Cannabis use, risk of cannabis use disorder, and anxiety and depression among bisexual patients: A comparative study of sex and sexual identity differences in a large health system

This study used electronic health record (EHR) data from 9869 sexual minority patients aged 18 and older who had a primary care visit within a Los Angeles university health system (June 2020–May 2023). Sexual minority patients, defined as lesbian, gay, or bisexual, were screened for cannabis use and risk of cannabis use disorder (CUD) during annual wellness visits. Mental health diagnoses were extracted from patients’ EHR. Multivariable regression models were used to assess associations between sexual identity, sex, and cannabis-related outcomes, including cannabis use, risk of CUD, mental health diagnoses among individuals reporting cannabis use, and cannabis use for symptom management among those with a corresponding diagnosis. All models controlled for age and race/ethnicity. Bisexual patients had higher adjusted odds of cannabis use compared to gay/lesbian patients (AOR females: 1.67; males: 1.47). Bisexual males had greater odds of risk of CUD (AOR: 1.48) and depression diagnosis (AOR:1.86) compared to gay males. Bisexual males with a diagnosis for depression had higher odds of cannabis use for managing depression or sadness symptoms (AOR: 2.44) compared to gay males. Bisexual females had higher odds of a severe stress diagnosis compared to gay/lesbian females (AOR: 2.44). These findings emphasize the importance of developing targeted primary care approaches that address both cannabis use and mental health concerns among bisexual patients.

While the prevalence of cannabis use is higher among sexual minorities as compared to their heterosexual counterparts, few studies have examined the differences in cannabis use across sex and sexual identity among sexual minority individuals, especially in the context of health care. This study examines the association of sexual identity and sex with cannabis use, risk of cannabis use disorder (CUD), symptoms managed with cannabis use, and mental health diagnoses among sexual minority primary care patients.

We conducted a cross-sectional study using electronic health record (EHR) data from 9869 patients ≥ 18 years of age who identified as sexual minority, defined as lesbian, gay, or bisexual, and had a primary care visit between June 2020 and May 2023 within a university-based health system in Los Angeles, CA. Routine screening for past 3-month cannabis use and risk of CUD was based on the Alcohol Substance Involvement Screening Test (ASSIST) and was conducted as part of all annual wellness visits. Patients were asked to report symptoms for which they used cannabis, and mental health diagnoses were extracted from patients’ EHR. Diagnoses meeting clinical threshold criteria were identified based on the International Classification of Diseases, Tenth Revision (ICD-10) codes and included anxiety disorders (ICD-10 F41), depressive disorders (ICD-10 F33), and severe stress (ICD-10 F43).

Differences in the prevalence of cannabis use by sociodemographic characteristics were stratified by sex and compared across sexual identity using chi-squared tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Multivariable regression models were used to assess associations between sexual identity, sex, and cannabis-related outcomes, including cannabis use in the past 3 months, risk of CUD, mental health diagnoses among individuals reporting cannabis use, and cannabis use for symptom management among those with a corresponding diagnosis. All models controlled for age and race/ethnicity.

Among the 9869 patients included in this study, 30.7 % reported cannabis use in the past 3 months. Bisexual patients had higher adjusted odds of cannabis use in comparison to gay/lesbian patients in both females and males (female adjusted odds ratio (AOR):1.67; 95 % Confidence Interval (CI) 1.46, 1.92; male AOR: 1.47; 95 % CI 1.24, 1.73). Among males reporting cannabis use, bisexual individuals had greater odds of risk of CUD (AOR: 1.48; 95 % CI: 1.14, 1.93) and depression diagnosis (AOR: 1.86; 95 % CI: 1.34, 2.56) compared to gay males. Bisexual males with a diagnosis for depression had higher odds of cannabis use for managing depression or sadness symptoms (AOR: 2.44; 95 % CI: 1.34, 4.52) compared to gay males. Among females reporting cannabis use, bisexual patients had higher odds of a severe stress diagnosis compared to gay/lesbian females (AOR: 2.44; 95 % CI: 1.45, 4.35).

These findings highlight the need for primary care providers to consider the unique experiences of bisexual patients, particularly regarding mental health and cannabis use. Increased odds of cannabis use among bisexual patients, coupled with their higher odds of mental health disorders, reinforces the importance of integrating mental health support and addressing cannabis use in routine healthcare.