, the objective of this work was to evaluate the perception of social support in a sexual minority and associate it with their risk for drug addiction.

METHOD

Sectional study with analytical components. Data collection took place from October to December 2019, in university and social LGBTQIA+ places in the city of Fortaleza, Ceará, such as university campi, freshmen parties, and places near LGBTQIA+ clubs. The university campi were selected because they are places where the population mentioned coexists and socializes, in addition to projecting the transitions that university life may favor, as well as more contact with psychoactive substances and the formation of friendships. Moreover, since this public may be more difficult to contact, the possibility of providing comfort and secrecy to the participants is greater. The inclusion criteria were self-declaring LGBTQIA+, being 18 years old or older, and having had at least one sexual encounter in the last 12 months. Those who showed any signs of disorientation due to the use of alcohol or other drugs were excluded. 262 participants were interviewed, 8 of whom were excluded due to incomplete data, resulting in a sample of 254 participants. To do so, a sample calculation for infinite populations, based on similar studies, was carried out, with an estimate of 246 participants7.

Graduation and post-graduation nursing students were previously trained for data collection, concerning the application of the forms, and went through a pilot test where they interviewed 15 people. Then, the layout of the form and the approach to participants were adjusted. The interviewees were recruited individually. At time of recruitment, the researcher presented themselves and explained the goals of the research. Later, the participants recommended friends who could also be included in the study, allowing for the recruitment using the snowball technique.

A semistructured form, adapted from another research8 was used, with 16 questions distributed in parts that represented the following categories: sociodemographic information and health care.

The Satisfaction with Social Support Scale (SSSS) was applied. This scale was validated in Brazil in 2014, with an internal consistency that varied from 0.64 to 0.83, with a value of 0.85 for the total scale9. The SSSS contains 15 questions distributed in four dimensions that evaluate the satisfaction in settings such as family and friend relationships. Its score is calculated through the Likert scale, varying from "completely agree" (1 point) to "completely disagree" (5 points). The maximum score is 75. The score of the SSSS is classified as low satisfaction when below 48, medium satisfaction from 49 to 61, and high satisfaction when above 62.

The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to estimate the amount of drug used. This questionnaire was developed by the WHO and validated in Brazil, with results of Cronbach's Alpha reliability of 0.80 for alcohol, 0.79 for marijuana, and 0.81 for cocaine10. The ASSIST has eight questions, all of which include the most common types of drugs and their score according with the responses, which are not equal. Finally, when the scores of all questions are summed up, the risk of use associated with each substance is indicated: low risk - less than 3 points (except for alcohol, where a score below 10 indicates low risk); moderate risk - from 4 to 26 points; and high risk - 27 points or more.

When the participant was interested and suited the eligibility criteria, they signed the free and informed consent form (FICF) and answered the questions of the semistructured form. The interviews lasted for a mean of 20 minutes.

The software Statistical Package for the Social Sciences® (SPSS) was used to create the database and treat the data. The first stage of the statistical analysis included the use of descriptive components, through the calculation of frequencies (of central tendency measures and dispersion measures). The Kolmogorov-Smirnov test was carried out to verify the normality of data distribution. For the association of data, likelihood tests for categoric variables and the Kruskal-Wallis test were used to compare the means of the groups.

The research was approved by the Research Ethics Committee of the Universidade Federal do Ceará, under CAEE nº 29499120.8.0000.5054.

RESULTS

In regard to sociodemographic characterization, 139 of the 254 participants (54.7%) were male and their mean age was 22 years old. Regarding their gender identity, most were cisgender (233 - 91.7%), and in regard to their sexual orientation, most were gay (104 - 40.9%), bisexual (97 - 38.1%), and lesbian (34 - 13.3%). In regard to their race, most were non-white (172 - 67.1%). Concerning sexual partners, 130 (51.1%) did not have partners, while 102 (40.1%) were. Most had no children (250 - 98.4%).

Regarding their income and occupation, most were students (144 - 56.6%), whose income came from their families, partners, or friends (78 - 30.7%). An income of up to a minimum wage (which, at the time, was R$1,006.00) was the most prevalent (132 - 71.53%), with a mean of R$1,001.90. Most reported living with their father and/or mother (141 - 55.7%). Participants had a mean of 15 years of formal education, most being between 13 and 16 (180 - 75.63%), and more than half had no religion (139 - 54.9%). Among those who stated to have a religion, little more than half felt embraced in their religious practices (58 - 50.4%).

The means of individual responses and the means of the dimensions are shown in table 1.

Table 1 -
Analysis of the SSSS in regard to central tendency and dispersion measures. Fortaleza, Ceará. 2021

Results of the responses	Mean	Min	Max	SD
Dimension 1: Satisfaction with friends	2.25	1	5	1.36
Friends do not look for me as often as I would like	3.49	1	5	1.33
I am satisfied with the number of friends I have	1.73	1	5	0.99
I am satisfied with the amount of time I spend with my friends	2.49	1	5	1.76
I am satisfied with the activities and things I do with my group of friends	2.05	1	5	1.12
I am satisfied with the type of friends I have	1.49	1	5	0.91
Dimension 2: Intimate relations	2.62	1	5	1.46
Sometimes I feel alone in the world, with no support	3.25	1	5	1.36
Sometimes I miss someone really intimate that understands me and with whom I can talk about intimate things	3.34	1	5	1.48
When I need to vent, I found friends to do so easily	1.89	1	5	1.21
Even in the most embarrassing situations, If I need emergency support I have a lot of people I can resor to	2.03	1	5	1.13
Dimension 3: Satisfaction with family	2.96	1	5	1.47
I am satisfied with the way I relate to my family	2.62	1	5	1.48
I am satisfied with what I do with my family	2.77	1	5	1.39
I am satisfied with the amount of time I spend with my family	3.49	1	5	1.39
Dimension 4: Social activities	3.03	1	5	1.49
I do not go out with friends as often as I would like	3.15	1	5	1.48
I miss social activities that satisfy me	3.03	1	5	1.46
I would like to participate more often in activities in organizations	2.93	1	5	1.53

• Source: Research data.

The questions with the highest means were about not being looked for often by friends and about the satisfaction with the amount of time spent with family, meaning that participants, in short, did not believe their friends looked for them too rarely and were not satisfied with the amount of time they spent with their family. The type and number of friends, however, had the lowest mean, showing dissatisfaction in these two aspects, that is, most participants were dissatisfied about the type and number of friends.

In the score of the SSSS, 77 (30.3%) had low satisfaction, 112 (44.1%) had medium satisfaction, and 65 (25.6%) showed high satisfaction with their support network. That is, the satisfaction of most participants was from low to medium (189 - 74.4%). The minimum general score in the SSSS was 27, with a maximum of 75, a mean of 54.5, and a standard deviation of 9.67.

From the 254 respondents, 30 (11.8%) had never used drugs, and the drugs they had used the most, at least once in their lives, were: alcohol (205 - 91.5%), tobacco (151 - 67.4%), and marijuana (150 - 66.9%). Regarding the risk for addiction, 73 (28.7%) had low risk, 119 (46.9%) had moderate risk, and 25 (9.8%) were classified as under high risk to develop an addiction.

The application of the likelihood ratio found that those with less than 14 years of schooling were more likely to have a low level of satisfaction with their social support when compared to those with 15 or more years of schooling (p=0.006).

Regarding their sexual behavior, 159 (62.5%) participants had regular partners. From these, 85 (53.4%) had already practiced chemical sex (use of PAS before or during the sexual act; in most cases, their satisfaction with the social support was medium 37 (23%). Casual partners were reported by 109 participants (42.9%), 50.4% of whom had practiced chemical sex. Most of those who had had chemical sex had a medium satisfaction in regard to the social support (30 - 54.4%); among those who did not, the high social support was more common (21 - 38.8%).

Table 2 shows the associations between the use of substances, found using the application ASSIST, and the degree of satisfaction with the social support.

Table 2-
Association between drug use at least once in the past and degree of social support. Fortaleza, Ceará, 2021

Substance	Satisfactionwith social support			P-value
	Low	Mean	High
Tobacco				0,88
Never used	31 (30.2%)	44 (42.7%)	28 (27.1%)
Used	46 (30.4%)	68 (45.1%)	37 (24.5%)
Alcohol				0.83
Never used	15 (30.6%)	20 (40.8%)	14 (28.6%)
Used	62 (30.4%)	92 (44.8%)	51 (24.8%)
Marijuana				0.60
Never used	36 (33.3%)	47 (43.5%)	25 (23.2%)
Used	41 (28.1%)	65 (44.5%)	40 (27.4%)
Cocaineor crack				0.94
Never used	70 (30.5%)	101 (44.2%)	58 (25.3%)
Used	7 (28%)	11 (44%)	7 (28%)
Stimulants				0.57
Never used	67 (29.4%)	101 (44.3%)	60 (26.3%)
Used	10 (38.5%)	11 (42.3%)	5 (19.2%)
Inhalant				0.38
Never used	63 (30.1%)	89 (42.6%)	57 (27.3%)
Used	14 (31.1%)	23 (51.1%)	8 (17.8%)
Hypnoticsandtranquilizers				0.20
Never used	73 (31.8%)	100 (43.7%)	56 (24.5%)
Used	4 (16%)	12 (48%)	9 (36%)
Hallucinogen				0.66
Never used	71 (31.2%)	100 (43.8%)	57 (25%)
Used	6 (23%)	11 (42.4%)	9 (34.6%)
Opiates				0.76
Never used	76 (30.5%)	109 (43.8%)	64 (25.7%)
Used	1 (20%)	3 (60%)	1 (20%)

• Source: Research data.
• ^*Likelihood ratio

The level of satisfaction with one's social support was mostly around low and medium, reaching 82.2% among those who used inhalants. The highest rates of satisfaction could be found among those who used hypnotic, tranquilizer, and hallucinogen drugs. However, their satisfaction was no more than medium.

When the risk of addiction to substances was associated to social satisfaction (Table 3), it was found that 189 (74.4%) participants had a low-to-medium risk for addiction. There was no statistical association between the degree of satisfaction with social support and the risk of substance addiction.

Table 3-
Association between the degree of satisfaction with one's social support and the risk for substance addiction. Fortaleza, Ceará, 2021

Risk for addictionon substances	Satisfaction with social support			Total	P-value
	Low	Medium	High
Low	33 (42.8%)	44 (39.3%)	33 (50.8%)	110 (43.3%)	0,67
Moderate	37 (48.1%)	56 (50%)	26 (40%)	119 (46.9%)
High	7 (9.1%)	12 (10.7%)	6 (9.2%)	25 (9.8%)
Total	77 (100%)	112 (100%)	65 (100%)	254 (100%)

• Source: Research data.
• ^*Likelihoodratio

DISCUSSION

Processes of that increase vulnerability lead to the weakening of the health of individuals and, therefore, the aspects involved require investigations so they can be analyzed and overcome. The theory of minority stress (MS) states that social minorities experience specific stressors in addition to daily life ones, based on external (social) and internal (personal) factors, as the analysis of the discourse of gay men and the struggle for acceptance, interpersonal stigma, and the migration process "searching for happiness", represented by leaving one's home towards an environment that is considered to be more embracing11.

In this context, LGBTQIA+ persons need to be more adaptive, because in addition to the daily stressors common to all people, they must deal with the specific stressors that their minority face daily.

The intersectional analysis of potential factors related to the mental health of minority groups reiterates the importance of the socioeconomic situation for the individual wellbeing; furthermore, clinical frameworks related to mental health, such as drug abuse, may be related to social stress. These data corroborate the findings of this study, which shows that participants had certain level of financial dependence/instability, high levels of drug abuse, and intense fluctuations in their responses about social support, with a tendency of social satisfaction from low to medium12.

The prevalent profile found shows young adults in the university, who live with their parents. It has been reported that the social support perceived by minorities is greater when it comes from society as a whole than when it comes specifically from the LGBTQIA+ population in regard to hope, and the support network, with riends and other social interactions, is highly important. Although this study did not compare groups, it became clear that family and involvement in social activities were important for the wellbeing of the participants13.

The educational level interfered in the perceived social support and, in spite of the scarcity of studies associating social support and educational level, it is believed that social support can benefit from more sensitization and identification of needs, as well as from a greater ability to solve problems and maintain relationships. A study that evaluated the quality of life of Taiwanese gays and bisexuals found that the lower the educational level, the lower the quality of life in the physical, psychological, and environmental domains, which is, up to a certain point, related to social support14.

Social relations, as the base of social support, reflect some behaviors, such as the approximation to one's peers, which increases the feeling of recognition and validation. The LGBTQIA+ community, although not a homogeneous group, tends to recognize its elements and be sensitive to the issues they face, such as stigma and discrimination, which is also represented by the model of MS. These relations, if experienced in a health way, favor social support. However, some strategies to deal with difficulties may be harmful, such as drug use.

Sexual minorities are more likely to have disorders related to the use of alcohol, tobacco, and other drugs than the heterosexual population, with male and female bisexuals presenting the higher prevalence of psychic suffering and alcohol and tobacco abuse, when compared to heterosexuals15.

In the myriad types of sexual partnerships, trust (a feeling often related to the perceived social support) may guide decisions, such as that of using or not condoms or using or not substances before or during sex (chemical sex). A British research with more than 2,500 LGBTQIA+ teens showed that those who lived in supportive environments consumed less substances than those who lived in environments where they received little LGBTQIA+ support, which, in regard to casual sexual partnerships, this study corroborates16.

There was no statistically significant associations between drug consumption and the degree of satisfaction with social support. However, it is important to highlight that literature indicates that sexual and gender minorities use more substances when compared to other groups, often as a strategy to deal with issues related to personal experiences of prejudice, in addition to stress in one's daily life17.

Although this research address sexual minorities in general, we recognize that the vulnerability of transgender people is related with the use of substances to deal with gender-related stressors, as shown by a Brazilian study with the youth transgender population that found that drug abuse was more related with stress relief than with leisure3.

Considering the fragility of the social support of this population, this study asks for a more careful look towards the risk of drug use in its population.

Among the substances investigated, alcohol, tobacco, and marijuana are the most used in the population studied Alcohol use was coherent with the result of an Australian study that investigated harmful alcohol use in youth sexual minorities, 75.4% of whom had used the substance in the month prior to the research17. Therefore, we must understand how this can influence the life of these subjects.

Concerning the association of the risk for substance addiction and the degree of satisfaction with the social support, the results had no statistical significance. There was a prevalence of those under risk for moderate addiction(50%), considering those with low or medium levels of satisfaction with social support. Most also showed a medium risk for addiction to substances.

Although the participants of the study showed a low-to-medium risk for substance addiction, it should be highlighted how relevant social support is for damage control in regard to the use of alcohol and other drugs, since this behavior is common in the LGBTQIA+ population. It should also be highlighted that few studies in literature associate the degree of satisfaction with social support and the risk for addiction to substances in LGBTQIA+ people.

The low and medium satisfaction with the social support shows the potential barriers faced by the sexual minorities in receiving support from their family, friends, and from society as a whole. A well-structured social network with social support characteristics is significantly associated to the reduction of risky behavior in homosexual youth, for example, leading them to reduce or stop the use of psychoactive substances18.

A study carried out in the Brazilian Northeast analyzed the association between the use of substances and suicide in the LGBTQIA+ population, showing that the use of illegal substances, especially marijuana, ecstasy, and cocaine were associated with suicide attempts from individuals that are part of sexual minorities. Low social support may increase the odds of suicide in this vulnerable population19.

Family support has been associated with an increase in the degree of satisfaction in many domains of life of LGBTQIA+ people, including diminutions in suicide, suffering, depression, loss of hope, and use of substances. The sexual minority youth receive different levels of social support in many different places, which is associated to the health of these individuals. Therefore, there must be a holistic and humanistic perspective that goes beyond a single domain, such as family and friends, so high-level support can provided, in order to generate a collective impact in the satisfaction of this population.

Social environments of support to sexual minorities are identified as the main factors in the promotion of the wellbeing and satisfaction of the individuals. The LGBTQIA+ of the communities are one of these environments. These groups express a feeling of acceptance and satisfaction through the identification as LGBTQIA+, in addition to the strong support received from those who identify as they do, highlighting identification and the collective struggle, considering the lived and shared experiences. The social and cultural support in LGBTQIA+ networks and the important contribution of common interest groups significantly increase the satisfaction with social support20.

CONCLUSION

The LGBTQIA+ showed a moderate risk of becoming dependent on the use of substances, and the most commonly used substances were alcohol, tobacco, and marijuana. Their satisfaction with social support was from low to medium. However, there was no statistical significance between these two factors.

People with 15 years or more of schooling and those who did not practice chemical sex showed a higher level of satisfaction with social support. Therefore, we highlight the importance of embracing better the more vulnerable population, who perceive their social support network as weaker.

The goal of our approach was not to evaluate cause-effect relations and cannot be generalized due to its design; therefore, we suggest further researches with other designs and approaches that can achieve these goals. Moreover, for comparisons to be possible, we suggest similar studies to be carried out with groups with different characteristics (groups of people who are not from universities, for example). Still, this research contributes for the practice of nursing, since its findings may guide strategies to promote the health of sexual minorities about the perception of social support and its relationship with the risk of drug addiction.

The nurse has an essential role in providing social support to the LGBTQIA+ population, since, often, support, embracing, and help are sought in the health services. Nursing professionals can also aid in the insertion of the practices from public policies and in the reduction of inequality in the context of the care provided to the LGBTQIA+ population.

Funding/acknowledgements:

We would like to thank the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq - the National Council for the Scientific and Technological Development) for the funding provided through public notice CNPq/MS-DIAHV nº 24/2019- Researches in Actions of Surveillance, Prevention, and Control of Sexually Transmitted Infections, HIV/AIDSand Viral Hepatitides. We would also like to thank the Coordenação de Aperfeiçoamento Pessoal e de Nível Superior (CAPES - the Coordination for the Improvement of Higher Educational Personnel).

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Edited by

Associated editor:

Rosana Maffacciolli

Head editor:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  31 July 2022
• Date of issue
  2022

History

• Received
  18 May 2021
• Accepted
  06 Dec 2021