Sexual and Gender Minority Youth and SUDs

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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.⁷ 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.