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Addressing Bisexual Substance Use: A Conversation Long Overdue

By: Karla Kovacek

Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

Bisexuality is a common sexuality, where over half of LGB individuals identify as bisexual1. In its simplest form, bisexuality is the romantic and/or sexual attraction to more than one sex or gender. This typically includes one’s own gender, and one or more other genders.

While bisexuality has been acknowledged increasingly over the past decade, and more people have started openly identifying as bisexual, bisexual-specific issues are still underdiscussed1. In extension, the issues have not been appropriately addressed.

Particularly, bisexual individuals tend to commonly present with various substance use issues2. For instance, it is estimated that 55% of bisexual individuals are likely to report binge drinking in the past year. Additionally, it is estimated that 46% of them are likely to report non-medical cannabis use, and roughly 14% to report the use of illicit drugs all within the past year. Even more, it is estimated that 31% of bisexual individuals report these uses of substances as a coping response to abuse and violence2. It is deeply troubling that these startling numbers are not more commonly discussed. More particularly, the root causes of this problem must be acknowledged. 

Are bisexual individuals at a higher risk when it comes to substance use?

In comparison to straight individuals, those who identify as bisexual appear to have much higher rates of substance use and related problems. A study using the U.S National Survey on Drug Use and Health, surveying nearly 150,000 adults, found that compared to straight individuals, bisexual identity was related to significantly higher use of substances such as alcohol, cigarettes, cigars, cannabis, illicit drugs and opioids3. Bisexual individuals were also more likely to be presented with a clinical substance related problem, such as alcohol use disorder, nicotine dependence, and substance use disorder. However, the findings suggest some gender differences in bisexual men and bisexual women’s substance use patterns in comparison to straight men and straight women:

  1. Compared to straight women, bisexual women have higher rates of alcohol use, cannabis use, and illicit drug use (including misuse of opioids).
  2. Compared to straight women, bisexual women are more likely to have a substance use diagnosis, and a nicotine dependence.
  3. Compared to straight men, bisexual men have higher rates of cannabis and illicit drug use.

Interestingly, this pattern is found within the LGBTQ+ community as well. The same study suggests that those who identify as bisexual appear to have increased substance use and substance related problems in comparison to those who identify as gay or lesbian3. Gender differences between bisexual men and women regarding substance use and related problems are suggested:

  1. Compared to lesbian women, bisexual women have higher rates of binge drinking, cannabis use, illicit drug use (including misuse of opioids).
  2. Compared to lesbian women, bisexual women were more likely to be diagnosed with alcohol use disorder.
  3. Compared to gay men, bisexual men have higher rates of cigar use.

A study using the U.S National Epidemiological Survey on Alcohol and Related Conditions, consisting of roughly 36,000 participants, particularly focused on cannabis use differences between gay/lesbian, straight, and bisexual individuals4. The results suggest that those who identify as bisexual are more likely to report severe cannabis use disorder compared to straight individuals. Meanwhile, gay and lesbian individuals were only more likely to report mild cannabis use disorder. While both groups display more disordered cannabis use compared to straight individuals, the severity is increased for bisexual individuals.

However, explicit identification with bisexual sexuality may not be necessary for increased substance use problems. In another study, using the same U.S national data, the researchers found that those who engaged in both same sex and opposite sex romantic/sexual behaviour in the past year had higher chances of reporting severe alcohol use disorder and tobacco use disorder in that same year, compared to individuals engaging only in same sex romantic/sexual behaviour. Additionally, in comparison to straight individuals, those who are not sure of their sexual identity label had higher chances of reporting severe alcohol use disorder, tobacco use disorder and drug use disorder5.

It is important to note that there are limitations to these findings, as individuals who are “not sure” of their sexuality are often left out of research. This is a limitation because bisexuality is frequently invalidated as a real sexual identity. As such, bisexual individuals report difficulty with accepting their sexuality, and are told by straight and gay/lesbian individuals that there is no such thing as bisexuality – they must be gay/lesbian in denial, or straight, but curious5. As a result, this may force bisexual individuals into the “not sure” category more frequently.

This “not sure” label has been found to increase one’s risk of developing not only alcohol and tobacco use disorders, but also drug use disorder6. However, this is understudied, as not many studies on sexual minorities and substance use consider individuals who are unsure of their sexuality, although this factor may be directly related to increased substance use as a coping strategy6. These limitations also may lead us to underestimate substance use in the bisexual community – meaning that their substance use may be even greater than anticipated.

Why are bisexual individuals at such a heightened risk?

There are several explanations for why bisexual individuals report higher substance use and development of substance use disorders compared to straight and gay/lesbian individuals.

Bi-negativity

Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

Bisexual individuals are faced with a unique set of prejudicial attitudes and discriminatory actions, specifically targeting the aspect of their sexuality that is attracted to more than one gender/sex. Broadly, bi-negativity (also referred to as biphobia) refers to attitudes that are commonly underpinned by beliefs that bisexuality is not real, that bisexual individuals are promiscuous, and that they cannot be trustworthy partners6.

For gay and lesbian individuals, LGBTQ+ community spaces are a safety resource that protects them from stigma and harmful stereotyping that occurs in the general population. However, for bisexual individuals, the stigma does not stop, even within the LGBTQ+ community. The notions that bisexual individuals are less gay, straight passing, or at risk of leaving their same sex partner for somebody of opposite sex are widely held in the LGBTQ+ community, which can isolate bisexual individuals from what was intended to be their safe space3.

However, there are suggested differences in bi-negativity across genders. In a study of 253 straight men and women, researchers administered a Gender-Specific Binegativity Scale, and two open ended questions regarding bisexuality in men and women7. The results suggest that straight women are equally accepting of bisexual women and men. Meanwhile, straight men are less accepting of bisexual men compared to bisexual women.

The study also suggests notable differences in beliefs about bisexuality based on the gender of the bisexual individual. That is, bisexual men are perceived extremely negatively, and are perceived as gender non-conforming and “actually gay.” Higher acceptance rates of bisexual women, however, may be related to oversexualization of bisexual women by straight men. This is evident in straight male participants describing bisexuality as “sexy” in women. To directly assess the relationship between bi-negativity and substance use in bisexual women, 224 women identifying as bisexual completed a survey to report on their experiences with bi-negativity, substance use, and motivations to use alcohol as a coping strategy. The results suggest that increased bi-negativity experiences are related to more frequent alcohol use as a coping strategy, which in turn generally increased alcohol use in bisexual women8. Considering this link between bi-negativity and alcohol use, it is particularly concerning that bisexual individuals cannot escape stigma and discrimination, not even within the LGBTQ+ community spaces.

Sexual violence and oversexualization

Compared to straight and lesbian women, bisexual women are at an increased risk of sexual violence1. These findings may be applicable to bisexual men, but sexual violence towards bisexual women oftentimes stems from oversexualization of bisexuality in women by straight men. As previously mentioned, straight men report holding beliefs that bisexual women are “sexy”. Consequently, bisexual women are targets of sexual violence.

In a study examining perceived attitudes towards bisexuality by bisexual individuals, both bisexual men and women commonly reported being sexually objectified, sexually harassed, sexually assaulted, and raped. They reported believing that they were specifically targeted because of their bisexuality6.

Furthermore, bisexual teenage girls report sexual dating violence and forced sexual intercourse at a higher rate than lesbian girls. Similarly, bisexual adult women report sexual assault more commonly than lesbian women3.

These high rates of sexual violence and oversexualization relate to increased substance use in bisexual women, as they often report using substances to cope with sexual victimization3. Further, bisexual women also report using alcohol to cope with pressure to engage in sexual behaviour, including being pressured to engage in sexual activity with multiple sexual partners at once3. This pressure stems from widely held beliefs that bisexual women are promiscuous and non-monogamous.

Collectively, bisexual individuals are extremely prone to experiences that may increase their substance use and increase the risk of developing substance use disorders. Unlike those identifying as gay/lesbian, bisexual individuals are uniquely targeted both inside and outside of the LGBTQ+ community, isolating a group that is particularly in need of strong social support.

How can substance use issues in bisexual individuals be addressed?

Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

Given that some of the motivation for substance use in bisexual individuals stems from bi-negativity and consequences of stereotyping, those issues must be addressed. Individual-level interventions aimed at bisexual individuals are necessary, but cannot fix issues that are rooted in societal misconceptions and attitudes. As such, a group of authors propose micro, mezzo, and macro solutions for improving mental health and problematic substance use in the bisexual community9.

Micro solutions refer to resources that are targeted at an individual bisexual person. This may include developing a specific therapy to help teach bisexual individuals to cope with bi-negativity in more positive ways9. The authors suggest that there must be a focus on delivering interventions that are bisexual-affirmative, meaning that the bisexual client is validated and advocated for. This is particularly important, as bisexual clients report being stigmatized by some health care professionals6.

Mezzo solutions refer to resources that are targeted at improving environments bisexual individuals may be a part of. This may include educating school counsellors on bisexual issues and creation of bisexual-safe spaces. The authors propose ensuring bisexual-affirmative care before the client even identifies themselves as bisexual. This may take a form of a sign that states that a clinician’s office is a safe space for people identifying as bisexual, and/or including a bisexual pride symbol9.

Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

Another proposed mezzo solution is offering multiculturalism training to clinicians, as this could assess their attitudes about bisexuality and provide knowledge and skills that may be required for positive interaction with bisexual clients9. This would ultimately ensure that clinicians are competent at providing a service that recognizes the complexity of bisexual experience, and are aware of potential risks that bisexual individuals may face, such as problematic substance use.

In addition, it may be particularly useful to introduce early interventions, as research suggests that sexual minorities tend to be motivated to begin using substances as a coping strategy as early as in adolescence10. A study found that supportive community resources in gay, lesbian, bisexual, and questioning high school students are related to lower substance use compared to those who did not have access to such resources11. As such, introducing resources to bisexual adolescents may be particularly effective at promoting community inclusion, and decreasing risky coping behaviours, such as substance use.

Macro solutions refer to targeting an entire population in ways that would indirectly improve bisexual issues. This may include campaigns to reduce stigma towards bisexuality. The authors propose that non-discrimination policies must be enacted to protect bisexual individuals. In particular, clinicians are encouraged to advocate for these changes, as advocacy is a large part of bisexual-affirmative care9.

In addition, there is a call for research regarding how to reduce bi-negativity in the general population. Although more research is needed, a potential bi-negativity reduction strategy is as simple as exposing the population to bisexual individuals, as there is some evidence that it might decrease negative attitudes towards bisexuality9. On that note, another solution at the macro level might involve encouraging contact between bisexual individuals and the rest of the population, either directly or vicariously (through displaying straight-bisexual interaction in the media)9.

Bisexual individuals are facing substance use issues at alarming rates compared to gay, lesbian, and straight individuals, and this can be changed. It is important to understand that the proposed solutions do not have to stay limited to clinicians and bisexual individuals themselves. Sharing an informative article, conversationally spreading knowledge about bisexuality, and correcting misconceptions are some of the easiest, yet meaningful, ways in which everybody can tackle some of the root causes of the issues that bisexual individuals face far too often.

Substance use does not have to be the unwritten legacy of bisexual individuals, and meaningful change can start with you.

Superscript References

  1. Gates, G. (2011, April). How many people are lesbian, gay, bisexual, and Transgender? Retrieved April 20, 2021, from https://williamsinstitute.law.ucla.edu/publications/how-many-people-lgbt/
  2. Government of Canada, S. (2020, September 09). Health risk behaviours, by sexual orientation and gender. Retrieved April 20, 2021, from https://www150.statcan.gc.ca/n1/pub/85-002-x/2020001/article/00009/tbl/tbl09-eng.htm
  3. Schuler, M. S., & Collins, R. L. (2020). Sexual minority substance use disparities: Bisexual women at elevated risk relative to other sexual minority groups. Drug and Alcohol Dependence, 206, 7. doi:http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1016/j.drugalcdep.2019.107755
  4. Boyd, C. J., Veliz, P. T., & McCabe, S. E. (2019). Severity of DSM-5 cannabis use disorders in a nationally representative sample of sexual minorities. Substance abuse, 41(2), 191–195. https://doi.org/10.1080/08897077.2019.1621242
  5. Boyd, C. J., Veliz, P. T., Stephenson, R., Hughes, T. L., & McCabe, S. E. (2019). Severity of Alcohol, Tobacco, and Drug Use Disorders Among Sexual Minority Individuals and Their “Not Sure” Counterparts. LGBT health, 6(1), 15–22. https://doi.org/10.1089/lgbt.2018.0122
  6. Doan Van, E. E., Doan Van, E. E., Mereish, E. H., Mereish, E. H., Woulfe, J. M., Woulfe, J. M., Katz-Wise, S. L., & Katz-Wise, S. L. (2019). Perceived discrimination, coping mechanisms, and effects on health in bisexual and other non-monosexual adults. Archives of Sexual Behavior, 48(1), 159-174. https://doi.org/10.1007/s10508-018-1254-z
  7. Yost, M. R., Yost, M. R., Thomas, G. D., & Thomas, G. D. (2012). Gender and binegativity: Men’s and Women’s attitudes toward male and female bisexuals. Archives of Sexual Behavior, 41(3), 691-702. https://doi.org/10.1007/s10508-011-9767-8
  8. Livingston, N. A. (2017). Ecological momentary assessment of daily microaggressions and stigma-based substance use among lesbian, gay, and bisexual individuals
  9. Feinstein, B. A., Dyar, C., & Pachankis, J. E. (2019). A multilevel approach for reducing mental health and substance use disparities affecting bisexual individuals. Cognitive and Behavioral Practice, 26(2), 243-253. doi:http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1016/j.cbpra.2017.10.003
  10. Ramos, J. (2020). Coping motives as a moderator of the association between minority stress and alcohol use among emerging adults of marginalized sexualities and genders (Order No. 27738508). Available from ProQuest Dissertations & Theses A&I: Health & Medicine; ProQuest Dissertations & Theses A&I: Social Sciences; ProQuest Dissertations & Theses Global: Health & Medicine; ProQuest Dissertations & Theses Global: Social Sciences. (2428584534). Retrieved from http://ezproxy.lib.ryerson.ca/login?url=https://www-proquest-com.ezproxy.lib.ryerson.ca/dissertations-theses/coping-motives-as-moderator-association-between/docview/2428584534/se-2?accountid=13631
  11. Eisenberg, M. E., Erickson, D. J., Gower, A. L., Kne, L., Watson, R. J., Corliss, H. L., & Saewyc, E. M. (2020). Supportive community resources are associated with lower risk of substance use among lesbian, gay, bisexual, and questioning adolescents in minnesota. Journal of Youth and Adolescence, 49(4), 836-848. https://doi.org/10.1007/s10964-019-01100-4

Hyperlink References

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APA Dictionary (n.d.). Coping strategy. In dictionary.apa.org dictionary. Retrieved April 1, 2021, from https://dictionary.apa.org/coping-strategy

APA Dictionary (n.d.). Multicultural education. In dictionary.apa.org dictionary. Retrieved April 1, 2021, from https://dictionary.apa.org/multicultural-education

Juergens, J., & Parisi, T. (2019, January 2). Illicit drug abuse and addiction. Addiction Center. Retrieved April 01, 2021, from https://www.addictioncenter.com/drugs/illicit-drugs/

Mayo Clinic. (2017, October 26). Drug addiction (substance use disorder). Retrieved April 01, 2021, from https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112

Mayo Clinic. (2018, July 11). Alcohol use disorder. Retrieved April 01, 2021, from https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/symptoms-causes/syc-20369243

Mayo Clinic. (2020, March 14). Nicotine dependence. Retrieved April 01, 2021, from https://www.mayoclinic.org/diseases-conditions/nicotine-dependence/symptoms-causes/syc-20351584

Merriam-Webster. (n.d.). Microaggression. In Merriam-Webster.com dictionary. Retrieved April 1, 2021, from https://www.merriam-webster.com/dictionary/microaggression

Merriam-Webster. (n.d.). Monogamy. In Merriam-Webster.com dictionary. Retrieved April 1, 2021, from https://www.merriam-webster.com/dictionary/monogamy

Merriam-Webster. (n.d.). Prejudice. In Merriam-Webster.com dictionary. Retrieved April 1, 2021, from https://www.merriam-webster.com/dictionary/prejudice

The Center. (n.d.). Defining LGBTQ. Retrieved April 01, 2021, from https://gaycenter.org/about/lgbtq/