Alcohol-related problems and suicidality disparately impact specific minoritized communities. These public health problems may have common risk factors; alcohol use increases factors that predispose people to suicidality (e.g., impulsivity, impaired social support, hopelessness), which in turn increase factors that precipitate suicidal behavior (e.g, depressive symptoms, interpersonal difficulties, negative life events; Lamis & Malone, 2012). Alcohol intoxication may increase suicide risk by decreasing inhibition and increasing suicidal ideation (SI; Conner & Bagge, 2019), and persons with suicidality may use alcohol to distract from limited social connections (Shepherd & Brochu, 2021) and painful internal experiences (Khantzian, 1997), including distress from oppression. In the US, persons with minoritized1 sexual identities face stigma and discrimination that result in health disparities due to heterosexist social structures (Brooks, 1981, Meyer, 2003, Diamond and Alley, 2022). Native Americans also face stigma and discrimination that result in health disparities due to racist social structures and lasting effects of imperialism (Alcántara and Gone, 2008, Beauvais, 1998). Understanding co-occurring SI and alcohol-related problems within specific minoritized groups is important for targeted outreach and interventions.

In the US, persons with minoritized sexual identities experience greater rates of SI (Salway et al., 2019) and attempts (Hottes et al., 2016, Meyer et al., 2021) relative to heterosexual counterparts. Suicide death appears to be more common among women who have sex with women, relative to presumed heterosexual counterparts (Cochran & Mays, 2015). Lesbian and bisexual women also show greater past month drinking (Medley et al., 2016), binge drinking, and high intensity binge drinking than heterosexual women (Fish et al., 2018). Lesbian, gay, bisexual, and those unsure of their sexual identity report higher rates of each alcohol use disorder (AUD; McCabe et al., 2019) criteria and AUD diagnosis (Boyd et al., 2019). Persons with minoritized sexual identities may therefore experience elevated rates of co-occurring SI and alcohol use, binge drinking, and AUD.

Native Americans experience higher rates of SI (Center for Behavioral Health Statistics and Quality, 2021) and AUD (Grant et al., 2015) relative to non-Hispanic White Americans. Native Americans show the highest rates of alcohol intoxication and blood alcohol content at suicide death of any racial group in the US (Caetano et al., 2013). Somewhat paradoxically, Native Americans report higher rates of alcohol abstinence and do not differ from non-Hispanic White adults in binge drinking (Cunningham et al., 2016). Although a greater proportion of Native Americans do not drink relative to White Americans, a greater proportion of Native Americans who do drink appear to have AUD. As a doubly minoritized group, Native Americans with minoritized sexual identities may be at increased risk for co-occurring SI and AUD and potentially for co-occurring SI and binge drinking. Rates of co-occurring SI and alcohol use may be lower among Native American groups, yet persons with intersecting Native American and minoritized sexual identities may not share this lower risk.

Intersectionality theory suggests that systems of racist and heterosexist oppression are inextricably connected and work in tandem to shape people’s experiences (Collins, 1998, Crenshaw, 1989, McCall, 2005) and, by extension, their health (Velez et al., 2019). Most sexual identity health research relies on predominantly White samples and has not examined health disparities experienced by persons with intersecting sexual and racial/ethnic identities. A recent review shows that Native American people with minoritized sexual identities, particularly Two Spirit people (i.e., a modern umbrella term used by some indigenous North Americans to describe gender-variant community members), are underrepresented in health research. The majority of research on Native Americans with minoritized sexual identities focuses on sexual risk behaviors (Thomas et al., 2021); understanding risk and resilience for mental health and alcohol outcomes is limited.

To address these gaps, we tested differences in odds of co-occurring SI and three levels of alcohol use (alcohol use, binge drinking, AUD) among adults with intersecting racial and sexual identities in a nationally representative US sample. We expected Native American groups to show lower odds of alcohol use, but we expected that Native American sexual minoritized groups would experience higher rates of SI+alcohol use. We expected that, as persons with intersecting minoritized identities, Native American sexual minoritized adults would show greater SI+binge drinking, and SI+AUD, compared to White heterosexual adults and Native American heterosexual adults.