Differences in Substance Use and Mental Health by Sexual Identity Among U.S. Adolescents and Young Adults

Purpose: This study examined associations between sexual identity and both substance use and mental health outcomes via nationally representative data from adolescents and young adults, using a six-response sexual identity assessment. Methods: Data were from 11,328 adolescents (12–17 years) and 13,131 young adults (18–25 years) completing the 2023 National Survey on Drug Use and Health. Sexual identity had six-response options: heterosexual, lesbian/gay, bisexual, using a different term, unsure/don’t know, and do not understand the question. Substance use variables included alcohol, cannabis, nicotine, prescription drug misuse, polysubstance use, and substance use disorder (SUD). Mental health variables included major depressive episodes, suicidal ideation, and serious psychological distress (measured only among young adults). Multivariable logistic regression models were fitted to examine whether substance use and mental health differed by sexual identity. Analyses adjusted for sociodemographics, occurred separately by age group and sex, and heterosexual individuals were the reference category. Results: Youth identifying as lesbian, gay, bisexual, unsure/don’t know, or using a different term had significantly higher rates of all mental health concerns than their heterosexual peers, with 80% of adjusted odds ratios above 3.0. Substance use-sexual identity links were less consistent, although lesbian and bisexual females were more likely than heterosexual females to have past-year SUD. Individuals not understanding the sexual identity question had lower rates than their heterosexual peers on 15 of 36 outcomes (41.7%). Conclusion: Screening and indicated prevention for mental health concerns and SUD are needed for sexual minority youth, along with the development of culturally sensitive interventions.