Special Challenges for LGBTQ Addiction Treatment and Recovery Butler Center for Research | January 1, 2016 Download the Substance Abuse Factors Among LGBTQ Individuals Research Update, and read the follow-up Q&A with Bethany Ranes, PhD. National surveys have estimated that 2%–11% of Americans self-identify as LGBTQ,1 yet as a population, these individuals have historically been underrepresented in addiction research. As scientists have worked over the past three decades to remediate this gap, substance use characteristics and treatment factors present among the LGBTQ population have begun to emerge. Substance Abuse and Dependence Among the LGBTQ Population Since the late 1970s, when substance abuse research first began to include lesbian, gay, and bisexual (LGB) subjects in study findings, scientists have reported significantly higher overall rates of substance use and substance use disorders among sexual minorities as compared to their heterosexual counterparts.2, 3, 4, 5 Gay and bisexual men also have a much higher propensity to abuse methamphetamine than heterosexual men.2, 6The elevated use of methamphetamine is particularly troubling, as it has been linked to increased risk of HIV transmission, especially among gay and bisexual men.6 On average, gay men who have been diagnosed with a substance use disorder report significantly later ages of first use for all substances as compared to heterosexual men, particularly for first use of cocaine and methamphetamine; however, no significant differences in age of first use have been identified for women or bisexual men with substance use disorders.2 More recently, transgendered individuals have also been identified as displaying higher-risk substance use behaviors as compared to "cisgender individuals" (those whose identified gender is congruent with their birth-assigned gender).7 As with gay and bisexual men, transgender women (those who endorse a male-to-female transgender status) also report significantly higher-than-average rates of methamphetamine abuse—a 2014 study found that transgender women in San Francisco were more than 6 times as likely to seek treatment for methamphetamine use as compared to cisgender women.7 Transgender women were also significantly more likely to have used needles in the previous year to inject a drug than cisgender women were.7 Characteristics of LGBTQ Individuals Entering Drug and Alcohol Addiction Treatment In order to better understand the increased prevalence for substance abuse and dependence in the LGBTQ community, scientists have made attempts to identify common characteristics of LGBTQ individuals who report problematic substance use or seek treatment for substance use disorders. Many studies have found that LGBTQ individuals often face significantly increased trauma as a result of various internal and external factors.8 When compared with heterosexual and cisgender individuals, LGBTQ individuals have been found to suffer significantly higher incidences of stressful childhood experiences,9 school victimization,10 neighborhood-level hate crimes,11 and family conflict within the previous 30 days;7 each of these stressors has been found to correlate significantly with increased substance abuse.9, 10, 11 Treatment-seeking LGBTQ individuals also display significantly higher rates of mental illness than do non-LGBTQ individuals.7, 12 Transgender men and women are more than twice as likely to have a diagnosis of a mental illness as cisgender men or women.7 A 2014 study of LGBTQ individuals seeking treatment at the Hazelden Betty Ford Foundation found that 92% of LGBTQ patients were diagnosed with a co-occurring Axis 1 disorder, as compared to 78% of non-LGBTQ patients.12 Further analysis showed that LGBTQ patients were significantly more likely to be diagnosed with depressive and anxiety disorders.12 These results are consistent with other studies that have determined that LGBTQ individuals are 2–3 times more likely than heterosexual individuals to report suicidal ideation or attempts.8 Treatment Factors for LGBTQ Patients Comparisons of treatment-seeking rates between LGBTQ and non-LGBTQ individuals have determined that LGBTQ individuals seek treatment for substance abuse and mental health disorders at a significantly higher rate than heterosexual individuals.13 Despite this, there are surprisingly few programs specifically geared toward treating LGBTQ patients. Studies have found that a significant number of counselors in substance abuse treatment programs endorse negative attitudes toward LGBT clients,14 while others simply fail to consider the unique needs of this population; these factors can have a significant negative impact on treatment effectiveness and have encouraged many providers to develop LGBTQ-specific services.15 Unfortunately, finding such services may be more difficult than treatment seekers first assume. A 2007 study of substance abuse programs throughout the United States and Puerto Rico found that, of the 854 programs that reported via national survey to have specialized treatment services for LGBT individuals, only 62 programs (7.3%) confirmed during telephone follow-ups that such services actually existed.17 A 2013 interview study of gay and lesbian alumni from various treatment programs identified three major themes for ideal service provision: (1) A separate unit or facility welcoming to sexual minorities and LGBTQ allies; (2) Safe and supportive treatment milieu, including LGBTQ and/or affirming staff; and (3) Specialized treatment modalities for different substances and/or addictions.15 A similar study conducted with transgender individuals identified three themes that described their actual experiences in treatment: The first two themes included social rejection/violence and transphobia/stigma, while the third theme was representative of positive, "trans-friendly" treatment.16 Unsurprisingly, the two negative themes were associated with premature discharges from treatment, while patients reporting inclusiveness reported a much more positive overall treatment experience.16 Treatment Outcomes Among LGBTQ Patients Despite a growing trend of research studies investigating treatment factors for the LGBTQ population, there are virtually no reports on recovery outcomes following treatment for LGBTQ individuals or how their outcomes compare to heterosexual patients. Many early studies have been criticized for problematic research design;17, 18 however, more recent studies have used large-scale population data to more accurately assess substance abuse outcomes among patients who self-identify as members of the LGBTQ community.18 A 2012 study using National Treatment Improvement Evaluation Study (NTIES) data suggested that there are no significant differences in outcomes for LGBTQ patients who utilize substance abuse treatment programs as compared to heterosexual patients.18 While replication from additional studies is badly needed, these findings underlie the importance of seeking treatment even when a specialized LGBTQ program is unavailable. Given the relatively recent development of specialized LGBTQ treatment settings, outcomes specific to these culturally competent programs, and how they compare to traditional programs, are not readily available.