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Research Paper

Treatment of sexual minorities facing co-occurring diagnoses of substance abuse disorders

and other mental health disorders

DeLante Fludd

School of Nursing and Health Professions, Trinity Washington University

COUN 553: Alcohol and Substance Abuse in Counseling

Dr. Lenese Stephens

May 4th, 2023

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Treatment of Sexual Minorities facing co-occurring diagnoses of Substance Abuse

disorders and other mental health disorders

Substance abuse and mental health issues impact everyone around the world on some

level, whether directly or indirectly. Research has shown these issues tend to impact the Lesbian,

Gay, Bisexual, Transgender, Queer/Questioning community (LGBTQ+) at far more significant

levels. Causes for the increased risks are often linked directly to discrimination and trauma faced

by individuals who identify as LGBTQ+. This paper will focus on issues related to the treatment

of LGBTQ+ individuals with co-occurring substance use and mental health disorders.

Terms Defined

Sexual minorities are often identified as those who do not identify as heterosexual and

represent a wide range of identities. The Human Rights Foundation (n.d.) has worked to define

the many identities represented within this community. LGBTQ+ is a term that is used to

describe the many sexual orientations and gender identities within the community. The terms gay

and lesbian are used by men, women, and non-binary individuals to describe a same sex

attraction to the person of the same gender. Bisexual individuals express a romantic or sexual

attraction to more than one gender and may be used interchangeably with pansexual. Other terms

such as queer and same-gender loving are used to describe a broader sense of attraction for

individuals.

Not to be confused with sexual orientation, gender identity is a complex concept for

many to understand and distinguish. Gender identity relates to the self-concept of how an

individual perceives themselves which may or may not be related to their sex assigned at birth

(Human Rights Foundation, n.d.). Transgender is typically used for individuals who identify as a

gender that differs from the gender assigned at birth. Many trangender individuals experience
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gender dysphoria which is the distress caused when a person’s assigned gender differs from how

they identify. As gender is often defined as male or female, those who do not fit into these

categories often identify as non-binary, which is a representation of being neither male nor

female but falling outside of these genders. Conversely, cisgendered individuals are those who

identify with their birth-assigned sex.

While all LGBTQ+ individuals may not experience discrimination, many do.

Homophobia, biphobia, and transphobia are commonly experienced in the community from

those who identify as heterosexual and those belonging to the LGBTQ+ community. This is

often the cause of increased stress for members of this community which leads to poorer mental

health outcomes. Those identifying as bisexual and transgender often face increased risks of

discrimination due to monosexual societal beliefs. This paper will explore the mental health

issues of the LGBTQ+ community further.

Alcohol and Substance Abuse in the LGBTQ+ Community

Research indicates across the board that individuals who identify as a sexual or gender

minority experience higher rates of substance use disorder than their heterosexual and

cisgendered counterparts. In addition to within group differences for bisexual and transgender

individuals, disparities have been found among those belonging to racial and ethnic minority

populations as well (Freitag et al., 2021). Substance use among this group varies in the use of

alcohol and a variety of drugs to include marijuana, tobacco and inhalants, commonly referred to

as poppers.

Alcohol Abuse
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LGBTQ+ individuals were found to have a significantly higher consumption of alcohol

compared to heterosexual and cisgender counterparts (Dimova et al., 2022). This is attributed to

a variety of factors, one largely being a cultural phenomenon for the group. The club and bar

scene has served as a safe haven for this group and allows space for individuals to freely express

themselves. The need for this space is a direct result of discrimination faced by this group.

LGBTQ+ individuals are often the target of hate and discrimination leading to stress and trauma.

Alcohol is used as a coping mechanism to deal with these stressors faced in everyday life.

Another leading factor for alcohol misuse in the community relates to family history of

alcohol consumption. McCabe et al. (2022) found that sexual minorities who struggle with

alcohol misuse and dependence are more likely to have a parent or adult figure with the same

issue. The negative relationship with alcohol contributes to the adverse childhood experiences

(ACEs) of an individual and increases the risk of the child developing the same issue. ACEs are

a significant indicator for mental and physical health professions for the likelihood of negative

health outcomes being passed down or increased for individuals (Rojas el at., 2019).

Drug Abuse

Similar to alcohol abuse, drug use was found to be significantly increased for LGBTQ+

individuals. Drug type was found to vary not only with this particular demographic but also

geographically (Westmoreland et al., 2021). For example, drug distribution regionally showed

higher usage of marijuana in the west and higher stimulant use in the midwest. The variety of

drugs may also lead to differences in health outcomes. The method of drug intake also has

varying associated health risks. Those who utilize injection over other methods of intake increase

their risk of contracting HIV.

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Another culturally significant connection to the LGBTQ+ community is the use and

misuse of poppers. Poppers are derived from alkyl nitrite compounds and are used to elicit

euphoric and sexual arousal effects (Demant & Oviedo-Trespalacios, 2019). While poppers are

used by all, they are more commonly used by gay and bisexual men. Similar to alcohol, poppers

are commonly found in spaces such as clubs and bars but have a higher prevalence in spaces

where sexual activity is likely to occur. The usage of poppers is significant in that they were

originally created to treat heart conditions. The prolonged use of the substance however leads to

other physical conditions such as skin lesions, hypotension and hypertension. They may also lead

to death when mixed with other drugs.

Within Group Differences

While the LGBTQ+ community all experience alcohol and substance abuse at

significantly higher rates, this is further increased for those identifying as bisexual and

transgender. Research however is limited on this topic as sample surveys are often limited or

exclusive of these communities. In the study conducted by Westmoreland et al. (2021), bisexual

individuals represented about 14% and transgender individuals represented about 0.5% of the

participants. In the LGBTQ+ community, biphobia and transphobia are just as prevalent from

within the community as it is outside of the community. Bisexuals are often excluded as gay and

lesbian individuals believe they should pick one or the other. Additionally, Transgender

individuals are often excluded for their identity as well. This exclusion from within the

community further leads to negative mental health outcomes such as depression, anxiety, and

suicidality.

Co-occuring Diagnosis of Substance Use Disorder with Mental Health Disorders

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According to Capuzzi & Stauffer (2020), co-occurring disorders of substance use and

mental health disorders have increased significantly over time. The treatment of co-occurring

substance use and mental health disorders is costly and many treatment centers are not equipped

to deal with both disorders concurrently. Significant research, including that of Rojas et al.

(2019), indicates that LGBTQ+ individuals are often faced with higher rates of mental health

problems in addition to experiencing substance use disorder of some form. As previously

mentioned, oftentimes the community struggles with higher rates of depression, anxiety and

suicidality. In addition to these more commonly addressed disorders, other significant mental

health outcomes are prevalent such as eating disorders, posttraumatic stress disorder, and

personality disorders.

Treatment of Co-occurring disorders

Treatment planning for co-occurring disorders should be specialized to address the

specific needs of the client, which is particularly true for LGBTQ+ individuals. One major step

practitioners should take is to eliminate the stigma around receiving services (Rojas et al., 2019).

For LGBTQ+ clients with co-occurring disorders, one issue is that stigma surrounding substance

use disorders leads to a complete disregard for treatment. Even when treatment is sought out,

another stigma surrounding healthcare exists and services are often discontinued prematurely due

to discrimination and improper treatment.

In the mental health field, treatment modalities such as motivational interviewing and

cognitive behavioral therapy have proven successful. In a study focusing on the treatment of

alcohol use, Dimova et al. (2022) found that the person-centered approach of motivational

interviewing allowed individuals to be more successful as it relied on the unique experiences of

the client. The first step to treatment is to identify the disorders through adequate assessment and
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screening (Rojas et al., 2019). Once identified, system barriers should be explored such as

culturally incompetent care and discrimination in the health field. Genetics and family history

play a major role in the prevalence of the co-occurring disorders, so this should also be assessed

specifically for the client. Once these factors are considered, care should be provided that focuses

on the specific needs of the individual with respect to their sexual orientation and/or gender

identity.

While not a specific modality for treatment, the ballroom community for LGBTQ+ youth

was identified to further support the specific needs of individuals (Harper et al., 2022). Ballroom

refers to the underground system of “houses” that compete in vogue competitions. Houses have

become a safe haven for displaced youth who were forced from their homes due to their sexual

orientation/gender identity. While the dance competition is a major part of house culture, the

house is more representational of a chosen family. Youth are mentored in adequate life skills and

are supported in living a healthy lifestyle. Through the study conducted by Harper et al. (2022),

it was found that the ballroom/kiki scene allowed adolescents to explore their identity while

achieving developmentally appropriate milestones. This is an example of a culturally significant

approach to supporting the LGBTQ+ community that may be adapted for the treatment of co-

occurring disorders.

Conclusion

Substance use disorder and mental health disorders are significantly increased for the

LGBTQ+ community. Factors for this increase include discrimination, trauma, and a lack of

culturally competent care in the physical and mental health fields. Treatment for co-occurring

disorders of this nature are often overlooked for specialized treatment that focuses solely on the

mental health disorder or the substance use disorder but rarely both simultaneously. Care for this
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specific issue should be well researched in the family history and the cultural signifiers of the

individual. Care should be adapted not only to address the co-occurring disorders, but also meet

the specific needs of issues faced by LGBTQ+ individuals.

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References

Capuzzi, D. & Stauffer, M. D. (2020). Foundations of Addictions Counseling (4th ed.). Pearson

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Demant, D., & Oviedo-Trespalacios, O. (2019). Harmless? A hierarchical analysis of

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Freitag, T. M., Chen-Sankey, J. C., Duarte, D. A., Ramsey, M.W., & Choi, K. (2021). Variations

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