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Commentary: Substance Abuse in the LGBT Community

Psychiatrist Daniel Linhares, M.D., explores some of the reasons LGBT people have higher rates of substance abuse.
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Studies have shown a significantly higher prevalence of illicit drug and alcohol use within the LGBT community. Identifying triggers for substance use is helpful and is one of the goals for patients in therapy. Some triggers are unique to the LGBT population and likely account for the higher rates of substance abuse.

Mental Illness and Substances of Abuse

When ongoing substance use co-exists with some other psychiatric disorder, it can be very difficult for psychiatrists to know which one came first: the mental illness or the substance use. According to Petros Levounis, M.D., M.A., Professor and Chair of the Department of Psychiatry at Rutgers New Jersey Medical School and an addiction specialist, at least a third of people with substance use disorders also have an underlying mental illness. When they co-exist, one tends to feed the other.

For example, although a psychiatrist might try to improve one’s depression post-cocaine use with an antidepressant, the benefits this medication can provide will be limited until this person is able to quit using cocaine. The effects of the antidepressants might be helpful but they are subtle and tend to take a while to build up and be therapeutic. Meanwhile, the effects of cocaine are quick and devastating in the brain, disrupting the antidepressant’s effect, particularly with repetitive use.

Cocaine is just an example, but the same paradigm can be applied to many other substances of abuse. Even prescribed drugs could have an impact in one’s mood, particularly when misused. The deleterious effects of excessive and long-term use of controlled substances such as anxiolytics (like Xanax, Klonopin, etc.) and opiates (like Percocet) are well established. They may cause continuous sedation, low energy level, poor memory and concentration, not to mention the withdrawal symptoms upon abrupt discontinuation after long-term use. Furthermore, mixing substances (either legal or illegal) can lead to dangerous - even fatal - side effects. For example, drinking alcohol while using Xanax can cause death by respiratory arrest.

"With advancement of societal acceptance of LGBT orientations, and the new generations internalizing less homophobic beliefs, we should see a decrease in the rates of substance use."

"People who suffer from depression and substance use disorders often fall into two categories," said Dr. Levounis. "Either they assume that substances are their primary problem and perceive that all their misery stems from using, while others only accept mental illness as their true, core underlying problem and dismiss substance use as only the consequence of depression, anxiety or PTSD. More often than not, neither of them are correct."

Dr. Levounis said it's best to address both sides of the problem and offer treatment for both, regardless of whether the addiction or mental illness came first.

"We believe that if a person is reluctant to engage in both addiction treatment and antidepressant therapy at the same time, it’s better to 'meet the person where the person is at,' as we often say. Attack one of the problems, even if the person does not accept the other side, because she or he will be a better off by advancing the treatment unilaterally than not all. Hopefully, later the person will be able to gain some insight and integrate the other side into her or his treatment. In other words, if someone suffers from dual-diagnosis (substance use and depression) and wants zero help with the substances, but does accept treatment for depression, absolutely give them antidepressants."

This last part, of course, is assuming that there are no pharmacological contraindications between the drugs the person is using and the psychiatric drugs they are being prescribed.

Marijuana as Self-Medication for Anxiety and Depression

Self-medication is a wonderful theory in explaining the origins of some substance use problems but a terrible strategy in dealing with one’s psychological problems. Although one might experience a transient improvement in psychiatric symptoms, negative effects often lurk down the road.

Ongoing use of marijuana in order to self-medicate depression, for example, may compound low energy, problems with memory and concentration and problems at work, thus making the underlying depression more difficult to treat. Interestingly, according to Dr. Levounis, “there is an incredible concordance between fighting for LGBT rights and advocating for legalization of marijuana."

Without discussing the merit of marijuana legalization, it is well-understood that cannabis is not a harmless substance. The editorial page of the American Psychiatric Association magazine this month talked about the increasing prevalence of marijuana use in our society, fueled by a common perception that it as a benign substance. It also reminded us that its use can be associated with increased risk for memory, physical, psychiatric and social problems. Furthermore, it can have unpredictable (and still not very well understood) negative effects on the developing brain when used regularly in adolescence.

Causes for Higher Rates of Substance Use among LGBT people

“One can think of three reasons for the increased rates of addiction among LGBT people - all resulting in increased stress, which is a very well-known contributor to the initiation and perpetuation of substance use," Dr. Levounis said. "Number one is flat out bias, stigma and discrimination against LGBT people. Number two is a perceived discrimination. Whether you are discriminated or not, you are suspicious of the world around you, which also leads to hyper-vigilance, hyper-arousal, and, of course, stress. And the third one is internalized homophobia.”

Dr. Levounis points out that studies suggest “as discrimination increases, so do the rates of substance use. But in the absence of real or perceived discrimination, the rates of substance use among LGBT people approximates to rates of the general population.“ Therefore, according to these data, if one was born and raised within a nurturing environment that does not discriminate against LGBT people, the chances of people using drugs are pretty much the same, regardless of their sexual preference.

However, moving to a more accepting place does not always result in lower drug use. Although not well-studied, an opposite phenomenon frequently occurs when an LGBT person moves from a rural area to an urban centers with an active party culture, which is commonly saturated with excessive drug use. This can be a socially-driven pathway to addiction.

Internalized Homophobia

Overall, modern society is growing more accepting of different sexual orientations. However, sometimes the enemy lies within. Traditional society enforces heterosexual orientation, and any diversion thereof is considered deviant. Regardless of one’s sexual orientation, it is very difficult to avoid internalizing the value systems defined during one’s upbringing. When this value system creates self-loathing, how does one cope?

As mentioned previously, internalized homophobia may be a trigger for substance use in the LGBT community. A person might need to resort to drugs and alcohol in order to blunt the self-loathing and achieve temporary self-tolerance and acceptance.

In an extreme example of internalized homophobia, someone with same-sex attraction might live a heterosexual life, marrying an opposite-sex partner, having kids and maybe even protesting against LBGT rights. However this person falls into the habit of using substances to achieve a level of disinhibition that allows the expression of repressed desires. This pattern of behavior can increase the addiction potential, because the user now experiences a double-reward effect: a chemical high from the substance use and an emotional high from enjoying his or her natural self.


Hopefully, with advancement of societal acceptance of LGBT orientations, and the new generations internalizing less homophobic beliefs, we should see a decrease in the rates of substance use (and mental illness, in general) within our communities.

If you or a loved one suffers from drug or alcohol addiction, you should check out the National Institute of Drug Abuse website, where they offer a few step-by-step guides on how to proceed to seek help nationwide.

Daniel Linhares, M.D., is a psychiatrist practicing in New York City and a Fellow of the American Psychiatric Association.

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