"Small Victories of Survival in a Deeply Homophobic World": Current Realities and Paths Forward for Substance Use in the LGBTQIA+ Community

According to the National Institute on Drug Abuse, members of the LGBTQIA+ community are disproportionately impacted by problematic substance use (

I n a YouTube video by Brujas World (2019), a New York-based feminist street collective and streetwear brand, a group of young people of color stand watching a soccer game, passing around a joint.Meanwhile, a New York City Police Department watch tower looms overhead.What starts as an everyday scene of friends hanging out and playing soccer suddenly morphs into a public health announcement.A powerful voice informs viewers that "deaths due to opioid-related overdoses nearly tripled in 2015" (Brujas World, 2019, poor people, gay people, sick people, to keep us, punished for our looks dizzy, and their friends run over to help.The voice reminds with you.Give them to your loved ones.Help them use them.When According to the National Institute on Drug Abuse (2020), LGBTQIA+ than the cisgender, heterosexual population.This paper explores the prevalence of substance use in the LGBTQIA+ community, barriers to treatment, and suggested paths forward through the lens of the minority (2003) as occurring when "stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems," thus increasing the likelihood of substance use and its potential associated risks (p.674).This model thus posits that minority stress increases the likelihood of substance use, as well as its potential associated risks.
LGBTQIA+ individuals struggling with substance use, this paper argues that treatment approaches must evolve.Suggested approaches include treatment models, strategies that address co-occurring Post-Traumatic Stress Disorder (PTSD) and substance use disorder (SUD), harm reduction methods, and non-police crisis intervention.Approaches with these considerations would better support the needs and well-being of

METHODS & LIMITATIONS
Research for this article includes meta-analysis and thematic analysis of various sources from databases including Columbia University Library behavioral healthcare," "substance use treatment," "crisis intervention," "LGBTQIA+ people of color," "harm reduction," and "minority stress one pilot study, six surveys, one sample study, one systematic review, 2 pieces of advocacy-oriented content, four creative pieces, and one educational training video.Publication dates range from 2003 to 2023, with most from 2014 forward.
With the intent of surveying the literature, this article analyzes 20 peerreviewed studies with evidence from 13 additional sources, such as prominent LGBTQIA+ advocacy centers, healthcare facilities, harm reduction centers, news organizations, and companies.The available sources exhibit noticeable disparities in their demographic and topical foci.Among the 20 peer-reviewed articles, 14 discussed substance use, while others explored topics such as minority stress, social services, and the health and mental health issues of these populations.Fourteen articles broadly focused on the LGBTQIA+ community, three on LGBTQIA+ youth, three on the trans population, 2 on the LGB population, and one on the LGBTQIA+ homeless population.Concerning racial demographics, 9 sources on people of color are referenced, including 3 on the Black population and 1 on the Latinx population.Two sources pertain to substance use among people of color more broadly.Finally, 8 articles discuss substance use in the LGBTQIA+ population, with 1 focusing on youth within that category and 1 solely on trans substance users.
Limitations include a lack of research on substance use treatment in LGBTQIA+ communities (Glynn & van den Berg, 2017).Alarmingly, the National Survey on Drug Use and Health does not even include sexual orientation or gender identity in demographic surveys (Glynn & van den men and trans women of color, is practically nonexistent.In addition, there is a huge gap in research on older adults in the community (Crath et al., 2021;Vareed & Mendoza, 2019).

LGBTQIA+ HISTORY, CULTURE, AND REALITIES CONCERNING SUBSTANCE USE
In a Youtube video from an event called "HaHa Harm Reduction," Del Castillo (2017) describes an experiment in which a rat was locked in a cage and provided a water bowl containing heroin.Quickly, the rat became addicted to heroin.When the scientists took the rat out of the cage, they gave it a jungle gym to climb on, lots of space to run, food, and water, and added other rats to the area.Some rats tried heroin but remained disinterested in it; none of the rats in the second cage became addicted to heroin.In the words of Del Castillo, "Is the problem the Del Castillo (2017) elaborates that for many LGBTQIA+ individuals, substance use is not so much about the high, but instead about "the safe haven from a hostile world that would not otherwise embrace the rainbow," a statement that illustrates an experience of the minority providers are aware of their patients' gender identity or sexual orientation, the patients are more likely to build rapport with their providers and disclose health information, and the providers, in turn, are and trans people, that is a luxury.While healthcare spaces have not always provided a safe space for the LGBTQIA+ community, bars and clubs have always been a central part of the history of the LGBTQIA+ around relationships, connection, community, and chosen family.While bars and clubs can be a liberating source of joy, spaces centered around drugs and alcohol can also come with risks, especially for those with preexisting challenges related to substance use (Vareed & Mendoza, 2019).An example of this is the use of party and play (PNP), which is a term describing the use of party drugs, such as crystal meth and ecstasy, during sex among men who have sex with men (Mallon, 2018).
for developing substance use disorders.On this topic Mallon (2018) states, "The role of oppression, being part of a marginalized population, and the importance women place on relationships are integral to understanding addiction among lesbian women" (p.71).This suggests that lesbians may use substances as a way to relate to one another.Therefore, Mallon (2018) argues treatment interventions for people who identify as lesbians should focus on relationship development and "expression of the true self, examining both external and internal homophobia, including addressing shame or a lack of self-acceptance" stereotyping of women, community building and building authentic connections are time-honored pieces of LGBTQIA+ culture.
Unfortunately, in addition to high rates of substance use in the on LGBTQIA+ history.Much work has been done around the trans population, for example, in the context of HIV risk due to the high use within a syndemic framework (Glynn & van den Berg, 2017).The AIDS epidemic points not only to another collective trauma but also to co-occurring illnesses with the potential to be treated together.For example, a summary of 12 studies on LGB youth informs readers that the most common risk factors for substance use include experiences of victimization, stress, and housing insecurity (Goldbach et al., 2014).Risk LGBTQIA+ substance users, point toward the necessity for increased research, improved access to care, and treatment for this group.

THE PREVALENCE OF SUBSTANCE USE IN LGBTQIA+ COMMUNITIES
the organization elaborates that it is impossible to establish long-term trends on this topic because surveys only recently began to include gender identity and sexuality.Much research on the topic orients this exposure to discrimination over time by people in marginalized groups leads to higher rates of mental health and substance use challenges (Glynn & van den Berg, 2017).Studies have shown that discrimination and substance use are correlated (Glynn & van den Berg, 2017).Social stigma and discrimination increase the likelihood of harassment and violence.These sources of added stress expose the community to a greater risk of behavioral health vulnerabilities (NIDA, 2020).To compound matters, a disproportionate number of LGBTQIA+ young people go without housing each year in the U.S. LGBTQIA+ youth without housing have excessive rates of substance use issues and mental health challenges, higher rates of suicidal behavior and HIV risk, and are more likely to be victims of violence (Keuroghlian et al., 2014).
Similarly, substance use is comparatively high within the trans community.Among transgender individuals, there are higher rates of use for alcohol, illicit drugs, and non-medical prescription drugs compared with the cisgender population (Glynn & van den Berg, 2017).Reasons for the higher prevalence of substance use among trans people include the prevalence of intimate partner violence, low-income status, housing instability, PTSD, and participation in sex work (Keuroghlian et al., 2014).In fact, 35% of trans people who have experienced verbal harassment in school, physical or sexual assault, or have been expelled from school report using substances as a coping mechanism for these gender-related traumas (Keuroghlian et al., 2014).Furthermore, the psychological stress of disparities in healthcare access that trans people experience is another trauma that worsens mental health and increases the likelihood of substance use.This stress also leads to decreased healthcare utilization, which puts the trans population at increased risk under the minority stress model (Keuroghlian et al., 2014).

FURTHER DISPARITIES WITHIN LGBTQIA+ SUBSTANCE USE RESEARCH
Despite well-documented disparities, research on the mental health outcomes of LGBTQIA+ people of color lacks nuance and heterogeneity, with many studies grouping people of color into one singular group or looking only at Black and Hispanic populations (Allen & Leslie, 2020;Eisenburg et al., 2022).However, people of color in the LGBTQIA+ example, Drazdowski et al.'s (2020) study surveyed 200 LGBTQIA+ people of color about their experiences with racism, LGBTQIA+ discrimination, and substance use.The study found that being both a person of color and LGBTQIA+ puts one at a higher likelihood of using all researched types of "illicit drugs," disaggregating data based on experiences of internalized racism, homophobia, and discrimination based on both identity groups (Drazdowski et al., 2020).2022) study displays that Latinx and Black trans youth are the group with the highest prevalence of substance misuse of their age group.The experiences of multiple marginalizations and minority stress, including racism from within the LGBTQIA+ community, are likely to impact the prevalence of service utilization and completion (Cyrus, 2017).Therefore, a more thorough analysis of varied racial groups' substance use trends, treatment access, and treatment outcomes may help improve health outcomes for those from diverse cultures and experiences.While advocacy groups like the Trevor Project and aforementioned researchers are working toward expanding the research and data on this topic, the absence of earlier research suggests there is still a long way to go (2022National Survey on LGBTQ Youth Mental Health, 2022.; "Substance Use and Suicide Risk Among LGBTQ Youth," 2022).

ACCESS TO SUBSTANCE USE TREATMENT IN THE LGBTQIA+ COMMUNITY
The reasons canvassed above prove the necessity of using traumainformed, community-based, holistic, person-in-environment centered treatment modalities for substance use in LGBTQIA+ populations.
the clear need for these services, culturally competent substance use treatment remains scarce (Williams & Fish, 2020).modalities has improved treatment outcomes compared to programming exception is a study which examined the outcomes of participants in an Austin, Texas-based recovery housing facility for men who have sex with men (Mericle et al., 2020).The study displayed that relief from minority LGBTQIA+ individuals have lower completion and abstinence rates on average in substance use treatment than their cisgender, heterosexual complicate the potential for success in traditional substance use-related services.Twelve-step programs, such as Alcoholics Anonymous (AA), have higher success rates among those who identify as part of the group and believe in a higher power (Vareed & Mendoza, 2019).Since LGBTQIA+ people might be more uncomfortable with the religious aspect of 12-step programs due to the fear of certain religious groups displaying homophobia or transphobia (Vareed & Mendoza, 2019), groups.
"AA is not the only model that responds to alcoholism.Scholars of the history of the Alcoholics Anonymous program have pointed out that the program often eclipses harm reduction approaches.Even as I dream of the abundance of those options," Jain adds, "I believe in that meeting.In the embodied warmth of the church room in Oakland, in the happy existing harm reduction services in their area were usually inaccessible, unsafe, and a space where they experienced judgment from providers (Goodyear et al., 2021).Many participants feared they would face drug sometimes chose not to use drug-checking services, which screen for the presence of risky substances, including fentanyl, because of the concern that the police would stop them (Goodyear et al., 2021).Since harassment, drug criminalization is a massive issue for the LGBTQIA+ population, especially for people of color, who are even more at risk of police harassment and violence (Goodyear et al., 2021).Professionals accessible substance-use services.

BEST TREATMENT PRACTICES have been shown to improve treatment utilization and outcomes
LGBTQIA+ population, historical and cultural themes of the people,

"SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD"
and treatment access trends.Several models are discussed, including implementing integrated behavioral healthcare to improve access and utilization of care, implementing treatment models tailored for the trans population to address disparities, and providing treatment for co-occurring PTSD and SUD.As these disorders are prevalent that account for realities within the LGBTQIA+ community and putting into action means of crisis de-escalation outside of policing

BEHAVIORAL HEALTH INTEGRATION
According to the Integration Academy, "Integrated behavioral health care blends care in one setting for medical conditions and related Integrated Behavioral Health?[WIBH?]," n.d., para.2).When working within an integrated care model, providers must recognize that physical and behavioral health are interrelated and that clinicians working on both sides of the healthcare sphere must work together to treat patients and help them meet their health goals ("WIBH?").This convenience makes it easier for patients to access behavioral healthcare treatment, However, most healthcare professionals have not received training to work in that system ("WIBH?").In the highest level of integrated care, there is complete collaboration between providers in a merged practice within the same building (Keuroghlian, n.d.).Advocating for more training imperative in order to reduce the disproportionate risk of substance use.Fenway Health, a Boston-based LGBTQIA+-focused healthcare center, explains that Fenway's integrative behavioral healthcare improves the patient experience because its holistic approach reduces stigma around substance use and mental health while simultaneously improving access to treatment and reducing healthcare costs.In addition, Keuroghlian has positively impacted outcomes.

TRAUMA-INFORMED, LGBTQIA+-SPECIFIC TREATMENT MODELS
The literature broadly suggests a person-in-environment model that is holistic and also trauma-informed is the best course of action.Due to the disproportionate rates of substance use and lack of access among trans individuals, this section will focus on treatment models for trans substance users.As a treatment model, Behavioral Health Integration for this population should take place in an environment tailored for the to be aware of the minority stress model and implement a traumainformed framework that centers on the realities faced by people impacted by minority stress and that highlights the strengths of the trans individuals are more susceptible to having a background of trauma associated with violence compared to the cisgender, heterosexual population, adopting trauma-informed practices is critical in mitigating the likelihood of substance use relapse (Vareed & Mendoza, 2019).Hence, interventions should celebrate identity.

TREATMENT OF CO-OCCURRING PTSD AND SUBSTANCE USE: THE SEEKING SAFETY STUDY
fostering relationships and community while acknowledging and mitigating the impacts of the societal "cage" of transphobia and homophobia can be essential factors in preventing substance misuse.from both substance use disorders and PTSD is impactful in improving both diagnoses (Keuroghlian, n.d.).A 2017 study called Seeking Safety sought to address substance use through a holistic model (Empson et al., 2017).Seeking Safety is a treatment program that uses cognitive behavioral therapy for co-occurring PTSD and substance use disorder.It was tested in 12 sessions with a group of women of trans experience "SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD" PTSD symptoms, alcoholism, and substance use (Empson et al., 2017).This study shows the importance of confronting substance use in the trans community holistically, in line with the concept of integrated behavioral healthcare (Empson et al., 2017).

HARM REDUCTION
programmes, and practices that aim to minimize negative health, social and legal impacts associated with drug use, drug policies and drug laws" ("What is Harm Reduction?"para.1).Harm reduction is a rightsbased approach that focuses on support without discrimination.This philosophy implies that models which do not prescribe harm-reduction strategies may involve discrimination, which explains why marginalized Soprano, one of the producers of the Brujas World video, does this well with his production of harm reduction kits, which include practical tools for safer sex and drug use as well as more artistic items, such as a para.6).According to Soprano, "so much of harm reduction practices and theories came out of sex working communities, people who are chemically dependent, sick and disabled people, and communities of care made up of gay men of color and trans women of color" (Kuwabara Blanchard, 2020, para. 5).Soprano expands by asking, "What if the both a piece of utility and a piece of political propaganda?" (Kuwabara Blanchard, 2020, para.5).Such creative approaches to harm reduction may reduce stigma and increase service utilization.
Another group which focuses on harm reduction education is Queer Appalachia (Worlley, n.d.).Their website explains that "with the disheartening and exponentially increasing rate of opioid use in to recover only further exacerbates these experiences" (Worlley, n.d., in providing impactful and accessible services when it comes to substance abuse treatment, especially if the intersection of race is considered (Dradzowski et al., 2022).For this reason, communities have turned to harm reduction and mutual aid practices to support their loved ones and community members in a way that does not rely on government support.

CRISIS INTERVENTION OUTSIDE OF POLICING
The criminalization of substance use is intrinsically linked to the history of racism in the U.S., with disproportionate negative impacts on people of color.Plus, as previously discussed, there is a collective trauma associated with police violence in the LGBTQIA+ community.Hence, building methods of crisis intervention that exist outside of the policing and carceral systems is another critical next step in supporting LGBTQIA+ people who use substances (Alang et al., 2017;Atlas, 2021;Bor et al., 2018;Goodyear & Knight, 2021).For example, implementation of crisis intervention models outside of policing has proven impactful among the general population in Portland, Oregon through the Crisis Intervention Helping out on the Streets program, which proved successful not only in de-escalating crises, but also reducing costs and leading to only a 1% need to obtain police backup ("Cahoots Media Guide," 2020).In addition, implementing this model in communities could increase access to care by drawing a direct line between communities and behavioral health providers, instead of a line between substance users and the carceral system.

CONCLUSION
substance use-related services and higher substance user rates, helpseeking behaviors, and treatment completion rates (Vareed & Mendoza, 2019).From literature assessment, historical and cultural factors, and statistics, this paper concludes that while more research and funding "SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD" are certainly needed to support this vital issue, service models must additionally be rethought to best support LGBTQIA+ communities.stress on those in the LGBTQIA+ community who use drugs include models, cognitive behavioral therapy focusing on co-occurring PTSD and substance use disorder, harm reduction, and crisis intervention What might it look like to build models of care for alcohol abuse mind?Models that recognize the interconnectedness of social marginalization and alcohol abuse instead of pathologizing alcoholism?That commemorate the small victories of survival in a deeply homophobic world?That to accept and even celebrate that sometimes, you have to hide parts of yourself?(para.15)