Psychiatric Annals

CME Article 

Compounded Stigma in LGBTQ+ People: A Framework for Understanding the Relationship Between Substance Use Disorders, Mental Illness, Trauma, and Sexual Minority Status

Julio I. Rojas, PhD, LADC; Raina Leckie, LCSW; Erin M. Hawks, PhD; Jessica Holster, PhD; Maria del Carmen Trapp, PhD; Britta K. Ostermeyer, MD, MBA, FAPA

Abstract

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) people are sexual minorities and have higher rates of substance use disorders, mental illness, and trauma, which translates into compounded stigma for them. Compounded stigma is the additive and cumulative impact of belonging to one, or several, marginalized groups (eg, racial/ethnic minority, LGBTQ+) and also suffering from addiction, mental illness, and/or trauma. There are important interactions among these comorbidities, trauma, and sexual minority status that affect patient behavior, treatment planning, and treatment outcomes. This article presents a Venn diagram as a helpful clinical tool to visually illustrate the complex interactions of mental illness, addictions, trauma, and LGBTQ+ minority status for both health care providers and patients. Having an awareness and understanding of these important interactions can enhance patient rapport and treatment experience as well as treatment planning. [Psychiatr Ann. 2019;49(10):446–452.]

Abstract

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) people are sexual minorities and have higher rates of substance use disorders, mental illness, and trauma, which translates into compounded stigma for them. Compounded stigma is the additive and cumulative impact of belonging to one, or several, marginalized groups (eg, racial/ethnic minority, LGBTQ+) and also suffering from addiction, mental illness, and/or trauma. There are important interactions among these comorbidities, trauma, and sexual minority status that affect patient behavior, treatment planning, and treatment outcomes. This article presents a Venn diagram as a helpful clinical tool to visually illustrate the complex interactions of mental illness, addictions, trauma, and LGBTQ+ minority status for both health care providers and patients. Having an awareness and understanding of these important interactions can enhance patient rapport and treatment experience as well as treatment planning. [Psychiatr Ann. 2019;49(10):446–452.]

Substance use disorders commonly co-occur with psychiatric conditions and trauma, resulting in a number of challenges related to diagnosis, treatment, and patient retention. Both the challenges and unique needs are greatly magnified among lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) people.1 For this reason, it is important to be generally aware of these challenges and the clinical adjustments required to effectively work with LGBTQ+ people who present for treatment of substance use disorders and related comorbidities.

One such challenge, stigma, is commonly cited as a significant negative factor when discussing patient experiences and disparities in behavioral health care settings.2 The article by Hawks et al.3 in this issue outlines two conceptual frameworks for understanding stigma specific to LGBTQ+ people (the minority stress model and the socio-ecological model) from an intrapersonal and structural perspective.

Another perspective on stigma relates to an additive and cumulative process related to the nature of brain disorders. People with behavioral health disorders experience significant stigma in having brain-based conditions and having several types of behavioral disorders, such as addiction and depression, creates additive effects beyond the stigma related to membership in a sexual minority group. Conversely, behavioral health care providers may have deeply ingrained beliefs about mental illness and addiction, beyond those of sexual minority status, which can deleteriously affect patient encounters. This complex layering of stigmatize illness (compounded by stigma) may not be fully understood or appreciated by clinicians. However, the obstacles it poses for both clinicians and patients must be better understood if we intend on achieving more culturally sensitive and affirming experiences for our patients.

In our collective clinical experience, a key challenge in working with addiction, mental illness, and trauma is the concept of compounded stigma. Compounded stigma is a term created by the lead author to underscore the complex challenges LGBTQ+ people face related to sexual minority group membership and living with brain disorders such as addiction, mental illness, and trauma.1 Brain disorders and the treatment of those who suffer from them have a highly concerning history in the United States. Although we are making progress to eliminate stigma with the help of neuroscience and best practices protocols, stigma toward brain disorders remains deeply rooted and destructive.2

In this article, we propose two definitions to help the reader better understand stigma:

  • Behavioral health stigma: one's internalized negative self-view and sense of defectiveness related to having addiction, mental illness, and trauma (each with its own stigma) because of societal beliefs about the role of personal control, will power, decision-making, responsibility, and normalcy.
  • Compounded stigma: the additive and cumulative impact of being a member of one, or several, marginalized groups (eg, racial/ethnic minority, LGBTQ+) and suffering from addiction, mental illness, and/or trauma, each of which carries its own stigma.

Venn Diagram

The lead author's experience is that visually framing the clinical discussion using a Venn diagram helps patients understand how addiction, mental illness, and trauma inter-relate.4 For this article, a Venn diagram was created to explore the relationship among addiction, mental illness, trauma, LGBTQ+ child and adult challenges, and compounded stigma among people who identify as LGBTQ+ (Figure 1).

Compound stigma in lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) people. The complex interaction between substance addiction, psychiatric illness, trauma, and LGBTQ+ challenges. Adapted with permission of Rojas4 and The Board of Regents of the University of Oklahoma. © Board of Regents of the University of Oklahoma.

Figure 1.

Compound stigma in lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) people. The complex interaction between substance addiction, psychiatric illness, trauma, and LGBTQ+ challenges. Adapted with permission of Rojas4 and The Board of Regents of the University of Oklahoma. © Board of Regents of the University of Oklahoma.

Each circle in the Venn diagram is comprised of several parts. These components can be considered the unique aspects and the shared aspects (overlapping areas labeled A, B, C, D) that represent how the addiction, mental illness, trauma, and LGBTQ+ challenges may interact and manifest in the patient's life. Areas A, B, C, and D interact in a bi-directional fashion and can co-mingle at a level outside of the patient's awareness. For example, Area A represents the relationship between addiction and mental illness. A common issue in this dynamic is self-medication of psychiatric symptoms. Addictive thinking tells the patient they need the substance to feel better, while psychiatric illness alters thinking by telling the patient that things are hopeless for them and why bother with sobriety. Another common example is the use of alcohol and drugs among people with trauma to numb emotions and cope with traumatic symptoms. Lastly, the isolation of trauma and LGBTQ+ challenges can contribute to depression in terms of hopelessness. Note that areas A, B, C, and D each contribute to E (compounded stigma in LGBTQ+ patients), making it a prominent and central theme of therapy (eg, shame, self-rejection, helplessness, hopelessness).

The dotted line around the Venn diagram denotes the defense mechanisms, personality features, and personality disorders that are described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).5 Within marginalized groups, this dotted line can be viewed as defenses developed or adopted to counteract a harsh, oppressive, condemning environment by interpersonal withdrawal and suspicion, strongly protesting/rebelling against it, conflict avoidance, or other defense strategies such as use of humor, internalized homophobia, and staying closeted. This more functional and adaptive view is in contrast to the negative connotation associated with character pathology. The big red arrow denotes the powerful influence of societal messages for being an LGBTQ+ person, addict, and mentally ill person. The smaller green arrow represents intra- and interpersonal strategies to buffer against societal messages and internalized shame. The green arrow could also include environmental conditions such as social support and community connectedness.

Substance Use Disorders in LGBTQ+ Patients

Using the adapted Venn diagram (see Figure 1) as a visual roadmap to frame our discussion of addiction, mental illness, trauma, and LGBTQ+ challenges, we begin with addiction. Behavioral health providers encounter and provide treatment to LGBTQ+ patients with substance use disorders in multiple settings. Despite findings from multiple studies that show higher rates of substance abuse disorders among LGBTQ+ people, they often do not seek treatment or are less forthcoming with their substance use during appointments compared to their cisgender heterosexual peers due to stigma, prejudice, and discrimination.6,7

Klein and Nakhai8 noted that sexual minority populations have the highest rates of tobacco, alcohol, and other drug use. A comprehensive guide for working with sexual minorities in substance abuse settings by the Substance Abuse and Mental Health Services Administration noted that compared to the general population, sexual minorities are more likely to use both alcohol and drugs, to have higher rates of substance abuse, and more likely to continue heavy drinking patterns into later adulthood.9 In addition, sexual minorities were less likely to abstain from alcohol and drugs into later adulthood. Also, gay men and lesbians reported greater use of cigarettes, marijuana, and alcohol than the general population.9

Cabaj1 noted that providers with extensive treatment experiences with the LGBTQ+ population estimate an incidence of substance abuse of all types at just shy of one-third. This is in contrast to general population estimates of 10% to 12%. Among LGBTQ+ persons, Cabaj1 found that bisexual people may experience even higher substance abuse rates than their gay men and lesbian counterparts.1

Differences within those who identify as a sexual minority was explored closely by Kerridge et al.10 The authors looked at DSM-5 substance use disorders (SUDs) among sexual minorities (ie, gay/lesbian and bisexual) relative to cisgender heterosexuals and found disparities and increased risk for SUDs among those three groups. Going from heterosexual to gay/lesbian to bisexual, the prevalence across four categories of a substance use disorder (ie, any, alcohol, drug, nicotine) always increased whether examined within the past 12 months or over the course of a lifetime. The increased pattern across the three groups was also noted when comparing men and women within a 12-month period and mostly for lifetime prevalence.

One limitation of the Kerridge et al.10 study was that the SUD group was a catch-all for several types of substances (such as opioids, stimulants, benzodiazepines, hallucinogens, inhalants, and “club” drugs). In addition, severity of the SUD was not measured in terms of mild, moderate, or severe. Assessing addiction severity and controlling for this in future studies is an important component of untangling this complex relationship.

Understanding the reasons behind higher rates of substance abuse among sexual minorities is important. Some have suggested that race/ethnicity, spending time at gay bars or nightclubs, depression, age of onset, societal homophobia, internalized homophobia, and sensation seeking are among the salient factors that account for higher rates of substance use disorders.1 However, in our experience, the higher rates of substance use disorders in LGBTQ+ people could relate to self-medicating of psychiatric illness and traumatic experiences, which occur at higher rates in this population.9,10

Process Addictions

“Process,” or behavioral addictions, are compulsive-like behaviors marked by perceived loss of control, risk, and significant adverse impact on daily functioning.11 Process addictions share neurobiological (ie, dopaminergic neurotransmission) similarities with substance addictions.10 It is also important to note that process addictions co-occur with SUDs in as many as one-third to one-half of patients.

Research is limited on rates within the LGBTQ+ community, although studies support differences and, in several cases, increased risk.11–13 Research is strongest regarding eating disorders; sexual minorities demonstrate higher rates of disordered eating and levels of food addiction symptoms, particularly in men.11,13 Risk may be elevated among those who are transgender (ie, associated with distress experienced as part of body dissatisfaction) and racial/ethnic sexual minorities.13 Studies suggest that (1) lesbian and bisexual females are at an increased risk for binge eating; (2) male and female sexual minorities are at an increased risk for purging, fasting, and extreme dieting; and (3) all LGBTQ+ groups are at an increased risk for abusing diet pills.13

Research regarding other behavioral addictions is scarcer and mixed. To illustrate, Broman and Hakansson12 found that problematic gaming and Internet use, but not problem gambling, may be more common in sexual minorities in a mixed-gender pilot study, hypothesized to be associated with nonstigmatizing features of the online experience. Yet, a higher prevalence of pathological gambling among homosexual and bisexual males was supported in a separate study.14 Internet gaming has also been found to be overrepresented among transgender people.15

Regarding sexual addictions, research involving males within the sexual minority community suggests a higher proportion of homosexual and bisexual males acknowledge more compulsive sexual behaviors than cisgender heterosexual males.14 Further, a separate study found that 16% to 20% of gay men reported compulsive symptoms related to pornography use, with 7% having extreme scores consistent with DSM-5 criteria for compulsive disorders.16

Psychiatric Disorders

Although addiction by itself is hard to treat, it becomes even more challenging when it co-occurs with psychiatric disorders. Current research indicates that sexual minorities experience higher rates of mental health problems, including anxiety, depression, and substance abuse, when compared to their cisgender heterosexual counterparts.6,7

In a meta-analysis of LGBTQ+ people, Meyer17 found that the odds of lifetime mood and anxiety disorders were twice as high for lesbian, gay, and bisexual people compared to cisgender heterosexuals. In a population-based survey, Fredriksen-Goldsen18 found that 31% of LGBTQ+ respondents reported current depression, 24% of LGBTQ+ respondents reported a lifetime diagnosis of an anxiety disorder, and 39% of LGBTQ+ respondents reported a lifetime prevalence of suicidal ideation.

Similar rates of anxiety and depressive disorders among LGBTQ+ people were found in a report by Guasp.19 In this study, Guasp19 found the lifetime prevalence of depression among lesbian and bisexual women to be around 40%, and for gay and bisexual men around 34%. In this same study, the lifetime prevalence of an anxiety disorder was 33% for lesbian/bisexual women and 29% for gay/bisexual men. Kerridge et al.10 found elevated rates at 12 months as well as elevated lifetime rates of major depressive disorder, persistent depressive disorder, panic disorder, agoraphobia, social phobia, generalized anxiety disorder, posttraumatic stress disorder, and borderline and schizotypal personality disorders among gays and lesbians relative to their cisgender heterosexual peers.

Two recent studies found that rates of depression, anxiety, and overall psychological distress were even higher for transgender people, with 48% of transgender participants screening positive for depression when compared to nontransgender women and men.20,21 Nuttbrock et al.22 found a lifetime depression rate of 52%, history of suicidal ideation rate of 53%, suicidal planning rate of 35%, and suicide attempt rate of 28% for transgender women. In a small study of 579 transgender people, Hoshiai et al.23 found comorbidity rates to be 19.1% among male-to-female participants and 12% among female-to-male participants. The lifetime positive history of suicidal ideation and self-mutilation was 76.1% and 31.7%, respectively, among male-to-female participants, and 71.9% and 32.7%, respectively, among female-to-male participants.23

Given that psychiatric disorders commonly co-occur with SUDs, it is important to screen for all psychiatric disorders, educate on the disorder(s), outline a menu of treatment options for each disorder, explore the patient's acceptance and understanding of the condition, discuss in what ways the patient understands how the conditions co-mingle (eg, self-medication of psychiatric symptoms), and formulate a treatment plan that addresses each psychiatric and substance abuse component separately (eg, cognitive-behavioral therapy for depression, assertiveness training for avoidant personality features).

Trauma

Trauma has gotten more attention in the past 2 decades due to the Centers for Disease Control and Prevention and Kaiser Permanente's adverse childhood experiences (ACE) study that was published in 1998.24 This study was the foundation for numerous follow-up studies, which yielded important insights and guidance for enhanced patient care.24

There is a strong relationship between childhood trauma (more broadly defined as experiences such as child abuse, neglect, violence, drug use, mental illness and/or economic challenges in the home, as well as suicide in the family) and both psychological and physical health in adulthood. It appears that even one ACE event is sufficient to dramatically increase propensity toward negative adult medical health, mental illness, and/or addiction outcomes. But with two or more events, the impact becomes even more profound. Of note, this trauma-related negative impact is significantly compounded in adulthood when a patient is also a member of the LGBTQ+ community.25 In many cases, these people experience dual aspects of being stigmatized and marginalized.

Although it has been well established that ACE events provoke mental health issues in adulthood, and that LGBTQ+ people have a higher prevalence of traumatic childhood events, it is important to also recognize the continued poly-victimization that LGBTQ+ members experience even in adulthood. This trauma is further exacerbated by institutional discrimination and traumatization in adulthood.26,27

Personality Disorders in LGBTQ+ People Who are Chemically Dependent

Grant et al.28 reported that 95% of LGBTQ+ patients in a specialized substance abuse program had at least one personality disorder (PD). More specifically, 64.1% had borderline PD, 56.6% had obsessive-compulsive PD, and 49% had avoidant PD; 84.1% had two or more PDs; and 69.7% had three or more PDs. The authors noted that this higher rate may be reflective of the impact of addiction on inter-and intra-personal functioning. They also posited that traumatic experiences may have fueled the development of character pathology. Nonetheless, character pathology is usually associated with a poorer prognosis, negative counter-transference, and a more complicated course of treatment.

Grant et al.29 reported that in a large nationwide sample from 2004, 28.5% of people with a current alcohol use disorder and 47.7% of people with a current drug use disorder also had at least one PD. There were no differences between patients with or without PDs related to their substance use or symptom severity, and both groups had similar past histories of psychiatric hospitalizations, suicide attempts, chemical substance treatment, and legal issues. However, when personality disorders were examined by cluster grouping (ie, A, B, and C) patients with cluster A PD were less likely to abuse methamphetamines and more likely to have comorbid posttraumatic stress disorder; those with cluster B were significantly more likely to have attention-deficit/hyperactivity disorder (ADHD); and those with cluster C were less likely to have ADHD.

Unique developmental challenges in LGBTQ+ patients may give rise to higher rates of PDs, and perhaps substance use may assist in self-medication. In general, certain PDs in chemically dependent patients, such as antisocial PD, place patients at high risk for multiple chemical abuse, high treatment dropout, and poorer treatment outcomes.29 Although Grant et al.29 speculated that PDs may have had little impact on sexual minority patients with severe psychiatric and chemical dependency issues, they did conclude that sexual minority patients with SUDs, in particular, should be carefully screened for PDs, as such comorbidity may have treatment implications.

By recognizing that the origin of character pathology might be rooted in early life wounds, we accept that these patients may have more challenges in developing therapeutic rapport. They may require more empathy, both greater interpersonal flexibility and firmness, and a more adaptive or protective view of personality features and defenses and their necessity in marginalized and stigmatized groups.

Treatment Recommendations

Compounded stigma plays an important key role in the sexual minority patient's experience of addiction, mental illness, trauma, and LGBTQ+ challenges. Compounded stigma also translates into decreased help-seeking, is reinforced by negative experiences in clinical settings due to pervasive homophobia and heterosexism, and leads to premature termination of services. Table 1 and Table 2 provides recommendations for improving the experiences of sexual minority people who seek behavioral health services. Table 1 and Table 2 are philosophically consistent with best-practice resources.2,9

Treatment Recommendations for LGBTQ+ Patients with Addiction, Mental Illness, and Trauma

Table 1:

Treatment Recommendations for LGBTQ+ Patients with Addiction, Mental Illness, and Trauma

Treatment Recommendations for All LGBTQ+ Patients

Table 2:

Treatment Recommendations for All LGBTQ+ Patients

Conclusion

Higher rates of SUDs, mental illness, and trauma in LGBTQ+ people translate into compounded stigma for them and into a complex dynamic that fuels morbidity and mortality. The Venn diagram in Figure 1 can be a helpful clinical tool for illustrating the complex interactions of mental illness, addictions, trauma, and LGBTQ+ minority status for both health providers and patients. Having an awareness and understanding of how compounded stigma impacts help-seeking, disclosure of experiences and symptoms, therapeutic rapport, and treatment planning is critical.

References

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Treatment Recommendations for LGBTQ+ Patients with Addiction, Mental Illness, and Trauma

Areas of Higher Incidence in LQBTQ+ Patients Recommendations
Substance use disorders Regular screening/assessments for substance use disorders Become familiar with addiction services in your community at various levels of care (eg, outpatient, intensive outpatient, daytreatment, residential) Focusing on the disease model of addiction and family history (genetic contribution) can reduce shame/stigma In early sobriety, be mindful of the difficulty in finding safe, sober, and supportive environments that reinforce recovery Recognize that patterns of substance abuse can vary by region and subgroup within the LGBTQ+ community
Process addictions Occur in one-third to one-half of patients who are chemically addicted and share similar neurobiological features Differ from chemical addictions sufficient to seek out specialists (eg, eating disorders)
Mental illness Less likely to be forthcoming with symptoms due to compounded stigma, so an affirming environment is key to buildingrapport
Trauma Screening for adverse childhood event factors and intimate partner violence Provide trauma-informed care
Personality disorders Consider viewing personality features/defenses as mechanism to defend self from societal stigmatization, marginalization, homophobia, heterosexism
Suicide Regular screening/assessment for suicidal ideation

Treatment Recommendations for All LGBTQ+ Patients

<list-item>

■ Use the LGBTQ+ Venn diagram in Figure 1 as a worksheet to create the problem list, clarify consultation needs, identify assessment tools, develop a referral hierarchy, and make note of key factors to address routinely

</list-item><list-item>

■ Focusing on the psychological impactof homophobia and heterosexism can help explain vulnerability to mental health disorders

</list-item><list-item>

■ Ask about compounded stigma. Howdoes your patient feel about having addiction, mental illness, and/or trauma? What experiences have they had with stigma?

</list-item><list-item>

■ When referring out, confirm providers are knowledgeable in LGBTQ+ affirming practices

</list-item><list-item>

■ Consult frequently and refer when outside of your area of expertise

</list-item><list-item>

■ Encourage participation of partner/significant other in treatment

</list-item><list-item>

■ Query about family of origin messages toward LGBTQ+ patients

</list-item><list-item>

■ If applicable, query about “coming out” process and/or experiences with family

</list-item>
Authors

Julio I. Rojas, PhD, LADC, is an Associate Professor and the Director of the ExecuCare Program, Adult Mental Health Division. Raina Leckie, LCSW, is a Clinical Instructor, Adult Mental Health Division. Erin M. Hawks, PhD, is an Assistant Professor, Division of Child & Adolescent Mental Health. Jessica Holster, PhD, is an Assistant Professor, Division of Neuropsychology. Maria del Carmen Trapp, PhD, is an Assistant Professor, Adult Mental Health Division. Britta K. Ostermeyer, MD, MBA, FAPA, is a Practicing Board-Certified Forensic Psychiatrist; the Paul and Ruth Jonas Chair in Mental Health; a Professor and the Chairman; and the Chief of Psychiatry for OU Medicine and the Mental Health Authority of the Oklahoma County Detention Center. All authors are affiliated with the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma College of Medicine and the University of Oklahoma Health Sciences Center.

Address correspondence to Julio I. Rojas, PhD, LADC, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, Oklahoma City, OK 73104; email: julio-rojas@ouhsc.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20190912-01

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