Hazardous alcohol consumption is a pattern of alcohol use that increases the risk of harmful consequences [1]. As a leading risk factor for poor health outcomes worldwide, hazardous drinking is a global public health concern. According to the World Health Organization (WHO) [2], heavy drinking is a causal factor in more than 200 disease and injury conditions; it is also among the top 4 risk factors highlighted in the WHO global strategy for prevention and control of noncommunicable diseases. Efforts to reduce hazardous drinking are a major challenge because in many parts of the developed world, consuming alcohol at risky levels is widely socially acceptable and oftentimes viewed as preferable to abstinence, particularly within social worlds structured around heavy drinking norms [3].

The 2018 WHO Global Status Report on Alcohol and Health [4] suggests that women’s drinking has decreased in most countries. However, this is not the case in some Western high-income countries including the United States [5], the United Kingdom [6], and Australia [7]. An increase in women’s drinking is among the most prominent trends in alcohol consumption in the United Kingdom in recent history [8]. Further, alcohol consumption patterns and alcohol-related harms are not evenly distributed across population groups of women [9-12]. As described by Bloomfield's [13] “alcohol harm paradox", although different groups of women may drink similar quantities of alcohol, they often experience differential harms based on their level of social disadvantage. It is important to understand the contemporary determinants of health that contribute to hazardous drinking and make it more (or less) difficult for socially marginalized women to reduce alcohol consumption, particularly when alcohol is readily accessible and is used to facilitate or form social connections. In this paper, we review the literature regarding existing alcohol interventions for sexual minority women (eg, lesbian, bisexual, and queer), discuss barriers and facilitators to interventions that support sexual minority women who wish to reduce their alcohol use, and describe 2 studies, one in Scotland and one in the United States, that aim to support the development of an intervention designed to reduce alcohol-related harms among sexual minority women.

Hazardous drinking is among the most prominent health-related disparities when comparisons of heterosexual and sexual minority women are undertaken globally [14-16]. For example, findings from a US national sample found that compared to heterosexual women, sexual minority women were nearly 4 times as likely to engage in heavy episodic drinking [17]. A population-based study conducted in England found that lesbian, gay, and bisexual (LGB) adults (32%) were more likely than heterosexual adults (24%) to drink at harmful levels [18]. This sexual orientation–related disparity is hypothesized to be due to several factors: (1) minority stress related to discrimination and marginalization that impacts mental health and contributes to using alcohol as a coping strategy [14,19-21]; (2) sexual minority women are more likely than heterosexual women to have experienced lifetime trauma, including childhood sexual abuse, childhood physical abuse, adult sexual assault, and intimate partner violence [22-27], that also contributes to alcohol use as a means of coping [28]; (3) the predominantly alcohol-driven nature of the commercial lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (lesbian, gay, bisexual, transgender, queer or questioning [LGBTQ+]) scene, which facilitates connections and provides a key social environment for many LGBTQ+ individuals and communities [29,30]; and (4) the important role that alcohol plays in identity formation for LGBTQ+ people [14,30,31].

An emerging body of literature suggests that heavy drinking norms also contribute to the heavier drinking patterns of sexual minority women [32]. Drinking is primarily a social activity, often a central part of social occasions in a “social world” where members come together around something they have in common, such as an occupation or an identity [3]. In addition, research suggests that sexual minority women perceive the expectation to drink to be higher in LGBTQ+ spaces than in other contexts [33]. Understanding the drinking norms and drinking behaviors of sexual minority women is essential to informing the development of effective interventions to reduce heavy drinking and alcohol-related harms.

In the general population, women are less likely than men to seek help related to their drinking [34-36]. Women who drink heavily report experiencing gendered stigma that negatively impacts their desire or ability to access mainstream alcohol treatment services and their experiences when help is sought. Such stigma may be particularly salient for sexual minority women who are already stigmatized based on their sexual identity [35,36]. For example, Dimova et al [37] found that sexual minority women (and sexual minority men) who accessed alcohol treatment were rarely asked about their sexual or gender identity, which precluded exploration of how these factors might impact their drinking or desire to reduce drinking. Both lesbian and bisexual women also reported experiencing heterosexist assumptions (eg, that they were partnered with a man) and feeling judged because of their drinking. Moreover, one recent study using data from the 2020 US National Survey of Substance Abuse Treatment Services found that only 2.4% of substance use treatment facilities offered LGBTQ+-tailored programming [38].

Compared to intervention studies aimed at reducing hazardous drinking among women in the general population, those that focus on the experiences of sexual minority women are more recent and more limited [14,39,40]. The small body of literature on interventions designed to reduce drinking among sexual and gender minority populations has focused predominately on sexual minority men [14,41]. A few studies have been conducted on sexual minority women’s perceptions and experiences of alcohol treatment in the United States, but nearly all have focused on formal treatment or 12-step programs such as Alcoholics Anonymous (AA) [42-48]. Interventions that might be appropriate for heavy-drinking sexual minority women who are not accessing services or for whom alcohol use is not yet problematic enough to warrant formal treatment—but likely to worsen without early intervention—have not been explored.

Many alcohol treatment programs, especially 12-step programs such as AA, emphasize powerlessness, character defects, and making amends to those harmed by one’s drinking—features that may be off-putting for sexual minority women who experience stigma, discrimination, and rejection based on their gender and sexual minority status. While AA is not affiliated with a religious organization, it uses a framework based on religious spirituality. Sexual minority women who do not identify with a particular religion or who have had negative experiences with religious institutions are less likely to access AA [43]. Access to nonreligious and affirming alternatives to AA is important, given research documenting low rates of endorsing religiosity and an absence of a protective effect of religiosity on heavy drinking among sexual minority women relative to heterosexual women [49,50]. Sexual minority women and sexual minority men are more likely than their heterosexual counterparts to express interest in accessible, nonstigmatizing alternatives to AA and traditional treatment approaches [51]. Sober curiosity, described in detail in “Potential Usefulness of an Intervention Based on Sober Curiosity” section, is an identity-affirming approach to alcohol reduction that offers such an alternative.

In a large global scoping review of studies focused on alcohol and other drug use among sexual minority women, Hughes et al [14] describe the dearth of research related to substance use interventions as “a gaping hole.” Although studies of alcohol treatment effectiveness sometimes report findings for sexual minority participants, they rarely report findings specific to sexual minority women. For example, Zajac et al [52] used data from 5 randomized clinical trials to compare the effectiveness of contingency management with financial incentives versus standard intensive outpatient care treatment among 920 LGB and heterosexual participants with a substance use disorder. Differences between LGB and heterosexual participants were compared across 3 substance use outcomes: treatment retention, the longest duration of abstinence, and percent negative substance use screens. Contingency management plus intensive outpatient treatment did not show statistically significant differences for any of the 3 outcomes. However, the LGB group means were higher than those of heterosexual participants for treatment retention and the longest duration of abstinence. Although not strong enough to reach statistical significance, these differences were considered potentially clinically significant. Unfortunately, analyses aggregated LGB participants, which prohibited specific examination of outcomes among sexual minority women.

In another study that combined sexual (and gender) minority participants, Gilmore et al [53] evaluated Positive Change (+Change) with 24 undergraduate students from a large university in the Southwestern United States. Of the 24 participants, most (n=17) identified as cisgender heterosexual; 7 identified as sexual minority, gender minority, or both sexual and gender minority. The intervention included content from an integrated alcohol and sexual assault risk reduction program developed for women and a web-based adaptation of a brief motivational interviewing personalized feedback protocol. +Change had high usability and acceptability ratings among both cisgender heterosexual and sexual and gender minority participants. Differences based on sexual and gender identity were not examined because of the small sample size.

In the only intervention study undertaken with sexual minority women prior to 2020, Fals-Stewart et al [54] evaluated the efficacy of behavioral couples therapy plus individual therapy compared to individual-based therapy only among lesbian and gay couples, in which at least 1 partner had an alcohol use disorder. Treatment intervention components included developing recovery contracts with partners, teaching partners communication strategies and strategies for reducing triggers and exposure to alcohol, and increasing shared activities. Results indicated that among lesbian couples, those who received the behavioral couples therapy condition reported fewer heavy drinking days at 12-month follow-up compared to those receiving individual therapy only.

Pachankis et al [55] conducted a small (N=60) sexual minority women–adapted cognitive behavioral therapy (CBT) intervention that focused primarily on mental health. This waitlist-controlled trial, Empowering Queer Identities in Psychotherapy, was designed to help sexual minority women understand emotion-driven behavior, reduce emotional avoidance, and learn behavioral skills and other resilience-building strategies. Pachankis et al [55] found that Empowering Queer Identities in Psychotherapy demonstrated preliminary efficacy in reducing sexual minority women’s depression, anxiety, emotion dysregulation, and rumination in the intervention compared to the waitlist control group. The effects of alcohol use were marginally significant, with the immediate intervention group outperforming the waitlist control group. Minority stress responses were not significantly affected by the intervention. In line with previous research, findings suggested that greater attention to sexual minority women’s elevated rates of trauma and hazardous drinking is needed to enhance CBT interventions for sexual minority women.

Boyle et al [56] examined the feasibility and efficacy of reducing alcohol-related risks using personalized normative feedback delivered within a digital competition designed to challenge negative stereotypes and norms about sexual minority women’s drinking. This study was the first to find that activities aimed at correcting sexual minority women–specific drinking and coping norms via personalized normative feedback reduced alcohol consumption among participants receiving this condition compared to those in the control condition who received information about nonsexual minority–specific topics.

In a study conducted with Australian same-sex attracted women, Bush et al [57] used SMS text messaging to examine the feasibility, acceptability, and efficacy of an alcohol intervention called the Step One program. In total, 97 same-sex attracted women who met the criteria for hazardous drinking by scoring ≥8 on the Alcohol Use Disorders Identification Test were randomly assigned to the Step One condition (n=47; mean age 37 years old)—which included a variety of SMS text messages about the health benefits of reducing alcohol intake—or a control condition of messages containing a link to a website with health information and support services for LGBTQ+ people (n=50; mean age 34 years). Participants in both conditions showed significant reductions in alcohol consumption and improved well-being over 4 weeks. The frequency of help-seeking was low; only 4 intervention group participants and 3 control group participants sought help. In total, 10 participants in the intervention group were interviewed about acceptability. Overall findings indicated that the intervention needed to be revised prior to its implementation.

Except for the study by Bush et al [57], all the intervention studies described earlier were conducted in the United States. Although a variety of approaches were used (eg, personalized normative feedback, couples therapy, and CBT), they were all based on individual behavior change models, which have limited effectiveness for heavier drinkers [58]. Efforts that target individual drinkers typically ignore the fact that most drinking is social, occurring in the company of others, and that how much one drinks is influenced by others (eg, pressure to drink more or less).

In summary, sexual minority women have seldom been the focus of intervention studies. When included as part of LGBTQ+ samples, outcomes are rarely reported separately by gender and sexual identity. Consequently, given this population’s social and structural marginalization, it is unknown whether existing treatment options are suitable for sexual minority women. Because the drinking patterns of sexual minority women appear to be in large part motivated by seeking social connection and a sense of belonging, any intervention developed for sexual minority women must address these social and affective needs [59-61]. An intervention that incorporates these elements within sober curiosity, a wellness movement that challenges the centrality of alcohol in social life and questions the notion that alcohol is required on all social occasions [62], offers a potentially scalable approach to alcohol interventions suitable for sexual minority women. Supported by popular and well-known periods of nondrinking such as “Dry January” or “Sober October,” sober curiosity is geared toward developing longer-term, sustainable lower-risk drinking practices.

There is evidence of substantive social change regarding alcohol consumption, including the exponential rise in the marketing and availability of no or low alcohol (referred to as “NoLo”) content wines, beers, and spirits [63,64] and a growing number of sober venues and events, as well as proliferation of web-based support forums that are based on sober curiosity tenets. For example, Grace [65], author of This Naked Mind and founder of The Alcohol Experiment, reported on February 22, 2023, that in less than 1 year, more than 80,000 people globally had subscribed to the This Naked Mind web-based alcohol reduction program; notably, most subscribers are women. Similarly, Club Soda in the United Kingdom reportedly has helped “tens of thousands” of people reduce their harmful drinking.

The sober curious movement encourages individuals to question the centrality of drinking alcohol in their daily lives, to make a conscious decision to “be curious” about their reasons for drinking, and to consider if drinking alcoholic beverages is necessary in situations where drinking would typically occur. The growing popularity of sober curiosity provides support for a more positive identity for light or nondrinkers than has been previously available. It offers opportunities for both personal and social change, recognizing that individual alcohol consumption behaviors cannot be separated from their contexts. However, no research has examined how sober curiosity or similar interventions to reduce alcohol consumption are perceived by sexual minority women. An established literature on the links between minority stress and poor health [66-68] provides strong evidence that the contexts in which sexual minority women live and experience life differ in important ways (eg, marginalized identities and shame) from heterosexual women’s life experiences, making it critically important that such experiences be considered in any intervention effort to reduce sexual minority women’s alcohol consumption.

Drawing on several decades of our own and others’ research investigating and seeking to understand sexual minority women’s drinking, we believe that a sober curious approach may increase the desire of sexual minority women to reduce alcohol consumption and increase their self-efficacy to resist drinking. Sexual minority women typically participate in alcohol-centric social contexts (social worlds) to connect with other sexual minority people, establish inclusive friendships with like-minded people, and gain social supports that are limited in other contexts [59,60]. These social worlds, although contoured by heavy drinking norms, can be especially helpful during periods of transition or stressful events (eg, coming out, experiencing violence, or relationship dissolution), contexts in which sexual minority women may be more likely to drink heavily [69].

Sober curious approaches could promote wider availability of alternatives that meet important personal and interpersonal needs but do not involve drinking alcohol. This alternative is promising, given research that has found social norms, particularly perceived peer-drinking norms, are strongly predictive of heavy drinking among sexual minority women [32,70,71]. Sober curiosity focuses on shifting cultural and subcultural heavy-drinking norms (not just individual behavior), and interventions that are shaped around the philosophy of sober curiosity may be an important way to address persistent sexual orientation–related disparities in hazardous drinking among women. Sober curiosity is nonjudgmental; it emphasizes alcohol and its addictive properties rather than the person as the “problem.” Research across various domains of sexual minority women’s health suggests that approaches that are nonpathologizing and nonstigmatizing, that focus on community norms and social connection, and that emphasize health, wellness, and mindfulness are likely to be most effective for sexual minority women [72]. Yet, no studies have been conducted that use these approaches in conjunction with sober curious principles to address sexual minority women’s drinking.

Therefore, we are conducting 2 studies that combined to use a variety of methods to explore the feasibility, potential usefulness, and key elements of a tailored intervention based on sober curiosity for sexual minority women. One of the studies includes focus groups and a national survey with sexual minority women in Scotland; the other includes in-depth interviews with sexual minority women in the United States, followed by a review of findings by 2 international panels of experts. The aims of this research are (1) to explore the perspectives of the drinking social worlds of sexual minority women, their awareness of the sober curious movement, perceptions of their own and their peers’ drinking and desire to drink less, and perceived barriers and facilitations to changing their drinking behaviors and (2) to identify key elements of an alcohol reduction intervention tailored for sexual minority women.

The conceptual framework informing our work incorporates “social world” perspectives [58] and tenants of the health equity framework [73]. The social worlds of heavy-drinking sexual minority women are characterized by a connection point that can be thought of as a space where drinking alcohol is perceived to be an important aspect of shared activities or of a shared culture [3]. Research addressing heavy drinking social worlds is nascent; yet, this perspective can provide a unique lens for understanding and addressing harmful drinking in at-risk populations. The health equity framework builds on 3 foundational concepts: equity at the core of health outcomes; multiple, interacting spheres of influence; and historical and life-course perspectives. It illustrates how complex interactions between people and their environments affect health behaviors and outcomes. The importance of each of these concepts for LGBTQ+ people is highlighted in a 2011 landmark report on LGBT health [74].

Most sexual and gender minority health research, especially research on alcohol use, has been conducted in North America [14,75-78]. We chose to collect data from sexual minority women in Scotland because the sober curiosity movement appears to be more prominent in the United Kingdom than in other European countries and in most other parts of the world [79,80]. Further, hazardous drinking in the UK general population is more prevalent than in other countries in continental Europe [81], and alcohol-related harm is disproportionately higher in Scotland than in the rest of the United Kingdom [82]. In 2018, as part of a raft of evidence-based strategies to tackle this “alcohol crisis,” Scotland became one of the first countries in the world to implement minimum unit pricing with the aim of reducing alcohol-related deaths and decreasing health care use [83,84]. Although relatively little research on alcohol use among sexual and gender minority people has been conducted in Scotland, or in the United Kingdom, limited research has documented higher rates of hazardous alcohol use in sexual and gender minority people in the United Kingdom relative to their heterosexual counterparts [85]. Thus, although no studies have compared rates of sexual and gender minority drinking in Scotland and in the United States, there is reason to believe that sexual minority women in each country are at heightened risk of harmful alcohol use. Our research aims to understand similarities and differences in the cultural contexts of sexual minority women’s drinking in the 2 countries and how such differences impact sexual minority women’s drinking.

Because Scotland’s population is predominately White (only 4% are Asian, African, Caribbean or Black, mixed, or members of other ethnic groups) [86] and because we wanted to include diverse sexual minority women’s perspectives, we chose to also collect data in the United States. We created a sampling frame consisting of diverse sexual minority women in regard to age, sexual and gender identity, race or ethnicity, education, and geographic residence from participants enrolled in an ongoing longitudinal study of risk and protective factors for hazardous drinking among sexual minority women [87].

In a separate but complementary study, we are conducting in-depth interviews with a purposive, diverse sample of approximately 18-20 sexual minority women in the United States. Interviews lasting approximately 60 minutes are conducted via Zoom or phone by 2 researchers (LB and Ellen Riggle) with extensive qualitative training and research experience in sexual minority women’s health. Questions explore the same areas of inquiry as the focus groups in Scotland. For example, sexual minority women are asked about their perceptions regarding alcohol use within sexual minority women’s social worlds and about their personal experiences with drinking. During interviews, we ask if sexual minority women are aware of the sober curiosity movement, are interested in considering ways to reduce their alcohol consumption (are they sober curious?), factors and barriers that impact their decisions and preparedness to reduce consumption, alternatives to alcoholic beverages and alcohol-based events perceived to be available, attitudes toward and experiences with NoLo beverages, and perceptions of conditions that would support consideration of reducing their own and other sexual minority women’s alcohol consumption. The US interview guide is available upon request.

We are recruiting adult sexual minority women who participated in a longitudinal study of drinking among sexual minority women led by first author Hughes [14, 94]. This approach permits more efficient and accurate identification of sexual minority women who either drink at moderate or heavy levels (ie, at least 14 drinks per week on average) or reported that they were thinking of cutting down on their alcohol use. The sample will include sexual minority women with diverse demographic characteristics, such as age, race or ethnicity, sexual identity (eg, lesbian, bisexual, and queer), residence (urban or rural), educational level, and relationship status. Interviews last 60-90 minutes, and participants are given a US $50 Amazon gift card in appreciation of their time.