Stress, coping, and context: Examining substance use among LGBTQ young adults with probable substance use disorders

Abstract

Objective

The authors qualitatively examined how lesbian, gay, bisexual, transgender, and queer (LGBTQ) young adults with probable substance use disorders conceptualized their substance use vis-à-vis their LGBTQ identities.

Methods

Individual, in-depth, semi-structured interviews were conducted with 59 LGBTQ young adults (ages 21–34 years) from participants of a larger longitudinal cohort and who met criteria for a probable substance use disorder. Data were analyzed via iterative, thematic analytic processes.

Results

Participants’ narratives highlighted minority stress processes shaping substance use, including proximal LGBTQ stressors (e.g., self-stigma, expectations of rejection), and distal LGBTQ stressors (e.g., interpersonal and structural discrimination) and associated coping. Participants also described sociocultural influences, including the ubiquitous availability of substances within LGBTQ social settings, as salient contributors to their substance use and development of substance use disorders. Gender minority participants, all of whom identified as sexual minorities, described unique stressors and coping at the intersection of their minority identities (e.g., coping with two identity development and disclosure periods), shaping their substance use over time.

Conclusions

Multi-level minority stressors and associated coping via substance use in adolescence and young adulthood, coupled with LGBTQ-specific sociocultural influences, contribute to the development of substance use disorders among some LGBTQ young adults. Treatment providers should address clients’ substance use vis-à-vis their LGBTQ identities and experiences with related stressors and sociocultural contexts and adopt culturally humble and LGBTQ-affirming treatment approaches. Efforts to support LGBTQ youth and young adults should focus on identifying alternative contexts for socializing outside of substance-saturated environments.

Introduction

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ) youth and young adults experience disparities in substance use and disorders (1–7). These disparities have been predominately explained by minority stress theory, which posits that LGBTQ-related stressors shape negative mental health outcomes and associated coping behaviors, including substance use (8–11). Emerging from research on racial minority stressors and health (12, 13), minority stress theory identifies proximal (i.e., intrapersonal) and distal (i.e., interpersonal, structural) stressors experienced by LGBTQ individuals, such as self-stigma and discrimination, as determinants of health.

Although minority stress theory describes how stress and coping shape health among LGBTQ individuals, it does not provide a nuanced perspective on why some LGBTQ people develop substance use disorders, while most do not. LGBTQ youth initiate substance use earlier and escalate use more rapidly than non-LGBTQ peers (14–17). How youth cope with LGBTQ-related stressors during identity development may shape substance use disorders in adulthood. For example, adolescents who employ avoidant coping strategies (e.g., substance use) in response to LGBTQ-related stressors experience more stress (18), lower self-esteem and life satisfaction (19), and lower educational attainment (20) compared with those who employ more healthful coping strategies.

Sociocultural influences, such as more permissive substance use norms (21, 22), and targeting of LGBTQ people by alcohol and tobacco companies (23–25), also contribute to substance use disorders among LGBTQ people. LGBTQ bars may be especially relevant, as such contexts offer “paradoxical space” for community building and high-levels of substance use and other risky behaviors (26, 27), contributing to substance use and other health disparities (24, 28, 29).

Few have qualitatively examined relationships between experiences of LGBTQ-related stressors, substance use, and sociocultural influences in adolescence and young adulthood. This research is needed to understand youth substance use initiation and escalation, how these processes contribute to the development of substance use disorders, and effective substance use disorder prevention strategies (24, 30, 31). This article qualitatively examines narratives from LGBTQ-identified young adults about their substance use initiation, escalation, and usage in adolescence and young adulthood vis-à-vis their LGBTQ identities.

Methods

Data were collected between 2015 and 2017 from participants of an ongoing, U.S. longitudinal cohort, the Growing Up Today Study, enrolled in 1996 or 2004 (N=27,805). Participants in the cohort are children of nurses enrolled in the Nurses’ Health Study II and complete paper or web-based questionnaires covering a variety of health-related domains annually or biennially. More information about the cohort is available elsewhere (32, 33).

In 2015, we invited recent Growing Up Today Study responders (n=13,340) to complete a questionnaire assessing lifetime and current substance involvement, past 12-month probable substance use disorders based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and substance use treatment histories (response rate=73%, n=9683). Among those meeting criteria for a substance use disorder or reporting a history of substance use treatment (n=1789), we purposively sampled a subset of participants based on sexual orientation and gender identity to participate in a follow-up qualitative telephone interview (n=179).

A total of 126 participants (70% of those invited) engaged in semi-structured interviews with trained interviewers (average: 1 hour; range: 18–150 minutes). First, interviewers asked participants about their use of specific substances by gathering a detailed substance use history. If a participant indicated use, the interviewer asked follow-up questions about the context of the participant’s use of each substance, such as How old were you when you first used [X]?, How did your use change over time?, and What factors contributed to that change/increase/decrease in use?

Next, interviewers asked participants open-ended questions about their current sexual orientation and gender identity, including specific categories to select from if necessary (i.e., Are you: completely heterosexual? mostly heterosexual? gay or lesbian? bisexual? Pansexual or asexual? Or, are you not sure?; Are you male, female, transgender, or another identity?). Interviewers then asked how participants perceived their gender/gender identity and sexual orientation influencing their substance use: How has your gender/gender identity and experiences as a [gender identified by the participant] influenced your substance use? and How has your sexuality and experiences as a [sexual orientation identified by the participant] influenced your substance use? When relevant, interviewers elicited elaboration. Interviews were audio recorded, transcribed verbatim, and de-identified. Participants provided informed consent and received a $50 gift card for their time. We obtained ethics approval from Partners Healthcare Human Research Committee/Institutional Review Board.

For the present article, we analyzed data from participants explicitly identifying as LGBTQ in the interview (n=59) using an iterative, thematic analytic process to examine participants’ narratives within their own social and historical contexts (34). We developed a codebook of a priori codes (e.g., “use in the context of sexual orientation”) and codes grounded in the data (e.g., “influence of relationships on use”). Two analysts tested codes on transcripts (n=13), resolving discrepancies until achieving sufficient agreement. Analysts then coded the remaining transcripts based on the revised coding schema (84% reliability). We identified emergent themes via analysis of coded excerpts, code co-occurrence, analytic memos (applied throughout data collection and analysis), and discussion with the study team (34–36).

Results

Table 1 provides sample demographics. The average age of participants was 28 (range: 21–34, standard deviation: 3). Participants were predominately non-Hispanic white (n=46, 78%) with 49% identifying as cisgender female (n=29), 39% as cisgender male (n=23), and 12% as gender minorities (i.e., transgender, gender non-binary, or gender queer; n=7). Most identified as lesbian or gay (58%, n=34) with the remainder identifying as bisexual (36%, n=21), and queer (7%, n=4).

Table 1.

Descriptive characteristics of Growing Up Today Study interview participants who identified as LGBTQ, 2015–2017

Characteristics	N=59	%
Gender Identity
Cisgender Male	23	39
Cisgender Female	29	49
Transgender/Genderqueer	7	12
Sexual Orientation
Lesbian/Gay	34	58
Bisexual	21	36
Queer	4	7
Age
21–28	28	48
29–34	31	53
Race/Ethnicity
White, Non-Hispanic	46	78
Other	7	12
Missing	6	10
Received Treatment for a Substance Use Disorder
Yes	35	59
No	24	41

Note: Percentages sum to 100% except for rounding error.

Minority/LGBTQ-Related Stressors and Coping

Participant narratives highlighted experiences of stress and coping in response to LGBTQ-related stressors. Most participants described coping with specific stressors in adolescence and young adulthood via substance use. Generally, participants described proximal stressors (those internal to the individual) during adolescence and distal stressors (those outside the individual, at the interpersonal and structural levels of the social ecology) during young adulthood.

Proximal Stressors: Identity Formation and Disclosure, and Substance use in Adolescence

Cisgender participants detailed exposure to and experiences with intrapersonal LGBTQ-related stressors – i.e., internalized stigma, concealment, and fear of identity disclosure – in early and middle adolescence, concurrent with sexual orientation development. Often, these stressors related to fears of rejection, rather than actual rejection. In fact, some participants described relief and decreased stress after disclosing their sexual orientation to supportive friends and family. For example, one participant (Table 2, Excerpt 1) explained that, prior to coming out, substance use was a coping strategy for dealing with identity concealment. After coming out to a supportive family, his fears and stress decreased, but his substance use continued.

Table 2.

Excerpts from participant narratives by thematic category

Excerpt Number	Excerpt Narrative
Theme: LGBTQ-Related Stressors and Coping Proximal Stressors: Identity Formation and Disclosure, and Substance use in Adolescence
1	[When I was younger] I was dating a guy and was lying to everyone. It was so much work and was hard to lie. I was in a bad way having to deal with that before I came out. After I came out [at 19], it was a huge weight off my shoulders -- my family welcomed me with open arms and had no problem with it. It put me in a way better place. After that, I wasn’t using [drugs] as a coping mechanism [anymore], it was just kind of still part of my day to day, but I was in a positive state of mind so it was different usage.
	– Cisgender man, gay, age 32
2	When I was younger, before I accepted myself, I felt such a disconnect with my body and loathed it. I literally hated my body, so self-destructive things were oddly pleasing. [Substance use] was like [having] some control over my body since I had been placed in this situation I didn’t want. My mom accepts me now, but initially, she just didn’t know. It was such a new thing, so definitely [I feared] rejection by family and peers. The drinking made that stuff not, matter to me; the drugs also helped that not matter.
	– Transgender man, pansexual, age 24
3	I think trans people have like a 43–45% suicide attempt rate and I am definitely part of that number. Like, that the idea of having to come out as trans [in early adolescence] drove me to drink. I think having gone through those issues in formative years – two things happened. One, it crowded out doing the heavy lifting that you normally do of finding yourself and figuring out what you want to do with your life, like the shit you are supposed to do in your twenties, I didn’t do. I was working on figuring out my own gender identity. Two, coping with the feelings in the unhealthy way still resonate through me -- you drink yourself into oblivion or the way you cope with a feeling is well suicide is always on the table type of thing.
	– Transgender woman, bisexual, age 31
Distal Stressors: Interpersonal and Structural Stressors, and Substance Use in Young Adulthood
4	Almost two years ago, I finally came out to my parents. That’s when my drinking got much heavier. Only within the last six to nine months, I’ve been able to, very consciously and intentionally, cut back on my drinking, which is directly related to distancing myself from my parents and my family, and learning other ways to replace that pain.
	– Cisgender woman, bisexual, age 29
5	Coming out in terms of the family was entirely negative. Things like “you’ll never see my kids”--siblings saying that, or “when we have kids, you’ll never see our kid, you’re going to hell”, all that kind of stereotypical, conservative Christian family response to homosexuality was pretty much given to me and so as a result of that, I don’t talk to any of them anymore. I maybe seen the once of a year kind of thing. My friends were exactly the opposite…you’re normal, you’re okay, there’s nothing wrong with you so I naturally gravitated and spend more time and still do with my friends than any of my family members. […] I would literally credit [marijuana use] with taking me out of depression, making me not suicidal, enjoying life, keeping calm and not being anxious or stressed out. Marijuana was a huge, huge part of that.
	– Cisgender man, gay, age 30
6	I went to the psychologist [at work] and the whole trans thing finally came out. […] At first they were just going to bounce me out of [state A] and send me to [state B] and just make the problem ago away. But at that point, they were just like, “Well, you are not able to [work here] anymore.” […] They blamed it on like bipolar, but like even now today I [know] it was more of a trans thing than anything. Ultimately that experience still travels with me -- I think the emotional baggage and hurt it still there.
	– Transgender woman, bisexual, 31
7	I think substances are used more in LGBTQ communities, because there’s a lot more stress and trauma in those communities. So, even if I’m not going through stress or trauma related to my sexuality at the time, I might be around people that were. Right now, with Donald Trump as our president, it stresses me out as a queer person and I feel like I’m smoking more. With the election season and then now with the new presidency – I didn’t have self-care as much [as I used to] so I reverted to [that] old crutch.
	– Cisgender man, queer, age 31
Themes: Sociocultural Influences: Outsider identities, Community Norms, and the “Gay Bar”
8	I would say a lot of the social activities that are geared towards camaraderie in the gay and lesbian community often surround and involve drinking. The pride parade is sponsored by tons of alcohol brands. I mean if you [want] to go dancing or to socialize or seek that queer space -- it’s always in a bar. That’s where the events are so you’re always around it. So, if you were somebody who, you know, is inclined to abuse alcohol or you are somebody who is recovering, like you’re sort of excluded from those spaces because that’s always there.
	– Cisgender woman, lesbian, age 34
9	You can’t really cut alcohol out and still go to gay bars. It’s not compatible.
	– Cisgender woman, bisexual, age 32
10	If you told me tomorrow the predominant gay activity will not be a gay bar, but a hike, I would be overjoyed. My straight friends behave and do things very differently than my gay friends. Those two lives have been separated [for me]. When I’ve needed help, I’ve gone and hung out with my straight friends more. But then I don’t feel satisfied with my life because I don’t have my gay friends.
	– Cisgender man, gay, age 30
11	Within like gay culture [you] use drugs and to party and have fun and be wild, so to fit in or to kind of figure out your own identity, you kind of just play along with that stuff, or you go along with whatever, ‘cause you see the other people that you identify with are doing it too.
	– Cisgender man, gay, 32 years old).
Theme: The Intersection of Minority Sexual and Gender Identities, and Substance Use
12	Almost every single time I got heavily into opiates it had something to do with my family. The first time, around 24, was when I first came out to my parents and it went terribly. We didn’t speak for six months or something like that, and they had been pretty much heavily in my world up until that point. Later, when I transitioned from female to male -- that was another whole zoo with my family. [When I] relapsed last year, my mom came out to visit me and it was the first time she had ever been in my environment where I present as male -- it was just really stressful and I was not prepared for it at all.
	– Transgender man, gay, age 32
13	My gender and sexuality are so intertwined that like it’s kind of the same thing. When I was younger, I didn’t see how I internally felt [would] ever be able to be a possibility as a lifestyle, especially coming from a [religious], conservative background. My way of handling feelings of rejection and guilt was to self-medicate. And then, just it gets out of hand and then, somehow you’re not very in control of it anymore. As I got older and I was able to get a better grasp over my substance use, [but] emotions are brought up by accepting the fact that your gender identity isn’t going to change no matter how much you want it to. Because of that, I would fall back into use.
	– Genderqueer, queer, age 23
Theme: Divergent Cases: “I’ve Never Really Thought About it Like That”
14	I never really thought about it like that.
	– Cisgender man, bisexual, age 30
15	No, I’ve had a very positive experience in life in general.
	– Cisgender woman, lesbian, age 27
16	To 90% of the world, I’m straight -- married and boring. Most people don’t know to interact with me as anything except a straight woman. But the times that I’ve been able to interact with someone as not entirely straight, you know, I notice that sort of interaction.
	– Cisgender woman, bisexual, age 27

Similar to cisgender participants, gender minority participants (n=7) described intrapersonal stressors related to identity development. Their narratives, however, suggested more severe self-stigma, concealment, fear and experiences of rejection. Gender minority participants also described developing and disclosing their gender identities at older ages, and experiencing less acceptance and more negative consequences when coming out. One participant (Excerpt 3) reflected on how gender minority youth may miss developmental milestones during adolescence, as their primary need is to address a discordant gender identity.

Distal Stressors: Interpersonal and Structural Stressors, and Substance Use in Young Adulthood

Participants highlighted distal stressors in the context of young adult relationships and settings, including family, work, and college, and associated coping via substance use. For example, one participant explained that her substance use decreased after distancing herself from an unsupportive family (Excerpt 4), whereas another participant explained that marijuana use was a key coping mechanism for dealing with negative reactions and family rejection (Excerpt 5). These two narratives suggest that distance from an unsupportive family may decrease stress and substance use for some LGBTQ young adults and increase or compound stress and substance use for others.

Participants also reflected on structural-level LGBTQ-related stressors (e.g., discriminatory laws/policies) and substance use. Some described general structural stressors (e.g., “living in a predominately hetero world”), whereas other participants explained that specific governmental policies (e.g., “Don’t Ask, Don’t Tell”) engender stress and increase substance use. A few participants specifically reflected on multi-level stressors interacting to shape use. For example, one participant commented that stressors affecting LGBTQ people individually also affect LGBTQ communities broadly (Excerpt 7). Their discussion of being “stress[ed] out as a queer person” living in a country with a president who is widely perceived as anti-LGBTQ, provides an example of how, even in the absence of specific intrapersonal or interpersonal stressors, structural factors can influence stress and coping among LGBTQ people.

Sociocultural Influences: Outsider Identities, Community Norms, and the “Gay Bar”

Intersecting with participants’ descriptions of LGBTQ-related stressors and coping were discussions of sociocultural influences and substance use. Many participants described predominately socializing with LGBTQ peers within substance-saturated environments (e.g., “gay bars”) and events (e.g., Pride; Excerpt 8). While participants discussed the historical and cultural significance of these environments for LGBTQ people, they suggested that over-reliance on gay bars may contribute to the development of substance use disorders among LGBTQ people, with one participant explaining that sobriety and gay bars are “incompatible” (Excerpt 9).

Several cisgender and gender minority male participants discussed feeling social pressure to use substances while spending time with LGBTQ friends. For example, one participant explained that he would be “overjoyed” if “the predominant gay activity” were to go on a hike rather than to a gay bar, as he often had to choose between spending time with his gay or straight friends (Excerpt 10). Relatedly, some cisgender and gender minority male participants described internal and external pressures to use substances to “fit in” with LGBTQ peers, especially during identity development (Excerpt 11).

The Intersection of Minority Sexual and Gender Identities, and Substance Use

All gender minority participants also identified as sexual minorities (i.e., LGBQ). Because of their intersecting “minority” identities, these participants often reflected simultaneously on how sexual and gender minority-related stressors and sociocultural influences shaped their substance use. A few gender minority participants described having more than one identity development and disclosure period (one for sexual orientation, the other for gender identity) each with its own unique stressors. For example, one participant described substance use escalation following rejection by his family after coming out as gay and then again when transitioning his gender (Excerpt 12). Another participant described their gender and sexuality as “intertwined”, reflecting on substance use as self-medication during adolescence – a time when they could not imagine a path to societal acceptance of their identities. While the participant described decreased use over time, they also explained that persistent gender-identity-related stress shapes their current substance use (Excerpt 13). These findings suggest that adolescents and young adults who are sexual and gender minorities may have compounded “outsider” identities, more complex identity development and disclosure processes, and may experience intersecting stressors, shaping substance use and disorders over time.

Divergent Cases: “I’ve Never Really Thought About It Like That”

Our analysis yielded a small proportion of thematically divergent cases. These participants (all cisgender) perceived little or no relationship between their sexual orientation, related stressors, sociocultural factors, and substance use. For example, one participant explained that he had “never thought about” a connection between his experiences as a bisexual male and his substance use (Excerpt 14). Another participant also did not perceive a connection between sexual orientation and substance use, suggesting her experiences as a bisexual person were positive (Excerpt 15). Finally, a bisexual female participant indicated experiencing few LGBTQ-related stressors because she is perceived as heterosexual. She explained that when perceived as “not entirely straight”, however, her social interactions are more negative (Excerpt 16).

Discussion

Substance use among LGBTQ young adults with probable substance use disorders may be understood within the context of multi-level LGBTQ-related stressors and coping (10) and sociocultural influences (21). Similar to other studies of LGBTQ stress, coping, and health (18, 19), our findings highlight adolescence as a critical period shaping substance use and disorders over time, including avoidant coping strategies (i.e., substance use) in response to intrapersonal stressors during LGBTQ identity development (8, 37). Our findings also contextualize previous quantitative research identifying adolescence as the developmental period with the largest LGBTQ disparities in substance use initiation and escalation (14, 38–40).

Several cisgender participants in our study described decreased stress after coming out to family and/or accepting their sexual orientation, aligning with research finding that identity integration (e.g., disclosure) may be protective for health (41). For these participants, substance use may have become a habitual coping strategy that they continued to employ in the face of stressors, even those that were not LGBTQ-related, leading to the development of substance use disorders over time. Participants also described coping with distal stressors, such as family rejection, and structural stressors, such as anti-LGBTQ political climates. This emphasis on structural stressors aligns with research highlighting the link between “structural stigma” and higher rates of substance use among LGBTQ youth (42, 43).

It is critical to highlight the age of our participants. As all are young adults now, the adolescent experiences they described occurred between 5 and 20 years ago. We found that regardless of whether they occurred in the 1990s or the 2010s, participants detailed similar intrapersonal stressors in adolescence. This suggests that LGBTQ-related intrapersonal stressors may continue to affect contemporary LGBTQ adolescents, despite growing acceptance of LGBTQ people nationally, echoing findings of persistent disparities in substance use among LGBTQ adolescents, even as overall adolescent substance use declines (44).

Overlapping with LGBTQ-related stressors were descriptions of sociocultural influences on participants’ substance use, including the role of gay bars and LGBTQ-specific environments (e.g., Pride). Despite the importance of such contexts, participants described them as contributing to a culture of normative substance use. Similar to other research on identity construction among LGBTQ people (45), some participants described pressures to use substances in order to be part of the LGBTQ “community”.

Gender minority participants described experiencing unique stressors, often intersecting with their sexual minority identities. This is an important nuance emerging within our data and supported by a recent study of substance use among young adults transwomen in which researchers found that sexual minority transwomen (i.e., lesbian, bisexual, queer) evidenced greater disparities in heavy episodic drinking and illicit prescription drug use than did heterosexual transwomen (46).

Treatment Implications

Based on our findings, we offer the following recommendations for treatment providers working with LGBTQ clients. First, providers should explicitly address experiences of multi-level LGBTQ-related stressors and sociocultural influences, and concurrent substance use, during identity development (especially among adolescents) and in personal and professional contexts (especially among young adults). Identification of harmful or avoidant coping strategies may be especially useful for preventing the development of substance use disorders among young adults.

Second, providers should embrace “cultural humility” as a guiding approach to client interactions. Differing from more traditional, static “cultural competency”, cultural humility requires on-going, active learning about clients’ intersecting cultural identities and social positions, and how societal power and privilege shape individual experiences (47–50).

Third, providers should stay abreast of current LGBTQ rights-related policies as these may profoundly affect clients’ mental health and substance use. For example, while the Supreme Court struck down state bans against same-sex marriage in 2015 (51), many state and federal policies continue to restrict LGBTQ rights and promote anti-LGBTQ sentiments (52). As such, LGBTQ people in conservative settings may need additional support from substance use providers during treatment interactions – something providers who are aware only of broad scale, pro-LGBTQ policies may fail to provide.

Fourth, providers should discuss with LGBTQ clients their current social support networks and the role of substance use in social interactions. This may be useful for discussing and identifying concrete strategies to address substance use within clients’ social contexts.

Finally, treatment environments should be welcoming to LGBTQ people (e.g., providing gender-neutral restrooms, LGBTQ-specific reading materials). Providers should adopt LGBTQ-inclusive screening procedures and carry out LGBTQ-affirming interactions with clients. These affirming practices are critical to supporting LGBTQ people in substance use treatment. See Box 1 and the online supplement (“Further Reading”) for additional guidance.

Box 1. Recommendations for creating LGBTQ-inclusive and affirming treatment environments and interactions.

Create a Welcoming Environment

• Provide resources and materials specifically for LGBTQ people (e.g., referral list of LGBTQ providers).

• Display LGBTQ symbols and images (e.g., rainbow flags, posters of LGBTQ people) in the physical treatment space and on websites and social media pages.

• Display LGBTQ-specific media, brochures, and reading materials, both in waiting and treatment rooms.

• Create, disseminate, and enforce non-discrimination policies that include sexual orientation and gender identity.

• Acknowledge LGBTQ-related observances (e.g., National Day of Silence, World AIDS Day, Pride month)

• Recruit and retain LGBTQ staff and providers.

• Provide a designated gender-neutral restroom in the treatment setting.

• Provide ongoing training and capacity building to staff and providers on culturally-affirming care for LGBTQ people.

• Foster a culture of openness to discuss LGBTQ issues and concerns among office staff and providers.

Adopt LGBTQ-Inclusive Screening and Evaluation Procedures

• Provide non-stigmatizing opportunities for clients to provide information about their identity/identities on intake/screening forms.

  • Forms should reflect the diversity of LGBTQ. Provide opportunities for clients to self-identify sexual orientation, gender identity, relationship status, and preferred name and gender pronouns.
• Inquire about clients’ sexual orientation and gender identity (e.g., identification, gender of past sexual partners) during in-person evaluations.

  • Explain that questions about sexual orientation and gender identity are asked of all clients.
  • Ask all clients their gender pronouns, e.g., she/her/her, he/him/his, they/them/theirs. Know that for some clients, especially younger people, pronouns may change over time. Be prepared to honor any changes in pronouns.
• Ensure that data collection procedures do not further stigmatize LGBTQ clients or their families.

  • Gather “relationship status” rather than “marital status”.
  • Inquire about “parents” rather than “mother” or “father”.
  • Provide space for clients to provide legal name, preferred name, and gender pronouns.

Adopt LGBTQ-Inclusive and Affirming Interactions and Behaviors

• Express empathy, openness, and non-judgmental attitudes.

• Avoid making assumptions about gender identity, sexual orientation, and sexual behaviors (e.g., many lesbians have had sexual contact with men, gender identity and presentation may not be the same).

• Understand that LGBTQ people may believe providers either focus too much or too little on their sexual orientation or gender identity.

  • Be prepared to follow a client’s lead about how much to discuss their LGBTQ identity in the context of treatment.

• Recognize and leverage the strengths and resilience of the LGBTQ population.

• Recognize that “coming out” is a life-long experience for LGBTQ people.

• Ensure and emphasize confidentiality.

• Recognize and understand implications of diversity within LGBTQ populations.

• Use gender-neutral language, e.g., when assessing for violence exposure, partnership status, etc., to avoid assumptions about clients’ partners’ gender(s).

  • E.g., “Are you currently being hurt by someone you are close to or involved with?”

• Use the terms clients use to describe themselves, e.g., If a client refers to themselves as “gay”, do not refer to them as “queer” or “homosexual”.

• If you make a mistake, such as using the wrong gender pronouns when addressing a client or referring to their partner/spouse, politely apologize and correct the behavior, but avoid over-apologizing‥

Study Limitations and Future Directions

Our findings represent narratives of young adults with probable substance use disorders who are children of nurses and primarily non-Hispanic white; therefore, the extent that findings are generalizable to LGBTQ people broadly is unknown. Indeed, a robust theoretical literature (e.g., 53, 54) and, to a lesser extent, scientific evidence base (e.g., 55, 56), highlight the additional, intersecting stressors and health disparities experienced by LGBTQ people of color and of varying socioeconomic positions. Future studies should build on this work by further explicating how LGBTQ-related stressors and sociocultural contexts influence substance use and disorders across the life course among diverse groups of LGBTQ people.

Our sample included seven gender minority individuals. Future research should explore the unique experiences of a larger sample of gender minority people with probable substance use disorders to better understand and address the stressors and sociocultural contexts shaping their substance use and coping. Further, research on substance use and disorders among gender minority people should also examine nuances at the intersection of gender identity and sexual orientation, as gender minority people who identify as sexual minorities may have unique experiences and outcomes compared to those who identify as exclusively heterosexual.

Finally, our study does not address alternatives for LGBTQ people to socialize and build community outside of substance-saturated environments, though such environments are emerging in direct response to some of the sociocultural influences identified in our analysis (57). Future research should explore these alternative spaces and the needs and desires of LGBTQ subgroups with respect to socializing contexts, and their potential to decrease substance use and disorders among LGBTQ people.

Conclusion

Our study extends the literature by examining how LGBTQ young adults with probable substance use disorders perceive their substance use in the context of an LGBTQ identity over time. Our findings highlight the role of minority stress and sociocultural influences in adolescence and young adulthood in shaping substance use and disorders. These findings have implications for treatment providers and prevention researchers.

Highlights.

• The authors conducted in-depth qualitative interviews with 59 LGBTQ young adults ages 21–34 years with probable substance use disorders from across the U.S.

• Participants described substance use as a coping mechanism for dealing with LGBTQ-related stressors in adolescence and young adulthood, and as a function of sociocultural influences.

• Gender minority participants (n=7) described unique stressors (e.g., coping with two identity disclosure periods) at the intersection of gender identity and sexual orientation, shaping substance use and disorders over time.

• Findings suggest treatment providers should address clients’ substance use vis-à-vis their LGBTQ identities, experiences with related stressors and sociocultural contexts, and apply culturally humble and LGBTQ-affirming approaches in their practice.