Using photovoice to understand experiences of opioid use among sexual and gender minority youth in Vancouver, Canada

Abstract

In Canada, sexual and gender minority youth use opioids at disproportionately high rates. Yet, little is known about the distinct contexts of opioid use within this group, challenging capacity to develop well founded policy and practice supports. This case study aims to examine – in depth – the experiences and contexts of opioid use among a sample of four sexual and gender minority youth in Vancouver, Canada. Qualitative data from photovoice methods and in-depth, semi-structured interviews were collected in 2019. Analysis adopted a reflexive thematic approach from a critical interpretive standpoint, informed by minority stress theory. Three interconnected themes were constructed: (i) minoritised contexts of entry into and continuation of opioid use; (ii) mental health-maintaining and stress-mitigating effects of opioid use in the context of minoritisation; and (iii) intersections of stigma, violence and poverty with opioid use and minoritisation. Findings suggest that the health of sexual and gender minority youth who use opioids is shaped by minority stress and overlapping forms of structural marginalisation. They signal the need for responsive strategies that hold promise in supporting this population, including advancing integrated approaches to substance use and mental health care alongside interventions targeted towards the social and structural determinants of health.

Introduction

In Canada and many Western countries, lesbian, gay, bisexual, transgender, and other queer (herein, sexual and gender minority) people experience high rates of substance use throughout adolescence and young adulthood (Roxburgh et al. 2016; Corliss et al. 2010; Lachowsky et al. 2017). Sexual and gender minority youth (<30 years of age) who use drugs are also more likely to experience drug dependence and be diagnosed with substance use disorders, when compared to their cisgender and heterosexual peers (Lachowsky et al. 2017; Girouard, Goldhammer and Keuroghlian 2019). For example, data from a recent cross-sectional study in the USA indicated that sexual and gender minority youth were twice as likely to use opioids intensively relative to cisgender, heterosexual youth (Schrager et al. 2014). Among sexual and gender minority youth who use opioids, an emerging body of evidence has documented how opioid use coincides with, and is associated with, the use of additional substances, including stimulants, cannabis and alcohol, among others (Dermody 2018; Day et al. 2017; Kecojevic et al. 2017). Sexual and gender minority youth who use opioids thus constitute a priority population for research and policy, but have thus far largely been overlooked by researchers in this area (Moazen-Zadeh et al. 2019).

High rates of opioid use among sexual and gender minority youth are linked to interrelated individual (e.g. mental illness), social (e.g. family rejection, bullying) and structural (e.g. queer/transphobia, violence, criminalisation, poverty) factors that shape the concentration and accumulation of risks across the life course (Friedman et al. 2011; Morgan, Feinstein and Dyar 2020). These factors place sexual and gender minority youth at higher risk of opioid use-related health and social harms, both in the immediate and over the long-term (Goodyear et al. 2020; Moazen-Zadeh et al. 2019). Despite evidence that young adulthood represents an important and vulnerable moment in time for this population, the existing literature offers limited insights into how sexual and gender minority youth experience opioid use across key contexts and transitional periods in their lives.

There is also increasing concern that fentanyl-adulterated, unregulated drug supplies and corresponding overdose crises internationally are disproportionately impacting sexual and gender minority youth who use drugs, including in our study setting in British Columbia (BC), Canada (Moazen-Zadeh et al. 2019). Here, more than 1,700 young people have lost their lives to overdose since an official public health emergency was declared in 2016, with increased deaths since the onset of the COVID-19 pandemic (British Columbia Coroners Service 2022). Given the overdose emergency, empirical research with sexual and gender minority who use opioids in this study setting has understandably prioritised attention toward overdose prevention and response efforts (Goodyear et al. 2020). However, there remain significant gaps in understandings of opioid use more broadly in sexual and gender minority populations, which challenges capacity to develop comprehensive public health policy and practice supports. Accordingly, the aim of this qualitative case study is to examine the experiences and contexts of opioid use among sexual and gender minority youth who live in Vancouver, Canada.

Methods

Study overview

The authors comprise an interdisciplinary research team – representing nursing, public health and anthropology – invested in advancing health equity with sexual and gender minority youth who use drugs. This collective motivation stems from our varied personal and professional and experiences as sexual and gender minority people/allies, nurses working with people who use drugs, and loved ones to people affected by substance use and structural inequities. Together, we approached this study (Yin 2003) with a view to explore in-depth the phenomenon of opioid use within the real-life contexts of four sexual and gender minority youth. This methodological approach was selected due to the targeted focus of our study, and because of the resource-intensive and limited nature of this research with a so-called “hard-to-reach” population, for which feasibility concerns were further complicated by the COVID-19 pandemic. Importantly, we did not aim for – nor do we claim – data saturation or generalisability; rather, we sought to mobilise the value of in-depth analyses and illustrative examples to showcase the distinct contexts in which a sample of sexual and gender minority youth are navigating opioid use and related harms. To do so, we also selected to use photovoice research methods (Nykiforuk, Vallianatos and Nieuwendyk 2011; Han and Oliffe 2016), whereby participants take and narrate photographs to illustrate their experiences. This approach can enhance accessibility and facilitate sharing of perspectives in ways that do not rely solely on words and that shift authority and power from the researcher to participants, including by beginning the conversation with participants photographing what they believe is most important about their experiences.

Data collection

We identified and recruited study participants through the Vancouver-based At-Risk Youth Study – a long-standing cohort study of street-involved youth who use drugs. Participants were eligible for inclusion if they were between 10 and 29 years old, lived in Vancouver, had sexual and/or gender minority identities, and had used opioids in the previous 12 months. Participation occurred between April and October 2019; significant recruitment challenges resulted in a relatively small study sample, though we were prepared for this given our analytical focus on the specific intersections of sexual and gender minority identity, youth, and opioid use. These targeted data collection methods are supplemented by substantive insights gained from an ongoing, six-year programme of community-based qualitative research, led by RK, with over 100 local sexual and gender minority youth who use drugs. In the current study, participants received a $75 CAD honorarium and signed a photo-release form allowing publication of their photographs. Ethics approval was obtained from the University of British Columbia and Providence Health Care Research Ethics Board (#H18-02803).

Data collection occurred in three stages and was informed by prior photovoice research using one-on-one interviews (Han and Oliffe 2016; Nykiforuk, Vallianatos and Nieuwendyk 2011), an adaption of photovoice that is useful for facilitating in-depth exploration of stigmatised and sensitive topics, such as substance use and queerness, which may be difficult to discuss with peers. First, participants met with research staff to obtain informed consent, collect socio-demographic information, and acquire a disposable camera that could take up to 27 photographs. Research staff also reviewed photovoice safety guidelines with participants, advising them to (i) not take pictures of people, or at least not of identifying features (e.g. faces, tattoos); (ii) not take pictures in areas considered private property; and (iii) not take pictures of criminalised activities (e.g. substance use, theft). Participants were given instructions to photograph anything they felt was important and relevant to their opioid use, with particular attention to key life experiences related to opioid use initiation and trajectories, intersections between opioid use and their gender and sexual identities, and how their experiences with health and opioids have been impacted by various features of their local contexts. Participants took photographs over a two-week period and then returned to our research offices for individual, semi-structured interviews. The interviews started with participants describing their photographs, one photo at a time, while the interviewer asked about the motivations and meaning behind the photographs, including in relation to opioid use. Participants had the opportunity to discard photographs (although none did so) and were encouraged by the interviewers to title their images, through prompts such as “if you were to give a title to this photo, what would you call it?”. Finally, participants were asked open-ended questions that paralleled the prompts provided for the photovoice assignments.

Data analysis

Interviews were audio-recorded, transcribed verbatim, accuracy checked, and anonymised. Participants’ photographs were juxtaposed against the transcribed interviews such that they could be analysed alongside the text. We engaged with the data by drawing on a reflexive thematic analysis approach (Braun and Clarke 2019). The first author began by immersing themself in the data to become familiar with participants’ experiences, which included reading and re-reading the interview transcripts while concurrently examining the photographs, noting the distinct intersections (or lack thereof) between these data sources. Open-coding techniques were then used to organise the data into preliminary codes, which we developed to capture key data elements and aspects that responded to our study objective. We iteratively grouped and deconstructed these codes into related categories to generate and contextualise initial themes.

We approached this analysis from a critical interpretive standpoint (Kagan, Smith and Chinn 2014) while drawing on minority stress theory (Meyer 2003; Brooks 1981). With this philosophical and axiological positioning, our analysis was first and foremost directed toward how intersecting forms of structural marginalisation may influence the health-related experiences of sexual and gender minority youth who use opioids – particularly, in ways that may restrict and/or promote opportunities for equitable health and wellbeing. In a more targeted sense, we leveraged minority stress theory to interrogate the ways in which sexual and gender minority-specific stress processes (e.g. internalised shame, social stress, overt queer/transphobia) feature within sexual and gender minority youths’ experiences of using opioids, and to critically analyse how these distinct stressors may be implicated in intersecting societal inequities (e.g. substance use stigma, criminalisation, poverty). By paying careful analytical attention to interconnected issues of identity, minoritisation and marginalisation, we inductively constructed and refined the central themes presented below.

Findings

Sample demographics

The four participants in this study selected pseudonyms and informed us of their personal pronouns: Tony (he/him), VRVT (he/him), Peach (he/him), and Rylie Romah (she/her/they/them). Participants’ socio-demographic data are largely presented at the aggregate level here to maintain confidentiality, given the highly sensitive nature of this analysis. Participants ranged in age from 20 to 29 and identified as queer (n=1), bisexual (n=1), gay (n=1), and both gay and asexual (n=1). Tony, VRVT, and Peach identified as cisgender men; Rylie Romah identified as trans, genderqueer, and non-binary, and as a woman. The sample was ethnoculturally diverse, including participants who identified as Indigenous (n=2), Black (n=1), Arab/West Asian (n=1), Latin American (n=1), Jewish (n=1), and white (n=1), with some participants reporting more than one ethnocultural identity.

Participants were living in independent housing (n=3 alone; n=1 with their partner) at the time of the interviews, though each had previously experienced significant socio-economic deprivation, including recently living on very low incomes and in precarious housing situations (e.g. couch surfing, shelters, outdoors). All participants were taking opioid agonist therapy (OAT) medications and were receiving psychiatric care for diagnosed mental health conditions. Participants had lived experience of using opioids (e.g. heroin and/or fentanyl) and non-opioid drugs (e.g. crystal methamphetamine, crack/cocaine, alcohol, cannabis) on daily to weekly bases, and through diverse routes of administration, including injection, smoking/inhalation, and oral ingestion. VRVT, Peach, and Rylie Romah were actively using opioids at the time of the interviews, whereas Tony had stopped using opioids within the last year.

Overview of thematic findings

Drawing on Rylie Romah’s, Peach’s, VRVT’s and Tony’s experiences, we constructed three interconnected themes. The first theme detailed the complex set of circumstances – which were often instrumentally or incidentally related to minority stress – in which participants had begun using opioids. The second theme characterised participants’ purposeful use of opioids to maintain mental health and ‘numb’ experiences of social stress and isolation. The final theme juxtaposed these mental health benefits with descriptions of the social and structural harms participants navigated as young people who use opioids and who hold marginalised identities.

Minoritised contexts of entry into and continuation of opioid use

Each participant offered a rich description of how diverse aspects of their past life circumstances and contexts contributed to their initiation into and continued use of opioids. Our initial approach to interview questions and prompts was admittedly, however, focused on the single intersection between opioid use and sexual and gender minority identities. Participants responded to this line of inquiry somewhat cautiously, often expressing pride in their identities and resisting the connection between this aspect of themselves and their opioid use. This sense of pride and perception of community strengths was also highly visible in participants’ photographs, among which many showcased Vancouver’s ‘gaybourhoods’ and other symbols of sexual and gender minority community pride, such as a photo of a rainbow flag taken by Tony (Figure 1), titled ‘my community, my home.’

Figure 1.

‘My community, my home’ (Tony_P05)

While characterising these rich community ecologies and responding to our interview questions, participants tended to locate their use of opioids in the immediate and through somewhat ahistorical, individualised perspectives. Indeed, although all participants acknowledged that sexual and gender minority youth – as a whole – experienced higher rates of substance/opioid use, due to societal inequities faced, they were quick to resist and complicate these population-level narratives when describing their own experiences. For example, Peach openly affirmed that minority stress – in his words, ‘struggling to come out,’ ‘hiding it,’ ‘feeling trapped,’ and ‘wanting to feel free’ – could predispose sexual and gender minority youth to opioid use; yet, he did not characterise his own opioid use trajectory in this manner:

I definitely would agree that we [sexual and gender minority youth] are a lot more vulnerable to substance use, whether it is drinking, or smoking, or doing [other] drugs [… But,] I’m more so a drug addict that happens to be gay. I wouldn’t say that I use because I’m gay. […] I feel like my sexuality doesn’t come into factor a lot of the times. […] I don’t think I am any different from a straight person that uses. I think… an addict is an addict.

‘Pride narratives’ such as these are – as others have argued (Salway and Gesink 2018) – ubiquitous in queer literature, research, and culture; and, at their core, involve sexual and gender minority people actively rejecting societal stigma and deficit-oriented views of queerness, or that associate queerness with other stigmatised phenomena, such as substance use and HIV. Peach and Rylie Romah, in particular, seemed to adopt these pride narratives and often described their experiences with substances as being only incidentally related to minoritisation (e.g. Peach’s self-labelling as ‘a drug addict that happens to be gay’), as opposed to being instrumentally connected. In downplaying the role of minoritisation as a structural determinant of their opioid use trajectories, Peach and Rylie Romah associated their entry into opioid use with more proximal experiences of social stress and disconnectedness during adolescence – experiences that are arguably still intertwined with the minoritisation many sexual and gender minority people endure while growing up (Meyer 2003). These tensions between participants’ perceptions of their own lives and structural drivers of inequity were further complicated by discussion of other aspects of social location and context. For example, although Peach similarly did not identify racism/racialisation as an explicit driver of his opioid use, he nonetheless spoke about being a biracial person of colour and the difficult-to-pinpoint ways in which ‘not fitting in’ contributed to social stress and the shaping of his adolescence:

I’ve always had a weird disconnect with my race. […] It was a different kind of growing up for me, [which] kind of shaped me now […] It’s really weird because, like, I don’t really know where I fit in racially, ugh… [Participant pauses]

Interviewer: ‘That sounds hard’

I don’t even know how to explain it – how it can really suck – tie into psychology, or some kind of, like, disorder […] In my mind, it seems kind of complex, so it’s kind of hard to explain it in words.

Tony and VRVT characterised their experiences and trajectories with substance use and minoritisation in more direct ways, openly indicating that part of the reason they had begun using opioids had been to counteract everyday feelings of stress and social isolation that they linked to their sexual minority identities. For Tony and VRVT, opioids provided opportunities to mollify feelings of ‘otherness’ and shame associated with being bisexual/gay.

It’s stressful when you don’t feel like you can talk to anybody about your life, or your lifestyle, or whatever, in terms of the LGBTQ part. So, that probably pushed me to use [opioids], not be[ing] able to talk to my friends about it. – Tony

All participants indicated that social stress – whether directly or indirectly related to minoritisation – was a notable contributor to their initial use of opioids and other substances. Upon beginning to use opioids, often during early adolescence, participants tended to indicate that their substance use patterns had rapidly escalated in terms of frequency/intensity and potential for harms, including through the transition from taking pills orally to injecting intravenously, and through using street-based (and potentially adulterated) opioids rather than prescribed medications. Trajectories of aging and intensifying opioid use remained closely interwoven with minoritisation, even years after participants had ‘come out’ (i.e. disclosed their sexual and gender minority identities to others) and/or first begun using opioids. For example, the following quotation from Rylie Romah illustrates the overt and covert ways in which minoritisation continues to shape her experiences of using opioids and growing into herself as a young trans person:

Being trans, you know, when I go down onto the block to buy drugs, I don’t correct people on my pronouns [when they misgender me]. I don’t tell them that I’m trans, out of fear that I’ll get the shit kicked out of me, or get killed, or raped, you know, for being trans. And that causes me to have more stress, more [gender] dysphoria, more fucking bullshit about my gender, that just keeps piling on, to the point that it’s like, ‘Well, fuck it. I’ll just keep using drugs to ignore it.’

Overall, feelings of social disconnectedness and other direct and indirect manifestations of minority stress featured prominently throughout participants’ adolescent and young adult lives, including in their opioid use trajectories. As is reflected in Rylie Romah’s quotation above, this burden of minoritisation-related stress that ‘just keeps piling on’ was closely interconnected with struggles over identity and personhood, which, together with other forms of marginalisation, acted as key drivers of participants’ contexts of entry into and continuation of opioid use.

Mental health-maintaining and stress-mitigating effects of opioid use in the context of minoritisation

Participants tended to indicate that exposure to intersecting forms of marginalisation contributed to lasting and ongoing experiences of mental illness and distress, which could be partially alleviated through the use of opioids. Indeed, three participants (VRVT, Peach, and Rylie Romah) characterised their use of opioids as an essential source of healing and solace, particularly with respect to maintaining mental wellbeing and minimising experiences of social stress. In describing this strategic and purposeful use of opioids, Peach captured a photo of his journaling – an activity that, akin to his opioid use, he takes up as a coping mechanism for stress and anxiety. Similarly, Rylie Romah captured this photo – captioned ‘looking down’ – of an anxiety-relieving strategy wherein they look down at their feet to avoid eye contact with others (Figure 2). In describing this photo, they shared:

Figure 2.

‘Looking down’ (Rylie Romah_P04)

It’s just what I see constantly [my feet]. I’m always looking down. I have extreme anxiety. I use drugs to cope with it, and I find myself looking down a lot, at my feet. I try and avoid eye contact with people, just because it helps me with my anxiety. […] This [my feet] is something that I constantly see, and [my anxiety is] something that I use drugs to get through. It’s just looking down, always. Just always looking down. I don’t know why I wanted to take this one [picture], why it was super important, other than my anxiety, and just the connection between my anxiety and drug use.

Participants often described how the calming and euphoric effects of opioids could serve to mitigate experiences of mental distress, including anxiety and sadness, and generally support participants to feel well as they navigated life in contexts involving structural precarity. Here, opioids were described as one means of coping with specific mental health challenges, such as diagnosed mood and anxiety disorders, as well as broader experiences of marginalisation, including the intersecting hardships surfaced in the above theme (e.g. minoritisation, violence). For example, Peach described the link between opioid use and mental health while also drawing a connection to minority stress (in his words, ‘the anxiety of functioning as a human being’):

I use drugs because I don’t have to deal with the anxiety of functioning as a human being. […] [My] anxiety is kind of like a fear of nothing, but you just don’t know, you don’t feel whole as a person, and you kind of just go with the motions.

VRVT distinguished his mental health-maintaining use of opioids to ‘get through the day’ from what he described as more common experiences of recreational substance use within sexual and gender minority communities. VRVT perceived that although many of his peers only use drugs episodically or in particular contexts (e.g. with sex, while partying), his use of opioids is distinct in that it is employed as an essential, therapeutic strategy for maintaining mental health and wellbeing. Similar to the first theme, VRVT and other participants seemed to resist characterising their current opioid use solely through a queer lens, effectively differentiating their use from what they perceived to be the more prominent norm of sexualised/recreational substance use within some sexual and gender minority communities. Rather, they perceived their use of opioids to be a survival tool for maintaining health against backdrops of social stress and mental health hardships. Often, participants explicitly indicated that their opioid use was ‘making [them] stronger’ and better equipped to ‘face life’s challenges.’ For example, VRVT shared:

There’s a lot of people that are geared towards drugs, and there’s lots of drug use, like recreational drug use in the gay community, and then quite often for some people, it keeps them moving right along. […] [For me], it’s coping with life’s problems, it’s a painkiller, so physical and mental. Because it’s pretty closely entwined, both your psyche and your physical body, so, it definitely helps with, yeah, getting through the day. […] Right now, it’s just [to] keep on trucking along and helping me, yeah, stay stable or cope with everything that life throws at me. Because it’s always a struggle.

As demonstrated by VRVT’s description of using opioids to cope with day-to-day experiences of ‘struggle,’ participants contrasted the affective state of pervasive social stress – implicated in their marginalised social locations and contexts – with the perceived stabilising effects they experienced as a result of regular opioid use. The above quote’s depiction of opioids as painkillers in both the physical analgesic sense, and also in terms of protecting one’s overall mental ‘psyche,’ featured throughout the interviews. Tony offered a somewhat retrospective perspective to this point, however, as he was the only participant not actively using opioids at the time of our interview. In reflecting back on his opioid use nearly one year prior, Tony cautioned that although opioids may indeed ‘numb’ experiences of mental distress and pain, the broader sources of this pain (e.g. mental illness, marginalisation and trauma) are often left unaddressed.

[Using opioids] kept me from being depressed all the time, numbed my feelings [… But,] the mellowness from getting high and whatever doesn’t really do anything at the end of the day. The pain’s still there. Trauma – your feelings are still there. It doesn’t solve or change anything that’s going on in your life.

Salient across the interviews was an understanding that using opioids could mitigate interrelated experiences of mental and social stress, and support participants to feel well.

Intersections of stigma, violence and poverty with opioid use and minoritisation

Participants’ perceptions of the positive, individual-level effects of opioids were juxtaposed with descriptions of navigating contexts of significant violence, loss, and minoritisation. Accounts of experiencing substance use-related judgement and stigmatisation were often recounted in our interviews. These accounts included regular occurrences of stares, glares, and derogatory comments from passers-by and people with whom participants routinely interacted (e.g. retail workers, bus drivers), which Rylie Romah succinctly characterised as: ‘Day to day, it’s just like random people who think that they know better than you, or whatever, they treat you like shit.’ Participants also detailed highly personal experiences of ‘othering’ from close family members, peers, and friends and romantic/sexual partners within sexual and gender minority communities. All four participants pointed to the ways in which their loved ones had, to varying degrees, distanced themselves from participants as their opioid use had intensified. This loss of family and friends precipitated intense feelings of loneliness and not belonging. Unanimously, this ‘othering’ was described as having had very tangible, deleterious impacts on mental wellbeing, thereby complicating the protective mental health effects of opioids surfaced in the above theme. To this point, Rylie Romah captured this photo of graffiti with the phrase ‘fuck my life’ (Figure 3) and shared that:

Figure 3.

‘Fuck my life’ (Rylie Romah_P03)

I’ve dealt with suicidality for a really long time. It’s very passive, at this point in my life. But, I do remember in the past it’s – it’s gotten really bad, you know? […] When I first started using drugs, and I started losing friends and family because of it, I was so fucking fucked up by that, so suicidal because of it, that I had tried to take my life more times than I can count. Because it was just too hard to deal with. […] That really hit me hard, and it hurt, when I first started losing people.

Participants occasionally recounted facing compounding forms of stigma related to their sexual and gender minority identities, opioid use and experiences of poverty and street entrenchment. Tony, VRVT, and Rylie Romah described several past negative interactions with police, including instances in which they felt they had been specifically targeted and mistreated on the basis of not only their substance use, but also for being sexual and gender minority youth and for being visibly poor or homeless (i.e. as is suggested in Rylie Romah’s quotation below: ‘I’ll be sitting in an alley, minding my own business, and…’). Related to participants’ experiences with policing and criminalisation, VRVT captured a photo (Figure 4) of signage posted at the clinic where he accesses his OAT, which read ‘End the stigma. End the arrests. End prohibition,’ and which he captioned ‘taking a little stand against all the arrests and all the harm.’

Figure 4.

‘Taking a little stand’ (VRVT_P06)

This activist-oriented sentiment around drug policies was shared by Tony, who, when describing the need for a safer drug supply and decriminalisation, underscored the need to ‘shift towards helping people rather than punishing them.’ In the absence of this paradigm shift, participants unfortunately indicated that experiences of drug criminalisation and stigmatisation remained pervasive in their lives. As participants elaborated, the extent to which marginalisation featured within policing and (over)surveillance was revealed in past violent and queer/transphobic police encounters, including Rylie Romah’s experiences:

The police are based on a system of oppression. […] The police need to stop fucking, like – I’ll be sitting in an alley, minding my own business, [and] they will pull up, and ask me my name and my birthdate, and shit, and ask if I have any court things. And, it’s like, they would never fucking do that if I wasn’t sitting in an alley. They would never fucking come up to a random person on the street and start asking them their fucking name and shit, ever! And it’s just because I’m a drug addict, that they think they can do that to me.

This happened to me the other day, actually. And when I did go to tell them [the police] my name, because I didn’t want to tell them my deadname [i.e. the name they no longer use, since transitioning] – I didn’t want to tell them what my legal name is, because I don’t want everybody around me to know. And so, I went up to the [police] car to tell them, and the fucking cop in the driver’s seat was like, ‘Step back!’ like, I was going to fucking hurt them or something. And I was like, ‘Dude, I’m just coming up to tell them my fucking name, because I don’t want everybody else to hear.’ And he was like, ‘I don’t care. You can tell us right now.’ […] And so, I had to out myself [as trans] to everybody there.

Across the interviews, participants also frequently characterised the bidirectional ways in which structural poverty shaped – and was shaped by – their experiences with opioids, minoritisation and inequity. Here, participants indicated that income-generating activities to purchase and procure opioids could be distressing and have socially isolating knock-on effects. For example, despite not wanting to do so, participants described feeling compelled to do sex work and to steal/redirect money from loved ones in order to generate the funds to obtain opioids. Peach referred to this use of survival strategies as ‘scraping by,’ about which he captured this photo of loose change surrounding injection drug equipment and other personal belongings (Figure 5).

Figure 5.

‘Scraping by’ (Peach_P13)

Participants described the ways in which income-generating activities that they perceived as unwanted but necessary had precipitated internal distress (e.g. guilt, shame, trauma), and had also created turmoil in their relationships with others (e.g. if loved ones discovered that participants had stolen from them), exacerbating social stress and isolation. For instance, Peach’s engagement in survival sex work to support his opioid use led to concerns for both himself and for peers, including those who are similarly marginalised and at risk of experiencing related kinds of trajectories. Peach also described how those experiences adversely impacted his ability to meaningfully connect with future romantic/sexual partners:

You can get really sucked into doing escorting – and I feel like that really affects with your mental health a lot. And, I just, I know whenever I do see a young person that is gay, [participant trips on his words as he becomes tearful], I really empathise with the person. Ugh… sorry… I just don’t want someone that go through what I go through, where, you know a person would have to – like, a young 18-, 19-year-old would have to do something [sexual] to an older man, just to get money, I just… don’t want anyone else going through that, you know? [… And now,] I don’t even have stable relationships with guys anymore, ‘cause I feel with the whole escorting thing, like, I feel that kinda like fucked it up a bit.

Peach’s deep empathy for younger sexual and gender minority people who may find themselves in similar hard places was informed by his own lived experience of poverty, ‘scraping by,’ and associated stressors and harms, including lost romantic and intimate prospects. Experiences of socio-economic deprivation were disheartening and stress-inducing for participants, negatively impacting overall wellbeing and quality of life, and necessitating reliance on harmful income-generating activities to support ongoing opioid use. Often, participants indicated that income and housing supports could alleviate the need to engage in such activities, as they would have more disposable income to direct toward opioids, rent, and other necessities (e.g. food, public transit). To this point, and contrasting a photo about asking for money on street corners that Rylie Romah titled “crack change” (Figure 6), Peach captured a photo of a short-term payday financial lending service (Figure 7). He captioned this photo ‘happy place’ and referred to it as ‘the right way of making money,’ sharing:

Figure 6.

‘Crack change’ (Rylie Romah_P23)

Figure 7.

‘Happy place’ (Peach_P04)

I don’t have a bank account, so I always have to cash my welfare cheque at this location. And, I mean, my drug habit is kind of [supported] through my welfare, or like, my disability [pay] and stuff. Without this place, I wouldn’t have money, basically – right? […] If I didn’t have money and if I needed to use, then I would be committing a crime, or just some kind of thing I would do to get money, which I don’t like!

As Peach’s quote implies, participants’ socio-economic circumstances featured prominently in their characterised of experiences with substance use. Participants’ accounts of navigating poverty complicated their narratives about the perceived mental health benefits of opioids. Indeed, participants described how the income-generating activities they viewed as harmful were key sources of social stress and disconnectedness. Over and above these social strains, participants pointed to the ways in which everyday contexts of violence and stigmatisation reinforced processes of minoritisation, othering and stress.

Discussion

This case study provides insights into four sexual and gender minority youth’s intersecting experiences with opioid use and minoritisation. Findings from this study contextualise and complicate the positioning of sexuality/gender and minoritisation as key determinants of sexual and gender minority youth experiences with opioid use. This is not to diminish the centrality of sexual and gender minority identities and queer/transphobia in the production of health experiences and outcomes; rather, these findings frame opioid use within this group as complex and shaped by multiple and intertwined social determinants, inclusive of but not limited to sexuality- and gender-specific minoritisation.

Findings from this study add to understandings of the determinants and trajectories of opioid use among sexual and gender minority youth. In keeping with minority stress theory (Meyer 2003; Brooks 1981), participants indicated that they had begun using opioids, in part, to offset feelings of social isolation and disconnectedness implicated within their minoritised sexual and gender identities. Yet, participants’ experiences with opioid use were also linked to other forms of structural marginalisation, including socio-economic and mental health hardship. Targeted research using minority stress theory with intersectional perspectives (Hankivsky et al. 2014; Collins et al. 2019) may help to further interrogate pertinent interconnections between distal structural inequities (e.g. interlocking systems of oppression) and more proximal experiences of social stress and mental illness, particularly as these issues coalesce to shape trajectories and contexts of substance use among sexual and gender minority youth.

In this study, sexual and gender minority youth described using opioids to mediate experiences of mental distress and social stress. This strategic use of opioids may be effective in the short-term, but, as Tony cautioned in his interview, it may do less to address the root causes of one’s distress. Previous research and our study’s findings also suggest that this kind of ‘self-medication’ may have bidirectional effects that exacerbate mental illness and harms related to substance use (Giang et al. 2020). This potentially reinforcing loop – whereby intersecting forms of structural marginalisation and social stress shape opioid use, implicated in which are additional stressors and inequities – can best be interrupted by acting on social and structural determinants of health. Especially needed are efforts to redress persistent systems of inequality and oppression, as well as equity-oriented improvements to the social safety net, such as through enhancing access to universal basic income and safe, affordable housing (Abramovich and Shelton 2017; Moazen-Zadeh et al. 2019; Kagan, Smith and Chinn 2014). From a service provision standpoint, this necessitates that healthcare providers working with sexual and gender minority youth who use opioids carefully consider and open up conversation about the psycho-social aspects of substance use and centre these aspects when developing individualised care plans. Here, integrated approaches to substance use and mental health policy and practice hold promise for supporting the health of sexual and gender minority people (Morgan, Feinstein and Dyar 2020), with our study underscoring that such approaches must be responsive toward individuals’ distinct social locations, contexts, and structural vulnerabilities. This could include, for example, clinician referrals to targeted social support (e.g. income/employment, housing) and queer- and trans-affirming services (e.g. counselling, peer support groups), and the scale-up of youth-specific programming and services (e.g. harm reduction, safer supply) that are safe and accessible to sexual and gender minority youth (Abramovich and Shelton 2017; Moazen-Zadeh et al. 2019).

Strengths and limitations

Our study design yielded highly contextualised descriptions of opioid use from the standpoints of a sample of sexual and gender minority youth. The inclusion of strengths-based interviews and photovoice methods deliberately centred four young people’s’ voices, perspectives and knowledge; yet these insights were not validated by member checking. Indeed, although we had initially intended to hold community dialogue sessions and photovoice exhibits for this study, these plans were interrupted by the COVID-19 pandemic and associated public health measures. Importantly, this study had a small sample size and neither aims nor claims to fully reflect all variations of sexual and gender minority youths’ experiences with opioid use. Relatedly, while the study has offered some discursive and theoretical insights, there is demand for ongoing intersectional and sociological investigation in this area.

Conclusion

In this study, opioid use featured as a paradoxical source of healing and harm in the lives of sexual and gender minority youth. Peach, Rylie Romah, VRVT and Tony underscored how minority stress implicated in their sexual and gender identities and intersecting social locations and contexts had shaped their adolescent and young adult lives, including their contexts of entry into and trajectories of opioid use. Against the backdrop of minoritisation, participants often characterised opioid use as a way to mediate interrelated experiences of social stress and mental ill health. Yet, descriptions of these benefits were complicated by the social and structural hardships participants faced, including harms related to intersecting stigma, criminalisation, violence, and poverty, which compounded experiences of minoritisation. These findings highlight the nuanced ways in which minoritisation and overlapping forms of structural marginalisation intersect with sexual and gender minority young peoples’ experiences and contexts of using opioids, while also pointing to responsive policy and practice interventions that hold promise for supporting the health and wellbeing of this group.

Data availability

Data analysed are not publicly available because they contain information that would compromise research participant privacy and consent, but are available from the corresponding author on reasonable request.