LGBTQ Addiction Guide

Substance use and substance use disorders are a serious problem among members of the LGBTQ (lesbian, gay, bisexual, transgender, and queer/questioning) community. Less than 5% of adults in the United States identify as sexual minorities. ^[1] Yet a disproportionately high percentage of sexual-minority adults struggle with substance use compared to heterosexual (i.e., straight) adults. ^[2] Substance use among LGBTQ adults may include engaging in heavy drinking, and using more serious drugs like methamphetamine, cocaine, heroin, and prescription opioids.

Coping through substances is not unique to LGBTQ people; heterosexual people can cope through substances as well. However, LGBTQ people experience minority stress, defined as high levels of stress due to the stigmatization of having a minority identity ^[3]. Stigmatization might look like discrimination and prejudice towards LGBTQ people. Turning to alcohol and drugs to help cope with the difficult emotions (e.g., anger, sadness, and fear) from experiencing discrimination and prejudice is not uncommon. Although drugs and alcohol appear to help with these emotions initially, in the long term they lead to several negative consequences, including addiction and other health complications.

LGBTQ people are twice as likely to meet criteria for any substance use disorder compared to heterosexual people. ^[4] Specifically, LGBTQ people are more likely to use methamphetamine, cocaine, or crack than heterosexual people. ^[5] Not only are substance use disorders more common among LGBTQ people, but members of this community suffer from more severe substance use problems than heterosexual people. ^[6] As a result, LGBTQ people need more intense, specialized addiction treatment and can benefit from better utilization of medical services to overcome their substance use disorders.

Risk Factors for Substance Use and Use Disorders Among LGBTQ Individuals

Members of the LGBTQ community continue to fear that they do not fit into society, or they perceive that society rejects them. There are two ways in which this happens: (1) their minority stress influences their daily living experiences, and (2) minority stress in the form of discrimination may be internalized. Both of these processes can lead to increased substance use. ^[7]

Causes of Substance Use and Addiction Among LGBTQ Individuals

Several factors contribute to substance use and use disorders among LGBTQ individuals. People who identify as lesbian, gay, bisexual, transgender, or questioning/queer often face challenges that are not encountered by heterosexual individuals. For example, members of the LGBTQ community are at greater risk of facing social stigma, discrimination ^[8], violence ^{[9] [10]}, and harassment. As a result, mental health problems are common in this population. Some of the triggers that can lead to substance use and dependence in the LGBTQ population are listed below:

Sexual Identity Discrimination/Social Stigma: Although there is growing acceptance of LGBTQ people in the United States, almost every member of the community has faced social stigma. For example, homophobic victimization among adolescents, consisting of verbal insults, offensive words about the victim, and spreading rumors happens more frequently to gay/lesbian and bisexual students than to heterosexual students. ^[11] Dealing with social stigma and discrimination may drive some sexual minority individuals to drugs and alcohol as a means of coping with the stress.

Family Rejection: LGBTQ individuals are often subjected to rejection by their loved ones. Family rejection has a serious impact on the mental and physical health of sexual minorities. Studies have shown that LGBTQ young adults with high levels of family rejection are at 3 times higher risk for both suicidal ideation and suicide attempts compared to LGBTQ young adults with high levels of family acceptance. Low family acceptance is associated with more substance misuse for LGBTQ young adults compared to LGBTQ young adults who have high levels of family acceptance.^[12]

Lack of Support: Members of minority sexual communities often suffer from feelings of isolation, loneliness, and anxiety. This can lead to a variety of mental health issues. For example, studies show that transgender youth have higher rates of depression, self-harm, suicidal ideation, and eating disorders compared to their cisgender (i.e., assigned sex at birth aligns with gender identity) heterosexual peers.^[13]

Internalized Homophobia: Many people in the LGBTQ population develop self-loathing or self-hatred and start identifying with stigmas. This is known as internalized homophobia/transphobia. It prevents LGBTQ individuals from feeling comfortable with their sexual/gender minority identity. As a result, they sometimes use alcohol and drugs to cope with negative thoughts. Internalized homophobia has been found to have a direct positive association with depression and drug problems among gay and bisexual men. ^[14] Among sexual minority women (i.e., lesbian, bisexual), internalized homophobia is associated with more substance use as well. ^[15]

Legal Issues and Addiction in the LGBTQ Community

Many states in the US have implemented laws making it illegal to discriminate based on sexual orientation. In a landmark ruling in June 2020, the U.S. Supreme Court held that it is unlawful for employers to discriminate against an employee based on their gender identity or sexual orientation. ^[16] These advances in societal acceptance of non-heterosexual orientations hopefully will help decrease rates of substance use and substance use disorders in the future.

Currently, however, many LGBTQ people continue to face prejudices in the workplace. They may be forced to conceal their sexual orientation because of hostile work environments. Concealment is linked to feelings of isolation as well as a lower likelihood of reporting discriminatory incidents. ^[17] This can become a vicious cycle in which hostile attitudes force concealment and concealment limits the ability to confront homophobic behavior. Moreover, people in the LGBTQ community face discrimination in a range of areas, such as housing ^[18], harassment regarding bathroom use, ^[19] and health coverage for spouses. ^[20] These stressors are risk factors for substance use and addiction in the LGBTQ population.

Health Challenges Faced by the LGBTQ Community

Mental Health Disorders: The prevalence of mental health disorders, such as anxiety, depression, suicidal ideation, and substance use disorders is significantly higher in sexual minority groups ^{[21] [22]}. Roughly 37% of sexual minority adults have mental illness compared to 17% of sexual majority adults. Dealing with these co-occurring mental health conditions can predispose the LGBTQ population to substance use and use disorders and also interfere with the desire to seek addiction treatment.

Physical Health Conditions: In addition to an increased incidence of mental health issues, the LGBTQ community also has higher odds of suffering from chronic medical conditions, activity limitations, smoking, obesity, and binge drinking (i.e., drinking 5 or more drinks for men or 4 or more drinks for women on one occasion). ^[23] People who have not revealed their sexual orientation to others are sometimes hesitant to seek treatment for medical issues, including substance use disorders, for fear that healthcare providers will disclose this information.

HIV/AIDS: LGBTQ people are at greater risk of acquiring HIV/AIDS due to risky sexual behaviors. In particular, gay and bisexual men (men who have sex with men) and transgender women who have sex with men are at high risk of HIV infection. Treatment for substance use disorders is important to reduce HIV transmission in this community. Addiction treatment can reduce drug use, protect against intravenous needle transmission, and also lead to a decrease in risky sexual behaviors.

Facts and Figures: Addiction Stats in LGBTQ People

Surveys and studies have only recently started tracking data on substance use in sexual minorities. Surveys thus far have revealed that substance use disorders are more common among sexual minorities compared to people who identify as heterosexual. Long-term trends will emerge over the coming years, but here is what the data currently shows about addiction in LGBTQ populations: ^{[24] [25] [26] [27]}

• According to the 2018 NSDUH Survey, 2.1 million LGB adults had a substance use disorder, 1.5 million had both substance use disorder and mental illness (e.g., depression, anxiety, suicidal ideation), and 5.7 million had mental illness.
• Approximately 38% of sexual minority adults report past-year use of marijuana compared to a prevalence of 16% in the overall adult population in the US.
• Past-year misuse of prescription opioids or heroin was reported by 9% of sexual minority adults on the 2018 NSDUH survey, compared to less than 4% of the overall adult population. The majority of people who misuse prescription opioids obtain the medications from friends or relatives, either for free or by stealing or buying. More than 1.1 million LGB adults received medication-assisted treatment for opioid use disorder in 2018.
• Roughly 64% of LGB adults report alcohol use, compared to 56% of the overall US population. Approximately 12% of sexual minority young adults aged 18–25 report alcohol use disorder, compared to 10% in the overall population.
• Transgender women have a higher likelihood of seeking treatment for substance use disorders compared to non-transgender people.
• LGBTQ individuals have elevated rates of smoking and vaping compared to heterosexual individuals.

Frequently Used Drugs by LGBTQ Individuals

Members of the LGBTQ community use many different addictive substances, but the following substances are the ones that are most commonly used:

Tobacco: The tobacco industry specifically markets its products to LGBT people through direct and indirect advertising. ^[28] Research consistently shows that tobacco use is higher among LGBT adults compared to the general population. Roughly 1 in 3 LGBTQ people report smoking currently. An additional 25% of LGBTQ people are former smokers. ^[29]

Alcohol: Among heterosexual people, men are more likely than women to drink alcohol and to drink heavily. Studies on alcohol use among sexual minorities have revealed a more complex picture. Nonetheless, those who identify themselves as sexual minorities have a 3 times higher chance of lifetime alcohol use disorder and lifetime substance use disorder compared to heterosexual women. ^[30]

Marijuana: Nearly 38% of sexual minority adults report marijuana use in the past year, compared to 16% of the general population. Moreover, regular marijuana use (more than or equal to once weekly in the past 3 months) is associated with HIV positivity and mental health problems among gay, bisexual, and other men who have sex with men. ^[31]

Methamphetamine: Crystal meth is a stimulant that became popular with urban gay and bisexual men in the 1990s and 2000s because of its perceived benefits, such as increased sex drive and pleasure, weight loss, easing of social anxiety, and lowering of sexual inhibitions. However, meth use is associated with sexual compulsivity, sexually risky behaviors, and sexually transmitted infections in the LGBTQ population. ^[32]Approximately 2.3% of sexual minority adults report past-year meth use compared to 0.6% of sexual majority individuals. ^[33]

Prescription Pain Relievers: Within the past year, more than 10% of sexual minority individuals report misusing prescription pain pills, compared to less than 5% of sexual majority adults in the United States. ^[34]

Other Illegal Drugs: In the past year, 0.9% of sexual minority adults report heroin use, compared to 0.3% of sexual majority adults. Drug use is also higher in the LGBTQ community for cocaine, hallucinogens (LSD and ecstasy), inhalants, prescription tranquilizers, prescription stimulants, and prescription sedatives. ^[35]

The above-mentioned statistics are worrisome. There is a need to work towards increased acceptance of sexual minority individuals, which may help reduce the rates of addiction in the LGBTQ community. Studies show that sexual minority adolescents who reside in communities with a supportive LGBTQ environment (i.e., more supportive climates and more LGBTQ events) have lower odds of illegal drug use, marijuana use, and smoking during their lifetime.  ^[36]

Preventing Addiction in the LGBTQ Population

The LGBTQ population is particularly vulnerable to substance use and use disorders. Drug and alcohol addiction in sexual minorities is a serious problem that warrants immediate attention. Yet homophobia and discrimination against LGBTQ people make it difficult for them to seek addiction treatment. Many drug rehab facilities do not cater to LGBTQ people. The staff at many rehab facilities are insensitive or hostile towards members of these communities. More needs to be done to reduce the risk of addiction in the LGBTQ community. Some of the strategies that can mitigate addiction in the LGBTQ population include:

Decrease bullying of LGBTQ teenagers:

Lesbian, gay, bisexual, transgender, and queer/questioning teens experience more bullying and sexual harassment than heterosexual teens. Bullying is associated with poorer physical health and more trauma symptoms among LGBTQ teens. ^[37] This is hypothesized to place them at risk of substance use disorders. Anti-bullying campaigns may help create safer environments for LGBTQ youth and thus prevent drug and alcohol addiction in this population.

Provide access to mental health services: LGBTQ people have 2 times higher risk of suffering a mental illness like generalized anxiety disorder or major depression compared to others ^[38] For those who are still “in the closet,” the fear of being rejected can lead to anxiety, post-traumatic stress disorder, suicidal ideation, and substance use. Those who have come out still struggle with various discriminations and social stigmas. There is a need to increase access to mental health services for the LGBTQ community. According to SAMHSA, 40% of LGB young adults and 31% of LGB adults with serious mental illness received no treatment. ^[39] Moreover, therapists and counselors need to be provided with up-to-date knowledge and adequate training to understand the unique needs of this population.

Assist victims of abuse: LGBTQ individuals are at high risk of poverty, marginalization, stigma, hate crimes, and sexual assault. There is a need not only to prevent these crimes against sexual minorities but also to provide increased support and care for survivors of these crimes. This may include both raising awareness and making more resources available to LGBTQ victims of crime.

Advocate for equal rights: Marginalization may cause LGBTQ people to turn to drugs or drink alcohol to cope. ^[40] Advocating for equal rights for everyone is important to reduce the exposure of the LGBTQ community to discrimination and prejudice.

Specialized Addiction Treatment Programs

LGBTQ people deal with a unique set of challenges that puts them at higher risk of substance use disorders. In the United States alone there are 1.7 million sexual minority adults in need of substance use disorder treatment. When LGBTQ people are seeking alcohol or drug treatment, treatment centers should be sensitive to the needs of the LGBTQ community. Interviews with LGBTQ patients indicate that they prefer therapists who share a minority identity, to have in-depth experience with LGBTQ patients and LGBTQ-specific issues, to not assume a heterosexual identity, and generally to be LGBTQ “friendly” (therapist explicitly sharing their views on gender/sexuality, rainbow flag, sexual-minority-specific language on their website) ^[41]

Sober Sex and Addiction Treatment

Another facet of addiction treatment in the LGBTQ community is the idea of sober sex. People who use crystal meth, for example, often believe that sober sex can never replicate the intense pleasure of sex under the influence of meth. Therefore, sex becomes a trigger for meth use.

Treatment providers, therefore, have to change the perception that sober sex is boring or cannot be as good as sex on meth. Many sexual minority people feel that having sober sex will lead to fantasies of sex on meth and thereby promote drug use. There is also the misconception that meeting people for sex will lead to drug use. LGBTQ-specific methamphetamine treatment is helpful in reducing methamphetamine use as well as reducing psychological distress. ^[42]

Features of LGBTQ Culturally Appropriate Treatment For Addiction

LGBT-specialized addiction treatment produces more favorable results than traditional drug and alcohol rehab programs. ^[43]Yet only 11% of substance use treatment programs in the United States offer specialized services for LGBTQ patients. Moreover, 7 out of 10 programs that claim to cater to the LGBT population offer services that are no different from the services offered to the general population. Less than 8% of addiction treatment programs have services specifically tailored to the needs of LGBT patients. ^[44]

Last updated: March 8, 2023