Abstract
Background
High levels of alcohol and tobacco use among lesbian, bisexual and queer (LBQ) women are commonly explained with reference to the minority stress effect (Amos et al., 2022; Deacon and Mooney-Somers, 2017; Hughes et al., 2020; Marshal et al., 2012; McNair et al., 2016; Preager et al., 2019; Roxburgh et al., 2016). This posits that members of minority groups experience chronic stress due to stigma and discrimination, which can result mental ill-health (Meyer, 2003). This can be associated with increased rates of substance use for self-medicating or distancing purposes (Austin and Irwin, 2010; Bauermeister et al., 2018; Wilson et al., 2016). For example, negative family reactions to disclosure of sexual orientation, including rejection, have been associated with higher quantity of alcohol intake among young LBQ women (McNair et al., 2016). In contrast, other research has identified weak associations between minority stress and substance use among LGBTQ people and there is no clear evidence that suggests minority stress is the major variable explaining high rates of substance use in these communities (Hunt et al., 2019; Lea et al., 2014). Furthermore, the normative notion of minority stress as driving higher rates of alcohol or tobacco use is arguably underpinned by the assumption that substance use is invariably pathological, which fails to take account of the social and cultural contexts shaping consumption among this population. It also fails to account for pleasure, sociability, and the playful, party-based cultures that have defined LGBTQ communities for many people (Pienaar et al., 2020).
While LBQ women’s high rates of alcohol and tobacco use are now well-established in epidemiological scholarship, significantly less research has qualitatively examined the cultures of use among this population. LGBTQ communities have historically organised around bars, clubs and other licensed venues, for safety, to meet like-minded people, and to express their identities (Cochran et al., 2012). For example, Gruskin et al. (2007) observed positive outcomes of bar attendance for lesbian and bisexual women in the US, including safety and support, identity development, reduction of stress, and establishment of social networks and intimate relationships. It is widely theorised that the significance of alcohol-based socialising has further normalised substance use among LGBTQ communities (Green and Feinstein, 2012). Recent Australian research found heavier drinking lesbian and bisexual women were more likely to say that alcohol use was normal among LBQ women and that venues welcoming LBQ women were “saturated with alcohol” (MacLean et al., 2019). Boyle et al. (2016) found that more frequent bar and club attendance among lesbians was associated with overestimating heavy alcohol use among their community. The notion of high acceptability and a heavy drinking culture on the commercial LGBTQ scene and within community has been found across international samples (Demant et al., 2018; Emslie et al., 2017).
This social context and previous research reinforce an awareness of alcohol and tobacco consumption as intrinsically cultural acts (Condit et al., 2011), yet pivotal questions remain about how alcohol and tobacco are positioned in the lives of LBQ women, the nature and extent of harm, and how interventions can best respond. While a large body of research has documented changes in alcohol and smoking in line with life events among heterosexual populations (Tamers et al., 2014, 2015), few such examinations have been made of LBQ women (for an exception see Kolstee et al. 2019). In addition, most previous research has examined rates of alcohol and tobacco use among cisgender lesbians and bisexual women, with comparatively less known about trans women (for an exception, see Culbreth et al., 2022; Gilbert et al., 2018) and queer, pansexual, and other non-monosexual women (Barger et al., 2021). To address these knowledge gaps, this study will explore the following research questions: 1. What is the role of alcohol and tobacco use in the social and cultural lives of Australian lesbian, bisexual, and queer (LBQ) women?
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2. How do LBQ women understand, construct, and manage the potential risks and harms of alcohol and tobacco use over time? 3. What are LBQ women’s experiences and perceptions of smoking cessation and alcohol-related support services?
Method
Project Design
To our knowledge, this is the first research that will utilise a longitudinal qualitative approach to explore LBQ women’s cultural practices of alcohol and tobacco use. This multi-stage project will include three waves of semi-structured interviews about LBQ women’s experiences of alcohol and/or tobacco use, and a participant photography project designed to capture women’s perceptions of alcohol and smoking cultures through their own eyes. Interviews will be conducted with approximately 60 women, spaced six months apart, with the participant photography project occurring after interview 2 to allow for a discussion of the photographs in interview 3. In addition to the research team, a project steering committee will be established, including membership from LGBTQ community organisations and smoking cessation and alcohol support organisations in Victoria and New South Wales to co-design, advise, and monitor the project.
Theoretical Framework
Drawing on feminist and critical drug studies (Pienaar et al., 2020; Race et al., 2022), this study aims to look beyond simplistic or pathologising explanations for LBQ women’s substance use to develop a nuanced and convincing understanding of the role of alcohol and tobacco in the lives of LBQ women. Feminist research on substance use has resisted problematic or pathologising narratives of women, instead focusing on developing an understanding of the social or cultural context and significance of substance use for women. For example, Haines and colleagues (2009, 2012) found that smoking offered young women a form of cultural capital within their friendship networks and, in some cases, enabled them to resist narratives of what they should be like – ‘pretty girls don’t smoke’. Other studies have shown that playing with styles of smoking enables women to represent their gender in particular ways – adopting a masculine or ‘butch’ style of smoking or a more feminine, ‘elegant’ style of smoking as part of their gender performance, or as a conscious strategy to play with gender. A similar point is made by Shaw (2001) who posits that women’s leisure activities (e.g. sporting pursuits) may be a symbol of resistance to dominant cultural narratives around how women should be. Drinking behaviours where women adopt patterns of drinking conventionally accepted among men open opportunities for women to be disinhibited in public spaces in ways that require some resistance or challenge to feminine ideas (McHendrie et al., 2022). For LBQ women, the effect of drinking is not simply about the physiological effect (i.e. being drunk, although this is not immaterial or irrelevant as disinhibition is clearly part of the performance of gender in the example offered above), but substance use plays a broader role in the performance of gender and sexuality, individually and collectively.
A similar argument about substance use in LGBTQ communities has been posed by Race and colleagues (2022), who argue that, rather than approaching disinhibition caused alcohol or other substances as problematic or dangerous, we must also consider the productive effects of disinhibition for LGBTQ communities. Drawing on Foucault’s concept of ‘technologies of the self,’ Race et al. (2022) suggest that substances can be seen as a means to effect certain ways of being in one’s body – to transform one’s presentation or experience of the self. The effect of substances on the body, and one’s experience of themselves, is significant – the disinhibited effect of alcohol, for example, is important to the individual experience -- but it also has social and cultural effects. For LGBTQ communities, disinhibition may be part of generating a sense of collective resistance to normative gendered and sexual expectations. If we can make sense of the significance of disinhibition for LGBTQ communities, historically and today, then we may be able to conceptualise why there are high rates of alcohol and other substance use within these communities. In this study, we are interested in how alcohol and tobacco have enabled LBQ women to experience gender and sexuality in particular ways, and the ways these substances may have facilitated engagement with LGBTQ community. This approach is not intended to override or ignore the potential health or social harms that may be a consequence of smoking or drinking in some forms. Rather, the aim is to contextualise the reasons women may choose to disengage, or accept, health risks by developing our understanding of the relationship LBQ women may have with these substances at a personal and cultural level.
Methodology
Our conceptual approach calls for a methodology that enables in-depth exploration of the personal and cultural significance of alcohol and tobacco use among women, examining what the use of alcohol or tobacco achieves culturally or socially over time. Longitudinal qualitative methods offer ‘insights into how people narrate, understand and shape their unfolding lives and the evolving world of which they are a part’ (Neale, 2020). In contrast to cross-sectional data collection, longitudinal enquiry allows for a better appreciation of how dimensions of life are interconnected and how they operate dynamically to influence meanings and practices (Neale and Flowerdew, 2003; Tuthill et al., 2020). Longitudinal qualitative approaches have been used in projects examining changes in health and behaviour over time, which has proven useful in generating greater understandings of chronic illness (Namukwaya et al., 2017), breastfeeding (Jardine et al., 2017), and medication adherence (Weiser et al., 2017). Researchers investigating smoking and attempts to quit among heterosexual young people reported how repeated interviews improved the richness of the data and further illuminated the ways in which culture and smoking context influenced smoking-related practices (Stewart-Knox et al. 2005). In a similar vein, researchers examining provision of care for older people described how their rich insights into the impacts of changes in everyday practices would not have been achieved were it not for the use of longitudinal qualitative research, which enabled exploration of both the subtle and significant (Cameron et al., 2019).
Alcohol cultures are not static, nor is an individual’s engagement with them (Savic et al., 2016). Changes not only in life circumstances, but also in personal insight, reflections or choices will shape, or be shaped by, engagement with cultures of alcohol or tobacco use. Interviewing participants on multiple occasions will therefore allow for a nuanced understanding of how their immersion in, or connection to, specific cultures interact with the varied and changing aspects of everyday life. In addition, according to Tuthill et al. (2020: 2) longitudinal qualitative approaches ‘may also be applied to inform the development of health behaviour theories or interventions and may be used to understand if a policy or program was effective, why or why not and in what contexts might similar results be expected.’ As this project aims to inform the promotion and delivery of smoking cessation and alcohol support services for LBQ women, longitudinal methods will allow us to examine factors that contribute to changes in behaviour and patterns of use over time. The three waves of data collection will ensure sufficient space and time for such changes and reflections to occur and be explored. The waves of data collection have been strategically timed to enable us to explore the impact of significant community events, such as the 2023-24 festive season (Christmas/New Year), Victoria’s LGBTQ festival, Midsumma (held annually in January/February) and Sydney’s Gay and Lesbian Mardi Gras (held annually in February/March). Participant photography has been widely used in public health and social research (Murray and Nash, 2017) and is an impactful approach for engaging marginalised groups because it ‘enables them to act as recorders, and potential catalysts for change, in their own communities’ (Wang and Burris, 1997, p. 369). We chose to include participant photography in this longitudinal project to act as an important engagement activity to help retain participants’ interest in the project, while also allowing them to share aspects of their experience that may be difficult to put into words. Photo-elicitation interview methods draw on participant-produced photography to help explore memories and information that may not be included in a traditional interview (Harper, 2002). Women’s alcohol consumption has historically been relegated to the private sphere of the home or to concealed public spaces (e.g. lesbian bars), while public consumption has been highly stigmatised (Emslie et al., 2017; Lennox et al., 2018). By inviting LBQ women to visually represent their own experiences with alcohol and tobacco use, this project seeks to empower a community whose voices and experiences are often obscured from public discourse. In doing so, we seek to actively engage participants in challenging dominant representations of LBQ women’s alcohol and tobacco cultures, providing new insights into women’s lived experiences to inform improved service provision and community awareness. As well as providing visual data, the role of narration in photo-elicitation is essential to provide additional insights that may have been difficult to express verbally. Photo-elicitation allows for researchers to collect direct insights into the social world from participants’ perspectives at a particular point in time. The purpose of this aspect of the project is to allow women to capture and share aspects of alcohol cultures and tobacco use that are meaningful for them.
Interview Procedure
To understand how alcohol and tobacco use fit into LBQ women’s life narratives, we will interview participants three times over an 18 month period, with six month gaps between each interview. The first interview will gather demographic information and life narratives, including experiences of stress, mental health, stigma, discrimination, and standard patterns of alcohol and/or tobacco use. The second interview will revisit the previous discussion six months later, examining perceptions of alcohol and tobacco use within LBQ communities, and considering participants’ engagement with health promotion interventions and cessation support services, where relevant. The third interview will reflect on the previous interviews and examine the impacts of participation in the study on alcohol and/or tobacco use. At the final interview the researcher and participant will view the participant’s selected photographs together, discussing their content and meanings from the participants’ perspective. The interview team will comprise researchers with LBQ identities, who will be thoughtful about their own personal experiences and biases and will seek to understand how these compare with their interviewees (Ben-Ari and Enosh, 2011).
Participant Photography
Participants will be invited to use their own smartphone or digital camera to take photographs that capture their experiences and concerns about alcohol and tobacco cultures in their lives. Specifically, they will be asked to take a series of photographs between Waves 2 and 3 (approximately 6 months). At the conclusion of the second interview, the interviewer will discuss the participant photography element to the study. Participants will be provided with the following prompt to “photograph whatever you desire to reflect the cultural practices of alcohol and tobacco among LBQ women.” The instructions given to participants are deliberately broad so that the participants can decide what kind of story they wish to tell through their photographs. The pictures taken by the women will ideally convey reflections on and concerns about their own or others’ alcohol and/or tobacco use in a way that words alone might not. Participants will be invited to give their images names or captions as they go, selecting up to 5 favourite or most significant images to discuss at their final interview.
Participants will be invited to reflect on what they chose what to photograph and how they have felt about the experience of taking pictures for the project. When viewing their photographs collaboratively, participants will be invited to share the story behind their photographs and how they reflect their experiences or concerns about substance use. A semi-structured photo-elicitation approach will help us to explore how participants’ represent their own use of alcohol and/or tobacco, as well as their understandings of risk and harm, and their perceptions of health promotion and support services. Through this discussion, participants will be empowered to consider solutions for any perceived challenges their communities face in relation to substance use. At the conclusion of the project, participants will also have the option to include some of their photographs in a public exhibition designed to share the research findings with policy makers, service providers, and the wider community.
Sampling/Recruitment
To be eligible to participate, individuals must: identify as women (cisgender or transgender); identify as lesbian, bisexual or queer (or use another term to denote same or multi-gender attraction); be at least 18 years old; live in the states of Victoria or New South Wales; and have consumed alcohol and/or smoked tobacco/vaped within the previous month at baseline.
Sixty participants will be recruited via social media advertising for a total of 180 possible interviews over three waves of data collection. Eligibility will be established using a short online pre-screening questionnaire, which will capture basic demographic information. It will also include questions about frequency and quantity of alcohol consumption to obtain an estimate of current drinking practices, enabling the sampling of diverse alcohol experiences. Questions about smoking and vaping practices will allow for sampling women who are daily smokers/vapers, former but not current daily smokers/vapers, and others who smoke/vape infrequently or not at all. With regard to age, we will seek to balance the sample across a series of age bands (18–24, 25–44, 45–64 and 65+). Participants will be recruited primarily through targeted social media advertising and with the assistance of our LGBTQ community partner organisations who have agreed to share our call for participants within their extensive networks.
Retention
The initial sample size will also allow for possible attrition over the period of data collection. Farrall et al. (2016) outline several strategies for improving retention in longitudinal qualitative research, including ongoing dialogue with participants as well as ensuring permission is obtained to engage with them in a variety of ways. Building on this advice, we will regularly update participants with outputs of the study, and seek their permission to connect with them via phone, email, and social media. While we will explain the purpose of the longitudinal approach and encourage participants to attend all three interviews, participation in each phase of the project is voluntary and we acknowledge that some participants may not complete all three.
Data Analysis
Interview Analysis
The scale and richness of a longitudinal dataset of this kind typically necessitate more than one analytical approach (McLeod, 2003). We will draw upon both narrative (Riessman, 1993) and constant comparison (Charmaz and Thornberg, 2021) methods to explore initiations, transitions and broader experiential sense-making, as well as the ways in which culture shapes, and is shaped by, alcohol or tobacco consumption. Cross-case analysis (Miles and Huberman, 1994) will facilitate examination of if and how cultural practices of alcohol and tobacco use change over time given evolution in circumstances, insights, perceptions, or choices as well as broader social structures and political change. The focus will be exploring change for each woman (within cases) and commonalities and differences between women (across cases), as well as the meaning of such change in relation to our overarching objectives. Finally, thematic analysis (Clarke et al., 2015) will be used to examine data relating to health promotion and service use perception, engagement, or experience. Following the third wave, we will examine the utility of dominant frameworks (such as the minority stress effect) in explaining or accounting for the findings and develop and promote more emergent theoretical work. We will also use reflexivity to understand how the participant experiences compare with our own perspectives (Ben-Ari and Enosh, 2011).
Visual Analysis
All images in the project will be analysed using critical visual discourse analysis (CVDA) strategies outlined by Rose (2016) and using a feminist lens (Lazar, 2007). Feminist critical visual discourse analysis (FCVDA) is not only a method for visual analysis it is also implicitly a perspective on gender and focuses centrally on unravelling the interconnections between gender, power and ideology with the intention of critiquing patriarchal discourses and encouraging social change. In order to look at how discourses are structured and how they produce particular kinds of knowledge about LBQ women’s alcohol and tobacco practices, we will focus on three interconnected nodes of images: (1) the social (institutions/social subjectivities) (2) the aesthetic (visual codes) and (3) the technological (photographic technologies/equipment involved). As Rose (2016) suggests, the main analytical task is assessing how meaning is produced at each of these nodes. This framework provides the basis for asking a series of questions related to each node to uncover how competing discourses participate in these productions. Asking questions is a means to move the analysis of the production of the image from the individual to their social identity and from one image to ‘the conventions of its genre’ to further explain how different nodes and registers intertwine (Rose, 2016).
While Guillemin and Drew (2010) emphasise the importance of considering how verbal and visual data differ, we will also examine both visual and verbal data together during analysis to avoid prioritising one type of data. In many cases, participant-produced images can be difficult to interpret without taking participants’ own interpretations into account. In practical terms, we will examine the images with the above methodological approach in mind, collating all of the images and analysing for patterns or broader themes across the images, drawing on interview data to expand on the participants’ intended meanings behind the images. Initially, themes or codes will be developed inductively when viewing the images as a whole collection. We will also use codes developed from the interview data to analyse the images and explore further connections.
Consent is an ongoing process that will be clarified at the beginning of all the interviews renegotiated throughout the project. Competence to give consent will be determined based on the individual’s ability to read and understand the consent form. The interviewer will assess competence by asking them to explain their understanding of the topics the interviews will cover. Participants will be asked if they understand the details of the project, that they may withdraw from the interview at any time, they may withdraw their data up to four weeks after each interview, and they agree to have their data included in presentations and publications on the condition that they cannot be identified. The information sheet and consent form will include details regarding possible risks and harms that could arise from participation which, principally relate to the potential for emotional distress in the telling of difficult or traumatic experiences. Because this project examines the motivations behind LBQ women’s alcohol and tobacco use, as well as reasons for changes in practices over time, participation may involve recollection and discussion of personal experiences of ‘coming out’ as LBQ, discrimination, family rejection, abuse, trauma, and substance use issues. For this reason, there is a risk that some participants may become uncomfortable or distressed when sharing and reflecting on their experiences. To minimise the risk of harm to participants, a detailed support protocol to assess for and respond to potential participant distress will be developed among the team, with the support of the steering committee, including representatives from key LGBTQ community support organisations. The interview questions will be designed to allow participants to share as much or as little information as they are comfortable discussing, and the semi-structured nature of the interviews will allow participants to determine the flow of conversation based on what they are comfortable sharing. Should a participant indicate they are experiencing high levels of distress, or should their behaviours suggest distress, the interviewer will pause the interview and assess their mental state and capacity to continue. If the participant is unable to continue, they will be informed that they can leave the interview or Zoom call and contact will be made later that day to discuss potential follow-up options, including (1) encouraging the participant to seek support from their social networks; (2) encouraging them to seek support from their regular doctor or mental health practitioner; (3) provide phone numbers for national telephone counselling services, including those that cater specifically to LGBTQ individuals; (4) offer to follow-up with a phone call in the days following the interview.
Inviting participants to take photographs during their daily life may pose additional risks to participants. These include: (1) risk of photographing unsafe, illegal, or otherwise risky situations or content; (2) risk of non-consensual photography of non-participants; (3) risk of identifiability resulting from potential public display of the photos. To minimise the risk of harm to participants or others associated with the photography element, participants will be provided with a guide to safe and ethical photography for the purposes of the project. This resource, which will be discussed in person at the second interview, outlines how to take photographs in a safe manner that will not harm them or their subjects and given strategies for avoiding sensitive situations or illegal activity. Participants will be encouraged to always obtain consent of anyone identifiable in their photographs prior to taking them and will be given tips on how to discuss this with people or how to frame images in a less identifying manner.
Participant photography will be approached in the following three ways: (1) as a data collection tool and photo-elicitation discussion prompt; (2) as data; and (3) as a knowledge dissemination tool. In the first instance, participants will be encouraged to take a series of photographs for the purpose of the research. They will be prompted to consider the potential consequences (including unintended consequences) of their photography potentially being published and keep this in mind when capturing images for this project. If images do contain identifying features, these may be still discussed in the interview, but will not be published as data without participants’ (and subjects’) consent. Participants will be free to withdraw their consent to use their photographs in publications from the project at any time. At the conclusion of the research project, participants will have the option to include some of their images in a public exhibition. Consent to feature their images in the exhibition for the purposes of community engagement will be negotiated separately from the process of using images in the research project itself. Previous research using participant photography to explore alcohol and tobacco consumption has not found that the research activities impacted participants’ levels of consumption (Molina-de la Fuente et al., 2021) (i.e. encouraged them to drink or smoke more than usual). However, to mitigate any risk of encouraging unusual unsafe/harmful substance use for the purposes of the project, the researchers will discuss this with participants throughout the study and prior to commencing the photography element of the project. If taking photographs to convey their experiences and reflections on alcohol and/or tobacco use is deemed a potential risk to participants’ sobriety or smoking cessation, they may be asked to consider participating in a third interview without the photography element. Alternatively, participants may be invited to use photographs to capture their experiences of sobriety or smoking cessation. Both the interview questions and photography prompt are designed to promote critical reflection on alcohol and tobacco practices, which we do not anticipate posing risks to participants. Importantly, participants will not be encouraged to take photographs of themselves consuming alcohol or smoking/vaping but will be invited to consider creative or abstract ways to reflect on their experiences.
Rigor
We will ensure the rigor of this study and its methods in line with Lincoln and Guba’s (1985) criteria: credibility, transferability, dependability, and confirmability (Liamputtong, 2013: 25). Credibility will be supported by purposive recruitment of LBQ women from a range of diverse backgrounds, with varied experiences of both alcohol and/or tobacco use. In addition, the role of community partners and their participation on the project steering committee will be central in ensuring the credibility of the project design, analysis, and outputs. We will ensure our findings are transferable by providing ample context and details about the study procedures and participant demographics in all publications, ensuring possibility of replication. Dependability is supported by meticulous documentation of research processes, including analysis, and reflexivity. The project steering committee will provide feedback on preliminary analyses throughout the project, providing a layer of member checks. All analyses will be grounded in the data, and we will provide “thick description” of the findings, enabling confirmability of the results (Pontoretto, 2006). We will make use of regular team meetings to reflexively engage with our positions as researchers working in this space and to acknowledge the complex influences that shape our interpretation of data, a process that is key to delivering high-quality, qualitative research (Kitto et al., 2008).
Conclusion
Existing research on LBQ women’s alcohol and tobacco practices does not adequately explore the social and cultural factors shaping this population’s high rates of use. While minority stress and mental health are important considerations, we propose the need for a more critical analysis that centres women’s lived experiences. This protocol introduces a longitudinal qualitative research methodology to examine how LBQ women’s substance use and understandings and perceptions of use, health, and risk change over time. A longitudinal approach will uniquely allow us to explore the changing meanings, social contexts, and cultural practices associated with substance use among LBQ women, offering new insights into the connections between identity, community, and substance use. At the same time, this approach will help us capture motivations for behaviour change, cessation, and help-seeking that are essential for informing health promotion and service provision for this often under-served group.
Footnotes
Acknowledgments
We acknowledge the contributions of the project’s Steering Committee, including representatives from our partner organisations: ACON, Thorne Harbour, LGBTIQ+ Health Australia, Quit Victoria, and the Victorian Alcohol and Drug Association (VAADA).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is funded by an Australian Research Council Linkage Grant (LP210100122), with additional funding from Department of Health Victoria and Quit Victoria.
Ethical Approval
The project has been approved by La Trobe University’s Human Research Ethics Committee, alongside LGBTQ community organisation approvals from the ACON Research Ethics Review Committee and the Thorne Harbour Health Community Research Endorsement Panel. Gaining endorsement from the two major organisations supporting LGBTQ communities in the states of Victoria and New South Wales was an essential step, ensuring our research aligns with the best interests of the community and follows best practice in engaging LGBTQ people. Key ethical considerations for this project include ensuring informed consent, appropriate participant protection and support strategies, and managing potential risks associated with participant photography.
