The proportion of L, G, B, T, and Q people who suffer from addictions is far greater than in the rest of population. In part, this is linked to the greater prevalence of mental health conditions in the LGBTQ+ community in general, but it is also because the community must overcome several obstacles on their road to recovery. Although it is illegal in the UK (under the 2010 Equalities Act) to deny someone access to medical treatment on the basis of their gender or sexual identity, many LGBTQ+ people still feel that coming forward and seeking help is an almost insurmountable challenge.
With a better understanding of the unique needs of the LGBTQ+ community, however, healthcare professionals can help provide more successful treatment services for this population.
LGBTQ+ and Addiction
Members of the LGBTQ+ community are almost four times more likely to suffer from a drug or alcohol addiction at some point in their lives than the general population. Although it is impossible to pin down any one reason for this, a lower general level of mental wellbeing – due, in part, to battling against discrimination – is likely to be to blame.
20 to 30 percent of the LGBTQ+ population suffer from drug or alcohol addiction, compared with only 8.4 percent of the population as a whole. Those alarming figures, from the Substance Abuse and Mental Health Services Administration in the USA, make clear a need for more drug and alcohol recovery programs that focus on the LGBTQ+ community.
Trends in Substance Abuse in the LGBTQ+ Community
In their October 2016 report, the Substance Abuse and Mental Health Services Administration (SAMSHA) used data gathered in the US National Survey on Drug Use and Health to analyse patterns of drug and alcohol abuse amongst populations with different gender identities and sexual orientations.
The SAMHSA report discovered that adults who identified themselves as gay, lesbian or bisexual experienced higher rates of drug and alcohol abuse, and mental illness, than in the wider population. The results also showed that members of the LGBTQ+ community were much more likely than their peers to search out support and treatment for their mental health and/or drug and alcohol use problems.
Recent surveys show that the main substances which are abused by members of the LGBTQ+ community are:
• Nitrite inhalants
The SAMHSA report, mentioned above, showed that 39.1 percent of gay, lesbian and bisexual adults admitted to using recreational drugs during the previous year. This is more than double the overall rate of 17.1 percent. Additionally, 15.1 percent of LGBTQ+ individuals who completed the survey on which the report was based stated that they had suffered from a diagnosable drug or alcohol addiction in the last 12 months. The proportion of people in the general population reporting a drug or alcohol addiction the previous year was a full eight percent lower.
Although the needs and lives of transgender individuals necessarily differ from those of the L, G, B, and Q communities, all of the available evidence points to drug and alcohol abuse also being a serious concern. According to the SAMSHA report, the substances most commonly abused by trans people include cannabis, cocaine, methamphetamine, and injection drugs such as heroin.
The combination of drugs and sex is something that occurs across society, but chemsex has become particularly prevalent in the community of men who have sex with men (MSM).
For many LGBTQ+ people, alcohol is an ever-present part of their lives. The simple reason for this is that so much LGBTQ+ community life revolves around venues, locations, and events where drinking alcohol has become the social norm.
Evidence from the 2016 SAMHSA report showed that 63.6 percent of LGBTQ+ adults said they had consumed alcohol within the past month, as compared to a rate of 56.3 percent in the general population. LGBTQ+ women in particular were much more likely to drink to excess – binge drinking – than their cisgender/straight peers.
Separate reporting, also from SAMSHA shows that LGBTQ+ people are less likely than their peers to adopt a strategy of abstaining from drugs and alcohol altogether and are significantly more likely to indulge in binge drinking over extended periods of time.
Studies demonstrating that lesbian women are more likely to drink to excess than their straight counterparts are myriad, according to SAMSHA. Of particular note, however, is also the fact that bisexual women are even more likely than lesbians to report hazardous and excessive patterns of alcohol consumption.
A 2016 SAMHSA report found that 32.2 percent of LGBTQ+ people stated they had smoked in the last month, compared to 20.6 percent among the rest of the population. However, it was amongst non-LGBTQ+ people that levels of daily cigarette use – as opposed to occasional smoking – were found to be highest.
Why do people in the LGBTQ+ community use drugs?
LGBTQ+ individuals face a constant struggle against homophobia, segregation and disgrace that may have negative repercussions on their wellbeing. These negative emotions often lead to physical and psychological well-being issues that occasionally push them toward substance use. The harsh reality of this comes out in a 2014 Australian examination revealing that 58 percent of the LGBTQ+ young people reviewed recorded homophobia as one reason for their drug and alcohol abuse.
As if homophobia was not enough, LGBTQ+ people often face violence, bullying, and more. The Centers for Disease Control and Prevention (CDC) have reported that at least 40 percent of young people who are homeless are LGBTQ+, which gives just some indication of the level of personal struggles these young people can experience.
The same CDC report mentions a 2009 study which found that LGBTQ+ young adults who experienced rejection from their families were more than three times as likely to use recreational drugs than those whose families were supportive of the gender or sexual identity.
LGBTQ+ people face increased levels of stress, by comparison with others, often stemming from discrimination, perceived discrimination and internalised homophobia.
College and university students who identify as LGBTQ+ have, according to a 2010 study published in the journal Addictive Behaviours, much higher levels of substance abuse than their heterosexual and cisgender peers. The study explained that the reason for this is likely due – at least in part – to feeling unwelcome and unaccepted in their environment.
While modern society is, thankfully, increasingly accepting of LGBTQ+ people, and culture, many LGBTQ+ people experience some level of internalised homophobia. This type of homophobia is a direct result of the beliefs and attitudes that LGBTQ+ people experience in society as they grow up being internalised, resulting in the individual struggling to accept their own sexuality.
This internalised homophobia can cause low self-esteem and self-hate, which can in themselves be trigger factors for drug and alcohol misuse. A person might use drugs as an escape from their negative feelings. However, when people become dependent on drugs to feel comfortable in their own skin, it only increases their potential to become addicted. This is due to a double-high effect where the person experiences a positive result from using the substance, from both he pharmacological effects and also the emotional effect of feeling at ease with themselves.
Self-Medication, managing feelings
Despite the progress which has been made in recent years, many in the LGBTQ+ community still struggle with anxiety, stress and depression. To cope with these issues, some LGBTQ+ people turn to self-medication with drugs, notably cannabis.
In a 2013 study – published by the Journal of HIV/AIDS & Social Services – HIV-positive gay and bisexual young men talked about their use of cannabis. The participants in the research mentioned stress relief, social relaxation / peer pressure, and a desire to forget about their HIV status for a time, as reasons for their use of cannabis and other substances.
The Challenges Faced by LGBTQ+ people
Even though society is taking giant leaps forward in its acceptance of LGBTQ+ people, for some, the biggest battle they face is accepting themselves. Many members of the community find accepting their own sexuality or gender identity very challenging; and being ‘out and proud’ nigh on impossible.
Hate crime, and discriminatory speech, hurts and many LGBTQ+ people say that it is one of the biggest negative effects on their mental health and wellbeing.
Heterosexism is one name for discrimination against LGBTQ+ people; including denying, ignoring, denigrating, or stigmatising non-heterosexual behaviours and people. Discrimination like this can lead to LGBTQ+ people developing feelings of shame and self-loathing, which can become intensely self-destructive. Many LGBTQ+ people who resort to using drugs or alcohol to deal with their feelings are suffering in this way.
It is illegal, in Great Britain (the situation in Northern Ireland is different), to discriminate against any person, or group of persons, on the basis of their sexuality or gender. The current law – the Equality Act – has been in place since 2010 and includes strong protections for all LGBTQ+ people.
All local authorities and NHS services, amongst others, are legally required to provide appropriate help and support for LGBTQ+ people and the vast majority do so very effectively.
Unfortunately, there remains a small minority of private businesses who believe that they are above the law. One commonly occurring complaint from anti-LGBTQ+ individuals is that forcing them to provide services to the LGBTQ+ community discriminates against them on the basis of their religion. However, the courts have repeatedly found this not to be the case, and the Equality and Human Rights Commission regularly prosecutes businesses who seek to use this as a defence.
Northern Ireland has a legal system largely separate from the rest of the UK, and LGBTQ+ rights in the province lag sadly behind those of the rest of the country. In fact, LGBT rights campaigner Peter Tatchell once described Northern Ireland as, “the most homophobic place in western Europe.”
The Equality Act 2010, which protects the rights of LGBTQ+ people throughout the rest of the UK, does not apply to Northern Ireland. The province was the last part of the UK to legalise same-sex relationships, and still refuses to recognise equal marriage.
Other Health Issues
The majority of LGBTQ+ people will experience mental health challenges at some point during their life. Anxiety and depression are the most common, however mood disorders, eating disorders, and other mental illnesses are more common within the LGBTQ+ communities than they are in the wider population.
One of the challenges facing therapists and other professionals working with LGBTQ+ people is discerning which problem came first: drug and alcohol abuse, or mental illness. This is especially challenging, since many recreational drugs and alcohol can lead to mental illnesses themselves when used to excess. The reality, however, is that both substance misuse and mental illness often feed off each other, creating a vicious downward spiral which people find it very hard to break free from without support.
Substance abuse can also lead to other health concerns such as:
Gay and bisexual men who use injectable recreational drugs have been found by multiple studies to be at a greater risk of becoming infected with HIV and Hepatitis. This is often due either to the sharing of needles, or poor hygiene practices.
Many LGBTQ+ people are afraid to get tested for HIV, hepatitis, and other health conditions such as Sexually Transmitted Infections, as they are afraid that they will be judged because of the sexuality, or their sexual practices. Services for LGBTQ+ people are improving, however, with rapid access testing and treatment clinics taking place several times a week in most LGBTQ+ communities around the country.
Challenges in treating LGBTQ+ people
The substantive elements of treating LGBTQ+ people suffering from a drug or alcohol addiction are identical to treatment for cisgender, and straight individuals. However, it is vital that professionals take account of the unique needs, life experiences, and identities of the clients they are working with if treatment is to be successful.
Many LGBTQ+ people reported, at the start of treatment, that they felt:
It is hard enough for anyone to seek treatment for mental health issues, or for drug or alcohol problems, due to the prejudice and stigma which exists around these issues themselves. For LGBTQ+ people, who face homophobic and/or transphobic discrimination on top of that, finding help or support can seem an impossible hill to climb.
Many healthcare professionals are not trained or experienced in supporting LGBTQ+ people. Thankfully, LGBTQ+ specific healthcare services are now available in almost all areas of Great Britain (although once again, sadly, this is still not the case in Northern Ireland).
In some areas, LGBTQ+ specific healthcare and support services are run by the NHS, in other areas they are provided through charities and other organisations, often using NHS funding. In all cases, however, they are free at the point of use, and no person – LGBTQ+ or not – should ever pay for treatment for a drug or alcohol problem.
As well as making it more difficult for LGBTQ+ people to seek help and support for addiction problems, all these challenges only increase the stigma and general challenges they face and increase their risk of developing mental health or substance abuse issues.
Even more than others, LGBTQ+ people may feel daunted by the prospect of taking part in family, or group, therapy. They may be concerned that they will not fit in, or that the others involved in their sessions will make homophobic or derogatory comments towards them, or LGBTQ+ people in general.
LGBTQ+ couples sometimes face a lack of understanding or sensitivity towards them, stemming from the fact that society is still very much geared to the needs of straight, cisgender people and the fact that – for most of society – heterosexual is still considered the default.
Helping an LGBTQ+ Person Cope with Addiction
Studies, such as one published in 2012 in the US, show that although LGBTQ+ people are more likely to have issues with drug and alcohol misuse than their peers, they are also significantly more likely to seek support or treatment. Because of the community’s willingness to seek out help, it is important that all organisations who offer drug and alcohol treatment are prepared, and equipped with the necessary tools and knowledge, to support LGBTQ+ people.
Many of the mental health issues experienced by LGBTQ+ individuals stem from the continuing stigma and discrimination which the community faces on a day to day level. Addressing these difficulties is, often, key to enabling the individual’s successful recovery from substance misuse and there is strong evidence that LGBTQ+ people respond more successfully to treatment plans which are tailored to their own specific needs (although that should be no surprise, since the same is true for all clients).
Some experts have speculated that increasing levels of acceptance of LGBTQ+ people in society will lead to a drop in the number of members of the community suffering from drug and alcohol problems. The oft-opined theory being that as stigma decreases, and there is less discrimination towards LGBTQ+ people, fewer individuals will suffer the mental health challenges which that can cause, and so be at risk of developing substance misuse problems. Unfortunately, at the same time as acceptance across society has increased a small, right-wing, anti-LGBTQ+ minority have become more vocal, and virulent, in their discrimination and homophobia – especially on social media – meaning that many in the LGBTQ+ community feel as stigmatised and discriminated against as they ever have.
From experience, most drug and alcohol therapists agree that there are ten important basic principles which apply to the treatment of any individual suffering from substance misuse problems.
Understanding and flexibility
Therapists need to be understanding of the particular needs and circumstances of each of their clients. This is especially the case for LGBTQ+ people, who will often have differing life experiences from their straight, cisgender counterparts. Treatment programmes must always be flexible enough to adapt to an individual’s needs, whilst remaining consistent in approach throughout.
Provide a comprehensive range of treatment options
No two people are the same, and different individuals will respond best to different types, and styles, of treatment. For example, EMDR may be an effective option for one client, whilst counselling may be appropriate for another, and CBT for a third.
For larger treatment providers, offering a team-based approach, where a client can see the therapist able to offer the right treatment for them, is an ideal option. Individual therapists should never be afraid to take advantage of their professional network, and CPD opportunities, to ensure that clients have access to the most appropriate treatment options for them.
Responding to cultural needs
The life experiences of LGBTQ+ people are different from those of straight, or cisgender, people. At a time in their lives when they are already experiencing significant trauma, it is more important than ever that professionals working with LGBTQ+ clients are sensitive to their needs and understanding of their life experiences.
Staff members, or therapists, who are not experienced in working with LGBTQ+ people, should attend further training.
Most LGBTQ+ people will have directly experienced some level of stigma and discrimination at some point in their lives. It is of paramount importance, therefore, that treating professionals do nothing which could contribute to this further, and offer the utmost respect, and empathy, towards the person at all times. LGBTQ+ people should always be helped to feel that they are valuable, and valued, members of society, and raising self-esteem in this way is often a cornerstone of treatment.
Encouraging safe and healthy behaviours
Where appropriate and relevant, professionals should take the opportunity to provide education about safer sex and healthy relationships. As with all clients, it will also be important to encourage compliance with medication and treatment.
Supporting autonomy and decision making
Other than in circumstances where they lack capacity, it is the individual’s absolute right to decide how, and if, they wish to receive treatment. Although it is vital that treating professionals present all the facts and evidence, and it is often useful to make a recommendation to the client about what treatment the professional believes is the most appropriate, it is the individual client themselves who – at all times – is free to make their own decisions about what, if any, treatment they receive.
Even where a professional believes that a client is making a decision which is not in their absolute best interests – e.g. choosing an alternative treatment option or withdrawing early from a programme – it will rarely be appropriate for the professional to do anything other than respect the client’s decision.
UK, and EU, law provides strong protections for the ‘right to a private and family life’, especially where sensitive information such as health records is concerned. Almost never will it be appropriate for a professional to share with anyone (including other professionals within their own organisation) any information which could possibly be used to identify a client.
Other than in cases where there is an overriding public interest in disclosing confidential information (when therapists would be well advised seek advice from their professional body), it is unlawful to disclose even that a client is receiving treatment to anyone – including members of their family – without their explicit permission.
Particular care needs to be taken to ensure that LGBTQ+ people who may not feel safe being ‘out’ to their friends, family, or employer, are not outed by the actions of a treating professional. This can be especially challenging where a person is accessing an LGBTQ+ specific service, and professionals and organisations need to carefully consider how they communicate with their clients to ensure that confidentiality is respected at all times.
Reducing potential barriers to treatment
Organisations who provide treatment for substance misuse issues should continually work towards reducing – and where possible eliminating – any barriers which exist to LGBTQ+ people accessing treatment and support. This work should run alongside, and have parity of esteem with, work to engage other hard-to-reach groups.
Providing High-Quality, Evidence-Based Treatment
It is illegal in the UK to provide any kind of medical treatment which is not in the patient’s best interests. Given that – clinical trials aside – only those treatments which are evidence-based can be said to be in a patient’s best interests, it is of great importance that all therapists and organisations restrict themselves to using only those treatments and protocols which meet this standard.
Consider creating a community
A recovery community is a group of people which provides a safe space for individuals to share their experiences about substance misuse and recovery. Although it will not be appropriate for all clients – and indeed many, especially LGBTQ+ clients, will prefer to keep their treatment private and individual – communities and groups can be a valuable resource.
Consent to treatment
Note: this guidance applies ONLY in England and Wales. The law in Scotland, and in Northern Ireland, is different and professionals and organisations working in these regions must seek specialist advice. This is only a very brief summary of an incredibly complex area of law, and advice should be sought from the professional bodies if there is any doubt.
Healthcare in England and Wales is governed by three guiding principles:
1. Non-maleficence (first, do no harm)
2. Act in the best interests of the patient
3. Respect the patient’s right to refuse treatment
This last point, the right to refuse treatment, can sometimes be seen to be at odds with doing no harm, and acting in the patient’s best interests. After all, how can it be in the patient’s best interests to refuse treatment for an evidently damaging addiction?
However, where a patient is over the age of 18, they have an absolute legal right to refuse treatment if they so wish. Any professional who seeks to treat a person who has not given their consent is likely to be breaking the law and, in addition to being disciplined by their professional organisation, will likely be prosecuted.
A note about children and young people
The issue of to what extent a person under the age of 18 can consent, or refuse to consent, to medical treatment is highly complex. Professionals working with young people should ensure that they have received specialist training in this area and should not be afraid to seek advice from their professional body – or formal legal advice – in any cases which are not clear cut.
In summary, however:
• Children aged 16 and over can consent to their own medical treatment and can only be overruled in exceptional circumstances.
• Like adults, children aged 16 and 17 are presumed to have sufficient capacity to give consent to medical treatment unless there is significant and compelling evidence that this is not the case.
• Children aged under 16 can consent to their own medical treatment where they have enough competence, intelligence, and understanding to make a fully informed decision.
The practical impact of this is that a child does not need the consent of their parents, nor do their parents necessarily have any right to be informed, to seek treatment.
Where an LGBTQ+ young person seeks support and treatment, this is of special importance since involving their parents without their consent – potentially outing them – could make their situation worse and be detrimental to their relationship with their treating professional.
Young people refusing treatment
Where a child or young person is brought for treatment by their parent/carer, but refuses to give consent for their treatment, it will normally be unlawful to proceed with treatment against the child’s wishes. In this case, and if the child cannot be persuaded to consent, it will normally be necessary to seek a court order allowing treatment to be given.
Sources of funding for treatment
Unlike in many other countries, notably the USA, the UK is lucky to have a National Health Service, providing free at the point of use healthcare to anyone who is in need. In many areas of the UK, drug and alcohol services are provided directly by the NHS while in other areas private or charitable organisations hold contracts to provide services on the NHS’s behalf. Local authorities (councils) in the UK also have a public health function, and many fund drug and alcohol support workers as part of that provision.
No person who is suffering with a drug or alcohol problem need ever pay for any kind of therapy, support, or treatment in the United Kingdom. Any therapist or organisation seeking to exploit individuals in need by charging a fee for treatment which could otherwise be received free of charge is likely to be acting outside the ethical code of their profession and may be subject to disciplinary action or – in extreme cases – criminal charges.
The prevailing view amongst medical professionals is that drug and alcohol addictions cannot be cured as such. Instead, individuals must learn to manage and live with their addiction, a process known as ‘recovery’. Recovery, in this way, is a lifelong process; even once an individual has completed their course of treatment, they are still ‘in recovery’, meaning that they must continue to work at maintaining a drug-free and alcohol-free life.
We understand that taking the decision to commit to rehab can be difficult, you can schedule a tour of one your local rehab centers to see the available facilities, resources and environment. This can help you with taking the first steps towards your rehabilitation