exclusively with women (n = 16). Compared with the women who had sex exclusively with men, the women who had sex with both men and women were more likely to report past and recent injection drug use.

Stall and colleagues (2001) examined alcohol and recreational drug use among urban men who have sex with men (n = 2,172) using data from the Urban Men’s Health Study. The study sample included self-identified gay and bisexual men as well as men who reported a sexual encounter with another man in the past 5 years. Fifty-two percent of the sample reported recreational drug use and 85 percent reported alcohol use in the past 6 months. Further, 8 percent of the men who have sex with men engaged in frequent/heavy drinking (five or more drinks at a sitting at least once a week), 18 percent used three or more recreational drugs, and 19 percent used recreational drugs at least once a week.

Harawa and colleagues (2008) examined the role of drug use and addiction in sexual behavior by conducting focus groups with 46 nongay self-identified black men of predominantly low socioeconomic status. The authors identified drug use as playing a central role in same-sex sexuality, with participants describing alcohol and drug use and addiction and sex–drug transactions as being closely linked to same-sex sexual behavior (Harawa et al., 2008).

Many studies have found an association between nonheterosexual orientation and increased risk of substance use. However, McCabe and colleagues (2009) found significant variation in substance use outcomes across gender and sexual orientation definitions. Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 34,653 participants aged 20 and older), the authors found that most sexual-minority respondents did not report substance use or meet criteria for substance dependence. However, they also found that the effects of sexual-minority status on substance use and dependence were greater for sexual-minority women than for sexual-minority men, although this finding may be a result of the overall higher rates of substance use and dependence among men in the general population (McCabe et al., 2009).

While a meta-analysis of prior mental health research found that lesbian, gay, and bisexual individuals had a 1.5 times higher risk of alcohol and other substance dependence over 12 months compared with heterosexual individuals (King et al., 2008), data from convenience samples suggest that substance use may be a major concern among transgender people as well. Eighteen percent of 392 transgender women and 4 percent of 123 transgender men in San Francisco and 23 percent of 332 transgender women of color in San Francisco reported injection drug use. Fully 48 percent of 248 transgender people of color in Washington, DC, reported a problem with alcohol and drugs (Xavier et al., 2005). A previously mentioned study of 207 transgender individuals, 480 men who have sex with

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