Reframing the Narrative of Substance Use and Risk Among LGBTQ+ Communities

Margaret M. Paschen-Wolff, Columbia University Irving Medical Center and New York State Psychiatric Institute, Department of Psychiatry; Michael Dentato, School of Social Work, Loyola University Chicago; Jeremy D. Kidd, Columbia University Irving Medical Center and New York State Psychiatric Institute, Department of Psychiatry; Avery DeSousa, Columbia University Irving Medical Center and New York State Psychiatric Institute, Department of Psychiatry; Nevaeh Burton-Anderson, SimplyVee, LLC; Anathaleo Blake; Joey Metler, Howard Brown Health; Angela Weeks, National SOGIE Center, Innovations Institute, University of Connecticut School of Social Work. 

In June 2023, the US Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) published a report on substance use disorders among lesbian, gay, and bisexual (LGB) people using data from the 2021-2022 National Survey on Drug Use and Health (NSDUH),¹ reaffirming disparities among LGB populations compared to their heterosexual counterparts. Mainstream media outlets such as CNN² and U.S. News and World Report³ picked up the story, with headlines highlighting “problems” among LGB communities.

Yet, despite a rising tide of oppressive and discriminatory policies targeting LGBTQ+ communities, the majority of LGBTQ+ people are thriving in their personal and professional lives. In fact, most LGBTQ+ people are resilient – coping with and overcoming social and environmental stressors.^4,5 For example, the latest NSDUH report showed that approximately 70% of lesbian, gay, and bisexual LGB adults did not have a substance use disorder.¹ National population-based data on substance use disorders among transgender populations are not currently available (although the latest version of NSDUH includes a question on gender identity, data are still being collected);¹ in the 2015 U.S. Transgender Health Survey (the largest survey of transgender people in the U.S.), approximately 70% of transgender respondents had never used illicit drugs.⁶ Despite this resilience, narratives of “risk”, “victimization”, and “disorders” predominate in public policy discussions and media coverage of LGBTQ+ issues.^2,3

While it is understandable that government reports and media coverage focus on disparities between LGBTQ+ and heterosexual, cisgender individuals, this singular focus overlooks the opportunity to learn about resiliency among LGBTQ+ people, information that could aid those who are struggling with addiction. Risk-based reporting portrays LGBTQ+ people as “disordered” and obscures the community connectedness and joy that help LGBTQ+ people thrive even in the face of discrimination. LGBTQ+ individuals continuously flourish with personal optimism; support from and connection with birth and chosen family, friends, and community; and affirming policies and laws.^4,5,7-9 While LGTBQ+ bars, clubs, and the ballroom communities are often perceived by public health officials as promoting hazardous alcohol and drug use,¹⁰ these spaces have also provided generations of LGBTQ+ people with support, friendship, partnership, community, and safety.^11,12 For example, one of the authors of this article met her wife at a queer dance party; they celebrated their 10-year anniversary and the third birthday of their child in 2020. Often, this sense of safety is absent in most other parts of LGBTQ+ people’s lives. Relatedly, LGBTQ+ people in recovery from addiction who are navigating sobriety may risk losing friends if alternative affirming spaces are not available (e.g., bookstores, coffee shops, dry social events, etc.).

When LGBTQ+ people do misuse substances, they seek treatment at a higher rate than their heterosexual and cisgender counterparts,^13,14despite often encountering stigma and discrimination in health care settings.^15-20 Drawing on decades of HIV activism, LGBTQ+ people are also experts in protecting our communities from adverse drug-related health outcomes. LGBTQ+ people were early leaders in the harm reduction movement and in developing peer-led support groups.^21,22

To ensure all LGBTQ+ people can lead fulfilling lives and thrive in our communities, policies and laws must be implemented to counteract and minimize systemic forms of discrimination and oppression. LGBTQ+ communities must also work together to combat transphobia and racism within our own spaces and our broader society (e.g., state level policies banning access to healthcare for transgender youth;²³privileging of white LGBTQ+ people; conflation of gender identity and sexual orientation in research and reporting; and lack of data collection on transgender and gender diverse populations). Finally, addiction programs must ensure staff receive comprehensive training to deliver strengths- and resiliency-based treatment along with affirming and trauma-informed care.²⁴ In addition to changes in policy, practice, and research, media coverage would benefit from including the voices of a broad array of LGBTQ+ people to avoid perpetuating stigmatizing narratives that cast LGBTQ+ people as “disordered.” LGBTQ+ people disproportionately experience mental health and substance use problems. The LGBTQ+ community is also a tremendous resource of policy makers, treatment providers, and educators from whom the media and the public can learn strategies for promoting resilience and improving health outcomes among all LGBTQ+ people, and in turn a healthier society at large.

Referenced in this post: 

1. Substance Abuse and Mental Health Services Administration: Lesbian, gay, and bisexual behavioral health: Results from the 2021 and 2022 National Surveys on Drug Use and Health (SAMHSA Publication No. PEP23-07-01-001). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. . 2023. Available from: https://www.samhsa.gov/data/report/LGB-Behavioral-Health-Report-2021-2022. [Last accessed: July 12, 2023].
2. Christensen J, CNN: People who are gay, lesbian or bi have more mental health and substance use problems, survey finds. 2023. Available from: https://www.cnn.com/2023/06/13/health/lgb-people-mental-health-substance-use/index.html. [Last accessed: December 6, 2023].
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