Differences in Substance Use and Sexual Risk by Sexual Orientation and Gender Identity Among University and Community Young Adults in a U.S.-Mexico Border City

Abstract

Ethnic and sexual minority young adults in El Paso, Texas, are at high risk for substance use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV). In 2014, a Hispanic-serving higher education institution partnered with two community-based organizations to implement integrated substance use interventions and HIV and HCV prevention among young adults on campus and in surrounding communities. Among the 95 young adults, aged 18–24 years, who responded to a needs assessment survey, 91.5% were Hispanic, 53.7% were female, and 27.4% were sexual or gender minorities (SGMs) as defined by behavior and identity. SGMs had significantly higher rates of current smoking, drinking when bored, and of being told they had a drinking problem. Compared with the other young adult survey respondents, SGMs had lower health risk perceptions for tobacco, alcohol, and marijuana use and reported similar or higher rates of lifetime drug use during sex and higher rates of HIV risk behaviors. Study findings have implications for including measures for sexual orientation and gender identity in substance use studies, examining regional and cultural norms that may intersect to shape substance use among SGMs, and incorporating unique risk contexts for SGMs in interventions for substance use.

Keywords

health disparities LGBT minority health sexual health HIV/AIDS substance abuse university/college health

Although at high risk for substance use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV), ethnic and sexual minority young adults in the United States are underserved for prevention interventions—especially those with low education level, limited health literacy, and limited social skills. Also, they face vulnerabilities such as stigma, gender norms, and language and cultural barriers (Centers for Disease Control and Prevention, 2018). These personal and sociocultural factors not only act individually to shape substance use–related health disparities among ethnic, sexual, and gender minority young adults but also intersect to exacerbate risk for such disparities by increasing stress and negative coping behaviors (Ching et al., 2018; Meyer, 2003; Mink et al., 2014; Parent et al., 2019; Substance Abuse and Mental Health Services Administration [SAMHSA], 2019; Woodford et al., 2012).

Substance Use Among College Students

Young adults have experiences with drug and alcohol use as college students, including drug experimentation and excessive drinking (Boyd et al., 2003; Lewis et al., 2009; Rimsza & Moses, 2005). Tobacco use among young adults has been increasing, including through the use of hookahs and e-cigarettes (vaping), as an alternative to smoking cigarettes. Among college students, both behaviors are driven by peer norms and the belief that both are less harmful compared with other tobacco products (Montgomery et al., 2015). While marijuana and alcohol are reported as most commonly used substances among college students, they also have increased availability of and easy access to ecstasy, nonmedical prescription stimulants, and other illicit drug use (Arria & DuPont, 2010; Arria et al., 2017; Boyd et al., 2003; DeSantis et al., 2008; Garnier-Dykstra et al., 2012). A review of the literature indicates that college students combine drugs and alcohol with their sexual experiences, increasing their risk for sexually transmitted infections (Lewis et al., 2009).

Health Risks on U.S.-Mexico Border

Conditions unique to border populations, such as migration, language barriers, lack of access to health care, poverty, low health literacy, and structural violence (Pan American Health Organization, 2012), place individuals residing along the U.S.-Mexico border at increased risks for substance use, HIV, and HCV transmission, especially among minority young adults (Mangadu et al., 2017). A study examining HIV care along the California-Mexico border found that residents of Mexican origin and those who crossed the border frequently were less likely to have access to care due to stigma of being HIV positive, sick due to side effects, and concerned about others finding out about their status (Zuniga et al., 2008). Also, for low-income and less acculturated Hispanic/Latinos, HIV-specific stigma was less likely to be screened (Lopez-Quintero et al., 2005). Moreover, the day-to-day transborder movement of people and their diverse acculturation levels and immigration status are shown to increase risky behaviors (Strathdee & Magis-Rodriguez, 2008).

Substance Use Trends Among Hispanic Young Adults on the U.S.-Mexico Border

Among border populations, immigration-related issues and transborder mobility make it difficult collecting reliable behavioral data (Martinez-Donate et al., 2015; Pinedo et al., 2014; Robertson et al., 2012), although some studies have examined difference in substance use among young adults on both sides of the border. In the United States, alcohol and marijuana have been consistently reported as the most common substances used among college students (Rimsza & Moses, 2005). Ceballos et al. (2012) indicate that more college students in the U.S. side of the border reported drinking compared with their peers in Mexico. A study conducted among students (N = 803) in two large southwestern universities close to the U.S.-Mexico border revealed that students who crossed over to Mexico to drink alcoholic beverages tended to consume more drinks than their peers who did not (Shillington & Clapp, 2001). Findings from a more recent study conducted among college students in South Texas in the U.S.-Mexico border region (N = 296) suggest that less acculturated male Hispanics may be more at risk for alcohol abuse compared with more acculturated male or female Hispanic students (Montoya et al., 2016). A study observing acculturation among Hispanics/Latinos, stated that women with greater acculturation were at greater risk for alcohol use disorders compared with men (Castaneda et al., 2019). Compared with those not enrolled in college, there is a 51% increased probability of marijuana use among college students (Miech et al., 2017; Schulenberg et al., 2018). Findings from a local study in El Paso reveal that substance use, in general, is lower among foreign-born compared with U.S.-born Hispanic youth (Loza et al., 2017).

Sexual and Gender Minorities

Although the literature on the relationship between substance use and sexual minority status is reliable, there are limitations. The 2000 National Alcohol Survey results indicate differences by sexual minority status (Drabble et al., 2005). For example, compared with heterosexual women, lesbians were 7.1 times more likely to be classified as positive for alcohol dependence. Similarly, the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions reports sexual minorities at increased risk for substance use and substance dependence. Sexual minority women had 5.2 times higher odds of smoking marijuana compared with heterosexual women (McCabe et al., 2009). Several studies highlight the increased risk for substance use among sexual minority college students, particularly addressing the connection between the stress (as a result of societal-level sexual stigma, harassment, and violence) and substance use (Boyd et al., 2003; McCabe et al., 2003; Reed et al., 2010). Thus, some sexual minorities may cope with substances to face these day-to-day stressors (Meyer, 2003; Reed et al., 2010). College male students who identified as a sexual minority had higher rates of alcohol and substance use as compared with other male students of the same age who reported as heterosexual (Parent et al., 2019). Based on the 2015 National Survey on Drug Use and Health, compared with those identifying as heterosexual, bisexual individuals had more than 50% higher odds of reporting past-year and past-month opioid misuse (Duncan et al., 2019). A meta-analysis of 553 peer-reviewed articles published between 2007 and 2012 on substance abuse, highlights limitations in literature as it indicates that only 21 (3.8%) reported sexual orientation and only two (0.4%) reported both sexual orientation and gender identity (SOGI; Flentje et al., 2015). A 2011 literature review indicates that although the association between sexual orientation and alcoholism has been well established in the scientific literature, these results may be biased based on sampling techniques, accounting for relevant cofactors, and measures for sexual minority status (Hughes, 2011).

Theoretical Frameworks

Frameworks that explain the intersectionality (Giritli Nygren & Olofsson, 2014) among sexual minorities’ drug use and sexual risk behaviors may not be specific to ethnicity and related more to their sexual orientation (Ramirez-Valles et al., 2008). For example, the “minority stress model” suggests that stressors related to identity, homophobia, and prejudice subsequently lead to health disparities in substance use disorders (SUDs), affective disorders, and suicide among sexual and gender minorities (SGMs; Meyer, 2003). Also, the “intersectional ecology model” of LGBTQ (lesbian,gay, bisexual, transgender, and queer) Health addresses the impact of stressors and coping responses, which affect health and may elevate substance use rates among SGMs (Mink et al., 2014; Parent et al., 2019). Hence, identifying differences in sexual risk or substance use patterns between SGM and others is a first step to develop comprehensive evidence-based interventions related to substance abuse, HIV, and HCV targeted at sexual minorities.

Purpose

Since data on SOGI are not collected in most health care or social services settings (Loza et al., 2018), there are no reliable estimates on the unique risk contexts, vulnerability, substance use trends, and barriers in utilization. To our knowledge, this is the first study to assess substance use and sexual risk behaviors among sexual minority young adults in a predominately Hispanic setting in the U.S.-Mexico border city. Southwest Texas, including El Paso County, is considered a partially medically underserved area (Health Resources & Services Administration, 2016; Texas Department of Rural Affairs, 2009) with limited availability of prevention and treatment services.

This study is a result of a collaboration and partnership between The University of Texas at El Paso (UTEP) and two community-based organizations (CBOs) who provide mental/behavioral health promotion, SUD treatment, and HIV prevention services. UTEP is a minority serving institution of higher education where almost 80% of its 25,151 students are Hispanic (mostly of Mexican descent) and half are the first to attend college in their families (UTEP, 2019).

The results of this study are part of a larger needs assessment survey funded by the SAMHSA grant, which required an arrangement between minority serving institutions in partnership with CBOs to better understand existing disparities in access, service use, and outcomes related to substance abuse, HIV, and HCV among minority young adults aged 18 to 24 years belonging to vulnerable subpopulations on a university campus and surrounding communities, including SGMs. Insights gained from this study’s findings can make health policy decision makers aware of the need to develop culturally tailored, comprehensive, evidence-based bilingual substance abuse prevention interventions and treatment programs targeted at reducing health disparities in HIV and HCV health care among border young adults and highlight the SGMs identity as multifaceted and intersectional.

Method

Study Design

This was a cross-sectional study based on the survey responses from college students and young adults in the El Paso community. It was designed to better inform the development of data-driven strategies to develop and implement evidence-based interventions to reduce/prevent substance abuse, HIV, and HCV among border young adults.

Sample

A convenience sample consisted of 107 young adults 18 to 24 years of age recruited on the UTEP Campus through student leadership organizations, the UTEP Entering Students Program, and faculty. Participants from surrounding communities were recruited with the help of partnering CBOs through a purposive sample of individuals who had engaged in or were at high risk for substance abuse. Since UTEP is a commuter campus with about 90% of the students living at home in the El Paso community (UTEP, 2019), the student-based sample included participants recruited by the partnering CBOs who routinely work with the target population. The study sample is a reliable approximation of the makeup of the young adult population in El Paso.

Data Collection

Data collection took place from November 2014 through April 2015 by two partnering CBOs who provide mental/behavioral health promotion, SUD treatment, and HIV prevention services. Survey data were collected using a standardized electronic survey in English or Spanish using iPads, via Qualtrics, a data collection software, and took approximately 25 minutes to complete.

Measures

The needs assessment survey used scales based on SAMHSA’s “Communities That Care Survey,” and the “Community Level Instrument Part II” and consist of 50 items encompassing general demographic questions, questions about social media use, general well-being questions, the use of legal and prohibited mind-altering substances, and sexual behaviors.

Sociodemographic Characteristics

The following sociodemographic characteristics were collected: age; sex assigned at birth; gender identity; sexual orientation; Hispanic, Latino/Latina, or of Spanish ethnicity; and race/ethnicity. In terms of language and their social network, participants were asked how well they spoke English, if a language other than English was spoken at home, if so, what is this language, and ethnicity of close friends. Markers for socioeconomic status include level of education, whether currently attending UTEP, current employment status, income of participant and/or family in the past year before taxes, and whether they have health care or medical insurance.

Substance Use and Perception of Health Risks

To assess the initiation and use of drugs, participants were asked if they used marijuana or hashish, other illegal drugs, and prescription drugs without a doctor’s orders in the past 30 days, and lifetime polydrug use or injection drug use. Participants were asked about their current smoking status. Among smokers, smoking at least one cigarette daily for 6 months or longer and likelihood of smoking in any of the following situations: around other smokers, when drinking alcohol, celebrating/at a party, when anxious/worried, when stressed, when bored. Alcohol-related measures include current use and ever being told they drink too much.

To assess views on health risks due to drug use, participants were asked about smoking one or more packs of cigarettes per day, smoking marijuana once or twice a week, and having five or more drinks of an alcoholic beverage once or twice a week. For the following mood-altering substances, participants were asked their views on the health risks (no problem, minor/moderate problem, severe problem): alcohol (beer, wine, hard liquor), tobacco, marijuana, cocaine (coke), prescription pain relievers (Vicodin, Oxycontin, Tylox), tranquilizers (Xanax, Valium, Ambien), and stimulants (Ritalin, Adderall) without a doctor’s order, heroin (smack), methamphetamines (meth, crank crystal meth), psychedelic drugs (LSD [lysergic acid diethylamide], peyote, PCP [phencyclidine], bath salts), ecstasy, and inhalants (glue, gasoline, aerosol from spray cans).

Sexual Risk Behaviors

To assess sexual risk behaviors, participants were asked first about their current relationship status and if they ever had sex (vaginal, oral, or anal). If so, when was the last time they had sex (in the past 7 days, past 2 weeks, past month, 2–3 months ago, 4–6 months ago, more than a year) and frequency of condom use (never, sometimes, always).

Participants were asked if they ever had sex under the influence of drugs. In terms of HIV risk behaviors in the past 3 to 6 months, participants were asked if they had unprotected vaginal, anal, or oral intercourse; unprotected sex in exchange for money or drugs, with more than three partners, with an injection drug user, with someone they thought was HIV infected, with someone they thought had AIDS (acquired immune deficiency syndrome); or if they had tattoos or piercings. Unprotected sex was left to the interpretation of the individual noting that pre-exposure prophylaxis was not widely available during data collection. Last, participants were asked how frequently they thought their peers engaged in vaginal, oral, or anal sex.

Analysis

A person was coded as SGM if they identified as transgender, lesbian, gay, or bisexual using measures for SOGI. Hispanic, Latino/Latina, or Spanish origin was determined if they reported being Mexican, Mexican American, Chicano/Chicana, Puerto Rican, Cuban or another Hispanic, Latino, or of Spanish origin. Participants were asked to indicate their race/ethnicity and select all that apply. These responses were recoded to White, Black or African American, Native American, Asian, Pacific Islander, or Mixed Race/Ethnicity if they indicated more than one race/ethnicity. “Other illegal drugs” refers to use of cocaine, heroin, methamphetamines, psychedelic drugs, ecstasy, and inhalants.

Descriptive statistics for all measures will include mean and standard deviation for continuous variables and frequency and percent for categorical variables. Bivariate associations for measures of substance use and sexual risk behaviors by SGM status were determined using Pearson chi-square test or its nonparametric equivalents. Analyses were conducted using SPSS, Version 21 (International Business Machines, 2012).

Results

Descriptive statistics of substance use and perceptions and risk behaviors and bivariate associations by SGM status (n = 95) were determined (Tables 1 –3). Sample sizes vary in some questions due to nonapplicability of a question or, as is common in surveys dealing with illegal substance use of sexual behaviors, by participants’ refusal to answer.

Table 1

Descriptive Statistics of Sociodemographic Characteristics in Needs Assessment Among University and Community Young Adults in a U.S.-Mexico Border City (N = 95)

Sociodemographic characteristic	n	Frequency (%)
Age, years, M (SD)	85	22.6 (3.6)
Sex assigned at birth	95
Male		44 (46.3)
Female		51 (53.7)
Gender identity	95
Woman		51 (53.7)
Man		38 (40)
Transgender		6 (6.3)
Sexual orientation	95
Heterosexual, that is straight		69 (72.6)
Lesbian or gay		15 (15.8)
Bisexual		9 (9.5)
Declined to state		2 (2.1)
Sexual or gender minority	95	26 (27.4)
Hispanic, Latino/Latina, or of Spanish origin	94	86 (91.5)
Race/ethnicity	95
White		77 (81.1)
Black or African American		4 (4.2)
Native American		3 (3.2)
Asian		3 (3.2)
Pacific Islander		5 (5.3)
Mixed race/ethnicity		3 (3.2)
English proficiency	95
Very well		78 (82.1)
Well		15 (15.8)
Not well		2 (2.1)
Language other than English spoken at home	95	65 (68.4)
If so, other languages spoken at home	65
Spanish		62 (95.4)
Other language		2 (3.1)
Declined		1 (1.5)
Highest level of education completed	95
12th grade/high school diploma equivalent		19 (20)
Some college or university		47 (49.5)
Bachelor’s degree (BA, BS) or higher		21 (22.1)
Vocational/tech diploma after high school		4 (4.2)
Declined		4 (4.2)
Employment status	93
Employed		56 (60.2)
Unemployed		22 (23.7)
Other		15 (16.1)
Household income in the past year before taxes	86
$0–$20,000		23 (26.7)
$20,001–$40,000		21 (24.4)
$40,001–$60,000		13 (15.1)
More than $60,000		10 (11.6)
Declined/don’t know		19 (22.1)
Health care or medical insurance	82
Yes, private insurance		28 (34.1)
Yes, Medicare, Medicaid, or other public assistance		18 (22)
No		24 (29.3)
Declined/don’t know		12 (14.6)

Table 2

Descriptive Statistics and Bivariate Associations for Substance Use and Perception of Health Risks Among University and Community Young Adults in a U.S.-Mexico Border City by Sexual or Gender Minority Status (N = 95)

Substance use and perception of health risk	Overall		Sexual or gender minority
	(n = 95)		Yes (n = 26)		No (n = 69)
	n	Frequency (%)	n	Frequency (%)	n	Frequency (%)
Initiation and use of drugs
Marijuana in past 30 days	86		25		61	**
Yes		15 (17.4)		1 (4.0)		14 (23.0)
No		43 (50.0)		13 (52.0)		30 (49.2)
Declined/don’t know		28 (32.6)		11 (44.0)		17 (27.9)
Other illegal drug use in past 30 days	86		25		61
Yes		2 (2.3)		0 (0)		2 (3.3)
No		54 (62.8)		13 (52.0)		41 (67.2)
Declined/don’t know		30 (34.9)		12 (48.0)		18 (6.6)
Prescription drugs use without a doctor’s orders in past 30 days	86		25		61
Yes		3 (3.5)		0 (0)		3 (4.9)
No		55 (64.0)		14 (56.0)		41 (67.2)
Declined/don’t know		28 (32.6)		11 (44.0)		17 (27.9)
Lifetime polydrug use	81	10 (12.3)	22	5 (22.7)	59	5 (8.5)
Lifetime injection of any drugs	82	4 (4.9)	23	1 (4.3)	59	3 (5.1)
Current smoking status	90		25		65	*
Yes		19 (21.1)		9 (36.0)		10 (15.4)
No, quit smoking		13 (14.4)		2 (8.0)		11 (16.9)
No, never smoked		58 (64.4)		14 (56.0)		44 (67.7)
Among current or past smokers, ever smoked at least 1 cigarette daily for 6 months or longer	32	16 (50.0)	11	7 (63.6)	21	9 (42.9)
Among current smokers, how likely to smoke in these situations
Around other smokers	19		9		10
Likely		12 (63.2)		7 (77.8)		5 (50)
Not sure		4 (21.1)		1 (11.1)		3 (30)
Not likely		3 (15.8)		1 (11.1)		2 (20)
When drinking alcohol	19		9		10
Likely		14 (73.7)		7 (77.8)		7 (70)
Not sure		2 (10.5)		1 (11.1)		1 (10)
Not likely		3 (15.8)		1 (11.1)		2 (20)
Celebrating/at a party	19		9		10
Likely		13 (68.4)		6 (66.7)		7 (70)
Not sure		3 (15.8)		2 (22.2)		1 (10)
Not likely		3 (15.8)		1 (11.1)		2 (20)
When anxious/worried	19		9		10
Likely		13 (68.4)		6 (66.7)		7 (70)
Not sure		1 (5.3)		1 (11.1)		0 (0)
Not likely		5 (26.3)		2 (22.2)		3 (30)
When stressed	19		9		10
Likely		13 (68.4)		6 (66.7)		7 (70)
Not sure		1 (5.3)		1 (11.1)		0 (0)
Not likely		5 (26.3)		2 (22.2)		3 (30)
When bored	19		9		10	**
Likely		11 (57.9)		7 (77.8)		4 (40)
Not sure		2 (10.5)		2 (22.2)		0 (0)
Not likely		6 (31.6)		0 (0)		6 (60)
Current alcohol use	90		25		65
No, never drunk alcohol		16 (17.8)		6 (24.0)		10 (15.4)
Yes, currently drinks alcohol		62 (68.9)		16 (64.0)		46 (70.8)
No, quit within the past 6 months		8 (8.9)		3 (12.0)		5 (7.7)
No, quit more than 6 months ago		4 (4.4)		0 (0.0)		4 (6.2)
Ever been told they are drinking too much	67		19		48	**
Yes		12 (17.9)		4 (21.1)		8 (16.7)
Not sure		10 (14.9)		7 (36.8)		3 (6.3)
No		45 (67.2)		8 (42.1)		37 (77.1)
Views on health risks due to drug use
Risk of harming themselves physically or in other ways by the following
Smoking one or more packs of cigarettes per day	91		25		66	**
No risk		5 (5.5)		4 (16)		1 (1.5)
Slight/moderate risk		25 (27.5)		11 (44)		14 (21.2)
Great risk		60 (65.9)		9 (36)		51 (77.3)
Don’t know		1 (1.1)		1 (4)		0 (0)
Smoking marijuana once or twice a week	91		25		66
No risk		18 (19.8)		7 (28)		11 (16.7)
Slight/moderate risk		50 (54.9)		14 (56)		36 (54.5)
Great risk		19 (20.9)		2 (8)		17 (25.8)
Don’t know		4 (4.4)		2 (8)		2 (3)
Having five or more drinks of an alcoholic beverage once or twice a week	91		25		66
No risk		6 (6.6)		3 (12)		3 (4.5)
Slight/moderate risk		44 (48.4)		15 (60)		29 (43.9)
Great risk		39 (42.9)		6 (24)		33 (50)
Don’t know		2 (2.2)		1 (4)		1 (1.5)
Views on the health risks caused by the following mood-altering substances
Alcohol	83		23		60	**
No problem		18 (21.7)		9 (39.1)		9 (15.0)
Minor/moderate problem		38 (45.8)		11 (47.8)		27 (45.0)
Severe problem		27 (32.5)		3 (13.0)		24 (40.0)
Tobacco	83		22		61	*
No problem		16 (19.3)		7 (31.8)		9 (14.8)
Minor/moderate problem		33 (39.8)		10 (45.5)		23 (37.7)
Severe problem		34 (41.0)		5 (22.7)		29 (47.5)
Marijuana	81		21		60	**
No problem		27 (33.3)		11 (52.4)		16 (26.7)
Minor/moderate problem		38 (46.9)		10 (47.6)		28 (46.7)
Severe problem		16 (19.8)		0 (0)		16 (26.7)
Cocaine	83		22		61
No problem		14 (16.9)		4 (18.2)		10 (16.4)
Minor/moderate problem		12 (14.5)		5 (22.7)		7 (11.5)
Severe problem		57 (68.7)		13 (59.1)		44 (72.1)
Prescription pain relievers without a doctor’s order	81		21		60
No problem		14 (17.3)		5 (23.8)		9 (15)
Minor/moderate problem		23 (28.4)		6 (28.6)		17 (28.3)
Severe problem		44 (54.3)		10 (47.6)		34 (56.7)
Prescription tranquilizers without a doctor’s order	82		21		61
No problem		14 (17.1)		4 (19.0)		10 (16.4)
Minor/moderate problem		19 (23.2)		7 (33.3)		12 (19.7)
Severe problem		49 (59.8)		10 (47.6)		39 (63.9)
Prescription stimulants without a doctor’s order	81		21		60
No problem		14 (17.3)		4 (19.0)		10 (16.7)
Minor/moderate problem		18 (22.2)		6 (28.6)		12 (20)
Severe problem		49 (60.5)		11 (52.4)		38 (63.3)
Heroin	80		20		60
No problem		14 (17.5)		4 (20)		10 (16.7)
Minor/moderate problem		2 (2.5)		1 (5)		1 (1.7)
Severe problem		64 (80)		15 (75)		49 (81.7)
Methamphetamine	81		20		61
No problem		14 (17.3)		4 (20)		10 (16.4)
Minor/moderate problem		3 (3.7)		2 (10)		1 (1.6)
Severe problem		64 (79)		14 (70)		50 (82)
Psychedelic drugs	81		20		61
No problem		14 (17.3)		4 (20)		10 (16.4)
Minor/moderate problem		9 (11.1)		2 (10)		7 (11.5)
Severe problem		58 (71.6)		14 (70)		44 (72.1)
Ecstasy	80		19		61
No problem		14 (17.5)		4 (21.1)		10 (16.4)
Minor/moderate problem		17 (21.3)		5 (26.3)		12 (19.7)
Severe problem		49 (61.3)		10 (52.6)		39 (63.9)
Inhalants	77		19		58	*
No problem		15 (19.5)		5 (26.3)		10 (17.2)
Minor/moderate problem		16 (20.8)		7 (36.8)		9 (15.5)
Severe problem		46 (59.7)		7 (36.8)		39 (67.2)

Note. Significant (**p < .05) and marginally significant (*p < .10) associations noted.

Table 3

Descriptive Statistics and Bivariate Associations for Sexual Risk Behaviors Among University and Community Young Adults in a U.S.-Mexico Border City by Sexual or Gender Minority Status (N = 95)

Sexual risk behavior	Overall		Sexual or gender minority
	(n = 95)		Yes (n = 26)		No (n = 69)
	n	Frequency (%)	n	Frequency (%)	n	Frequency (%)
Current relationship status	85		24		61
Single		61 (71.8)		15 (62.5)		46 (75.4)
Married/informally married/living with a partner		17 (20.0)		6 (25)		11 (18)
Separated/divorced/broken-up		4 (4.7)		1 (4.2)		3 (4.9)
Declined		3 (3.5)		2 (8.3)		1 (1.6)
Ever had vaginal, oral, or anal sex	82	79 (96.3)	23	21 (91.3)	59	58 (98.3)
Last time they had vaginal, oral, or anal sex	79		21		58
In the past 7 days		33 (41.8)		6 (28.6)		27 (46.6)
Past 2 weeks		7 (8.9)		1 (4.8)		6 (10.3)
Past month		8 (10.1)		2 (9.5)		6 (10.3)
2–3 months		12 (15.2)		5 (23.8)		7 (12.1)
4–6 months		4 (5.1)		2 (9.5)		2 (3.4)
More than a year		15 (19.0)		5 (23.8)		10 (17.2)
Condom use	79		21		58
Never		21 (26.6)		5 (23.8)		16 (27.6)
Sometimes		34 (43.0)		11 (52.4)		23 (39.7)
Always		24 (30.4)		5 (23.8)		19 (32.8)
Ever had sex under the influence of any of the following drugs
Alcohol	79	47 (59.5)	21	11 (52.4)	58	36 (62.1)
Tobacco	79	18 (22.8)	21	8 (38.1)	58	10 (17.2)*
Marijuana	79	20 (25.3)	21	5 (23.8)	58	15 (25.9)
Cocaine	79	8 (10.1)	21	4 (19)	58	4 (6.9)
Prescription pain relievers without an Rx	79	8 (10.1)	21	5 (23.8)	58	3 (5.2)**
Prescription tranquilizers without an Rx	79	7 (8.9)	21	5 (23.8)	58	2 (3.4)**
Prescription stimulants without an Rx	79	5 (6.3)	21	5 (23.8)	58	0 (0)**
Heroin	79	3 (3.8)	21	3 (14.3)	58	0 (0)**
Methamphetamine	79	6 (7.6)	21	4 (19)	58	2 (3.4)**
Psychedelic drugs	79	2 (2.5)	21	2 (9.5)	58	0 (0)*
Ecstasy	79	11 (13.9)	21	5 (23.8)	58	6 (10.3)
Inhalants	79	4 (5.1)	21	2 (9.5)	58	2 (3.4)
HIV risk behaviors in the past 3–6 months
Unprotected vaginal intercourse	78	38 (48.7)	21	7 (33.3)	57	31 (54.4)*
Unprotected anal intercourse	78	20 (25.6)	21	13 (61.9)	57	7 (12.3)**
Unprotected oral sex	78	53 (67.9)	21	16 (76.2)	57	37 (64.9)
Unprotected sex in exchange for money	78	8 (10.3)	21	6 (28.6)	57	2 (3.5)**
Unprotected sex in exchange for drugs	78	7 (9.0)	21	6 (28.6)	57	1 (1.8)**
Unprotected sex with more than three partners	78	12 (15.4)	21	9 (42.9)	57	3 (5.3)**
Unprotected sex with someone thought to be an injection drug user	78	6 (7.7)	21	6 (28.6)	57	0 (0)**
Unprotected sex with someone thought to be HIV infected	78	8 (10.3)	21	8 (38.1)	57	0 (0)**
Unprotected sex with someone thought to have AIDS	78	8 (10.3)	21	8 (38.1)	57	0 (0)**
Received tattoos or piercings done in any part of your body	78	23 (29.5)	21	10 (47.6)	57	13 (22.8)**
Sexual behavior believed to be common among peers
Vaginal sex	82		23		59	**
Very common		67 (81.7)		13 (56.5)		54 (91.5)
Common		9 (11)		5 (21.7)		4 (6.8)
Not very common		3 (3.7)		2 (8.7)		1 (1.7)
Never		3 (3.7)		3 (13)		0 (0)
Oral sex	82		23		59
Very common		48 (58.5)		11 (47.8)		37 (62.7)
Common		22 (26.8)		6 (26.1)		16 (27.1)
Not very common		8 (9.8)		3 (13)		5 (8.5)
Never		4 (4.9)		3 (13)		1 (1.7)
Anal sex	82		23		59	**
Very common		14 (17.1)		9 (39.1)		5 (8.5)
Common		18 (22)		5 (21.7)		13 (22)
Not very common		36 (43.9)		7 (30.4)		29 (49.2)
Never		14 (17.1)		2 (8.7)		12 (20.3)

Note. Significant (**p < .05) and marginally significant (*p < .10) associations noted. HIV = human immunodeficiency virus; AIDS = acquired immune deficiency syndrome; Rx = prescription.

Descriptive Statistics

Sociodemographic Characteristics

Mean age of participants was 22.6 years. Close to half (53.7%) self-identified as female. More than one quarter (27.4%) were considered a sexual or gender minority: six (6.3%) participants identified as transgender, 27.3% identified as lesbian, gay, or bisexual. Most participants were Hispanic, Latino/Latina, or of Spanish origin (91.5%) and White (81.1%). Almost all participants spoke English well or very well (97.9%). Of those who spoke a language other than English at home (68.4%), almost all spoke Spanish (95.4%).

Close to two thirds (71.6%) of participants had some college or higher level of education. Three fifths (60.2%) were currently employed, and 26.7% had an income less than $20,000 in the past year. Almost one third (29.3%) did not have health care or medical insurance.

Substance Use and Perceptions of Health Risks

Participants reported using marijuana (17.4%), other illegal drugs (2.3%), and prescription drugs without a doctor’s orders (3.5%) in the past 30 days, and lifetime polydrug (12.3%) and injection drug (4.9%) use. More than one fifth (21.1%) of participants were current smokers of whom half smoked at least one cigarette daily for 6 months or longer and indicated that they were most likely to smoke when drinking alcohol (73.7%) and were likely to smoke (68.4%) when celebrating or at a party, when anxious/worried, or when stressed. More than two thirds of participants (68.9%) reported currently drinking alcohol and 17.9% had ever been told they were drinking too much. When asked how much they think people risk harming themselves physically or in other ways, 65.9% thought that there was a great risk in smoking one or more packs of cigarettes per day. Fewer thought that having five or more drinks of an alcoholic beverage (42.9%) or smoking marijuana (20.9%) once or twice a week was a great risk. Regarding their views on health risks, one fifth of participants did not find alcohol or tobacco use to be a problem, nor marijuana (33.3%) and other illegal drugs (16.9%–19.5%).

Sexual Risk Behaviors

Most participants were single (71.8%). Almost all participants (96.3%) reported having sex (vaginal, oral, or anal) at least once in their lifetime, and of those, half (50.7%) reported having sex within the past 3 weeks and more than a quarter (26.6%) reported never using a condom during sex. The most common drugs used during sex were alcohol (59.5%), marijuana (25.3%), tobacco (22.8%), and ecstasy (13.9%). The most common HIV risk behaviors participants engaged in during the past 3 to 6 months were unprotected oral (67.9%), vaginal (48.7%), or anal (25.6%) intercourse. More than one quarter (29.5%) reported being tattooed or having body piercings.

Bivariate Associations

Substance Use and Perception of Health Risks

Compared with other participants, SGMs reported significantly lower rates of marijuana or hashish use (4.0% vs. 23.0%) and higher rates of ever smoking (36.0% vs. 15.4%). SGMs had higher rates of currently smoking when bored (77.8% vs. 40.0%) and having ever been told they drink too much (21.1% vs. 16.7%). The risk from smoking, alcohol, tobacco, marijuana, and inhalant use were statistically significantly different for SGMs compared with others, and SGMs more often perceived that there was some risk with substance use.

Sexual Risk Behaviors

Compared with other participants, SGMs reported higher rates of drug use during sex; they used tobacco (38.1% vs. 17.2%), prescription pain relievers (23.8% vs. 5.2%), prescription tranquilizers (23.8% vs. 3.4%), and prescription stimulants (23.8% vs. 0%) without a doctor’s order, as well as heroin (14.3% vs. 0%), methamphetamine (19% vs. 3.4%), and LSD or other hallucinogens (9.5% vs. 0%). Compared with SGMs, other participants reported lower rates of unprotected vaginal sex (33.3% vs. 54.4%). SGMs also participated more commonly in unprotected sex acts in the past 3 to 6 months compared with others, including anal intercourse (61.9% vs. 12.3%), sex in exchange for money (28.6% vs. 3.5%), sex in exchange for drugs (28.6% vs. 1.8%), sex with more than three partners (42.9% vs. 5.3%), sex with someone who injected drugs (28.6% vs. 0%), or living with HIV (38.1% vs. 0%) or AIDS (38.1% vs. 0%). SGMs were also more likely to have a tattoo or piercings (47.6% vs. 22.8%). Compared with other participants, SGMs reported that anal sex was more common among their peers (39.1% vs. 8.5%), while those who did not identify as an SGM reported higher rates of vaginal sex among their peers (91.5% vs. 56.5% for SGMs).

Discussion

This study’s findings show differences in SGM status in rates related to self-reported/observed substance use, the perception that substance use being a problem, engaging in sexual risk behaviors, and, seeking health care and support for recovery. SGMs were more likely to engage in sexual risk behaviors and substance use while they were less likely to seek support and health care. Perceived risks due to drug use expressed by the SGM young adults in this study may be due to the intersection of acculturation and immigrant generation and residing in the U.S.-Mexico border (Castaneda et al., 2019; Marin, 2003; Ramirez-Valles et al., 2008).

Findings also reveal significant differences in sexual risk behaviors for SGMs compared with other young adults participating in the study. These may be due to being an SGM in the border cultural milieu where they are stigmatized, experience lack of support and social acceptance, and sometimes need to engage in survival/transactional sex to pay for living expenses (Hughes, 2011; Marin, 2003; The Williams Institute, 2017). Marginalization of SGMs may further increase their risk for HIV and other sexually transmitted infections (New Solutions Inc., 2014; The Williams Institute, 2017). Similar to SGMs, subgroups such as homeless individuals, people with disabilities, undocumented individuals, and other stigmatized groups may also be increasingly vulnerable to substance abuse. This increased risk is also a result of structural violence contexts, including poverty, unemployment, lack of access to health care, and low health literacy (Pan American Health Organization, 2012). Study findings also imply that in order to understand sociostructural drivers of substance use that may be unique to ethnic, sexual, and gender minority subgroups, future studies must include a representative sample of vulnerable subgroups populations. A past study in a Hispanic serving institution suggests using a mixed methods approach to better understand the utilization of HIV testing and prevention services among Hispanics (Fernandez et al., 2019), hence we suggest using this approach in future studies of Hispanic SGM.

Limitations

Team members faced a few challenges in achieving a representative sample of young adults aged 18 to 24 years in El Paso. Compared with the percentage of El Pasoans with a bachelor’s degree or higher (24.1%; U.S. Census Bureau, 2018), half of the study participants (51.6%) had some college or university level of education, and 53.7% were attending UTEP. Also, this study has oversampled SGMs (27.4%) since the Texas SGM population is estimated at 4.1% (The Williams Institute, 2019), recognizing the term SGM does not distinguish between the various identities and diversity within this population.

Only bivariate analyses were conducted due to limited measures and sample size, and the lack of comparative national or state data. Last, for risk behaviors, 16.8% or more observations were missing (n = 79 or less). This may have been a result of the nature of the survey question, since when researchers asked about illicit drug use and sexual behaviors, it consistently resulted in underreporting of these factors by participants (Flentje et al., 2015).

The problems discussed in this article and solutions suggested are topical to the discussion of SUDs as relevant to HIV/HCV prevention in the border region today. In the past 5 years, since the data were collected, given the geopolitical changes in immigration policies in the United States, the changes in drug enforcement policies in Mexico, a community levels hate crime in El Paso, and the change in government in both countries, substance use, especially the opioids crisis in the United States and its relation to HIV and HPV have only being exacerbated. Although there were no changes in drug policies in Texas, medical marijuana is now available in New Mexico, which abuts the City of El Paso. New drugs that are prevalent in El Paso, follow the same trends as Texas as a whole. Methamphetamine is the top drug threat and together with cocaine are leading stimulant drug-related deaths in Texas (Maxwell, 2019). Fentanyl is available, but not many overdose deaths have occurred due to the viscosity of black tar that does not allow for easy combination. The number of tramadol pills identified in toxicological laboratories continue to rise. Cannabis indicators focus on the effects of cannabidiol (CBD) oils, edibles, and other products brought in from states where they are legal (Maxwell, 2019). Also, the level of discrimination suffered by SGMs in El Paso, not much has changed since 2014. As with other SGM in Texas, they still suffer discrimination in employment, housing, and public accommodations; suffer bullying and harassment at school; and experience health disparities (The Williams Institute, 2017). Some of the problems have exacerbated by the changes in U.S. migration enforcement, which increased the stigma toward refugees crossing from Central America in large numbers, and by extension, toward any Hispanic individual that did not fit the existing societal norms (Pew Research Center, 2019).

Conclusions

Although measures for SOGI have been included in national health surveys recently, there still remains a significant dearth in data related to health disparities among SGMs, particularly among Hispanic young adults, where stigma, proximity to drugs and violence, low access to health care, and the immigrant context may place SGMs at even more increased risk for substance use (New Solutions Inc., 2014; Pew Research Center, 2013).

Evidence-based interventions addressing substance use, such as Popular Opinion Leaders and Mpowerment (What Works in Youth HIV, 2018) need to be adapted specifically to Hispanic SGM populations, given the regional and cultural substance use and gender norms discussed before. We posit that, given the ethnic and immigrant minority contexts, which may potentially intersect with SOGI context, the border region encompassing the contiguous cities of El Paso, in Texas, and Cd. Juarez, in Mexico, are optimal sites to implement larger studies examining the role of SGM contexts as facilitators of substance use and HIV infection. We also posit that future studies among SGMs must incorporate a trauma-informed approach to the discussion of stigma, the difficulty in revealing SGM status in personal and professional networks, the cultural norms defining what is being “gay,” men who have sex with men (MSM), “bisexual” and other descriptors, and also the self-medication use of antidepressants and other drugs (SAMHSA, 2014). The authors believe that the present study is an important piece of research considering the health disparities affecting the two risk populations (Hispanics and SGM) for substance use and sexual risk behaviors. Moreover, the intersection of these populations in this geographic setting is relatively understudied in the research literature. Last, this needs assessment was the first attempt to assess substance use and sexual risk behaviors among young adults, including SGM, in a U.S.-Mexico border city. Given the similarities in cross-border dynamics in terms of access to care, stigma, and (im)migration-related factors (U.S.-Mexico Border Health Commission, 2014), these results may be generalizable to Hispanics and SGM young adults residing in other U.S.-Mexico border cities.

Footnotes

Authors’ Note:

This study was funded through the U.S. Department of Health and Human Services (DHHS) Substance Abuse and Mental Health Services Administration (SAMHSA) grant number 1H79SP020656-01. The study protocol was approved by the Institutional Review Board at The University of Texas at El Paso (reference #725354-5). The findings and conclusions of this study in this manuscript are from the authors’ work and do not necessarily reflect the views of SAMHSA.

ORCID iD

Oralia Loza

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