What Causes Higher Rates of Substance Use and Mental Health Concerns in the LGBTQIA+ Community?

A new study finds that LGB people are more likely than heterosexuals to use drugs, have a substance use disorder and have a mental illness. The 2021 and 2022 National Surveys on Drug Use and Health from Substance Abuse and Mental Health Services Administration (SAMHSA), “A higher prevalence of substance use and mental health issues has been well documented among people who identify as lesbian, gay, or bisexual (also referred to as sexual minorities) than among those who identify as heterosexual or straight.”

While this study didn’t include transgender individuals, the National Center for Transgender Equality’s most recent survey paints a similar, troubling picture of the mental health of transgender people in the U.S. The 2015 U.S. Transgender Survey* states, “A staggering 39% of respondents experienced serious psychological distress in the month prior to completing the survey, compared with only 5% of the U.S. population. Among the starkest findings is that 40% of respondents have attempted suicide in their lifetime—nearly nine times the attempted suicide rate in the U.S. population (4.6%).”  *The 2022 U.S. Transgender Survey results are expected to be published in 2023.

So what causes these mental and physical health disparities? Here’s what you need to know about the unique challenges LGBTQIA+ people face and how you can better support this community.

Minority stress and erasure affect LGBTQIA+ people

Psychiatric Epidemiologist Ilan H. Meyer created the minority stress model to explain why more LGB people may struggle with substance use and have more mental health concerns. The American Psychological Association states, “Minority stress theory proposes that sexual minority health disparities can be explained in large part by stressors induced by a hostile, homophobic culture, which often results in a lifetime of harassment, maltreatment, discrimination and victimization and may ultimately impact access to care.” In other words, a homophobic society often harasses, discriminates and physically abuses LGB people, which is stressful and then causes health disparities, like substance use and mental illness.

While bisexuals experience this type of stress, they also face stressors unique to their sexuality, like erasure. Erasure is when others suggest bisexuality doesn’t exist at all, or that that individual in question isn’t bisexual (possibly because the person is partnered with someone of the opposite sex or even the same sex).

The minority stress theory has also been applied to transgender and other gender-diverse people, people of color, disabled people and other marginalized people.

Stress from marginalization can be internalized

Even if an LGBTQIA+ person doesn’t experience direct discrimination or harassment, they can still experience stress from being part of a marginalized group. VeryWell Health — an award-winning resource for credible, evidence-based research and health information — states, “As the minority stress model states, being part of a minority or stigmatized group can be stressful even when people do not experience any explicit bias. Simply expecting to experience such behaviors can cause physical and mental health stress.” Stress often occurs when people worry about the possibility of something going wrong, so it makes sense that the same is true for stress from marginalization.

Another way stress from being marginalized can negatively impact people is through internalized homophobia or transphobia. VeryWell Health, “The most obvious way is that when people dislike (or even hate) a fundamental aspect of themselves, it can lead to anxiety, depression and other forms of mental health dysfunction. It can also lead to engaging in risky behaviors, such as unprotected sex or illicit drug use. These behaviors may be used to either numb or distract from a sense of self-hatred.” If a queer or transgender person dislikes themselves, they’re more likely to feel depressed and anxious and turn to substances to distract themselves from these feelings.

Stress is often worse for people who have more than one marginalized identity

Individuals who identify as more than one marginalized identity are likelier to feel more stress. VeryWell Health also states, “Minority stress is both additive and intersectional. In other words, individuals who are members of multiple minority groups often experience greater minority stress than those individuals who are only members of one minority group. In addition, people with intersectional identities may experience stressors unique to those identities.” Stressors can build on each other and intersect to cause completely different kinds of stress. A Black woman who is a lesbian may experience racism, homophobia and gender inequality; however, if this same woman was also raised in a deeply religious household that believes homosexuality is a sin, she must also grapple with her religious upbringing and how that intersects with her sexuality.

LGBTQIA+ people encounter discrimination in healthcare settings

Another stressor for LGBTQIA+ people’s physical and mental health is healthcare discrimination. The 2015 U.S. Transgender Survey states, “One-third (33%) of those who saw a health care provider in the past year reported having at least one negative experience related to being transgender, with higher rates for people of color and people with disabilities. This included being refused treatment, verbally harassed, or physically or sexually assaulted or having to teach the provider about transgender people in order to get appropriate care.” Not only were 33% of transgender people refused medical treatment, they were also harassed and physically or sexually assaulted by healthcare providers. And this doesn’t just include gender-affirming care. It also includes “being refused treatment for emergencies, such as broken bones and other traumas.”

Transgender disabled people and people of color are even more likely to have a negative experience, like being refused care or harassed. Historically, Black people have been misdiagnosed and mistreated by healthcare providers. According to the American Psychiatric Association, “Black and African American people are more often diagnosed with schizophrenia and less often diagnosed with mood disorders compared to white people with the same symptoms. Additionally, they are offered medication or therapy at the lower rates than the general population.” VeryWell Health states, “One particularly pervasive issue that has been reported is that Black Americans are systematically undertreated for pain. This has been attributed to beliefs about Black people having ‘thicker’ skin that is less sensitive to pain, which leads to a tendency to underestimate the pain they experience.”

And, again, fear of mistreatment can cause LGBTQIA+ people not to seek mental or physical healthcare. VeryWell Health states, “Fear of experiencing discrimination in a healthcare setting has been shown to lead to avoidance of care. Avoidance of care can result in delays in testing and treatment that have negative effects on overall health.” The 2015 U.S. Transgender Survey states, “In the past year, 23% of respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person.” When people fear seeking healthcare treatment, serious health concerns go untreated, and minor concerns can become larger health problems. Fear and stress also have direct negative impacts on an individual’s mental and physical health.

Therapy that affirms LGBTQIA+ individuals can help

This doesn’t mean the LGBTQIA+ community is doomed to poor mental and physical health and substance use. Mental health professionals have found therapy helps, particularly affirmative care. The American Psychological Association states, “Clinical applications such as affirmative-based practice are effective when working with gay and bisexual men and other sexual minorities. Affirmative-based practice focuses on defining coping strategies, affirming a positive self-identity and increasing the ability to assess the effect of homophobia and stigma on psychological functioning and health risk behavior.” Therapy helps LGBTQIA+ people develop a positive self-image and address the impact of homophobia and transphobia in their lives, improving mental health and making them less likely to use substances. Coping strategies also help LGBTQIA+ people respond in a healthy way to mistreatment, harassment and abuse.

A supportive network can help

A good support network helps improve LGBTQIA+ people’s mental health and decrease substance use. A CNN Health article states, “But what can make a difference, especially for preventing substance use problems among young LGBT people, is having at least one supportive adult in their life, such as a parent, grandparent, teacher, counselor, faith leader or health care provider.” Having friends and family who listen to them and remind them of their worth improves mental health.

The 2015 U.S. Transgender Survey reflects the same findings. It states, “Those who said that their immediate families were supportive were less likely to report a variety of negative experiences related to economic stability and health, such as experiencing homelessness, attempting suicide or experiencing serious psychological distress.”

While LGBTQIA+ people are more likely to use drugs, have a substance use disorder and have a mental illness, there are ways to better support this community and reduce mental and physical health disparities. Affirmative mental healthcare and a strong support network can improve mental health and make LGBTQIA+ people less likely to use drugs. Likewise, more healthcare providers who are educated and supportive about the unique challenges faced by LGBTQIA+ people, particularly those with disabilities and people of color, can provide better, more inclusive care.