Demographic Refinement and Atrial Fibrillation Type in Stroke Risk Stratification beyond CHA(2)DS(2) VASc.

According to the Minority Stress Theory (MST), people who identify as lesbian, gay, or bisexual or are in a same-sex romantic partnership (i.e., sexual minority individuals) face unique stressors due to their perceived and actual identity in society (; ). MST differs from other social stress theories as it holds that people in minoritized groups must adapt to greater amounts of and different types of stress than people in non-minoritized groups (). Specifically, in addition to daily life stressors, sexual minority individuals experience cumulative, chronic stress stemming from broader social norms and systems and structures of power that contribute to deeply ingrained internalized and externalized stigma, prejudice, and discrimination related to their minority group identity (; ; ; ). These unique, cumulative, and chronic stressors, rather than sexual minority identity itself, explain the disproportionate burden of adverse health outcomes among sexual minority individuals compared to their heterosexual peers (; ). For example, MST explains the higher prevalence of mental health conditions among sexual minority individuals as compared to their heterosexual peers, which is due to both the proximal (i.e., internalized) and distal (i.e., external) stressors they experience, including a hostile social environment and discrimination based on their identity (). The MST highlights that sexual minority individuals may experience increased interpersonal victimization, internalized homophobia, and the need to conceal their sexual identity within society, resulting in increased psychological distress, and lowered self-esteem (). To combat these stressors, sexual minority individuals may turn to substance use as a mechanism to self-medicate, as a route to numb the pain caused by discrimination or to “un conceal” one’s identity (). Given these factors, substance use may be more widely accepted in sexual minority spaces, which may lead to unintended consequences (; ). Existing evidence indicates increased engagement in potentially risky health behaviors, including illicit drug use (i.e., use of crack/cocaine, methamphetamine, heroin, etc.) and non-medical prescription use (i.e., taking prescriptions in a manner or dose other than prescribed) among sexual minority individuals (; ; ; ). For example, adults who identify as sexual minority individuals (including but not limited to lesbian, gay, or bisexual) are two times more likely to either use illicit drugs or engage in non-medical prescription drug use compared to heterosexual adults (). These drug use behaviors are also associated with comorbid mental and physical health conditions and increased risk of overdose and violence-related deaths (; ; ; ). Given these associations, identifying factors that contribute to risky substance use is critical for informing interventions that could reduce these behaviors and associated adverse outcomes (; ; ; ). One stressor that may contribute to increased risk of drug use is intimate partner violence (IPV). Like illicit and non-medical prescription drug use, the prevalence of IPV is similar or higher among individuals who identify as sexual minorities or are in a same-sex romantic partnership compared to heterosexual individuals (; ; ; ). National data show that 44% of lesbian women and 26% of gay men report having experienced IPV compared to 35% of heterosexual women and 29% of heterosexual men (). Severe cases of IPV are also elevated for lesbian women (29% vs. 24%) and for gay men (16% vs. 14%) compared to their heterosexual peers (). The higher prevalence of IPV among sexual minority individuals relates to the MST. Increased IPV perpetration can be linked with internalized homophobia, concealment and stigma as these stressors may cause increased tension, decreased communication, and lower self-esteem, which may affect romantic relationships and increase risk for IPV (). Heterosexist discrimination experienced proximally and distally can decrease self-confidence, which becomes a risk factor for experiencing IPV (). Importantly, individuals who identify as lesbian, gay, or bisexual or who are in same-sex partnerships may face barriers to seeking services and support for experiences of IPV, including stigma and discrimination from service providers and isolation due to social norms regarding typical IPV experiences (i.e., a woman experiencing IPV by a male perpetrator; ; ; ; ; ). Prior studies show that IPV is associated with increased substance use, with some studies finding that this association is stronger for individuals in same-sex partnerships as compared to those in opposite-sex partnerships (; ; ; ; ; ; ; ). Via the MST, IPV may lead to loneliness, discrimination, or internalized stigma, with drug use functioning as a coping mechanism for these factors ().