Ryan E. Flinn, PhD, co-director, Mountain Plains ATTC, and Adam Viera, PhD, MPH, co-director, Peer Recovery Center of Excellence

Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+)* Pride Month is celebrated annually in June to acknowledge sexual minority and gender-diverse people and their contributions to this nation (Library of Congress, 2024). Approximately 5.5% of U.S. adults (13.9 million people) identify as LGBT, with significant differences in the proportion of the population identifying as LGBTQ+ across different states, regions, and age groups (Flores & Conron, 2023). 9.5% of youth (ages 13-17) across the nation identify as LGBT (Conron, 2020). Regardless of our age or location, Pride Month can represent many things for LGBTQI+-identified people. For those of us in substance use disorder (SUD) recovery or who support others in recovery, it offers an opportunity to reflect on how we cultivate LGBTQI+ pride in our recovery communities, healthcare and service centers, and larger communities; for those of us who identify as LGBTQI+, we can reflect on how we encourage and support our community members in recovery. The origins of the Pride celebration date back to 1969, in the context of the Stonewall Uprising, as LGBTQI+-identified people of color engaged in protest to create change (Tandon & Rao, 2021). Addressing substance use disorder disparities among LGBTQI+ people will require further change in 2024 and beyond.

LGBTQ I+ Behavioral Health Equity
Health equity is a state in which “everyone has a fair and just opportunity to be as healthy as possible” (Braveman, 2022). Progress toward achieving health equity is measured and monitored through population health research, involving multidisciplinary and multilevel examinations of the prevalence, causes, and consequences of disparities in health conditions, including SUDs (Beck et al., 2024). Multiple studies have demonstrated that LGBTQI+-identified people report substance misuse, substance use consequences, and are diagnosed with SUDs at rates significantly higher than cisgender and heterosexual people (Bränström & Pachankis, 2018; Day et al., 2017; Hughto et al., 2021; McCabe et al., 2013, 2022). Subgroup differences within the LGBTQI+ population in substance use exist (e.g., between cisgender and nonbinary people relative to transgender people; Cascalheira et al., 2023). Experiences of minority stress (Meyer, 2003), such as discrimination, also explain differences between LGBTQI+ people in terms of substance misuse and related mental health concerns (Dyar et al., 2020, 2022; Katz-Wise et al., 2021; Lee et al., 2016; McCabe et al., 2010). These studies suggest that LGBTQI+ people use substances, in part, to cope with the unique stressors they encounter from others in their environment (e.g., bullying, abuse, violence, rejection), who act in harmful ways because they disapprove of LGBTQI+ people’s sexual orientations and gender identities and expressions. Thus, effective treatment must consider LGBTQI+ patients’ experiences of minority stress and address LGBTQI+ patients’ SUDs and related mental health concerns in an affirming and responsive manner (Hughto et al., 2021). This requires treatment providers and recovery support specialists to recognize that SUD recovery, and LGBTQ+ behavioral health equity, is forestalled by unchecked experiences of minority stress (Burger & Pachankis, 2024), which LGBTQ+ people face outside of and within treatment settings and recovery communities.

LGBTQI+ Experiences in Treatment and Recovery
A large study of adults who identify as being in SUD recovery suggests over 11% of the US recovery population identify as sexual minorities (Haik et al., 2022) and a recent study found that sexual minority people utilize recovery community centers in ways that are similar to heterosexuals (Bernier et al., 2024). Yet research suggests that the experiences of LGBTQI+ people in recovery communities can be mixed. For instance, LGBTQ+ people who participate in Twelve Step recovery groups reported forming beneficial connections with other Twelve Step members but also indicate experience bullying, marginalization, and even violence in some meetings (McGeough et al., 2023). LGBTQI+ people who have sought professional SUD treatment services have also reported witnessing and experiencing a range of negative and hurtful behaviors from peers in recovery and even from treatment staff, including “name-calling, denial of services, misgendering, lack of intervention in peer bullying, and assumptions about participants’ sexuality” (Paschen-Wolff et al., 2024). These experiences were reported as distressing, and triggering a desire to use substances to cope, yet LGBTQI+ people also identify having a number of valuable experiences in treatment such as forming relationships with other LGBTQI+ peers in recovery, witnessing openly LGBTQI+ treatment staff advocating for equity, and receiving treatment services that were holistic in nature and responsive to their unique needs as LGBTQI+ people (Paschen-Wolff et al., 2024). Finally, research has also documented efforts to make recovery housing more inclusive and responsive to the needs of LGBTQ+ people (Mericle, Carrico, et al., 2019; Mericle et al., 2020; Mericle, Hemberg, et al., 2019). These trends in designing LGBTQI+-affirming spaces for SUD recovery will require continued support and investment from the LGBTQ+ and recovery communities, and effective allyship from providers.

Effective Allyship for LGBTQI+ People in Recovery
There are a number of actions you can take – whether you identify as LGBTQI+, in recovery, both, or neither – to support LGBTQI+ people in recovery and advance LGBTQI+ behavioral health equity.

1. Study to increase your awareness, knowledge, and skills in working with LGBTQI+ people. Many resources exist which can support your increased awareness and knowledge of issues impacting LGBTQI+ people and enhance your skills in providing effective services to this population. In addition to offerings by regional ATTCs and other TTCs, SAMHSA maintains a page of resources to support your knowledge about LGBTQI+ people. The Center of Excellence on LGBTQ+ Behavioral Health Equity serves as a hub for training and technical assistance related to LGBTQI+ people. Nonprofit organizations such as The Trevor Project and Faces & Voices of Recovery offer resources dedicated to LGBTQI+ people. Professional organizations, such as the American Psychological Association, offer resources and opportunities for collaboration and community. Other organizations focused on LGBTQI+ health include the Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies and GLMA: Health Professionals Advancing LGBTQ+ Equality.
2. Recognize and celebrate LGBTQI+ people’s strengths and resources. LGBTQI+ people utilize their cultural strengths and resources to overcome prejudice, discrimination, and structural stigma (e.g., heterosexism, cissexism). Amid times of struggle (e.g., COVID-19 pandemic) LGBTQ+ people identify their strengths to include engagement in activism; being authentic, proud, and visible; engaging in strategies to enhance collective and intergenerational resilience; attending to their mental health; and supporting others in their communities, including those experiencing multiple forms of marginalization (Abreu et al., 2023). LGBTQ+ communities of color provide their members with safety, acceptance, support, and access to shared resources (Hudson & Romanelli, 2019). Transgender youth adults of color identify their use of creativity to support identity development and community resilience (Pease et al., 2024). You can name and celebrate LGBTQI+ people’s strengths as you support them in SUD recovery.
3. Advocate to change policies and procedures that perpetuate minority stress. Relatively simple changes can be taken by healthcare providers and healthcare systems to welcome LGBTQI+ patients. Recovery-focused settings, such as recovery housing, can also be designed to be affirming and supportive of LGBTQI+ people’s identities (Mericle et al., 2019). All of us can affirm the importance of LGBTI+ community organizations, events, and program, which research indicates may be protective against substance use in LGBTQI+ youth (Watson et al., 2020), and support the continued operation of these programs and events in our communities.
4. Support and participate in research and evaluation to increase evidence-based interventions for LGBTQI+ people. Despite the need for SUD services, LGBTQI-specific SUD interventions are few (Kidd et al., 2022). Additionally, most of what is known about SUD treatment for sexual and gender minorities are based on studies of cisgender, sexual minority (e.g., gay, bisexual) men (Kidd et al., 2022). Healthcare systems can partner with research and evaluation experts to collect high-quality information on sexual orientation, gender identity, gender expression, and health service utilization and health outcomes among LGBTQI+ patients. More research is needed which utilizes an intersectional lens to consider LGBTQI+ people’s needs for SUD prevention, treatment, and recovery support services
5. Be patient. You will not undo the effects of centuries of homophobia, transphobia, and heterocentrism overnight. Mistrust of health and social services remains an understandable reaction by LGBTQI+ people given the pathologization of their identities by medical and mental health professionals (Marrow, 2023) and experiences of discrimination they have faced in seeking care (Casey et al., 2019; Henriquez et al., 2021; Howard et al., 2019). The creation of LGBTQI+ safe spaces require allowing the time and space for LGBTQI+ individuals to judge for themselves when and how services are acceptable for their use and who is most appropriate to deliver those services. Your reputation as a healthcare or social service provider or organization matters and is built over time.
   

Conclusion
By recognizing and affirming the importance of Pride Month and using this time to reflect on how to better support LGBTQI+ people living with SUDs and other mental health disorders, everyone can contribute to increasing LGBTQI+ behavioral health equity and serving as effective allies to LGBTQI+ people in recovery. Reach out to your regional SAMHSA-funded Addiction Technology Transfer Center, the SAMHSA-funded Peer Recovery Center of Excellence, and the SAMHSA-funded Center of Excellence on LGBTQI+ Behavioral Health Equity for further support in implementing LGBTQI+ affirming practices, policies, and procedures in your treatment or service setting.

*The authors of this article have chosen to use the acronym LGBTQI+ since it is consistent with SAMHSA’s Office of Behavioral Health Equity. The authors also note the omission of two-spirit as an identity that is often included within the acronym. In specific instances where studies are being cited, the acronym used matches what used in the study.

Author Biographies
Ryan E. Flinn, PhD, is an Assistant Professor at the University of North Dakota. Their scholarship aims to address the syndemic of trauma, substance use, and legal system involvement by promoting mental health and substance use disorder recovery. They currently co-direct the SAMHSA-funded Mountain Plains Addiction Technology Transfer Center (Region 8) and direct Region 8’s Opioid Response Network - Technical Assistance team.

Adam Viera, PhD, MPH, is a Research Assistant Professor with the University of Missouri Kansas City, serving as a director with the Collaborative Center to Advance Health Services. In this role, he acts as the co-director of the SAMHSA-funded Peer Recovery Center of Excellence. His long-term goals are to continue to build the selection of evidence-based harm reduction and recovery support interventions to address substance use and related health issues and to support their implementation across the United States.

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