Hazardous drinking is associated with the leading causes of preventable death in the United States (U.S.; Mokdad et al., 2018). Centers for Disease Control and Prevention (CDC) estimates there are approximately 93,296 alcohol-attributable deaths (AAD) per year in the U.S., and an average of 29 years of potential life lost (YPLL) per AAD (Esser et al., 2020). Although not examined in the CDC report, veterans (Hoggatt et al., 2021) and individuals who identify as lesbian, gay, or bisexual (LGB) evidence higher rates of hazardous drinking and alcohol-attributable harms (Demant et al., 2017, McCabe et al., 2009, Meyer, 2003, White, 2020), and LGB veterans have been shown to have higher prevalence of alcohol use disorder diagnoses compared to their non-LGB veteran counterparts (Shipherd et al., 2021). In the current study, we examine causes of AAD and associated YPLL between LGB and non-LGB veteran men and women, using Veterans Health Administration (VHA) electronic health record (EHR) data.

Higher levels of hazardous drinking among LGB individuals and LGB veterans are associated with higher rates of discrimination, trauma exposure, and internalized minority stress (e.g., shame, concealment) which predict general and coping-motivated substance use (Meyer, 2003, Hatzenbuehler, 2009, Livingston et al., 2017, Livingston et al., 2019). Added stressors at the intersection of veteran and LGB identities have also been reported, which include coping with discriminatory policies such as the prior Don’t Ask, Don’t Tell (DADT) policy in the military and its ongoing legacy (McNamara, Shipherd, & Adirim, 2021). Within group dynamics of communities often result in LGB veterans feeling excluded from LGB communities on the basis of their military identity and excluded from veteran communities on the basis of their LGB identity (e.g., Livingston et al., 2019).

While hazardous drinking and alcohol-related harms remain more prevalent among men than women, the margins are diminishing in the U.S. as rates of drinking are stabilizing or decreasing among men and increasing among women (White, 2020). Among individuals who drink, women are more susceptible to negative consequences of drinking at the same or lower alcohol concentrations than men and are at greater risk of alcohol-related harms, including accidents (e.g., rising emergency department visits), liver damage, cardiovascular disease, and certain types of cancer (White, 2020). Between 1999 and 2017, alcohol-attributable deaths increased at much higher rates for women than men (White, Castle, Hingson, & Powell, 2020). Similar gender disparities have been observed among men and women in the military (Brown, Bray, & Hartzel, 2010), which is notable in the context of higher prevalence of alcohol use disorder among veterans compared to non-veterans the U.S. (Boden & Hoggatt, 2018).

Recently, Lynch and colleagues (2022) examined rates of AAD and YPLL among LGB and non-LGB veterans using VHA EHR data, as well as National Death Index data. They observed significant disparities with respect to AAD between LGB and non-LGB veterans, at 487 vs 310 AADs per 100,000, respectively. Comparison of AADs between LGB and non-LGB veteran men vs women indicated clear disparity at the intersection of sex assigned at birth. Specifically, among LGB veterans, rates of AAD were 609 vs 258 per 100,000 for LGB men vs LGB women; among non-LGB veteran men and women, rates were 334 and 86 per 100,000, respectively. These disparities correspond to LGB men being 1.82 more likely than non-LGB men to experience AAD and LGB women 3 times more likely than non-LGB women veterans to experience AAD. Differences regarding YPLL per AAD suggest greater YPLL among women, regardless of sexual orientation than LGB men relative to non-LGB men.

The exact causes of AAD among LGB and non-LGB veteran men and women are unknown. From clinical, health services, and public health perspectives, identifying top ranked causes of AAD and drivers of higher YPLL among these subgroups could provide critical insights into what is needed to offset risk for alcohol-related harms. For instance, if disparities are driven by more acute causes of preventable death, such as alcohol-related suicide, this could help direct primary prevention efforts toward that risk and also focusing on demographic groups who are at greatest risk. It is also possible that the disparities are associated with chronic causes such as a more rapid onset of conditions (e.g., cancer, liver disease) and alcohol-related disease progression among LGB veterans and women, for which enhanced intervention and secondary prevention efforts may be needed. In the current study, we performed exploratory follow up analyses of previously published data (Lynch et al., 2022) to identify causes of the above-mentioned AAD and YPLL disparities, via the top ranked causes of AAD and associated YPLL, among LGB and non-LGB veteran men and women.