LGBTQ+ drug and alcohol use: discrimination breeds disparity

LGBTQ+ people are more likely than their heterosexual and cisgender counterparts to use drugs and alcohol, and to progress to addiction problems.^1–3 The underlying reasons for this will be different for every individual, but a multitude of psychological and social stressors may contribute. Despite global progress in equality, LGBTQ+ people still experience high rates of trauma, violence, and stigma. This often begins in childhood, with school bullying or parental disapproval being common experiences. The stress of belonging to a minority group may lead to an internalised sense of shame, alienation, and an expectation of social rejection.⁴ Many people hide their identities to stay safe, constantly policing their self-expression and living in fear of disclosure. Later, in adulthood, LGBTQ+ people may experience discrimination in employment, housing, and access to public services. They are more likely than the general population to be living with histories of physical, emotional, and sexual abuse.⁵ For some LGBTQ+ individuals, surviving an era where many of their partners, friends, and community members died from complications of HIV has taken a significant psychological toll. As a result of all these factors, health disparities are widely documented, with higher rates of mental and physical illness for this group.^2,6,7

Drug and alcohol use may be a way to cope with the legacy of traumatic experiences, or a form of self-medication for symptoms of mental illness. Drug and alcohol use may also be linked positively to community bonding and identity formation for LGBTQ+ people. Historically, when homosexuality was criminalised, gay bars were among the only social spaces where people could meet. In more recent times, stimulant drugs such as MDMA and (formerly legal) mephedrone have permeated the gay club and nightlife scene. Drug and alcohol use may allow people to enjoy the kind of dating or sex life that they want to have, reducing social anxiety, inhibitions, or sexual shame. For men who have sex with men, smartphone technology has increased access to both casual sex and drugs, with geolocation apps making it relatively easy to find nearby sexual partners. At least in urban areas, individual or group sexual encounters where drugs are used can be readily found. Among the chemsex community, sex enhanced by drugs such as crystal methamphetamine or GHB/GBL can be an immensely joyful, freeing, and pleasurable experience for participants.⁸

Not all LGBTQ+ individuals use drugs and alcohol, and among those who do, only a small proportion of use results in significant harm. However, once drug or alcohol use is established, problematic use or addiction may arise. This shift is frequently a result of structural vulnerabilities, such as exclusion from affirming health care, safe housing, financial security, or social support systems.⁹ At the most severe end of social inequality, the LGBTQ+ population is significantly over-represented among people experiencing homelessness. We know that nearly one in five LGBT people in the UK experience homelessness at some point in their lives (and around one in four trans people).¹⁰ The experience of homelessness further exacerbates existing vulnerabilities, creating a vicious cycle that can make it difficult to escape addiction. Distressingly, the average life expectancy for a person experiencing homelessness in the UK is 47 years, with over a third of deaths related to drugs and/or alcohol.¹¹

Given that drug use and excessive alcohol use are themselves generally stigmatised, prejudice towards LGBTQ+ people with addiction problems may layer and interact. An individual might find themselves doubly excluded — for example, discriminated against even within an addictions service. For people who have multiple marginalised identities in addition to being LGBTQ+, such as belonging to an ethnic minority group or having a visible disability, exclusion may be even more acute. Such intersectional discrimination can create an environment where individuals feel unseen, unheard, and unsupported in their struggles with addiction, leading to further isolation and hindering recovery efforts. We also know that there are disparities within the grouping of LGBTQ+, with bisexual people and trans people (of any sexuality) tending to experience worse health outcomes than lesbian and gay individuals. There is typically little to no research about the lives of people who identify as queer or as ‘other’ gender/sexual minorities.

Many LGBTQ+ people have had negative experiences of health care, and so understandably may be reluctant to seek support. If they are met with stigma and prejudice when they do access services, this is likely to reinforce a cycle of unmet health needs and worsening problems. Even welcoming services and staff may simply lack knowledge of the unique context of the LGBTQ+ community, meaning they cannot respond adequately to the needs of their patients. Ensuring that services are ‘culturally competent’ around LGBTQ+ health care is often a low priority in under-resourced healthcare systems, but changes do not need to be difficult or expensive: for example, proactively seeking feedback from LGBTQ+ patients, or ensuring training for all clinical and administrative staff. Conversations within public and preventative health care around LGBTQ+ drug and alcohol use have historically been pathologising, focusing on risks instead of trying to understand underlying causes. However, it is possible to do things differently, working in partnership with the LGBTQ+ community itself. For example, the tireless work of the Gay Men’s Health Collective (https://gaymenshealthcollective.co.uk) draws on the legacy of HIV activism and community knowledge in producing accessible and relevant harm reduction resources.

Taking a strengths-based and trauma-informed approach to clinical work with LGBTQ+ patients is likely to reduce the health disparities they face. We can sensitively enquire about mental health and drug/alcohol use, without assuming that all LGBTQ+ patients experience problems. We can model non-judgemental acceptance when problems are disclosed and consider how we can collaboratively reduce harms. We can ensure that the healthcare environment is free from discrimination and harassment around sexuality and gender (for staff as well as patients). We can believe and validate individuals’ past experiences of abuse, violence, and exclusion. We can involve individuals in their care and foster a sense of agency and empowerment. Being flexible in our support around harmful drug or alcohol use, we can recognise where our ideals (for example, abstinence from crystal methamphetamine) might conflict with a patient’s (for whom giving up chemsex might mean giving up their only social contact). We can research what community or third-sector options are available in our area to support our LGBTQ+ patients. People can and do recover from addiction problems, and often the most important clinical intervention that we can offer is listening, with compassion and hope.

Funding

Miriam Hillyard is funded by the Medical Research Council (MRC) Addictions Research Clinical Training Scheme (grant ID: RE11857). The views represented in this editorial do not necessarily represent the views of the MRC.

Provenance

Commissioned; not externally peer reviewed.

Competing interests

The authors have declared no competing interests.