Equitable Substance Use Disorder Treatment For LGBTQ+ Populations: Research, Tools, And Resources For Behavioral Health Providers

Mental Health and Adult Substance Use Risks For the LGBTQ+ Community

Research suggests that people who identify as lesbian, gay, bisexual, transgender, queer, or other sexual minority often face social stigma, discrimination, and other stressors not encountered by people who identify as heterosexual. In addition, the LGBTQ+ community also is at risk of experiencing harassment and violence. They experience a greater risk for substance use and mental health issues compared with people who identify as heterosexual.

The National Survey on Drug Use and Health (NSDUH) data on Substance use and mental health issues for adults by sexual identity tracks changes over time for substance use treatment, mental health issues, and the use of mental health services by sexual minority adults and will help guide future research. Main findings included a “greater likelihood of sexual minority adults to have substance use and mental health issues compared with their sexual majority counterparts was observed across subgroups of adults defined by sex and by age group. In particular, sexual minorities were more likely to use illicit drugs in the past year, to be current cigarette smokers, and to be current alcohol drinkers compared with their sexual majority counterparts. Sexual minority adults were also more likely than sexual majority adults to have substance use disorders in the past year, including disorders related to their use of alcohol, illicit drugs, marijuana, or misuse of pain relievers. Sexual minority adults were more likely than their sexual majority counterparts to need substance use treatment. Among adults who needed substance use treatment, sexual minority adults were more likely than their sexual majority counterparts to receive substance use treatment at a specialty facility “(Medley et al., 2016). In addition, “Sexual minority adults were also more likely than sexual majority adults to have any mental illness (AMI), serious mental illness (SMI), and AMI excluding SMI in the past year. Sexual minority adults were also more likely than their sexual majority counterparts to have a major depressive episode (MDE) or to have had an MDE with severe impairment in the past year. Sexual minority adults with AMI were more likely than sexual majority adults with AMI to receive mental health services during the past 12 months” (Medley et al., 2016).

These findings are very important as behavioral health providers delivering treatment to minority populations, including LGBTQ+ and other sexual minority populations, strive to provide health equity and eliminate behavioral health disparities. This topic is covered in the OnDemand blog post Cultural and Linguistic Competence: A Resource Review for Behavioral Health Providers.

Treatment Utilization for Substance Use Disorder Among LGBTQ+ Population

Treatment is often not accessed by people who belong to the LGBTQ+ community. In a study that looked at treatment utilization over three dimensions of sexual orientation – identity, attraction, and behavior – the majority of sexual minority respondents with substance use disorders generally had lower treatment utilization that was statistically significant. Some dimensional subgroups had fewer differences in treatment utilization than the sexual majority, or had greater utilization of treatment, such as the subgroup based on the dimension of sexual attraction, with 21% of bisexual respondents actually seeing a physician, psychiatrist, psychologist or social worker compared to just 7.5% of those identifying as heterosexual (McCabe, et al., 2013). A more recent study found that bisexual men and women were more likely to try to enter treatment than heterosexual respondents, but were also more likely to fail to access treatment, with the most commonly given reasons being lack of room or being put on a waiting list or financial inadequacy (Fisher, et al., 2016). An Australian study of 521 same-sex attracted women (SSAW) who completed an online survey reported that rates of alcohol treatment were very low, with just 41% of those needing treatment accessing mental health and alcohol treatment. The respondents cited barriers of “not feeling ready for help” and “previous negative experiences related to sexual identity” (McNair, et al., 2018).

Removing Barriers to Treatment and Increasing Treatment Utilization

The same study also found that disclosing sexual identity to a “regular,  trusted GP” improved use of alcohol and mental health treatment services by SSAW (McNair, et al., 2018). A recent study of substance use treatment programs found that treatment program representatives related specific ways that they made their program services “lesbian, gay, bisexual, and transgender (LGBT)-specific and provided culturally tailored interventions” (Mericle, et al., 2019). Although some programs in the study provided residential treatment while some provided outpatient or a combination, and only two of the 10 programs offered LGBTQ+-specific groups, all of the programs studied used strategies designed to create safe and supportive environments for sexual minority clients. Some of the strategies identified in this study that are potentially useful for all treatment programs included:

• Structuring the physical environment to be non-stigmatizing and especially welcoming for those of sexual minority groups. This strategy included displaying “signals” that acknowledged members of the LGBTQ+ community that members would recognize. Another strategy was to have genderless restrooms that were not identified as men’s or women’s, but were open to any person.
• Having a diverse staff that reflected their clientele. One example from the study was a Director who was gay and ran the LGBTQ+ group. Another example is providing staff with training and skills to provide treatment to sexual minorities.
• Tailor intake and treatment programs to LGBTQ+ clients by asking about gender identification and sexual preference during intake and assessment. Questions are asked to inform providers about unique needs of the individual and ensure that clients are adequately supported, and their needs are met within all aspects of programming. Clients can also be asked about preferences for treatment providers to accommodate clients needs for a specific clinician profile.
• Referral and linkages to outside programs such as LGBTQ+-specific 12-step meetings or other facilities and services that might better meet their needs. This takes the onus of being the sole provider of all services off of individual treatment programs. That is an important point because not all treatment programs can provide for every need. This networking aspect means that treatment programs can be part of a larger treatment provider community, with each program focusing on services that meet unique needs and referring to other programs that fill needs they don’t have the resources to fill. One example is that an outpatient clinic can refer to a residential program that accommodates LGBTQ+ and transwomen to better meet client needs.
• Organizational commitment to addressing the needs of sexual minorities must be the top priority. One program described it as a “top to bottom and back” commitment to diversity. Training to promote this commitment requires that staff has diverse composition and all staff attend all cultural competency trainings, from the janitor to the director to the board members. Organizational commitment to this degree of diversity is discussed during the trainings and meetings.
• Treatment philosophies must ensure safety and support for all clients. For most provider representatives who participated in this study (8 out of 10), sexual minority clients were “mainstreamed” with the general population programs and no sexual minority-specific services were offered. While this seems to be lack of accommodation, it is actually creating a community where members of sexual minorities can be with all members of the program and feel safe, welcomed, and not stigmatized, shamed, or embarrassed. One representative described it this way,

“I respect your difference. I honor and respect your need. If I missed anything, I need you to feel empowered enough to respectfully tell me what I missed. And you have every right to expect me to respectfully capitulate or adjust, adapt. I ask you to give me benefit of the doubt. I’m working with you and not against you. That’s the level of user-friendliness that we lead with here. Whether our population core is female LGBTQ+, or whether they are gay transgender men, or whether they are straight up gay, male, or female. (Program 1013)” (Mericle, et al., 2019).

Using these and other strategies to remove barriers to treatment is vitally important to ensuring health equity for sexual minorities. For behavioral health treatment providers and programs, it involves a commitment for both individuals and organizations and requires the use of a variety of tools and training opportunities to accomplish.

Tools for Raising Cultural Awareness and Increasing Cultural Sensitivity:

National CLAS Standards – 15 action steps in four categories have been developed by the U.S. DHHS Office of Minority Health to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services:

Principal Standard

1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership and Workforce

1. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
2. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.
3. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and Language Assistance

1. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
2. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
3. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
4. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement, and Accountability

1. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
2. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.
3. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
4. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
5. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
6. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
7. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Resources

Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+)– This web page on the Substance Abuse and Mental Health Services Administration (SAMHSA) website provides many resources on the LGBT population include national survey reports, agency and federal initiatives, and related behavioral health resources.

LGBT Training Curricula for Behavioral Health and Primary Care Practitioners – SAMHSA and the Health Resources and Services Administration (HRSA) have compiled a list of professional training curricula to improve the health and well-being of the LGBT population.

Think Cultural Health – This U.S. Department of Health & Human Services (DHHS) website features information, continuing education opportunities, resources, and more for health and health care professionals to learn about culturally and linguistically appropriate services, or CLAS. Launched in 2004, Think Cultural Health is sponsored by the Office of Minority Health

Improving Cultural Competency for Behavioral Health Professionals – Learn how to better respect and respond to your client’s unique needs in this free, online training.

Challenges and Rewards of a culturally-informed approach to mental Health – Dr. Jessica Dere

Addiction Technology Transfer Center (ATTC) Network upcoming Training and Events for LGBTQ+ Populations (enter LGBT in the keyword search box to find current trainings for those populations).

Pacific Southwest (HHS Region 9) training A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals, 2nd Edition

The Center of Excellence on Racial and Ethnic Minority Young Men Who Have Sex with Men and Other Lesbian, Gay, Bisexual, and Transgender Populations (YMSM+LGBT CoE) – This ATTC Center of Excellence funded by SAMHSA provides education, resources and events “to help providers develop skills to deliver culturally-responsive and evidence based prevention and treatment services for lesbian, gay, bisexual, and transgender populations dealing with co-occurring substance use and mental health disorders. Additionally, the CoE will provide a variety of innovative training and technical assistance resources, including training curricula, webinars, and a website clearinghouse to help providers working with LGBT populations and racial/ethnic minority young men who have sex with men (ages 18-26).”

The American Academy of Child & Adolescent Psychiatry (AACAP) Practice Guidelines– The AACAP Practice Parameter on Sexual Orientation, Gender Nonconformity, and Gender Identity Issues in Children and Adolescentsprovides guidance to help prevent the risk of mental health conditions caused by negative attitudes.

National LGBT Health Education Center – The National LGBT Health Education Center Mission is:

• To advance health equity for LGBTQI+ people and the populations which may intersect with the LGBTQI+ community
• To address and eliminate health disparities for the LGBTQI+ community
• To optimize access to cost-effective health care for the LGBTQI+ community
• To improve the length and quality of life for LGBTQI+ people by providing training and technical assistance to medical providers and staff across the globe

Cultural Genogram – This article describes the use of the cultural genogram as an educational tool for teaching health care professional to address client needs surrounding cultural beliefs and practices.

CASAT Catalyst Podcast: Season 3, Episode 4: Giving Voice to the LGBTQ+ Community

Continuing Education and Professional Development for Behavioral Health Providers

CASAT Learning also offers a self-paced, online course on Ethics and Suicide Prevention in Working with Transgender and Gender Non-Conforming Clients.

Facilitated by Dr. Sarah Steelman, participants can look forward to acquiring knowledge of ethical issues and suicide prevention in working with transgender and gender nonconforming individuals. Inpatient considerations and scholarship on elevated risk of suicide for the community. This will include tips on how to help client advocate for themselves if they go to an inpatient hospital as well as understanding minority stress theory and ways inpatient hospitals can impact a client’s dysphoria and how to help them when they return to your office to work through this. Course content will focus on WPATH (World Professional Association for Transgender Health) evidence-based Standards of Care.

To register for this course, visit CASAT Learning website.

The following are just a few of the tools and resources available on this important topic for behavioral health providers. Additional resources may be found in the CASAT OnDemand Resources & Downloads section of the website.

Additional References

Berg, M. B., Mimiaga, M. J., & Safren, S. A. (2008). Mental health concerns of gay and bisexual men seeking mental health services. Journal of Homosexuality, 54(3), 293-306. doi:10.1080/00918360801982215

Fish, J. N., & Pasley, K. (2015). Sexual (minority) trajectories, mental health, and alcohol use: A longitudinal study of youth as they transition to adulthood. Journal of Youth and Adolescence, 44(8), 1508-1527. doi:10.1007/s10964-015-0280-6

Fisher, D. G., Reynolds, G. L., D’Anna, L. H., Hosmer, D. W., & Hardan-Khalil, K. (2017). Failure to get into substance abuse treatment. Journal of substance abuse treatment, 73, 55–62. doi:10.1016/j.jsat.2016.11.004

Holt, M., Holt, M., Bryant, J., Bryant, J., Newman, C. E., Newman, C. E., . . . Kippax, S. C. (2012). Patterns of alcohol and other drug use associated with major depression among gay men attending general practices in australia. International Journal of Mental Health and Addiction, 10(2), 141-151. doi:10.1007/s11469-011-9330-9

Hardy, K. V., & Laszloffy, T. A. (1995). the cultural genogram: Key to training culturally competent family therapists. Journal of Marital and Family Therapy, 21(3), 227-237. doi:10.1111/j.1752-0606.1995.tb00158.x (https://onlinelibrary-wiley-com.unr.idm.oclc.org/doi/abs/10.1111/j.1752-0606.1995.tb00158.x)

Lee, E., & Kealy, D. (2018). Developing a working model of cross-cultural supervision: A competence- and alliance-based framework. Clinical Social Work Journal, 46(4), 310-320. doi:10.1007/s10615-018-0683-4

Lee, J. H., Gamarel, K. E., Bryant, K. J., Zaller, N. D., & Operario, D. (2016). Discrimination, mental health, and substance use disorders among sexual minority populations. LGBT Health, 3(4), 258-265. doi:10.1089/lgbt.2015.0135

Gutierrez, D. (2018). The role of intersectionality in marriage and family therapy multicultural supervision. The American Journal of Family Therapy, 46(1), 14-26. doi:10.1080/01926187.2018.1437573

D’Aniello, C., Nguyen, H. N., & Piercy, F. P. (2016). Cultural sensitivity as an MFT common factor. The American Journal of Family Therapy, 44(5), 234-244. doi:10.1080/01926187.2016.1223565

Greene-Moton, E., & Minkler, M. (2019). Cultural competence or cultural humility? moving beyond the debate. Health Promotion Practice, , 152483991988491. doi:10.1177/1524839919884912

McCabe, Sean Esteban, Ph.D., MSW, West, B. T., Ph.D, Hughes, Tonda L., Ph.D., RN, FAAN, & Boyd, Carol J., Ph.D., RN, FAAN. (2013). Sexual orientation and substance abuse treatment utilization in the united states: Results from a national survey. Journal of Substance Abuse Treatment, 44(1), 4-12. doi:10.1016/j.jsat.2012.01.007

McNair, R., Pennay, A., Hughes, T. L., Love, S., Valpied, J., & Lubman, D. I. (2018). Health service use by same-sex attracted Australian women for alcohol and mental health issues: a cross-sectional study. BJGP open, 2(2), bjgpopen18X101565. doi:10.3399/bjgpopen18X101565

Medley, G., Lipari, R. N., Bose, J., Cribb, D. S., Kroutil, L. A., & McHenry, G. (2016, October). Sexual orientation and estimates of adult substance use and mental health: Results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. Retrieved from http://www.samhsa.gov/data/

Mericle, A. A., de Guzman, R., Hemberg, J., Yette, E., Drabble, L., & Trocki, K. (2018). Delivering LGBT-sensitive substance use treatment to sexual minority women. Journal of Gay & Lesbian Social Services, 30(4), 393-408. doi:10.1080/10538720.2018.1512435

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