Unique Treatment Needs and Risk Factors for LGBTQ+ Demographics

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Rates of substance use disorder, including alcohol use disorder, are higher among LGBTQ+ people than in other demographics.¹ Studies suggest that the stigma against the community and the lack of support for LGBTQ+ individuals creates risk factors for substance misuse and addiction, as well as creating addiction treatment barriers.²

The National Survey on LGBTQ Youth Mental Health 2020 reports that 46% of youth 13-24 in the U.S. wanted counseling in the last year, but were unable to receive it.³

The unique risk factors for alcoholism and treatment barriers can make it more difficult to find rehab that has experience and cultural competence providing treatment for key populations in the LGBTQ+ community.

Understanding the Needs

Within the LGBTQ+ community, there is inherently a larger risk for people to develop substance use disorders—the formal way that mental health professionals describe the symptoms and behaviors of addiction.

Studies show that not only is the broader LGBTQ+ community at higher risk for alcohol use disorder (AUD) than other demographics, but that those who identify as bisexual or “not sure” have even a higher likelihood to develop severe AUD.⁴

While research indicates that many factors contribute to the prevalence of alcohol misuse and addiction, with unique risk factors for people of different identities (e.g., gay men of color experience different intersectional risk factors than transgender bisexual women), researchers agree that environmental factors are key.

There is a larger prevalence of certain environmental factors strongly related to an increased risk of substance misuse and addiction affecting LGBTQ+ people. These include: ⁵

• Homelessness
• Intimate partner violence and other forms of abuse
• Adverse childhood experiences
• Certain health concerns
• Identity-specific legal issues, such as employment and housing discrimination

In addition to these factors increasing the risk of AUD, some of these factors can also affect if individuals have access to addiction treatment and whether the treatment is effective. For example, unhoused individuals may not have the personal identification documents, insurance, medical oversight, transportation, or income necessary to pursue treatment entry in a conventional way.

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Treatment Concerns

If you are part of the LGBTQ+ community, you might have faced several barriers to treatment, manifested in multiple treatment concerns.

Safety and Accommodations

Not all treatment facilities understand how to provide safe accommodations specific to individuals’ needs. How do transgender and gender nonconforming individuals feel seen in facilities that are separated by gender?

How safe does someone feel discussing their relationship concerns in a group setting if in a room if other individuals have openly been homophobic? Or discussing hopes for their future with a therapist who repeatedly assumes that they will want to have a partner of a specific gender who they will have biological children with?

Gaps in Youth Treatment

The Human Rights Campaign reports that LGBTQ+ teens are 2 times as likely to be bullied and 40% less likely to have adult support than their peers.⁶

This lack of support, by extension, creates a gap in all types of resources, from education, reproductive health services, health care, and addiction treatment.

The National Survey on LGBTQ Youth Mental Health 2020 reported that out of the cisgender respondents:

• 50% were unable to afford care
• 44% were unable to receive care due to issues with parent permission
• 23% did not enter treatment because of concerns about provider competency
• 21% could not get transportation to treatment
• 20% were scared of being outed in treatment
• 20% had a previous bad experience in treatment
• 7% did not receive treatment because there were no LGBTQ providers available

All of these rates were higher among transgender and nonbinary respondents—almost 60% could not afford care and almost 30% had a previous negative experience.

Negative Self-Image

Studies show that there is a relationship between rejection of your identity by family and having negative self-talk.² Negative self-image, shame, and guilt are also associated with having difficulty with the decision to enter treatment. Distrusting oneself or having a low perception of one’s self-worth may also be a reason why someone ends their treatment early.

Co-Occurring Mental Health Conditions

Studies show that LGBTQ+ people are more than twice as likely to suffer from depression and have a higher risk of other mental health concerns, such as post-traumatic stress disorder (PTSD), generalized anxiety, and eating disorders.⁷

Co-occurring mental health conditions can affect treatment entry, treatment effectiveness, and treatment completion. In order to receive effective treatment, a person with a co-occurring disorder must receive that treatment from a provider who is aware of the secondary condition and knows how to address it.

Poor Cultural Competency in Treatment Settings

Not all addiction treatment providers are knowledgeable about the needs of the LGBTQ+ community.^{7, 8}

Surveys indicate that in some parts of the country, as much as 85% of treatment facility staff have no training on the specific needs of LGBTQ+ patients. ⁸ These facilities are also likely not to have any policies to improve treatment for these policies in place.

Treatment Advances

Up until even ten years ago, there was a large gap in national data for the key populations within the LGBTQ+ community. Several national surveys found that LGBTQ+ people had limited access to health insurance, poor quality of health care, and larger amounts of population stress due to stigma and discrimination.⁹

Some of the barriers described above have been reduced, however, access to addiction treatment and other healthcare is largely dependent on where you live. Generally, those living in urban areas have more access than those in rural counties and those in progressive states may have more options than those in conservative states.

Lack of cultural competency treatment is still a significant issue. However, there have been a large push to close this gap. For example, insurance companies that utilize funding from Centers for Medicare & Medicaid Services require providers to start writing policies and conduct training that specifically helps to educate professionals about the needs of LGBTQ+ patients.¹⁰

How to Find LGBTQ+ Friendly Treatment

It’s time to enter treatment. What do you do, where do you go, and how do you know you will receive the adequate care required to be successful in your recovery?

Here are some ways you can start your search:

• Call a national helpline—You may not know whether there are any local resources to help you break down treatment barriers or enter addiction treatment. The Pride Institute hotline provides chemical dependency and mental health referrals and information at (800) 547-7433. Other resources like the LGBT National Help Center provide phone and chat crisis counseling, as well as a searchable database for local resources.
• Visit your primary care doctor—While primary care doctors can’t diagnose alcohol use disorder or treat it, they can screen for it and provide referrals. If you feel comfortable with your doctor, their insight can help you find a friendlier program that is more likely to have open beds.
• Reach out to a local nonprofit—Local organizations and local chapters of national nonprofits often help match individuals with specific services. Examples of national organizations include PFLAG and The Trevor Project. If you have a doctor, mental health provider, teacher, pastor, or mentor who is involved in the LGBTQ+ community, they can help you find local resources like community center programs and addiction treatment scholarship programs.
• Evaluate how a facility presents itself—You may have treatment options based on which facilities are in-network with your insurance, which have openings at the moment, or other factors. When you’re looking at a prospective program, consider how it presents itself. Are inclusiveness, well-informed treatment, and cultural competency about intersectional identities centered on the facility’s website, advertising, brochures, and campus?
• Seek peer support—While peer support groups are not a form of therapy and are not a substitute for addiction treatment, especially if you experience withdrawal symptoms and need detox, many individuals find support groups helpful. Many communities have general LGBTQ+ support groups, groups for key populations (e.g., transgender and nonbinary people), and LGBTQ+ people facing a similar challenge (e.g., addiction). These groups may include LGBT Alcoholics Anonymous (AA) meetings, which are available in-person or online.

The most important thing to remember when entering treatment is that you are ultimately there to help yourself get on the path of recovery.

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How to Know You’re in Good Hands

Treatment programs can sometimes fall short of meeting the needs of LGBTQ+ patients even when they claim to be “friendly.” While treatment may not be comfortable, you can arm yourself with knowledge of which kinds of discomfort cross the line into microaggression, harassment, or discrimination. This empowers you to call out providers and leave toxic situations if necessary, as well as to warn other members of the community about the program in question.

You Become the Educator

If you find yourself in treatment explaining and educating your provider on your specific needs more than receiving treatment, this could be considered a red flag. While a few clarification questions are completely appropriate, constant education on your part to your provider might indicate a lack of training or education on theirs surrounding how to appropriately meet your treatment needs.

Competent providers are willing to learn, correct themselves, and do their due diligence outside of sessions with you to ensure that they can offer the best care possible.

You Have to Correct the Staff

LGBTQ+ competent program staff know how to correctly use participants’ names, pronouns, and other personal information. If you have to a staff member multiple times even after you let their higher up know or if all staff members seem to have the same issue, this could be a lack of cultural competence or an intentional form of discrimination. In some states, this is protected by law.

Here are some examples of how this may appear:

• Your dead name appears on your ID badge and on all paperwork. Staff use it to refer to you even though they know your name. They do not change your name in the system, even though other participants have “preferred names” on their badges (e.g., middle name instead of first name, Jim instead of James).
• A staff member uses incorrect pronouns for you and does not correct themselves. They do not respond when you correct them. Reporting the issue does not have any effect.
• Staff use your name and pronouns when with you, but you hear them using incorrect pronouns when speaking to each other about your treatment plan on multiple occasions.

You should be able to expect that your providers respect your pronouns, in fact it can be critical. Research indicates that transgender and nonbinary youth who report having pronouns respected by all or most people in their lives have better mental health outcomes, including half the risk of suicide attempts than those whose pronouns are not respected.³

The Staff Make Assumptions About Your Identity and Your Addiction

While there is value in discussing your identity, orientation, and experiences relating to being a member of the LGBTQ+ community, many factors bring a person into treatment. If your therapist consistently assumes you need to talk about your LGBTQ+ status or that your identity is the underlying cause of an issue, and always redirects the conversation, this could be another sign of a lack of training on how to provide the best treatment.

Treatment providers may also group all LGBTQ+ people under an enormous umbrella, misunderstanding that this category includes many identities and experiences and calls for many different approaches to treatment. A provider who takes a one-size-fits-all approach to every LGBTQ+ client does not have the cultural competency necessary to consider your background, individual history, and any other situations you might be facing that impact your treatment needs. This may reflect a lack of understanding, treatment, or investment in exploring this aspect of your identity.

You Experience Hostility or Mistreatment

While not intentional, some providers have unrealized biases and these, in turn, can lead to microaggressions, which can lead to an unsatisfying or ineffective treatment experience.

Mistreatment is the worst-case scenario, but can happen. If you experience jokes about your identity, have gender-affirming care withheld during treatment, or experience other mistreatment, you deserve better.

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Help is standing by 24 hours a day, 7 days a week.

Who Answers?

Before you enter treatment, discuss what you can do if you experience this during treatment and make an action plan. Check how insurance coverage, cost, and eligibility for future treatment may be affected if you voluntarily discharge from a program early. Advocacy groups like Lambda Legal can help you understand your protection against discrimination in treatment.

While there are barriers, LGBTQ+ friendly addiction treatment has never been more readily available, and we can also be a resource to help you find it. Call 800-948-8417 Who Answers? today to speak to a treatment specialist about your addiction treatment options.

Resources

1. National Institute on Drug Abuse. Substance Use and SUDs in LGBTQ* Populations.
2. Willoughby, B. B., Doty, N., & Malik, N. (2010, October 09). Victimization, Family Rejection, and Outcomes of Gay, Lesbian, and Bisexual Young People: The Role of Negative GLB Identity. Journal of GLBT Family Studies, 6(4), 403–424
3. The Trevor Project. (2020). National Survey on LGBTQ Youth Mental Health.
4. Boyd, C. J., Veliz, P. T., Stephenson, R., Hughes, T. L., & McCabe, S. E. (2019, January 14). Severity of Alcohol, Tobacco, and Drug Use Disorders Among Sexual Minority Individuals and Their “Not Sure” Counterparts. LGBT Health, 6(1), 15–22.
5. Cochran, B. N. & Cauce, A. M. (2006). Characteristics of lesbian, gay, bisexual, and transgender individuals entering substance abuse treatment. Journal of Substance Abuse Treatment, 30(2), 135–146.
6. Human Rights Campaign. Preventing Substance Abuse Among LGBTQ Teens.
7. Jennings, L., Barcelos, C., McWilliams, C., & Malecki, K. (2019). Inequalities in Lesbian, Gay, Bisexual, and Transgender (LGBT) Health and Health Care Access and Utilization in Wisconsin. Preventive Medicine Reports, 14,
8. Eliason, M. J., & Hughes, T. (2004). Treatment Counselor’s Attitudes About Lesbian, Gay, Bisexual, and Transgendered Clients: Urban vs. Rural Settings. Substance Use & Misuse, 39(4), 625-644.
9. Harbeck, K. M. (1993). Invisible no more: Addressing the needs of gay, lesbian and bisexual youth and their advocates. The High School Journal, 77(1–2), 169–176.
10. Bristol, S., Kostelec, T., & MacDonald, R. (2018, April 25). Improving Emergency Health Care Workers’ Knowledge, Competency, and Attitudes Toward Lesbian, Gay, Bisexual, and Transgender Patients Through Interdisciplinary Cultural Competency Training. Journal of Emergency Nursing, 44(6), 632–639.
11. Centers for Medicare & Medicaid Services. (2021, December 01). About CMS Office of Minority Health.