Diversity, Equity, and Inclusion in Substance Use Treatment

Jolynn L. Haney, PhD

LGBTQ+ refers to lesbian, gay, bisexual, transgender, queer, and questioning individuals. Although each of these groups has unique characteristics, one of the shared features across the LGBTQ+ community is that its members are at high risk for mental health and substance use disorders. Unfortunately, the stigma associated with having a substance use disorder, combined with the discrimination from being a member of a sexual minority, can be a barrier to getting treatment.

Understanding the Problem

Unfortunately, we do not have a clear idea of substance use disorder prevalence among the LGBTQ+ population. One of the reasons we lack this knowledge is because understanding prevalence depends on carefully constructed and conducted national studies that ask questions about sexuality. Until recently, few federally funded studies have asked about individuals’ sexuality. For example, the Survey on Drug Use and Health (NSDUH) did not include items about sexual orientation until 2015.1 The survey designers made these changes to identify health issues among sexual minorities and to track changes in these groups over time. By collecting this information, NSDUH researchers hoped to better understand the factors influencing substance use. In turn, this knowledge can help inform policies that support prevention, treatment, and recovery for the LGBTQ+ community.

Another issue that affects accurate statistics about LGBTQ+ individuals and substance use is openness in responding to survey questions. Survey participants, particularly those in older age groups or specific cultures, might be less likely to disclose information about their sexual orientation and preferences than younger age groups or other cultures.2 As a result, prevalence estimates on sexual orientation among those with substance use concerns could be underreported.

The Need for Specialty Services

In addition to needing better data on the LGBTQ+ population’s experiences with mental health and substance use treatment, we also need more services that offer specialty care. For example, in 2015, around 1.7 million sexual minority adults needed substance use treatment. Of these adults, however, only about 260,000 (10.6%) received treatment at a specialty facility.1 One critical reason we need specialized treatment and treatment choices is that these programs can improve access to services for the LGBTQ+ community. For instance, a 2021 study found that sexual minority adults were only half as likely to access treatment compared to non-sexual minority adults because they did not know where to go for treatment or could not find the treatment they needed.3

Consider the following facts to understand why improving substance use treatment access is essential for the LGBTQ+ community: • Sexual minorities are almost three times more likely to experience a mental health condition than heterosexuals.1 • Transgender adults are almost four times more likely than cisgender adults to have mental health conditions.4 • The risk of suicide (thoughts attempts, completion) is three to six times greater for lesbian, gay, and bisexual adults than for heterosexual adults.5 • LGBTQ+ youth are more than four times as likely to attempt suicide than their peers.6

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37.1%

21.8% Illicit Drug or Alcohol Use Disorder - Past Year by Age Group and Gender Sexual Minority Sexual Majority

32.5%

31.5%

12.4% 16.1% 35.6%

11.0%

Ages 18-25 Ages 26+ Male Female

Source: National Survey of Drug Use and Health, 2020, Public-Use Data Analysis System https://pdas.samhsa.gov/#/survey/NSDUH-2020-DS0001. Sexual minority = lesbian, gay, or bisexual; sexual majority = heterosexual. Illicit drugs include marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutics (i.e., pain relievers, tranquilizers, stimulants, and sedatives).

In addition, the LGBTQ+ community faces discrimination across different life domains: at home, at school, in the workplace, in the housing market (renting or buying), and in receiving healthcare, including life-saving medical care.6 “Minority stress” describes the chronic stress that marginalized groups experience when faced with long-term pervasive discrimination and stigma. This stress is intensified for sexual minorities who are also members of other minority groups (i.e., people of color who are sexual minorities).7

Deciding Where to Get Treatment

There are many things to consider when selecting a substance use treatment program. Although some treatment facilities offer specialty care for sexual minorities, one study found that 70% of these programs were no different from treatment programs that provided services to non-sexual minorities.8 A current Pennsylvania treatment facilities survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) showed that 133 (22.0%) facilities offer specialized substance use treatment services for sexual minority adults.9 Compared to the percentage of programs in other states and nationally, Pennsylvania fell below the national average. Although 22% is low, it is a notable improvement from 2010, when only 35 (less than 7%) of Pennsylvania facilities reported having specialty programming for sexual minorities.9

There are a few ways to find specialty care. For example, SAMHSA has a list of specialty programs on its website.9 Another free search tool is the Addiction Treatment Locator, Assessment, and Standards Platform (ATLAS.)10 As previously mentioned, some of these programs may offer sexual minority treatment services in name only. Therefore, the following questions may be helpful when deciding on an LGBTQ+affirming treatment program11:

• Does the facility have culturally diverse and competent therapists who can recognize and address the needs of individuals who identify as LGBTQ+? • Does the facility distinguish between the clinical needs of individuals within the LGBTQ+ group to provide clientcentered care that differs for each sexual minority subgroup? • Does the facility address relapse prevention in social contexts that apply to the LGBTQ+ community?

• Are stress management and other coping skills addressed to help clients who face discrimination and prejudice related to having a minority status? • Does the facility help clients with self-acceptance and selfdisclosure issues concerning their sexual orientation or gender identity? • Given the high rate of mental health distress among sexual minority populations, can the facility recognize and address co-occurring mental health concerns? • Does the facility address the intersection between sexual orientation or gender identity and other specialty population needs, such as those members of the LGBTQ+ community who are people of color, women, pregnant or postpartum women, veterans, and older adults? • Is the program trauma-informed? This question is critical because there is a high rate of trauma experienced by the

LGBTQ+ population.

Final Thoughts

When we talk about diversity and diverse groups, it is important to remember that diversity also exists within these groups. Although the LGBTQ+ community shares sexual minority status, each group has distinct characteristics. Therefore, even though it is a common practice to use the LGBTQ+ acronym to refer to this group collectively, we need to keep in mind that each group is diverse. In other words, “one size does not fit all” in specialty care within the LGBTQ+ community.

The pathway to recovery is a complex process experienced differently by each person undertaking the journey. Cultural sensitivity and humility are core components of care that enhance the treatment experience, encourage engagement, and support treatment retention. Specialized services for minority populations need to demonstrate that they offer unique care and are not simply branding themselves as “LGBTQ+” services. As community members, we can help improve things by being aware of these issues and supporting advocacy efforts to provide better, more diverse services.

Sources:

1. Medley, G., Lipari, R. N., & Bose, J. (2016). Sexual orientation and estimates of adult substance use and mental health: Results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review, 10, 1–54. https://www.samhsa.gov/data/sites/ default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.pdf 2. Morgan, R. E., Dragon, C., Daus, G., Holzberg, J., Kaplan, R., Menne, H., & Spiegelman, M. (2020). Updates on terminology of sexual orientation and gender identity survey measures (FSCM 20-03). Federal Committee on Statistical Methodology. https:// nces.ed.gov/fcsm/pdf/FCSM_SOGI_Terminology_FY20_Report_FINAL.pdf 3. Haney, J. L. (2020). Sexual orientation, social determinants of health, and unmet substance use treatment need: Findings from a national survey. Substance Use & Misuse, 56(2), 205-213. https://doi.org/10.1080/10826084.2020.1853775 4. Wanta, J. W., Niforatos, J. D., Durbak, E., Viguera, A., & Altinay, M. (2019). Mental health diagnoses among transgender patients in the clinical setting: An all-payer electronic health record study. Transgender health, 4(1), 313-315. DOI:10.1089/trgh.2019.0029 5. Ramchand, R., Schuler, M. S., Schoenbaum, M., Colpe, L., & Ayer, L. (2021). Suicidality among sexual minority adults: Gender, age, and race/ethnicity differences. American Journal of Preventive Medicine, 62(2), 193-202. https://doi.org/10.1016/j. amepre.2021.07.012 6. Johns, M. M., Lowry, R., Haderxhanaj, L. T., et al. (2020). Trends in violence victimization and suicide risk by sexual identity among high school students — Youth Risk Behavior Survey, United States, 2015–2019. Morbidity and Mortality Weekly Report, 69, (Suppl-1):19–27. 7. Schuler, M. S., Rice, C. E., Evans-Polce, R. J., & Collins, R. L. (2018). Disparities in substance use behaviors and disorders among adult sexual minorities by age, gender, and sexual identity. Drug and Alcohol Dependence, 189, 139-146. https://doi.org/10.1016/j. drugalcdep.2018.05.008 8. Williams, N. D., & Fish, J. N. (2020). The availability of LGBT‐specific mental health and substance abuse treatment in the United States. Health Services Research, 55(6), 932-943. https://doi.org/10.1111/1475-6773.13559 9. Substance Abuse and Mental Health Services Administration. (n.d.). Behavioral health treatment services locator. https://www. samhsa.gov/find-treatment 10. Addiction Treatment Locator, Assessment, and Standards Platform. (n.d.). https://www.treatmentatlas.org/ 11.New York State Office of Addiction Services and Supports. (2022). LGBTQ-affirming program endorsement standards and guidance. https://oasas.ny.gov/system/files/documents/2022/06/lgbtq-affirming-program-endorsement.pdf