Sexual and Gender Minority Youth and SUDs

Butler Center for Research / September 2022
young people in a row

Download the Sexual and Gender Minority Youth and SUDs Research Update

Introduction

As the prevalence of substance use disorders remains high,1 disparities in prevalence and consequences exist, particularly among Sexual and Gender Minority Youth (SGMY) or LGBTQ+ youth. Research shows that SGMY are not only at greater risk of substance use but are also more likely to develop substance use disorders (SUDs).2

Distinction between sexual and gender minorities

Sexual and Gender Minority Youth is an umbrella term which includes a variety of populations. Therefore, it is crucial to make the distinction between sexual orientation and gender identity. Sexual orientation refers to a person's sense of identity based on an enduring pattern of emotional, romantic and/ or sexual attraction to men, women or both sexes.3 This includes but is not limited to gay, lesbian, bisexual, straight, pansexual, asexual, etc. Gender identity is a component of gender that describes a person's psychological sense of their gender, such as transgender, cisgender, and gender nonbinary.3 This distinction has not always been applied in research, or data collection in general, which has limited the results of earlier research and most likely misinformed some treatment and prevention efforts.

Brief overview of the Minority Stress Model and how stressors influence substance use

In order to understand why SGMY might be more prone to use substances and to develop SUDs, researchers have used the Minority Stress Model. This theoretical framework was proposed by Meyer in 2003 to explain the effects of stressors and stress processes that affect individuals who belong to sexual minorities.4 The Minority Stress Model posits that certain groups experience greater incidents of minority stress based on race, sexuality, gender, disability, etc. in the form of prejudice and discrimination. As a result of those experiences, members of these communities experience greater negative health outcomes than majority group communities.4

Additionally, the Minority Stress Model has been used to explain the unique issues and stressors that transgender individuals face.5 This distinction is crucial since transgender youth face a variety of different challenges due to their gender identity.

Implications

Why should we focus on youth?

Adolescence is a developmental stage marked by change, both internal and external, and many of these changes can become stressors and risk factors in the lives of youth.6 The experience of LGBTQ+ youth can be complicated due to lack of acceptance from family and peers, internalized homophobia, lack of visibility, and school victimization.Adolescence is also a critical period for the onset and progression of mental health symptomology and substance use behaviors, the patterns of which set the stage for health and wellbeing across the life course.8

Research shows that substance use in LGBTQ+ youth co-occurs with a myriad of other risk factors. The comorbidity rate for substance use disorders and issues such as homelessness, mental health disorders, suicidality, and health problems such as HIV and COVID-19, is highly prevalent among these populations.9–14

A 2020 perspective on vulnerable youth noted that being homeless and having a substance use disorder may put youth at increased risk for becoming infected with COVID-19, which is complicated by the fact that they may also be less likely to have access to coronavirus testing and treatment.9 This lack of access to treatment is not only an issue for physical health but also mental health. Additional barriers to accessing and engaging with care have been identified for SGM youth and include the lack of awareness of services, stigma and shame around seeking help, and issues around confidentiality, trust and anonymity.15

The Trevor Project is a suicide prevention and crisis intervention organization for LGBTQ young people.16 This organization conducts an annual survey that gathers self-report information on the experiences and challenges of nearly 35,000 LGBTQ youth aged 13 to 24 years old across the United States. Although there are limitations with regard to conclusions that can be drawn from survey data, it can be used to investigate the characteristics, behaviors, or opinions of a group of people; in this instance, LGBTQ youth.

According to 2021 survey data published by The Trevor Project:16

  • 42% of LGBTQ youth seriously considered attempting suicide in the past year, including more than half of transgender and nonbinary youth
  • more than 80% of LGBTQ youth stated that COVID-19 made their living situation more stressful—and only 1 in 3 LGBTQ youth found their home to be LGBTQ-affirming
  • 48% of LGBTQ youth reported they wanted counseling from a mental health professional but were unable to receive it in the past year
  • more than 80% of LGBTQ youth of all races/ethnicities said it was important that a crisis line include a focus on LGBTQ youth

Prevalence of Problem and Risk Factors

How does each population relate to SUDs?

Several studies show that there are differences in the consumption of drugs when comparing SGMY and non-SGMY,4, 10, 17–20 including higher risk of polysubstance use when compared to heterosexual youth (e.g., alcohol, nicotine, and marijuana).18, 21-25 However, heterogeneity within the LGBTQ+ youth population and their consumption of drugs is rarely considered and requires additional study.

A 2019 study, focused on binge drinking and school victimization, showed that lesbian and bisexual girls were more likely to engage in binge drinking than their heterosexual peers. This same study showed that gay males were less likely to engage in high-intensity binge drinking.26 These results align with those of several other studies, which show that sexual minority females, and particularly bisexual females, show a substantial risk for substance use.

Another 2019 study, focused on drug consumption at EDM (Electronic Dance Music) dance parties, showed that sexual minority females were at greater risk for the use of hallucinogenic drugs, such as mushrooms and LSD, as well as stimulants such as cocaine compared to heterosexual females. This same study showed that gay males were at higher odds for use of ecstasy, GHB (gamma hydroxybutyrate), and methamphetamine while bisexual males were at higher odds for use of LSD and unknown powders.18

A 2016 study examining substance use among sexual minority college athletes found that this group may be at a greater risk of substance use.20 Sexual minority collegiate athletes had greater odds of cigarette use, alcohol use, and marijuana use in the past month, and of being diagnosed or treated for a substance use disorder during the past year when compared to either heterosexual collegiate athletes or heterosexual nonathletes, but had similar odds on these outcomes when compared to sexual minority nonathletes.20 These results may indicate that college sports may have differential risks and/or benefits for sexual minority athletes related to substance abuse.

Research on gender minority youth have found that transgender youth were more likely to have ever used alcohol, cigarettes, and marijuana than their non-transgender peers.10 Additionally, a 2017 study indicated that transgender youth were at higher risk of early onset of substance use as well as reporting recent use of substances.17 Lastly, it is worth noting that within gender minorities there is also a difference in substance use. A 2021 scoping review found that transgender men were at an elevated risk of developing alcohol use disorder when compared to transgender women. Although this analysis did not focus specifically on youth, it shows the importance of inclusion in research, as it provides more accurate and applicable results.27

Current Efforts and Future Directions

Research shows that some approaches have proved effective in preventing substance use in SMY. On an individual treatment level, there have been novel clinical interventions specific to LGBTQ youth that show promising results such as Attachment-Based Family Therapy, Relational Focused Therapy, and LGB-affirmative cognitive-behavioral therapy.6

Additionally, school-based approaches can be very beneficial for SMY. LGBTQ youth who participate in gender and sexuality alliances (GSAs), school-based clubs attended by SMY and allies, experience less school-based victimization and engagement has also been linked to reduced depression and anxiety.6 Lastly, research shows that LGBTQ youth are less likely to experience victimization, substance use, and suicidal ideation in states with policies that are more protective of this population.6

Although there has been an increase in data collection and studies that focus on the LGBTQ+ community, there is still a significant need for data that better informs prevention strategies and treatment. A 2017 study pointed to the scarcity of much needed research that would help to develop effective evidence-based interventions to specifically meet the unique needs of transgender persons.28 Recommended future research directions may include understanding how experiences earlier in life impact health and wellness later in life among LGBTQ people, advancing program development and prevention strategies that would address the mental health of this population.6 Also of importance is research that investigates specific risk factors for marginalized youth with a focus on the disparities in suicide and self-harm rates for sexual and gender minority youth.15

Conclusion

Adolescence is a critical period for development and a time full of stressors in lives of youth. Moreover, the stressors that specifically affect SGMY such as school victimization, rejection from family and peers, and lack of visibility and support, can make this developmental period more difficult with increased risk for mental and physical health problems. These risk factors are tied to a constellation of other comorbidities such as homelessness, suicidality, and substance use disorders. Therefore, future research is needed in order to provide a better understanding of mental health and substance use disorders in SGMY, as well as focus on specific populations within this group. Additionally, professionals who provide treatment and create prevention strategies need to be culturally informed and ensure that the services they are providing meet the needs of sexual and gender minority youth.

Sexual and Gender Minority Youth is an umbrella term which includes a variety of populations

The Hazelden Betty Ford Foundation Experience

Hazelden Betty Ford treatment centers provide special-focus drug addiction programming to address needs specific to LGBTQ individuals in promoting healthy, lasting recovery. Our addiction treatment and mental health experts recognize that many in the LGBTQ community have experienced negative interactions with rehab centers or other health care providers and may fear judgment, discrimination or other repercussions. At Hazelden Betty Ford, you will find a safe, affirming, compassionate and understanding counseling staff and an inclusive peer recovery support community. Learn more

Resources

For providers: A Provider's Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals:
store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/sma12-4104.pdf

Gay-Straight Alliance Network: gsanetwork.org

National Survey on LGBTQ Youth Mental Health 2021: thetrevorproject.org/survey-2021/?section=Introduction

References

  1. Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. samhsa.gov/data/sites/default/files/reports/rpt35325/ NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf 
  2. Gamarel, K. E., Mereish, E. H., Colby, S. M., Barnett, N. P., Hayes, K., & Jackson, K. M. (2018). Sexual minority disparities in substance use willingness among youth. Substance Use & Misuse, 53(1), 170–175. doi.org/10.1080/10826084.2017.1327977 
  3. American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). doi.org/10.1037/0000165-000 
  4. Meyer, I. H. (2013). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychology of Sexual Orientation and Gender Diversity, 1(S), 3–26. doi.org/10.1037/2329-0382.1.s.3 
  5. Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460–467. doi.org/10.1037/a0029597 
  6. Fish, J. N. (2020). Future directions in understanding and addressing mental health among LGBTQ youth. Journal of Clinical Child & Adolescent Psychology, 49(6), 943–956. doi.org/10.1080/15374416.2020.1815207 
  7. Bonnie, R. J., & Backes, E. P. (Eds.). (2019). The promise of adolescence: Realizing opportunity for all youth. National Academies of Sciences, Engineering, and Medicine. doi.org/10.17226/25388 
  8. Rothblum, E. D. (Ed.). (2020). The Oxford handbook of sexual and gender minority mental health. Oxford University Press. doi.org/10.1093/oxfordhb/9780190067991.001.0001
  9. Silliman Cohen, R. I., & Bosk, E. A. (2020). Vulnerable youth and the COVID-19 pandemic. Pediatrics, 146(1) e20201306. doi.org/10.1542/peds.2020-1306 
  10. Hao, J., Beld, M., Khoddam-Khorasani, L., Flentje, A., Kersey, E., Mousseau, H., Frank, J., Leonard, A., Kevany, S., & Dawson-Rose, C. (2021). Comparing substance use and mental health among sexual and gender minority and heterosexual cisgender youth experiencing homelessness. PLoS ONE, 16(3) e0248077. doi.org/10.1371/journal.pone.0248077 
  11. Johns, M. M., Lowry, R., Andrzejewski, J., Barrios, L. C., Demissie, Z., McManus, T., Rasberry, C. N., Robin, L., & Underwood, J. M. (2019). Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students—19 states and large urban school districts, 2017. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 68(3), 67–71. doi.org/10.15585/mmwr.mm6803a3 
  12. Johns, M. M., Lowry, R., Rasberry, C. N., Dunville, R., Robin, L., Pampati, S., Stone, D. M., & Mercer Kollar, L. M. (2018). Violence victimization, substance use, and suicide risk among sexual minority high school students — United States, 2015–2017. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 67(43), 1211–1215. doi.org/10.15585/mmwr.mm6743a4 
  13. Rimes, K. A., Goodship, N., Ussher, G., Baker, D., & West, E. (2019). Non-binary and binary transgender youth: Comparison of mental health, self-harm, suicidality, substance use and victimization experiences. International Journal of Transgenderism, 20(2–3), 230–240. doi.org/10.1080/15532739.2017.1370627 
  14. Siconolfi, D., Tucker, J. S., Shadel, W. G., Seelam, R., & Golinelli, D. (2020). Health, homelessness severity, and substance use among sexual minority youth experiencing homelessness: A comparison of bisexual versus gay and lesbian youth. The Journal of Sex Research, 57(7), 933–942. doi.org/10.1080/00224499.2019.1695723
  15. Wilson, C., & Cariola, L. A. (2020). LGBTQI+ youth and mental health: A systematic review of qualitative research. Adolescent Research Review, 5, 187–211. doi.org/10.1007/s40894-019-00118-w 
  16. The Trevor Project. (2021). 2021 National Survey on LGBTQ Youth Mental Health. thetrevorproject.org/survey-2021/?section=Introduction 
  17. Day, J. K., Fish, J. N., Perez-Brumer, A., Hatzenbuehler, M. L., & Russell, S. T. (2017). Transgender youth substance use disparities: Results from a population-based sample. Journal of Adolescent Health, 61(6), 729–735. doi.org/10.1016/j.jadohealth.2017.06.024 
  18. Griffin, M., Callander, D., Duncan, D. T., & Palamar, J. J. (2020). Differential risk for drug use by sexual minority status among electronic dance music party attendees in New York City. Substance Use & Misuse, 55(2), 230–240. doi.org/10.1080/10826084.2019.1662811 
  19. Krueger, E. A., Fish, J. N., & Upchurch, D. M. (2020). Sexual orientation disparities in substance use: Investigating social stress mechanisms in a national sample. American Journal of Preventive Medicine, 58(1), 59–68. doi.org/10.1016/j.amepre.2019.08.034 
  20. Veliz, P., Epstein-Ngo, Q., Zdroik, J., Boyd, C. J., & McCabe, S. E. (2016). Substance use among sexual minority collegiate athletes: A national study. Substance Use & Misuse, 51(4), 517–532. doi.org/10.3109/10826084.2015.1126741 
  21. Bryant, L. O., & Bowman, L. (2014). Tobacco use among sexual minorities. New Directions for Adult & Continuing Education, 2014(142), 63–72. doi.org/10.1002/ace.20095 
  22. Fish, J. N., Watson, R. J., Porta, C. M., Russell, S. T., & Saewyc, E. M. (2017). Are alcohol-related disparities between sexual minority and heterosexual youth decreasing? Addiction, 112(11), 1931–1941. doi.org/10.1111/add.13896 
  23. Schuler, M. S., & Collins, R. L. (2019). Early alcohol and smoking initiation: A contributor to sexual minority disparities in adult use. American Journal of Preventive Medicine, 57(6), 808–817. doi.org/10.1016/j.amepre.2019.07.020 
  24. Zaza, S., Kann, L., & Barrios, L. C. (2016). Lesbian, gay, and bisexual adolescents: Population estimate and prevalence of health behaviors. JAMA, 316(22), 2355–2356. doi.org/10.1001/jama.2016.11683 
  25. Talley, A. E., Turner, B., Foster, A. M., & Phillips II, G. (2019). Sexual minority youth at risk of early and persistent alcohol, tobacco, and marijuana use. Archives of Sexual Behavior, 48(4), 1073–1086. doi.org/10.1007/s10508-018-1275-7 
  26. Fish, J. N., Schulenberg, J. E., & Russell, S. T. (2019). Sexual minority youth report high-intensity binge drinking: The critical role of school victimization. Journal of Adolescent Health, 64(2), 186–193. doi.org/10.1016/j.jadohealth.2018.07.005 
  27. Ruppert, R., Kattari, S. K., & Sussman, S. (2021). Review: Prevalence of addictions among transgender and gender diverse subgroups. International Journal of Environmental Research and Public Health, 18(16), 8843. doi.org/10.3390/ijerph18168843
  28. Glynn, T. R., & van den Berg, J. J. (2017). A systematic review of interventions to reduce problematic substance use among transgender individuals: A call to action. Transgender Health, 2(1), 45–59. doi.org/10.1089/trgh.2016.0037