Substance Use
Anecdotal evidence and research findings have long pointed to an increased rate of substance use disorders in LGBTQ populations. A large population-level study in 2015 found that those who self-defined as sexual minorities (4.1% of the surveyed population) were more than twice as likely to have used any illicit substance in the last year as compared to their sexual majority counterparts (Medley et al., 2016). They were also more likely to have smoked cigarettes (though less likely to have smoked daily) and more likely to have used alcohol and to have engaged in binge drinking over the past year. The issue of substance use disorders is especially acute in the LGBTQ adolescent population, with a 2008 meta-analysis of available studies showing an odds ratio of 2.89 for substance abuse in the LGBTQ adolescent population as compared to their heterosexual counterparts (Marshall et al., 2008).
The reasons behind increased rates of substance use disorders in LGBTQ populations are not fully understood, but minority stress is thought to play a large role in the onset and continuation of problematic substance use in these populations. One meta-analysis of substance use in LGBTQ youth found that the largest risk factors for unhealthy substance use patterns in the populations studied were victimization, lack of supportive environments, psychological stress, internalizing/externalizing problem behavior, negative disclosure reactions, and unstable housing status (Goldbach et al., 2014).
As discussed elsewhere in this review, LGBTQ populations also experience higher rates of certain mental illnesses, including depression and trauma-related disorders, than non-minority populations. Mood disorders and eating disorders are often comorbid with substance abuse (SAMHSA, 2012). In essence, LGBTQ people face the same challenges and stressors throughout development as everyone else but additionally navigate stigma, shame, and isolation, which further increase the risk of substance abuse (SAMHSA, 2012).
Numerous studies and national surveys have also illustrated high rates of trauma among LGBTQ populations. For example, national data from the CDC’s Youth Risk Behavior Survey showed much higher rates of experiencing physical violence, sexual violence, and harassment among sexual minority (LGB) youth as compared to heterosexual-identified peers (Kann et al., 2016). Lesbian, gay, and bisexual-identified teenagers also reported much higher rates of tobacco, alcohol, and drug use as compared with heterosexual peers, and they also reported using alcohol and/or drugs before sex much more frequently than non-minority peers (Kann et al., 2016). Gender non-conforming and transgender youth similarly face high rates of violence, victimization, and discrimination (Institute of Medicine, 2011). LGBTQ youth are also known to experience alarmingly high rates of homelessness, which may further increase exposure to additional trauma and substance use. Forty percent of homeless youth served by national agencies report LGBTQ identities (Durso, 2012).
Prevention strategies and treatment options are essential to curb the high levels of substance abuse in LGBTQ communities. Unfortunately, targeted substance abuse programs are few and far between. In one study, approximately 12% of substance abuse treatment programs reported to the Substance Abuse and Mental Health Services Administration (SAMHSA) that they offered LGBTQ-specific programming, but when the researchers reached out to the programs, only 7.4% of those that claimed to have specific programming could identify a service tailored to the needs of LGBTQ clients (Cochran, Peavy, & Robohm, 2007).
Those seeking treatment for substance abuse issues are often in a vulnerable state, vacillating between a desire to wrestle some control over their addiction and being pulled back to the addictive behaviors. LGBTQ people in programs that do not recognize their unique struggles may feel misunderstood or unable to approach the work honestly. They may be the targets of discrimination and even violence in treatment settings. A study of transgender people with substance abuse issues revealed that 60% were required to sleep and shower in facilities inconsistent with their gender identities. Many were prohibited by staff from talking about trans issues in the treatment setting. In fact, participants reported experiencing more transphobic events involving staff than other clients (Lombardi, 2008).
Nevertheless, programs specifically designed for LGBTQ populations do exist. An example is the Crystal Clear Project at the Addiction Institute in New York City, which focuses on crystal meth abuse in MSM. The program provides an environment where it is explicitly acknowledged that crystal meth and sex are often overlapping in MSM communities (Mount Sinai West). Self-help 12-step programs such as Crystal Meth Anonymous also focus on MSMs, and provide similar spaces where LGBTQ people can be open about their reasons for substance use within a supportive community.
CME Question:
Which of the following does not contribute to substance use disorders in LGBTQ patients?
Higher rates of trauma
Robust access to substance treatment programs
Higher rates of psychological stress
Fear of violence and discrimination in treatment settings
Answer: 2