A national study was conducted on estimates of adult substance use and mental health among sexual minorities. Although previous research suggests that sexual minorities were at higher risk for co-occurring disorders, until 2015 there were no federally funded surveys that identified sexual minorities in their data collections. The 2015 National Survey on Drug Use and Health (NSDUH) is the first of its kind to collect comprehensive data by adding two questions to the survey that identified respondents’ sexual identity and sexual attraction. Respondents were divided into two groups for adults 18 and older. Those who identified as being heterosexual were categorized as the sexual majority group. The second group of respondents who identified as being gay, lesbian or bisexual was categorized as the sexual minority. The survey’s overall results show that there is a greater prevalence of substance use in the LGBT community compared to the sexual majority.
According to NSDUH, sexual minorities were more likely than the sexual majority to have engaged in the following types of drug use within the past 12 months prior to the interview date:
• Misuse of psychotherapeutics
The inclination of the LGBT population toward illicit drug use naturally calls for a higher need for substance use treatment at a specialty facility, but this does not mean sexual minorities have equal access to addiction treatment. In fact, many LGBT individuals encounter barriers when seeking treatment, such as seeking care from providers who hold prejudiced attitudes toward homosexual behavior. Previous negative experiences with health care and addiction treatment providers may also influence one’s decision to postpone treatment.
Mental illness is a disorder related to a person’s thought patterns, emotions, moods and behavior. Ranging from mild to severe, mental illness can cause problems in interpersonal relationships, job performance, and daily function. Mental illness varies widely from one person to another; even if two people received the same diagnosis, each person will experience the symptoms differently. Mental illness is more prevalent in the LGBT community than the general population, according to data from the 2015 National Survey on Drug Use and Health (NSDUH). Mental Health America, a large nonprofit organization that raises awareness about mental illness in the nation, provides the following facts and statistics about mental health challenges in the LGBT community:
Facts and Statistics
• Sexual minorities are three times more likely to experience a mental health condition
• LGBT youth are four times more likely to experience suicidal ideation (i.e., thoughts about suicide or actual attempts to take one’s own life)
• LGBT individuals are 2.5 times more likely to experience depression, anxiety and substance misuse
• About 38-65% of individuals who identify as transgender experience suicidal ideation
• Discrimination based on sexual orientation and gender identity is linked to higher rates of psychiatric disorders, substance use and suicide
The greater prevalence of mental illness among sexual minorities is due to the ongoing discrimination foreign to the general population. While the stigma of mental illness affects all populations, heterosexuals do not have to face the same level of psychological distress associated with stigma based on sexual orientation and gender identity. Sexual orientation is described as having three main components: sexual attraction, sexual (or gender) identity, and sexual behavior. Sexual attraction is one’s sexual interest in others, whether it’s the same sex, the opposite sex, or both sexes. Gender identity refers to the gender with which an individual identifies, which may or may not coincide with the biological sex assigned at birth. Sexual behavior refers to one’s sexual lifestyle, whether one has sexual partners of the same sex, the opposite sex or both.
The fear of coming out and being discriminated for one’s sexual identity and orientation is a major contributing factor to compromised mental health in the LGBT community. This fear is explained by the minority stress theory, which is based on the premise that sexual minorities distinctly experience chronic stressors such as victimization, prejudice and discrimination because of their stigmatized identities. Members of the LGBT community have to fight twice as hard as the general population to combat stigma, a battle which renders sexual minorities more vulnerable to mental health challenges and substance use disorders. Individuals within the LGBT community hide their mental illness from friends, and some who have a mental illness hide their sexual orientation from counselors for fear of ridicule and rejection.
Despite the increasing widespread acceptance of the LGBT community in recent years, many states still lack laws banning discrimination against sexual minorities.
Examples of LGBT discrimination
• Discrimination in the workplace – Employees who know about a colleague’s sexual orientation may turn the workplace environment into a hostile one in which the LGBT individual’s complaints are ignored. Law enforcement officer Jay Brome is one such example, and his lawsuit against anti-gay workplace discrimination is part of a wave of lawsuits in recent years
• Housing – There are no laws in Virginia that protect LGBT individuals against housing discrimination. Citizens may be prevented from renting or buying a home based on their sexual orientation and/or gender identity.
• Denial of health care for persons who openly identify as lesbian, gay, bisexual or transgender – A national survey by Lambda Legal examined the refusal of health care to LGBT individuals living with HIV. About 63% of the survey respondents reported at least one or more types of discrimination in health care, including outright denial, harsh language, refusal to have any physical contact with patients and blaming patients for their health status.
• Substandard care – Sexual minorities receive substandard medical care because health professionals lack adequate knowledge to meet the unique needs of the LGBT population, which is at higher risk for certain types of cancer, such as cervical or oral cancer
• Exclusion from opportunities for career advancement – A new survey by the Center for American Progress (CAP) reveals that though Fortune 500 companies may have anti-gay discrimination policies in place, subtle discrimination still exists among partners in a firm that could exclude opportunities for promotions. These subtle biases influence the way LGBT individuals carry themselves at the workplace, forcing them to push their true identities back into the closet.
Discrimination within the LGBT Community
As if discrimination within the heterosexual culture were not enough, bisexual adults face additional discrimination from their peers within the LGBT community. Bisexual adults reported higher levels of identity confusion and lower levels of self-disclosure and connection than their LGBT peers, according to a study published in the Journal of Counseling Psychology. Identity confusion is one’s uncertainty about one’s sexual orientation, which could result from the lack of LGBT-identified role modeling and pressure to conform to cultural norms. Lower levels of self-disclosure may be due to avoidance of negative labeling and fear of rejection by LGBT peers.
When seeking treatment for alcohol and drug addiction, how can you tell if a drug rehab is LGBT-affirming or not? A treatment center’s claim to be LGBT-affirming may not be substantiated by the types of programs it offers. According to a study on SAMHSA’s listings of treatment centers in the United States and Puerto Rico, an estimated 11.8% of substance abuse treatment programs purported to have specialized services for LGBT clients, but a follow-up survey revealed that 70.8% of these “LGBT” programs were no different than services offered to sexual majority adults, and only 7.4% could identify an addiction treatment center customized for the LGBT population.
What’s lacking in other treatment centers?
An addiction treatment provider that is not LGBT-affirming is likely to lack the resources necessary to address the complex issues facing LGBT individuals, such as rejection, isolation, heterosexism bias, socialization and cultural issues, internalized homophobia, and identity concealment. The absence of a designated substance abuse treatment program for LGBT members suggests that the facility overlooks or ignores these important issues, which are indicated by lack of best practices, research and data relevant to the LGBT community. Some treatment centers may be ill-prepared to address drug abuse issues for sexual minorities, which may be evidenced by prohibiting a transgender person from continuing hormone therapy until substance abuse treatment is completed. In a non-LGBT-affirming setting, transgender or genderqueer individuals may be distressed if they are required to conform to gender-specific dress codes or other similar gender-based requirements. Without the right supportive and social environment, LGBT individuals are more likely to less likely to fully divulge their medical problems and gender identity to avoid discrimination and substandard care.
What to look for in a gay-affirming or LGBT-affirming addiction treatment center
A legitimate LGBT-affirming drug rehab center would have a multidisciplinary team of culturally competent clinicians who are equipped to recognize and address the needs of individuals who identify as lesbian, gay, bisexual or transgender. Cultural awareness of distinct needs among sexual minorities makes a big difference in addiction treatment outcomes; for example, being culturally responsive in substance abuse treatment would mean providing client-centered care for a transgender individual that’s different from tailored treatment for a bisexual adult. Taking LGBT addiction treatment to another level means digging deeper into researching extensively into what those needs are for each sexual orientation.
LGBT-affirming addiction treatment would address some of the following common concerns that may occur during or after treatment:
• Relapse prevention skills in social contexts (i.e., club scene, house parties, social gatherings, etc.)
• Stress management skills in the face of discrimination and prejudice
• Coping skills with regard to depression and anxiety based on sexual orientation/gender identity
• Interpersonal skills in the face of opposition and negative or toxic social influences
• Proper self-acceptance and self-disclosure with regard to gender identity/sexual orientation
Due to the high risk for mental illness and the societal stressors that face the LGBT community, a culturally sensitive LGBT addiction treatment center would offer dual diagnosis treatment for co-occurring substance use and mental health disorders. Dual diagnosis treatment is integrated with a comprehensive array of specialized programs that address specific needs by sexual orientation. Gay men, lesbians, bisexual and transgender individuals each have their own set of substance use disorder and health concerns, which are described as follows:
According to data provided by The Office of Disease Prevention and Health Promotion:
• Gay men are at higher risk of HIV-infection and other sexually transmitted diseases (STDs)
• Lesbians are less likely to seek preventive services for cancer
• Lesbian and bisexual women are more likely to be obese or overweight
• Transgender individuals are at greater risk for victimization, HIV/STDs, victimization and suicide
• Older adults in the LGBT population face higher risks for social isolation and lack of social services
Health Risks for Gay Men
• Though eating disorders are relatively rare among men, a study shows a large percentage of gay and bisexual men are at high risk for eating disorders stemming from poor body image
• Compared to heterosexual men, gay men are 4.4 times more likely to use marijuana, 3.5 times more likely to use other drugs, and 2.9 times likely to have past-year alcohol dependence
• Of those entering addiction treatment, gay men are likely to report use of methamphetamine and less likely to report alcohol and marijuana use than heterosexual men
Health Risks for Lesbians
• A study on the prevalence of depression and alcohol use disorder among lesbians found White and Latina lesbians were more likely to experience lifetime depression than African-American lesbians. Depression was also more common among younger women and single women, and age was the strongest predictor of depressive symptoms and alcohol dependence.
• Compared to bisexual women, lesbians were less likely to receive mental health treatment and health care, according to research
• Lesbians report more problems with marijuana, cocaine and hallucinogens
Health Risks for Bisexual Men and Women
• Bisexual women and gay men are more likely to report physical problems
• Compared to heterosexual women, bisexual women are twice as likely to report illicit drug use
• Bisexual identity, attraction and behavior are associated with higher rates of mood/anxiety disorders for both men and women
• According to research, about 46.5% of bisexual men reported to have mood disorders, compared to 26.8% of gay men, and an estimated 38.9% of bisexual men reported having anxiety disorders compared to 25% of gay men
Health Risks for Transgender Individuals
• Transgender individuals are highly vulnerable to victimization based on physical attributes that reveal their sexual orientation
• A national study (1) revealed that 35% of transgender people who have experienced some form of assault or harassment reported substance use to cope with mistreatment related to gender nonconformity
• Non-conforming gender expression has been strongly associated with three- to four-fold higher rates of alcohol, marijuana and cocaine use
• Violent victimization has been linked with post-traumatic stress disorder (PTSD), major depression and substance use
In addition to addressing health disparities among sexual minorities, gender-responsive staff would take into consideration the sexual orientation of their clients and therapists. For example, a gay male client is less likely to disclose personal issues to avoid shaming and discrimination if the counselor is heterosexual.
At an LGBT-affirming addiction treatment center, gender bias and sexualized transference would be avoided at all costs to preserve a healthy therapeutic alliance between the counselor and client.
LGBT Equal Rights
The Human Rights Campaign (HRC) is one of the nation’s largest advocacy groups for the LGBT community. On the legislative level, the HRC aims to protect the equal rights of LGBT individuals, making society a safe place for sexual minorities to be who they are without fear of prejudice, discrimination and stigma. The HRC lobbies for LGBT rights in Congress, providing support for LGBT-affirming candidates and developing education programs that inform the public about LGBT-related issues.
Support for LGBT Parents
The Family Equality Council advocates for LGBT adults who wish to be parents via adoption, foster care, assisted reproductive technology or other means. Their mission is to build communities that protect and value the equal rights of LGBT couples who want to form families while maximizing opportunities for LGBT youth.
Support for Parents of LGBT Youth and Young Adults
Parents, Family & Friends of Lesbians and Gays (PFLAG) is an invaluable resource for parents, families and friends of LGBT individuals. With over 400 chapters across 50 states, PFLAG provides publications, online learning programs, advocacy support and media training to promote a safe environment for students in school and college.
The GLBT National Help Center provides support through national hotlines for age-appropriate LGBT groups, ranging from youth to adults and seniors. LGBT community members receive support and guidance on how to navigate sensitive issues, such as when they feel questioned about their sexual orientation and gender identity. Since its inception in 1996, the GLBT National Help Center has grown to provide 15,000 local resources across the United States.
Advocacy for LGBT Seniors
Services & Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE) aims to protect the rights of older adults who identify as lesbian, gay, bisexual or transgender. With key representatives in several states, SAGE is making a difference for LGBT seniors by informing policy makers about LGBT aging issues and forming partnerships with other advocacy groups to advance policy priorities for the aging LGBT population.
The United States Department of Health and Human Services provides resources for LGBT-related health issues and health needs. For more information about equal access to health services for the LGBT community, visit the HHS website.
The Office of Minority Health (OMH) through the HHS develops health policies and programs that eliminate disparities to improve the health of minorities. To view how OMH supports health equity, visit their website here.
The Centers for Disease Control and Prevention (CDC) lists resources and publications for clinicians, researchers and health professionals about LGBT health. For more information, visit the CDC Resource Page.
Find Behavioral Health Equity Resources on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) web page, where information about data on health disparities and health care quality among diverse populations are readily available.
1 Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: A report of the National Transgender Discrimination Survey. National Center for Transgender Equality, and the National Gay and Lesbian Task Force; Washington, DC: 2011