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. Author manuscript; available in PMC: 2025 Jun 1.
Published in final edited form as: J Subst Use Addict Treat. 2024 Mar 15;161:209340. doi: 10.1016/j.josat.2024.209340

Examining Sexual Minority Engagement in Recovery Community Centers

Lauren B Bernier 1, Jacklyn D Foley 1,2,3, Anna C Salomaa 4,5, Jillian R Scheer 6, John Kelly 1,2, Bettina Hoeppner 1, Abigail W Batchelder 1,2,3
PMCID: PMC11166124  NIHMSID: NIHMS1983369  PMID: 38494052

Structured Abstract

Introduction:

Research indicates that sexual minority (SM) individuals with alcohol and other drug use disorders may underutilize recovery resources generally but be more likely to use recovery community centers (RCCs). To inform recovery supports, this study characterized SM and heterosexual RCC members by demographics and clinical and recovery support service utilization.

Methods:

Cross-sectional secondary analyses compared SM and heterosexual RCC members in the northeastern U.S. (n=337). Qualitative analyses coded the top three recovery facilitators.

Results:

Of the 337 participants (Meanage[SD]=40.98[12.38], 51.8% female), SM RCC members were more likely than heterosexuals to endorse lifetime psychiatric diagnoses and emergency department mental health treatment (p<.01). RCC service utilization and qualitatively derived recovery facilitators were mostly consistent across groups.

Conclusions:

RCCs engaged SM individuals in recovery in ways consistent with heterosexuals. Despite otherwise vastly similar demographic characteristics across sexual identity, findings suggest a need for additional mental health resources for SM individuals in recovery.

Keywords: sexual minority, substance use, recovery, recovery community center, LGBTQIA+

Introduction

Sexual minority (SM) individuals (e.g., gay, lesbian, bisexual, queer) disproportionately experience alcohol and other drug (AOD) use disorders compared to heterosexuals (Kerridge et al., 2017). Whereas an estimated 86% of all adults with AOD use disorders do not seek treatment (Grant et al., 2016), research to date comparing rates of AOD treatment utilization between SM versus heterosexual individuals is inconsistent and varies by sexual identity (Hodges et al., 2023; Krasnova et al., 2021; McCabe et al., 2013). Even in instances where SM individuals show greater odds of AOD treatment utilization (Hodges et al., 2023; Krasnova et al., 2021; McCabe et al., 2013), these findings must be interpreted within the context of higher lifetime rates of AOD use disorders in this population. Additionally, SM individuals with AOD use disorders report greater perceived need for and less satisfaction with AOD treatment (Krasnova et al., 2021). Many seeking treatment––particularly bisexual women (Beard et al., 2017)––also report unmet behavioral health needs compared to heterosexual women (McCabe et al., 2018; Senreich, 2009), contributing to poor clinical outcomes (Probst et al., 2015). While some SM individuals do engage in AOD treatment, research has underexplored what may facilitate AOD treatment initiation and utilization among SM people who: a) are not engaging in treatment but who may benefit; and b) lack satisfaction with treatment (Allen & Mowbray, 2016; Haik et al., 2022; Krasnova et al., 2021).

Minority stressors (e.g., discrimination, anticipated rejection, internalized negative beliefs) may partially account for the disproportionate prevalence of AOD use disorders and the related unmet AOD treatment needs among SM individuals (Dyar & London, 2018; Evans-Polce et al., 2020). Minority stress may lead to increased AOD use to mitigate associated unpleasant emotions and delay or prevent AOD treatment engagement due to a perceived limited sensitivity to, or prejudice against, SM experiences.

Recovery community centers (RCCs) are community-based, largely peer-run spaces which offer both traditional AOD recovery services (e.g., relapse prevention groups, mutual help groups) and non-medical supports (e.g., employment assistance, recreation) (Cousins et al., 2012; Kelly et al., 2017, 2020, 2021). They share some similarities with other AOD recovery supports, including case management services or community housing options. RCCs represent a growing recovery support infrastructure, including for SM individuals. While some studies indicate an underutilization of AOD treatment or recovery support services by SM individuals (Batchelder et al., 2021; McCabe et al., 2013; Mericle et al., 2019), recent evidence reveals that SM adults actually may be more likely to engage specifically with RCCs compared to heterosexual individuals (Kelly et al., 2020, 2021). The positive and welcoming social climate, access to recovery capital such as social support, and flexible community-based options may suit SM individuals pursuing recovery well (Kelly et al., 2020, 2021; White et al., 2012). Supporting this idea, one recent study found a higher-than-expected proportion (>20%) of individuals initiating RCC engagement in the northeastern U.S. identified as non-heterosexual (Kelly et al., 2021).

Despite promising initial research, including on rates of comorbid AOD and mental health disorders among SM individuals (Lee et al., 2016), less is known pertaining to the demographic (e.g., race, ethnicity, education, income), AOD use, and psychiatric backgrounds of SM individuals attending RCCs for AOD recovery. As there is an association between RCC attendance and sustained remission and recovery by bolstering recovery capital (Kelly et al., 2021; Kelly & Hoeppner, 2015), a characterization of SM and heterosexual RCC members by demographics, AOD use history, psychiatric history, and RCC service utilization may help to inform and refine future recovery supports.

The present investigation uses content analysis to compare SM and heterosexual participants’ expressed recovery facilitators to identify potentially unique facilitators between groups. Advancing knowledge of potential differences between SM and heterosexual individuals in AOD recovery may help clarify future efforts to improve rates of stable AOD recovery among SM individuals.

Method

This study used cross-sectional data collected as part of a National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant awarded to the Massachusetts General Hospital (R21AA022693; PI: Kelly) focusing on the clinical and public health utility of RCCs across New England and New York state. Secondary analyses aimed to better understand demographic characteristics, AOD use history, psychiatric history, and RCC service utilization among SM compared to heterosexual RCC members. Survey data were collected via online self-report (Research Electronic Data Capture [REDCap]) (Harris et al., 2009). The study did not preregister analyses and thus results should be considered exploratory. The Partners HealthCare Institutional Review Board approved study procedures, and all participants provided informed consent.

Participants

The study recruited participants from 31 New England and New York state RCCs between February 2015 and October 2017. Eligible participants were ≥18 years of age, seeking or in recovery from a AOD problem, and participating in one of the 31 RCCs. The operational definition of “recovery” was the voluntary assumption of a lifestyle characterized by making positive changes in health and social functioning (“Recovery,” 2023). Survey discontinuation led to exclusion of one participant’s data, resulting in a sample of 337.

Measures

Demographics and Clinical Characteristics.

Demographics included age, race/ethnicity, gender, education, sexual identity (i.e., how the participant describes their sexual orientation), and income. Clinical questions included primary substance used (i.e., substance of choice), substance use history (i.e., lifetime use of substances 10 or more times), lifetime and multiple psychiatric diagnoses, and emergency department (ED) visits related to mental health or AOD use.

Overall Recovery and RCC Experiences.

Participants reported length of overall recovery and time attending an RCC, RCC visits in the past 90 days, and average hours spent per RCC visit (Kelly et al., 2021). Participants also indicated lifetime participation in any recovery support services or formal treatment programs.

RCC Appraisal.

Participants rated how helpful the RCC was to recovery (1=Not helpful at all to 7=Extremely helpful), and their agreement with ‘there is a sense of family (or community) at the [rcc]’ (1=Strongly disagree to 6=Strongly agree) (Kelly et al., 2021).

Facilitators of Recovery.

Participants responded in text to the question: “What do you consider to be the top three things that helped you resolve your problem with alcohol/drugs?”

Statistical Analysis

Descriptive statistics characterized heterosexual and SM groups based on demographics and RCC utilization. Independent sample t-tests and chi-square tests of association (IBM SPSS Version 28) determined any significant differences between sub-samples. Given the preliminary nature of this investigation, the type I error alpha level for statistical significance was 0.05.

Content Analysis.

Open-ended self-report responses (facilitators of recovery) were included in content analysis informed by a grounded theory approach (Chapman et al., 2015; Elo et al., 2014). The study prepared data by grouping responses according to SM versus heterosexual identity and reviewed for familiarization. There was no masking of participant identity during coding (LB). Second, for organization, the coder (LB) used an inductive approach to generate lower-order themes. Members of the team (LB, JF, and AB) met to discuss raw data interpretations and define higher-order themes, and subsequent meetings achieved further definition of categories. Subsequently, LB determined the proportion of participants reporting each theme. Chi square tests then identified whether there was an association between sexual identity and recovery facilitator themes.

Results

Descriptive Findings

Participants were 18–75 years old (Mage = 40.98, standard deviation [SD] = 12.38), and self-identified as 51.8% female, 76.8% white, and 88.9% not Hispanic/Latinx. Most participants reported an annual income ≤$30,000 USD and 21.1% had received an associate degree or higher (Table 1). In addition, 20% (n=68) of the sample reported a non-heterosexual identity: 32.4% (n=22) identified as gay/lesbian and 42.6% (n=29) identified as bisexual (Table 1).

Table 1.

Socio-demographics of Study Participants

Variable Heterosexual (n = 259) Sexual Minority (n = 68)
Age (Mean (SD)) 41.15 (12.10) 40.34 (13.50)
Race
 White or Caucasian 202 (78.0%) 49 (72.1%)
 Black or African American 39 (15.1%) 15 (22.1%)
 Asian 1 (0.4%)
 Native Hawaiian or Other Pacific Islander 1 (0.4%)
 Native Indian or Alaskan Native 7 (2.7%) 1 (1.5%)
Ethnicity
 Hispanic or Latino 27 (10.4%) 9 (13.2%)
 Not Hispanic 228 (88.0%) 59 (86.8%)
Gender
 Cisgender Male 130 (50.4%) 24 (35.3%)
 Cisgender Female 128 (49.40%) 41 (60.3%)
 Transgender Male 2 (2.9%)
 Other 1 (1.5%)
Sexual Orientation Total Men Women
 Non-sexual or asexual 7 (10.3%) 2 (2.9%) 5 (7.4%)
 Heterosexual or straight 259 (100.0%)
 Homosexual, gay or lesbian 22 (32.4%) 12 (7.7%) 9 (5.3%)
 Bisexual 30 (44.1%) 5+ (7.4%) 24 (14.2%)
 Questioning, curious, or not sure 8 (11.8%) 5+ (7.4%) 2 (2.9%)
 Other 3 (4.4%) 2 (2.9%) 1 (1.5%)
Education
 High School Graduate or GED or Less 137 (52.9%)** 21 (30.9%)**
 Some College or More 117 (45.2%)** 45 (66.2%)**
Annual Income
 < $10,000 USD 120 (46.3%) 31 (45.6)
  $10,001 - $29,999 USD 92 (35.5%) 16 (23.5%)
 > $30,000 USD 41 (15.8%) 17 (25.0%)
Unemployed (Last 90 Days)a 114 (45.8%) 38 (57.6%)
Lifetime Psychiatric Diagnosisb 115 (45.1%)** 45 (67.2%)**
Lifetime Emergency Room Treatment for Mental Health 93 (36.8%)** 37 (55.2%)**
 Lifetime Emergency Room Treatment for Alcohol and/or Drug Use 105 (41.8%) 30 (44.8%)
Primary Substance (Top 4)
 Alcohol 61 (23.6%)** 27 (39.7%)**
 Marijuana 22 (8.5%) 24 (35.3%)
 Cocaine 33 (12.7%) 13 (19.1%)
 Heroin 79 (30.5%) 14 (20.6%)
Substance Use History (Top 3)
 Alcohol 185 (71.4%)** 60 (88.2%)**
 Marijuana 161 (62.2%)** 54 (79.4%)**
 Cocaine 171 (66.0%) 51 (75.0%)
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M, mean. SD, standard deviation. n, sample size.

**

p<.01.

a

= ‘Did you hold a job anytime during the last 90 days (3 months)?’ (Y/N)

b

= Has a doctor, nurse, or counselor ever told you that you have a mental or psychological condition?” (Y/N)

Note: heterosexual men n = 130; heterosexual women n = 128.

+

, n includes 1 trangender male in total number.

Heterosexual individuals (52.9%) were more likely to report lower educational attainment (i.e., High School Diploma, GED, or less) than SM counterparts (30.9%), X2 (1, N=327) = 10.45, p<.01. SM individuals also were more likely to have attended some college or more, X2 (1, N=327) = 9.50, p<.01 (45.2% heterosexual, 66.2% SM). Both subsamples indicated lifetime use of alcohol, marijuana, and cocaine 10 or more times; SM individuals were more likely to indicate lifetime use of alcohol (88.2% SM, 71.4% heterosexual) and marijuana (79.4% SM, 62.2% heterosexual), X2 (1, N=327) = 8.10, p<.01; X2 (1, N=327) = 7.12, p<.01. SM individuals were also more likely to report alcohol as their primary substance (39.7%), X2 (1, N=327) = 7.15, p<.01.

SM participants were more likely than heterosexual individuals to endorse lifetime psychiatric diagnoses, X2 (1, N=327) = 10.33, p<.01 (67.2% SM, 45.1% heterosexual), and lifetime ED treatment for mental health concerns, X2 (1, N=327) = 7.49, p<.01 (55.2% SM, 36.8% heterosexual). There were no significant differences in ED treatment for AOD use.

No significant differences were identified between heterosexual and SM participants’ recovery length, formal treatment utilization, RCC utilization, and RCC appraisals (degree of helpfulness to recovery, sense of community; see Table 1).

Content Analysis

Content analysis revealed 21 recovery facilitator categories (see Figure 1). Figure 1 depicts the proportions of reported recovery facilitators, most of which did not differ by sexual identity (e.g., friends, community, and network; use of Alcoholics Anonymous (AA)/12-Step Programs/Narcotics Anonymous (NA); or treatment). Categories with the three highest proportions on average in both groups were: 1) friends, community, and network 2) family and children, and 3) AA/12 Steps/NA. More SM than heterosexual participants reported spirituality (X2 (1, N=327) = 4.20, p<.05), education (e.g., knowledge, seeking continued education on recovery, educating others in recovery) (X2 (1, N=327) = 11.82, p<.01), and loss (e.g., loss of identity, loved ones, agency) (X2 (1, N=327) = 5.74, p<.05) as recovery facilitators (Figure 1).

Figure 1. Heterosexual and Sexual Minority Individuals’ Self-Reported Alcohol and Other Drug Use Recovery Facilitators.

Figure 1.

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*p ≤ .05.

Note: Categorization of three open-ended responses to “What do you consider to be the top three things that helped you resolve your problem with alcohol/drugs?”

Discussion

This study characterized SM people engaged in RCCs and identified meaningful similarities and differences in characteristics, service utilization, and recovery facilitators among SM and heterosexual individuals (Kelly et al., 2020). Reported senses of community in RCCs and perceptions of their helpfulness to recovery were similar across SM and heterosexual individuals. SM individuals were more likely than heterosexual individuals to report higher levels of education and alcohol as their primary substance. Across sexual identity categories, however, histories of alcohol, marijuana, cocaine, and heroin use were common, consistent with existing literature (McCabe et al., 2013). SM individuals were also more likely than heterosexuals to report having a lifetime psychiatric diagnosis and receiving psychiatric treatment in EDs. Substance use and psychiatric findings are consistent with minority stress theory, indicating that SM individuals face identity-related stressors, including discrimination and stigma, resulting in a higher likelihood of substance use and psychiatric challenges compared to heterosexual individuals (Meyer, 2003). While the higher proportion of ED visits among SM individuals may be indicative of delayed help-seeking, it may also represent a greater willingness to seek out medical resources.

Content analysis revealed mostly similar AOD recovery facilitators between SM and heterosexual RCC members. Both groups identified friends and community, family, and AA/12-Step/NA programs as most helpful in their recovery. However, SM individuals more frequently cited spirituality, continuing education, and loss as facilitators. While religion continues to be a source of rejection and stigma for some SM individuals (Bower et al., 2023), the current study found that spirituality was beneficial to SM participants’ recovery. Consistent with research exploring lifetime trajectories of spirituality among SM adults (Bower et al., 2023), this finding may indicate the value of distinguishing between religion and spirituality as facilitative for SM individuals in recovery.

Evidence also indicates differential education disparities and benefits among specific SM identities. In this sample, SM individuals in aggregate reported higher levels of education and identified continuing education as facilitative to recovery. A larger sample of SM individuals would enable investigation of differences in education attainment and continuing education among SM subsamples. SM participants were also more likely than heterosexual participants to note “loss” as a recovery facilitator. Indeed, loss may increase appreciation of positive aspects of life and recovery or may indicate emotional openness and future focus in the wake of stressful events among SM people (Kwon, 2013). The facilitators cited significantly more among SM individuals may be attributable to learned resilience in response to disproportionate experiences of minority stress. The hypothesis that “loss” may be facilitative to recovery due to learned resilience among SM individuals is consistent with preliminary research on positive psychological outcomes following victimization, including posttraumatic growth, among SM populations (Ratcliff et al., 2022).

Limitations.

Although this study makes an important contribution to the literature on RCC utilization among SM individuals, it has several limitations. The cross-sectional sample was small (n=327, 68 of whom identified as SMs) and not representatively selected, limiting generalizability. Further, several questions were not included in the parent study protocol that may have meaningfully differentiated SM individuals, including anticipated and experienced homonegativity in RCCs or the availability of SM-specific programming (e.g., 12-Step groups specifically for SM communities). Future studies that selectively sample a higher proportion of SM individuals and employ multivariate analyses to control for covariates would enable additional investigation into SM-specific recovery facilitators among SM people in general and across specific SM subgroups. Disaggregated analysis in future studies may also explore the possible differences between SM and heterosexual women versus SM and heterosexual men, or across race and ethnicity by sexual identity.

Clinical Implications

Several clinical implications can be derived from these results. First, while SM individuals with AOD use histories may have unique needs and facilitators related to overcoming AOD use disorders (Haik et al., 2022; Stevens, 2012), results from this study suggest similarities demographically (with the exception of education) and regarding service utilization and recovery facilitators. Notably, these results also highlight mental health disparities, consistent with existing literature, indicating that while AOD-specific recovery needs may be similar for SM and heterosexual people, SM individuals pursuing AOD recovery may have more unmet mental health needs (Haik et al., 2022).

Further, the greater proportion of SM individuals receiving ED psychiatric care could indicate a delay in help-seeking until symptoms become more severe, calling for interventions within EDs and efforts to connect patients with appropriate follow-up care. The greater proportion of SM individuals receiving ED psychiatric care also suggests that increased access to culturally sensitive mental health services may be particularly beneficial for SM individuals in recovery to help sustain AOD use remission, increase emotion regulation skills, and prevent decompensation (e.g., suicidal ideation) to reduce ED visits.

Finally, SM and heterosexual individuals using RCCs reported largely similar recovery facilitators, with social support (i.e., friends, community, and network) being a highly valued recovery resource among SM and heterosexual RCC members. However, SM individuals reported higher proportions of several recovery facilitators, potentially indicating a need for different types of resources to foster resilience and the ability to combat minority stress. More detailed investigation may delineate the connection between utilization of such facilitators (e.g., spirituality and related practices such as mindfulness) and enhanced recovery for SM individuals.

Conclusion

This study found that SM and heterosexual RCC members in the Northeastern U.S. share similar demographics, apart from SM participants having attained more education. No differences were found between SM and heterosexual individuals in RCC service utilization, sense of community, and perceived helpfulness to recovery. As such, RCCs appear to be positive and welcoming recovery spaces for SM individuals. SM RCC members, however, report more psychiatric diagnoses and ED treatment for mental health concerns, potentially indicating greater unmet comorbid mental and behavioral health needs than heterosexual RCC members. Efforts to address these needs while capitalizing on sources of resilience could improve outcomes for SM individuals seeking support from RCCs and recovery efforts more broadly for this community.

Table 2.

Recovery Characteristics of Study Participants

Variable Heterosexual (n = 259) Sexual Minority (n = 68)
Length of Time in Recovery (Mean (SD))
 Years, n = 248, n = 63		 4.0 (7.36) 4.68 (7.32)
 Months, if year <1, n = 68, n = 19 5.47 (3.05) 5.26 (3.36)
Lifetime recovery support services or formal treatment
 Sober living environment		 108 (41.7%) 31 (45.6%)
 Recovery high schools 4 (1.5%) 0
 College recovery programs 3 (1.2%) 2 (2.9%)
 Faith-based recovery services 28 (10.8%) 7 (10.3%)
 State or local recovery community organizations (RCO) 21 (8.1%) 5 (7.4%)
 Outpatient addiction treatment 91 (35.1%) 31 (45.6%)
 Alcohol/drug detoxification services 66 (25.5%) 18 (26.5%)
 Inpatient or residential treatment 111 (42.9%) 30 (44.1%)
Length of Time Attending RCC
 Years, n = 257, n = 67		 2.44 (3.53) 2.21 (3.22)
 Months, if year <1, n = 82, n = 27 5.72 (2.81) 4.41 (2.53)
Visits to RCC in Past 90 Days 41.31 (28.33) 38.79 (30.16)
 Hours at RCC/Visit 3.10 (2.80) 3.23 (2.18)
RCC Helpfulness to Recoverya 6.20 (1.15) 6.22 (1.22)
Sense of Community at RCCb 5.03 (1.15) 4.94 (1.35)
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M, mean.

SD, standard deviation.

n, sample size.

RCC, recovery community center.

a

= ‘How helpful has the [rcc] been for you in your recovery?’ 1 = “Not Helpful at All”, 4 = “Moderately Helpful”, 7 = “Extremely Helpful”.

b

= ‘There is a sense of family (or community) at the [rcc].’ 1 = “Strongly Disagree”, 2 = “Disagree”, 3 = “Somewhat Disagree”, 4 = “Somewhat Agree”, 5 = “Agree”, 6 = “Strongly Agree”.

Highlights:

  • SM and heterosexuals reported similar demographics and RCC utilization trends

  • SM in RCCs reported more lifetime psychiatric diagnoses than heterosexuals

  • AOD recovery facilitators are similar between SM and heterosexual RCC members

  • SM in RCCs more often cited spirituality, education, and loss as facilitative

Acknowledgments:

This project was supported by 5R24DA051988 (MPIs: John Kelly and Bettina Hoeppner), 5K23DA043418-05 (PI Abigail Batchelder), and K01AA028239 (PI Jillian Scheer). This is a secondary analysis from a National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant awarded to the Massachusetts General Hospital (R21AA022693; PI: Kelly). We would like to thank the research participants who contributed to this project.

Funding Information:

This study was supported by a National Institute on Drug Abuse (NIDA) grant (PI: Batchelder). L.B.B. was supported by a research grant (R24).

Footnotes

Author Disclosure Statement:

The authors have no statements to disclose.

Disclaimer:

The content of this work is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The NIH had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

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