Individuals who identify as lesbian, gay, bisexual, transgender, or queer+ (LGBTQ+) experience high rates of trauma and discrimination at systemic (e.g., discriminatory laws) and interpersonal levels (Meyer, 2003; Hendricks & Testa, 2012). These stressors give rise to minority stress, including expectations of rejection, shame, and identity concealment, and have been shown to account for higher rates of substance use, hazardous use, and substance use disorder among LGBTQ+ individuals (Meyer, 2003; Hatzenbuehler, 2009; Livingston et al., 2017).
This substance use disparity has been known for decades (see Straussner, 1985) and is now supported by extensive replication using epidemiological data, longitudinal cohort studies, and meta-analytic research (e.g., King et al., 2008; Marshal et al., 2008). In our own research, we have found that minority stressors experienced throughout life, particularly bias-related sexual harassment and assault (Hinds et al., in press), is associated with higher risk of current hazardous substance use (Livingston et al., 2016). Beyond the cumulative effects of lifetime minority stress, daily exposure to more subtle forms of discrimination, including microaggressions, are associated with a substantial, 200-400% increase in the risk of same-day substance use, within hours of the experience (Livingston et al., 2017).
The self-medication model (Khantzian, 2003) is invoked most often to explain the link between minority stress and substance use, and motives to reduce minority stress-related distress are certainly understandable. As with Criterion A trauma, minority stressors, like discrimination and chronic microaggression experiences, have also been shown to produce re-experiencing, avoidance, and hyperarousal symptoms, as well as alterations in cognition and mood (Livingston et al., 2019). Functional associations between these reactions and substance use are well-documented in the trauma and PTSD literature and could help explain higher prevalence of substance use among LGBTQ+ individuals. LGBTQ+ individuals may also be motivated to use substances to gain “access” to parts of themselves that they might conceal otherwise or to lower inhibitions and increase affiliation or comfort with other people (Livingston et al., 2019). Substance use among LGBTQ+ individuals has also been linked to more permissive substance use norms within the LGBTQ+ community (Cochran, Grella, & Mays, 2012), which may be the direct result of minority stress that for generations relegated socializing among LGBTQ+ individuals to bars, nightclubs, and other venues in which substance use was, and remains, more likely or encouraged.
The consequences of elevated substance use among LGBTQ+ individuals cannot be understated. Indeed, in ongoing work within Veterans Health Administration, our team has found that alcohol attributable deaths are higher among LGBTQ+ veterans compared to their non-LGBTQ+ counterparts (486.5 deaths vs 309.7 deaths per 100,000, respectively). Years of potential life lost per alcohol-attributable death was 25 years for LGBTQ+ veterans vs. 19 years for non-LGBTQ+ veterans. These disparities highlight the exigent need for greater outreach, screening, and efficacious intervention to offset risk for LGBTQ+ veterans, but also non-veteran LGBTQ+ individuals given the high rates of hazardous substance use documented consistently in the literature.
Thoughtful and regular screening of substance use, and factors associated with greater risk for hazardous use, among LGBTQ+ individuals is strongly recommended. Valid and reliable screening tools for substance use are widely available, but it is also strongly recommended that clinicians consider other screeners that have or could be adapted for clinical use to assess trauma and other minority stressors among LGBTQ+ individuals (see Livingston et al., 2020 below for suggestions). This is not to say that minority stress is present or even primary for all LGBTQ+ individuals. However, if it seems relevant to the person, the information gleaned from these screeners could be incorporated into a mutually agreed upon treatment plan.
While LGBTQ+ identities are rarely reported in substance use intervention studies (Flentje et al., 2015), or trauma/PTSD trials (Harper et al., 2022), it is suspected that efficacious treatments generalize to LGBTQ+ individuals. It is still recommended that clinicians consider patient-centered modifications, as needed, that are responsive to extreme and bias-related trauma, chronic interpersonal and systemic discrimination, and adaptations to these stressors such as shame, identity concealment, and expectations of rejection. Whether or not minority stress is driving their substance use, an LGBTQ+ affirmative therapeutic approach to care is vitally important, as well as an understanding of the sociocultural context of LGBTQ+ individuals. For example, substance use recovery often involves significant changes to one’s social support network. This is a challenge for most but may be particularly challenging to LGBTQ+ individuals, for whom a transition of this kind might threaten important ties with affirming others, or “chosen family,” in cases where support available to non-LGBTQ+ individuals may be lacking.
Ideally, treatment would proceed in an LGBTQ+ affirming manner that considers LGBTQ+ individuals’ identities, past stressors, current context and recovery resources (e.g., social supports and other recovery capital), and other patient needs and preferences. This is important for all patients, but particularly for LGBTQ+ individuals who may have a reasonable distrust of the mental health profession due to its longstanding history of pathologizing sexual and gender diversity, and minority stressors perpetrated within healthcare settings (e.g., Livingston et al., 2019). Fortunately, all clinicians have the power to provide affirming and potentially corrective healthcare to LGBTQ+ individuals.
Recommended resources
Livingston, N. A., Berke, D., Scholl, J., Ruben, M., & Shipherd, J. C. (2020). Addressing Diversity in PTSD Treatment: Clinical Considerations and Guidance for the Treatment of PTSD in LGBTQ Populations. Current treatment options in psychiatry, 7(2), 53–69. doi: https://doi.org/10.1007/s40501-020-00204-0
Pachankis, J. E., Soulliard, Z. A., Morris, F., & Seager van Dyk, Iana (2021). A model for adapting evidence-based interventions to be LGBQ-affirmative: Putting minority stress principles and case conceptualization into clinical research and practice. Cognitive and Behavioral Practice. Epub ahead of print. doi: https://doi.org/10.1016/j.cbpra.2021.11.005
Shipherd, J., Berke, D., & Livingston, N. A. (2019). Trauma recovery in the transgender and gender diverse
(TGD) community: Extensions of the minority stress model for treatment planning. Cognitive & Behavioral Practice, 26(4), 629-646. doi: 10.1016/j.cbpra.2019.06.001
American Psychological Association. (2019). Bias-free language. http://apastyle.apa.org/style-grammar-guidelines/bias-free-language
American Psychological Association. (2021). Inclusive language guidelines. https://www.apa.org/about/apa/equity-diversity-inclusion/language-guidelines.pdf
Association of Behavioral Cognitive Therapies, Sexual and Gender Minorities Special Interest Group. (n.d.). Resources. http://www.abctsgmsig.com/resources.html
About the Author
Nicholas A. Livingston, Ph.D. (He/him) is a Research Psychologist in the National Center for PTSD, Behavioral Science Division, and Assistant Professor of Psychiatry at Boston University School of Medicine. Areas of clinical and research expertise include minority stress and LGBTQ+ health, trauma and PTSD, and substance use.
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