Factors to Consider When Treating the LGBTQ+ Population: An Overview for Treatment Professionals

WARNING: This article may contain content that may be triggering for some readers.

Research estimates that approximately 51.5 million adults in the United States—20.6 percent of United States adults—live with a mental health illness, and only 43.8 percent of that population received treatment in the past year (NAMI, 2021). Some fear the stigma about admitting they need mental health care, others are not aware they need help, and the rest face a number of obstacles such as concerns about social distancing, not knowing where to find a good therapist, or work and family obligations that make it difficult to attend counseling.

Of this nearly 52 million, when the focus is turned to the LGBTQ+ community, the list of reasons not to seek treatment grows even longer. Within today’s current political climate, the list would include a fear of discrimination (e.g., trans- and homophobia), having no health insurance, or simply having no access to technology. Individuals in this community, like many individuals in other oppressed and stigmatized communities in America today, are currently struggling with increased anxiety and depression, often intensifying other existing mental health issues. Prior to COVID-19, America was already in the midst of an opioid crisis—one that was already ravaging the gay male population at much higher rates compared to other populations (NIDA, 2021).

Managing continuity of care for LGBTQ+ clients still navigating substance abuse during a global pandemic—a pandemic that included quarantining at home and a total economics shutdown in most states—has challenged me to provide more competent care in order to help these clients remain safe and sober. Practicing physical distancing and quarantining at home often posed a huge risk for some in the queer community. Many people struggling with substance abuse also struggle with shame, isolation, and loneliness. Add the unhealed trauma from growing up LGBTQ+ and other adverse childhood experiences (ACEs; CDC, 2021; Felitti et al., 1998), and the continuity of care for individuals in this population becomes more vital than before. Pivoting, adapting, and modifying my services in order to continue to provide continuity of care for these clients has proven challenging. Overall, the experience has prompted me to write about this process in relation to treating queer clients with past child sexual abuse and chemical or behavioral addictions.

Out-of-Control Behaviors (OCB)

Being in private practice in a small office located in the Metro Detroit area, I have treated a variety of clients from many walks of life: those struggling with more common mental health issues such as depression and anxiety, to those with lesser known concerns like gender identity, sexual orientation, and sexual dysfunction. I have also specialized in substance abuse treatment, specifically with a concentration on treatment within the LGBTQ+ community. While I more often see queer clients struggling with alcohol use disorders, I see queer and other folks struggling with chemical and behavioral addictions as well.

I am trained in cognitive behavioral therapy (CBT), which is well-suited to substance abuse treatment. I also utilize aspects of dialectical behavior therapy (DBT) as well as minority and feminist theories. Over the years, I have also begun to frame an out-of-control behavior (OCB) approach in the treatment of addiction, taken from the sexual addiction field. As a foundation, this approach utilizes the stages of change (SOC) model (Prochaska & DiClemente, 1983)—precontemplation, contemplation, preparation, action, maintenance, and termination—that hopefully all substance abuse treatment counselors and providers are not only familiar with, but are utilizing within their own programs and treatment interventions. I recognize the limitations to treatment when utilizing any intervention or model for the treatment of substance abuse, and make the relevant assessments so I know when to make appropriate referrals to a higher level of care than talk therapy.

There are many other components to the OCB approach I utilize at my practice. Besides the aforementioned methods, harm reduction is another important approach I often utilize with LGBTQ+ clients. I often say that I have the “luxury” of operating within a harm reduction model and not having to “enforce” abstinence as a basis for treatment. Harm reduction helps to reduce any stigma and shame associated with the OCBs of chemical or behavioral addictions. More importantly, the OCB approach allows for a focus on behaviors that reduce the shame and stigma associated with addiction and “moral failings”; I can stop victim shaming and help empower my clients as they begin to heal their ACEs.
In fact, the following are five essential strategies my LGBTQ clients have found useful to avoid OCBs:

Building the Right Support System

Surrounding themselves with trusted friends, family, or extended family is critical for clients in order to help them navigate their LGBTQ+ identity, especially if they are still struggling with their true identity or considering coming out. Their support systems should not only build them up, but should act as validating sources—a personal Jiminy Cricket, if you will. This support system will assist with questions like “When I should come out?” “Where I should be open about my identity/gender expression?” and “Would I be in danger letting people know my authentic self?” In addition, a good support system increases positive coping skills, self-esteem, and self-confidence.

Developing Unique Coping Skills

Coping skills are a critical component to any healthy lifestyle, especially for those of us who identify as part of the LGBTQ+ community. I am talking about skills as simple as listening to a favorite pop diva as a stress reliever, taking on a small home-improvement project to have a sense of accomplishment, or simply making an awesome Snapchat or Instagram post that gets a gazillion likes! These are more than just ways of dealing with more intense emotions like anger or sadness; these will help with less-talked-about intense emotions like loneliness and isolation. For example, maybe encourage clients to consider mindfulness activities like taking a yoga or dance class. The important thing is for them to learn to process more intense emotions and modify their behaviors accordingly.

Setting Boundaries and Enforcing Them

People are not always able to cut negative people out of their lives (e.g., our more conservative family members, our overly-dependent mothers), but setting firm boundaries and enforcing them can have a big impact. Friends and family who do not support our clients should not necessarily be “cut off” from their lives. Instead, what we can help clients learn to do is protect themselves by setting up and enforcing appropriate boundaries. For example, not tolerating homophobic or transphobic language; ensuring those in their homes respect them with words and behavior; and limiting contact with unsupportive family members. Appropriate boundaries assist clients in finding their voices to self-advocate for safe and nonhostile environments.

Practicing Self-Care Every Day

Clients should spend at least fifteen minutes practicing self-care every single day. This time should be all about them and often includes a coping skill or two. Self-care can be as easy as taking a long, luxurious bath; making and/or eating a good meal; or simply relaxing and watching Netflix. Also, have clients consider a “technology off” night, either just for themselves or for themselves and their loved ones, where they try limiting, modifying, or stopping their social media consumption for a period of time.

Getting Enough Sleep

The Centers for Disease Control and Prevention (CDC) reports that sleep deprivation can increase many health conditions, including obesity, high blood pressure, and depression (2018). In fact, National Institute on Drug Abuse (NIDA) Director Nora D. Volkow, MD, reports that “Most common mental disorders, from depression and anxiety to PTSD, are associated with disturbed sleep, and substance use disorders are no exception” (2020). We should be getting between seven to nine hours of sleep per night, but according to a 2013 Gallup poll, 40 percent of Americans get less than the recommended amount of sleep (Jones, 2013). FOMO, late-night Netflix binging, Grindr, social media . . . encourage your clients not to let these and so many other distractions put them at risk of misusing alcohol or other drugs to “help” them sleep.

While I more often see queer clients struggling with alcohol use disorders, I see queer and other folks struggling with chemical and behavioral addictions as well.

These deceptively simple strategies come directly from my experiences counseling LGBTQ+ clients in recovery. They are critical building blocks to not only managing and maintaining a healthier lifestyle, but also in helping clients become active participants in the life they want to live.

Child Sexual Abuse

This past year in my practice, I began to see both male and female clients who presented with a past history of child sexual abuse. Unfortunately, individuals who experience child sexual abuse are at risk for numerous behavioral, mental health, and physical health consequences, including substance abuse (CDC, 2020a, 2020b). When this population also identifies with the LGBTQ+ community, the numbers change dramatically.

We are all familiar with the broad term “child abuse.” Usually the focus is on the physical abuse inflicted on a child or children. However, there are actually several forms of child abuse aside from the physical, including sexual abuse, emotional abuse, and neglect. In my experience, I have focused specifically on child sexual abuse perpetrated on individuals who identify with the LGBTQ+ community.

According to the CDC, child sexual abuse is a significant but preventable ACE (2020a). By their definition, “child sexual abuse is the involvement of a child (person less than eighteen years old) in sexual activity that violates the laws or social taboos of society” and that the child “does not fully comprehend, does not consent to or is unable to give informed consent to, or is not developmentally prepared for and cannot give consent to” (CDC, 2020a).

Getting back to CDC statistics, for the general American population, child sexual abuse numbers are staggering. Here are just a few (CDC, 2020a):

Approximately 3.7 million children experience child sexual abuse each year in the United States.
One in four girls and one in thirteen boys experience child sexual abuse at some point in childhood.
Approximately 90 percent of child sexual abuse is perpetrated by someone the child or child’s family knows.

Before beginning any discussion of statistics and research associated with the LGBTQ+ community, we need to keep in mind that this research could be inherently flawed owing to the inability to gather appropriate and germane statistical information. This is due to several issues that are too numerous to list here, but among the major ones are not using inclusive and nonjudgmental language and overcoming mistrust from the community. A quick example of this is the 2019 Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health (NSDUH), which includes statistics related only to lesbian, gay, and bisexual adults (SAMHSA, 2020). Another is that there is a glaring lack of evidence-based research on the transgender/gender-nonconforming population and virtually none for substance abuse treatment and transgender/gender-nonconforming individuals. The same is also true for LGBTQ+ people of color, though given the current conversation on racism today in the United States, this can now be framed as bias from a privileged position.
Unfortunately, for what is known, these numbers are much worse if children identify as LGBTQ+. The 2015 national Youth Risk Behavior Survey only accounts for lesbian, gay, and bisexual (LGB) youth, but shows that “18 percent of LGB students had been forced to have sexual intercourse at some point in their lives” and the CDC notes that “. . . some LGB youth are more likely than their heterosexual peers to experience negative health and life outcomes” (CDC, 2017).

For example, the Homelessness Policy Research Institute reports that “somewhere between 20 to 40 percent (300,000 to 600,000) of youth experiencing homelessness identify as LGBTQ compared to 4 to 10 percent of the total youth population” (2019), which may also lead to higher rates of sexual trauma. As a reminder, individuals’ sexual orientation or perceived orientation has nothing to do with child sexual trauma.

For LGBTQ+ adults, another consequence associated with child sexual abuse is revictimization during adulthood (CDC, 2020b). This may include higher risk of sexual trauma/victimization, intimate sexual partner violence, and engaging in sexual practices that are retraumatizing.

A good question here is this: Why are these youth more vulnerable? The CDC reports that “for youth to thrive in school and communities, they need to feel socially, emotionally, and physically safe and supported,” implying that the lack of that support can be a factor in why LGBTQ+ youth are more at risk than their heterosexual peers (2017). Nonacceptance leads people to hide their true selves, which in turn leads to all sorts of mental health issues, including shame and low self-worth. Consider that some perpetrators target their victims and others groom them. Given the intense rejection by family members and others, it makes sense that most perpetrators would believe they could abuse queer youth with little to no fear of consequences.

Our queer boys and girls are already labeled as “different” by society, and when they are rejected by peers as well as family, who can they trust to believe them if they come forward about abuse? Unfortunately, incorrectly focused mental health therapy can be damaging in that it does not allow for a safe space of trust for these victims to disclose past child sexual abuse. There is also the fear of being found out if they were to tell trusted adults about what happened to them. This often leads to shame, which can also prevent individuals from talking about this significant but preventable ACE.

Shame

Shame, by definition, is “a condition of humiliating disgrace or disrepute” and “a painful emotion caused by consciousness of guilt, shortcoming, or impropriety” (Merriam-Webster, 2021). In my practice, I often describe the feeling of shame as feeling like “being the mistake.” Shame lives in fear and darkness, so now is the time to bring the shame around this traumatic experience into the light.

Shame can affect and eventually permeate every aspect of people’s lives if left untreated. More common mental health consequences from child sexual abuse include depression, anxiety, and posttraumatic stress disorder (PTSD). Common behavioral consequences include substance misuse, risky sexual behavior, and increased risk for suicide attempts and suicidal ideation. In this community especially, individuals may be deemed “hypersexual” when in reality they suffer from unhealed sexual trauma.

Another aspect of shame is shame-based identity. Instead of shame being connected to past or current behavior, shame-based identities form the core beliefs of “I’m worthless,” “I’m abnormal,” or “I’m a mistake.” Where guilt is often a healthy attachment to behavior, years of living with a hidden identity can lead individuals to form shame-based identities into adulthood. As adults, shame-based individuals will focus on the self with a shame reaction and have attitudes of self-condemnation. For LGBTQ+ adults, untreated shame leaves them focusing on themselves and unable to form healthy relationships or secure attachment styles. In my experience, this also keeps them in the addiction cycle.

Microaggressions

This brings me to unconscious bias and microaggressions. Personally and professionally, I have issues with judgmental words and labels, especially words coming from stereotypes and biases. We need to be mindful of victim shaming (i.e., when we shame individuals for the consequences of their behaviors), which can occur unintentionally or intentionally. Examples of victim shaming include statements like, “Why would you meet up with that older guy who raped you in the first place?” or “You know going on PrEP will make gay men more promiscuous.” As substance abuse providers and counselors, we need to overcome our own unconscious biases, and to do that we need more training; specifically training in cultural competency and LGBTQ+ treatment.

According to the ACLU, the LGBTQ+ community is already fighting for equality on many other fronts—fewer barriers to health care, culturally competent doctors and nurses, and gaining back protections that have been taken away during the last presidential administration (2021), for example—and we can no longer afford to use labels, microaggressions, and stereotypes against this population. Lives are at stake.

According to an article in the American Psychological Association (APA) Monitor on Psychology magazine, microaggressions can be defined as “racism . . . so subtle that neither victim nor perpetrator may entirely understand what is going on—which may be especially toxic for people of color” (DeAngelis, 2009). By now we all should be familiar with this term and its known effects on stigmatized and oppressed populations. It is important to remember to frame treatment of oppression, stigmatization, and victimization within a minority stress theory model (Meyer, 2003), which validates the chronically high levels of stress that members of stigmatized minority groups navigate on a daily basis.

With the right combination of trauma-informed care, telehealth services, and culturally competent LGBTQ+ services, this continuity of care can be achieved.

Not too long ago in this country, gays and lesbians were often referred to as “sexual minorities,” a clinical term still being used today. This well-known term now has a negative connotation of stigma and shame. When more informed clinicians begin to understand how microaggressions, unconscious bias, and trans- or homophobia affect LGBTQ+ individuals, they can better connect with and improve the therapeutic relationship with their LGBTQ+ clients.

Trauma-Informed Treatment

Besides having more research focus for evidence-based studies and continued acceptance within the families and other communities of LGBTQ+ individuals, we can also seek culturally competent services from licensed and trained substance abuse professionals. This has become especially important in these current, unprecedented times during a global pandemic, which has been especially triggering for those living with unhealed trauma. Fortunately, there are viable treatment options: trauma-informed care and telehealth therapy.

Today, more and more informed therapists are getting trained in trauma-informed care. According to SAMHSA,

A program, organization, or system that is trauma informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings (2014b).

The trauma-informed approach has six principles (SAMHSA, 2014a):

Safety
Trustworthiness and transparency
Peer support and mutual self-help
Collaboration and mutuality
Empowerment, voice, and choice
Cultural, historical, and gender issues

I believe these six principles are also key pillars for competency of treatment for LGBTQ+ clients and substance abuse in general. In recognizing that trauma should now include growing up LGBTQ+, these six principles can be a general guide to treatment of all LGBTQ+ clients no matter the diagnoses. Trauma-informed care allows us as providers to create a truly safe space as well as respect our LGBTQ+ clients’ true dignity and worth, while validating and building on their individual strengths.

Telehealth Therapy

Currently, another option for treatment is telehealth therapy, which is therapy on an interactive video platform. Telehealth may be the answer for those who experience barriers to mental health services. For many years, researchers have studied the effects of telehealth on patient outcomes, and results repeatedly show it is an effective, convenient, and viable way for patients to receive the care they need (Seehusen & Azrak, 2019).

Teleheath does work! During this pandemic, many of my clients have chosen telehealth therapy and they are telling me the “magic” of therapy still exists: the therapist-client connection remains intact, care is seamless and effective, it reduces the stress and anxiety involved with an in-person counseling session, it is easier and more convenient, and they are happy they can continue with their sessions.

It is understood that for some clients there may be technology challenges with telehealth sessions. Our role as therapists is to assist clients with their technology needs so their therapy experiences will be successful. We need to provide the services our clients need; if we are not savvy in telehealth technology, it is our responsibility to obtain the training so we can help our clients. Technology should not be an obstacle.

Some clients have expressed concerns about privacy with questions like, “Will our conversations be overheard?” or “Is the location private?” These issues can cause additional anxiety for clients. My advice regarding telehealth therapy appointments is this: be mindful and be honest (both therapists and clients)regarding what is working and what is not so the appropriate adjustments can be made to keep therapeutic relationships safe and secure.

Conclusion

During these uncertain, unstable, and now more political times in our society, access to care—more importantly, access to competent care—is more vital than ever before for LGBTQ+ individuals struggling with substance abuse. Mental health professionals and providers still want to provide clients with the mental health services these individuals desperately need seamlessly, consistently, effectively, and comfortably. Anxiety, depression, family conflicts, communication issues, substance abuse . . . these are just a few of the problems intensifying during the COVID-19 pandemic. We may also never know the full extent of trauma on this generation’s young people, for example, due increased ACEs.

If this is painting a bleak and stark picture, it does not have to anymore! We can begin to talk about this more openly to show unity and support. There are research and studies focusing on treatment after abuse occurs, though little research has been done on preventing abuse from occurring. This means that in the queer community much effort needs to continue on acceptance, especially due to the rejection still happening in families. With the right combination of trauma-informed care, telehealth services, and culturally competent LGBTQ+ services, this continuity of care can be achieved.

If you have child sexual abuse in your past, know that you are no longer alone and that there is help. Please consider finding a clinician trained in trauma-informed care and gay-affirmative therapy. Know that you can move away from shame and towards your authentic self. There is hope!

References

American Civil Liberties Union (ACLU). (2021). Legislation affecting LGBT rights across the country. Retrieved from https://www.aclu.org/legislation-affecting-lgbt-rights-across-country
Centers for Disease Control and Prevention (CDC). (2017). LGBT youth. Retrieved from https://www.cdc.gov/lgbthealth/youth.htm
Centers for Disease Control and Prevention (CDC). (2018). Sleep and chronic disease. Retrieved from https://www.cdc.gov/sleep/about_sleep/chronic_disease.html
Centers for Disease Control and Prevention (CDC). (2020a). Preventing child sexual abuse. Retrieved from https://www.cdc.gov/violenceprevention/pdf/can/factsheetCSA508.pdf
Centers for Disease Control and Prevention (CDC). (2020b). Violence prevention: Preventing child sexual abuse factsheet. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/childsexualabuse.html
Center for Disease Control and Prevention (CDC). (2021). About the CDC-Kaiser ACE study. Retrieved from https://www.cdc.gov/violenceprevention/aces/about.html?CDC_AA_refVal=https%3A%2 F%2Fwww.cdc.gov%2Fviolenceprevention%2 Facestudy%2Fabout.html
DeAngelis, T. (2009). Unmasking ‘racial micro aggressions’. Monitor on Psychology, 40(2), 42.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventative Medicine, 14(4), 245–58.
Homelessness Policy Research Institute (HPRI). (2019). LGBTQ youth experiencing homelessness. Retrieved from https://socialinnovation.usc.edu/wp-content/uploads/2019/08/LGBTQ-Youth-Lit-Review-Final.pdf
Jones, J. M. (2013). In US, 40 percent get less than recommended amount of sleep. Retrieved from https://news.gallup.com/poll/166553/less-recommended-amount-sleep.aspx
Merriam-Webster. (2021). Shame. Retrieved from https://www.merriam-webster.com/dictionary/shame
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–97.
National Alliance on Mental Illness (NAMI). (2021). Mental health by the numbers. Retrieved from https://nami.org/mhstats
National Institute on Drug Abuse (NIDA). (2021). Substance use and SUDs in LGBTQ populations. Retrieved from https://www.drugabuse.gov/drug-topics/substance-use-suds-in-lgbtq-populations
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–5.
Seehusen, D. A., & Azrak, A. (2019). The effectiveness of outpatient telehealth consultations. American Family Physician, 100(9), 575–7.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2014a). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Retrieved from https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA). (2014b). Trauma-informed care in behavioral health services: TIP 57. Retrieved from https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4816.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). 2019 national survey on drug use and health: Lesbian, gay, & bisexual (LGB) adults. Retrieved from https://www.samhsa.gov/data/sites/default/files/reports/rpt31104/2019NSDUH-LGB/LGB%202019%20NSDUH.pdf
Volkow, N. D. (2020). Connections between sleep and substance use disorders. Retrieved from https://www.drugabuse.gov/about-nida/noras-blog/2020/03/connections-between-sleep-substance-use-disorders

Mark McMillan, LMSW, CAADC

+ posts

Mark McMillan, LMSW, CAADC, is in private practice at the Center for Relationships and Sexual Health (CRSH) located in Royal Oak, Michigan. He specializes in diverse populations struggling with issues involving recovery, chemical and behavioral addiction, sexual health, and sexual dysfunction. McMillan also serves as vice president to the national board of directors for the National Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies (NALGAP).