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Address complexities in the LGBT population

May 15, 2011
by Jon E. Grant, MD
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Programs and professionals that treat LGBT clients need to screen for general health concerns and should be aware of the effects of prejudice

Compared with the general population, lesbian, gay, bisexual and transgender (LGBT) individuals are more likely to use alcohol and drugs, have higher rates of substance abuse, are less likely to abstain from use, and are more likely to continue heavy drinking into later life.1,2,3

In a large community sample, rates of past-year substance use disorders were more than twice as high in the LGBT population compared to heterosexual adults (27.6 percent vs. 10.5 percent).4 The prevalence of any past-year substance use disorder was 25.8 percent for lesbian women, 24.3 percent for bisexual women, and 5.8 percent for heterosexual women. The past-year prevalence rate was 31.4 percent for gay men, 27.6 percent for bisexual men, and 15.6 percent for heterosexual men.4

Although LGBT persons use and abuse alcohol and all types of drugs, certain drugs seem to be more popular in the LGBT community than in the majority community. Studies have found that gay men are significantly more likely to have used marijuana, psychedelics, hallucinogens, stimulants, sedatives, cocaine, GHB (gamma hydroxybutyrate) and MDMA (Ecstasy).5 Abuse of methamphetamine has increased dramatically in recent years in the LGBT community6, with some describing it as an “epidemic” among gay men.7

Use of crystal methamphetamine is often related to compulsive and high-risk sexual behavior8 as well as unhealthy body image issues (the latter due to the fact that it promotes weight loss)9, and it may result in long-term psychotic symptoms that mirror the symptoms of schizophrenia.10

Screen for other illnesses

While all drugs of abuse carry significant health risks, those in the LGBT community with substance use disorders frequently have significant health issues that require treatment simultaneously with their addiction treatment. HIV, hepatitis B and hepatitis C all are linked with high-risk sexual behaviors and methamphetamine use.11 Syphilis has re-emerged as a common infectious disease in the LGBT population over the past several years.12 LGBT individuals in substance abuse treatment facilities, therefore, require screening for these illnesses as well as possible referrals to infectious disease treatment providers.

Research has found that nicotine dependence is more common among members of the LGBT community13, particularly among those with substance addictions. Because nicotine use has potentially deleterious health effects, particularly in individuals with HIV, and could influence the effectiveness of antiretrovirals14, treatment for nicotine dependence is essential to promote the health of the LGBT community.

Mental health-related issues are elevated in members of the LGBT community with substance use disorders, in comparison with the heterosexual population.3 LGBT individuals are more likely to report problems with depression and anxiety, and suicide attempts are twice as likely among LGBT individuals.3 LGBT substance users also may have higher rates of personality disorders such as borderline and obsessive-compulsive personality disorders.15

Screening for mental health concerns therefore should be considered mandatory, as these related health problems could affect substance abuse treatment outcomes. Referral to mental health professionals for additional treatment (for example, intensive therapy or medication for depression, Dialectical Behavior Therapy for personality disorders, etc.) is often required.

Understanding prejudice

To provide appropriate medical and mental health treatment for the LGBT community, substance abuse providers should have a general understanding of heterosexism and homophobia when working with LGBT individuals. Heterosexism and homophobia describe the forms of bigotry against LGBT people. Heterosexism denies, ignores, denigrates, or stigmatizes non-heterosexual forms of emotional and affectional expression, sexual behavior, or community.1 Homophobia is defined as the irrational fear of, aversion to, or discrimination against LGBT behavior or persons.1

Heterosexism can affect LGBT people by causing internalized homophobia, shame and a negative self-concept. Some LGBT individuals might resort to substance abuse to cope with these negative feelings. Clinicians should recognize that these effects result from prejudice and discrimination and are not a consequence of one's sexuality.1