The Impact of Substance Use-Related Stigma on Help-Seeking Among People Who Identify As LGBTQ: A Systematic Review

Background and Purpose: Problematic substance use is a global public health concern and one of the most stigmatized behaviors compared with other mental or physical problems. Despite high rates of substance use and related consequences, rates of treatment-seeking (e.g., help-seeking) remain low. Substance use-related stigma contributes to health inequities among people with Substance Use Disorders (SUDs), but this could be more challenging among those with intersecting stigmatized behaviors such as those who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ). To date, little is known about the influence of substance use-related stigma on help-seeking behavior among people who identify as LGBTQ. Thus, this systematic review aims to review the literature in this critical area to inform and improve SUD treatment access for the LGBTQ community. Methods: Three search strategies were used to search the literature: 1) electronic database search (Social Work abstracts, SocINDEX with full text, Sociological collection, PsycINFO, Psychology and behavioral sciences collection, MEDLINE); 2) review of reference lists of included papers; and 3) grey literature search. Eligible studies were included if peer-reviewed, in English, published between 2000-2019, had a focus on substance use, stigma, help-seeking behaviors, LGBTQ population, and a treatment study setting. Results: After removing duplicates (n=148/389), eight were deemed relevant and eligible for full-text review and six were included after full-text review (all published since 2015). The majority of studies were conducted in the United States (83%), with one study conducted in Canada. The sample size varied substantially, ranging from 14-11,811. Four studies (67%) focused on adults and two studies focused on youth. Target groups also varied based on gender/sexual minority (GSM, 33%), transgender (33%), lesbian (17%), and gay/bisexual (17%). The majority of studies (67%) were not focused on specific types of substances and the remaining studies focused on alcohol use. The Stigma Framework was used by most studies (67%), which included enacted stigma, anticipated stigma, and internalized stigma. Overall, findings revealed that stigma related to substance use and having been refused for treatment in the past due to sexual minority identity (enacted stigma) were significantly associated with avoidance of help-seeking. Secondly, increased substance use as a coping strategy was associated with gender minority stress (e.g., fear of being discriminated against during treatment due to sexual identity). Delays in both needed and preventive care (anticipated stigma) were related to increased substance use. Additionally, increased enacted stigma on sexual minority identity (e.g., others’ homophobic and transphobic comments/attitudes, being sexually assaulted and/or socially isolated in the treatment facility) was directly associated with early termination of SUD treatment. In contrast, participants who shared positive treatment experiences and/or remained in the treatment program reported being respected and accepted by facility staff and other clients. Conclusions and Implications: This review highlights the relationship between substance use-related stigma and help-seeking behavior in the LGBTQ population, and demonstrates the importance of accepting and respecting diverse individuals in SUD treatment. These findings emphasize the need for the availability of appropriate gender groups and establishing anti-stigma policies and programs in SUD treatment.