

































COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   45   

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

KATE ORCHARD



46  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

"SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD"

ABSTRACT

According to the National Institute on Drug Abuse, members of the 
LGBTQIA+ community are disproportionately impacted by problematic 
substance use (National Institute on Drug Abuse, 2020). Despite this 
well-documented reality, there is still limited funding and access to 
Z\IZ[HUJL�\ZL�[YLH[TLU[�MVY�X\LLY�HUK�[YHUZ�WLVWSL��;OPZ�L_WSVYH[VY`�
paper surveys the literature on the prevalence of substance use in 
the LGBTQIA+ community in the United States (US), highlighting 
the historical and cultural realities leading to this trend within the 
context of the minority stress model. The article then outlines a path 
forward, suggesting the best treatment models for social workers in 
[OL�ÄLSK��:\NNLZ[PVUZ�PUJS\KL�PU[LNYH[LK�OLHS[OJHYL��[YH\TH�PUMVYTLK��
3.);80(��ZWLJPÄJ�[YLH[TLU[�TVKLSZ��JVNUP[P]L�ILOH]PVYHS�[OLYHW`�
focusing on co-occurring Post-Traumatic Stress Disorder (PTSD) and 
substance use disorder, harm reduction, and crisis intervention outside 
of policing.

2L`^VYKZ!�Z\IZ[HUJL�\ZL�[YLH[TLU[��3.);80(���[YHUZ�HɉYTPUN�
healthcare, minority stress model, integrated behavioral healthcare,  
crisis intervention



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   47   

KATE ORCHARD

In 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, 
�!�����;OL�]VPJL�JVU[PU\LZ!�	;OPZ�Z����JVU[PU\LZ�[V�RLLW�)SHJR�WLVWSL��
poor people, gay people, sick people, to keep us, punished for our 
ULLK	��)Y\QHZ�>VYSK����� ���!�����(�WSH`LY�VU�[OL�ZVJJLY�ÄLSK�Z\KKLUS`�
looks dizzy, and their friends run over to help. The voice reminds 
]PL^LYZ!�	*HSS�`V\Y�MYPLUKZ�PM�`V\�YL�\ZPUN�P[�HSVUL��*HYY`�MLU[HU`S�Z[YPWZ�
with you. Give them to your loved ones. Help them use them. When 
`V\�YL�V\[�[OLYL��JOLJR�[V�ZLL�[OH[�ZVTLVUL�VU�[OL�Z\I^H`�VY�ZPKL^HSR�
PZ�IYLH[OPUN	��)Y\QHZ�>VYSK����� ���!����

According to the National Institute on Drug Abuse (2020), LGBTQIA+ 
PUKP]PK\HSZ�HYL�TVYL�SPRLS`�[V�Z\ɈLY�MYVT�Z\IZ[HUJL�\ZL�KPZVYKLYZ�
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 
Z[YLZZ�TVKLS��;OL�THYNPUHSPaH[PVU�VM�X\LLY�HUK�[YHUZ�WVW\SH[PVUZ�SLHKZ�
[V�TPUVYP[`�Z[YLZZ��^OPJO�PZ�H�[OLVYL[PJHS�JVUJLW[�KLÄULK�I`�4L`LY�
(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.

.P]LU�[OL�PUZ\ɉJPLU[�YLZLHYJO�HUK�SHJR�VM�HWWYVWYPH[L�ZLY]PJLZ�MVY�
LGBTQIA+ individuals struggling with substance use, this paper argues 



48  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

that treatment approaches must evolve. Suggested approaches include 
PU[LNYH[LK�ILOH]PVYHS�OLHS[OJHYL��[YH\TH�PUMVYTLK�3.);80(��ZWLJPÄJ�
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 
3.);80(��PUKP]PK\HSZ�HUK�MVZ[LY�TVYL�PUJS\ZP]L�HUK�LX\P[HISL�JHYL�

METHODS & LIMITATIONS

Research for this article includes meta-analysis and thematic analysis of 
various sources from databases including Columbia University Library 
6USPUL�HUK�7\I4LK��;OL�MVSSV^PUN�ZLHYJO�[LYTZ�^LYL�\ZLK!�¸Z\IZ[HUJL�
\ZL�¹�¸Z\IZ[HUJL�\ZL�KPZVYKLY�¹�¸[YHUZ�HɉYTPUN�OLHS[OJHYL�¹�¸PU[LNYH[LK�
behavioral healthcare,” “substance use treatment,” “crisis intervention,” 
“LGBTQIA+ people of color,” “harm reduction,” and “minority stress 
TVKLS�¹�:V\YJLZ�PUJS\KL�Ä]L�VIZLY]H[PVUHS�Z[\KPLZ��MV\Y�TL[H�HUHS`ZLZ��
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 peer-
reviewed 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 

"SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD"



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   49   

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 
)LYN����� ���:WLJPÄJHSS �̀�KH[H�HIV\[�[YHUZ�PUKP]PK\HSZ��LZWLJPHSS`�[YHUZ�
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 
Z\IZ[HUJL��VY�PZ�P[�[OL�JHNL&	��+LS�*HZ[PSSV��������� !�����

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 
Z[YLZZ�TVKLS����!�����+LS�*HZ[PSSV��������L_WSHPUZ�[OH[�^OLU�OLHS[OJHYL�
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 
TVYL�SPRLS`�[V�ZJYLLU�MVY�HUK�TVUP[VY�OLHS[O�PZZ\LZ��)\[�MVY�THU`�X\LLY�
and trans people, that is a luxury. While healthcare spaces have not 

KATE ORCHARD



50  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

always provided a safe space for the LGBTQIA+ community, bars and 
clubs have always been a central part of the history of the LGBTQIA+ 
TV]LTLU[��=HYLLK�
�4LUKVaH����� ���:V�T\JO�VM�X\LLY�J\S[\YL�JLU[LYZ�
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). 

(KKP[PVUHSS �̀�4HSSVU��������ÄUKZ�[OH[�SLZIPHUZ�TH`�IL�WHY[PJ\SHYS`�H[�YPZR�
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" 
�W�������>OPSL�4HSSVU�Z�L_WSHUH[PVU�JVU[HPUZ�[PUNLZ�VM�ZL_PZT�HUK�
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 
JVTT\UP[ �̀�HUV[OLY�LWPKLTPJ��/0=�(0+:��OHZ�THKL�H�ZPNUPÄJHU[�THYR�
on LGBTQIA+ history. Much work has been done around the trans 
population, for example, in the context of HIV risk due to the high 
WYL]HSLUJL�VM�YPZR�PU�[OH[�NYV\W��MVJ\ZPUN�VU�/0=�(0+:�HUK�Z\IZ[HUJL�
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 

"SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD"



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   51   

the most common risk factors for substance use include experiences of 
victimization, stress, and housing insecurity (Goldbach et al., 2014). Risk 
MHJ[VYZ�Z\JO�HZ�[OLZL��PU�HKKP[PVU�[V�J\S[\YHS�HUK�OPZ[VYPJHS�PUÅ\LUJLZ�VU�
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 

:\Y]L`Z�MYVT�[OL�50+(��������JVUÄYT�Z\IZ[HUJL�\ZL�PZ�HU�PZZ\L�[OH[�
KPZWYVWVY[PVUH[LS`�PTWHJ[Z�[OL�X\LLY�HUK�[YHUZ�JVTT\UP[PLZ��/V^L]LY��
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 
Z[YH[PÄJH[PVU�^P[OPU�[OL�TPUVYP[`�Z[YLZZ�TVKLS��^OPJO�WVZ[\SH[LZ�[OH[�
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 

KATE ORCHARD



52  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

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+ 
JVTT\UP[`�YLX\PYL�K\L�KPSPNLUJL�HUK�U\HUJL�YLNHYKPUN�YLZLHYJO��-VY�
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). 

Eisenburg et al.’s (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 

"SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD"



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   53   

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 (2022 National 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 trauma-
informed, community-based, holistic, person-in-environment centered 
treatment modalities for substance use in LGBTQIA+ populations. 
/V^L]LY��VUS`�����VM�Z\IZ[HUJL�\ZL�[YLH[TLU[�JLU[LYZ�WYV]PKL�X\LLY�
HUK�[YHUZ�ZWLJPÄJ�WYVNYHTTPUN��>PSSPHTZ�
�-PZO���������7S\Z��P[�JHU�IL�
L]LU�TVYL�KPɉJ\S[�V\[ZPKL�VM�SHYNL�TL[YVWVSP[HU�HYLHZ�Z\JO�HZ�[OVZL�PU�
5L^�@VYR�HUK�*HSPMVYUPH�[V�ÄUK�Z\JO�WYVNYHTZ��:LUYLPJO���������+LZWP[L�
the clear need for these services, culturally competent substance use 
treatment remains scarce (Williams & Fish, 2020).

+H[H�PZ�SHJRPUN�VU�^OL[OLY�HJJLZZ�[V�X\LLY�HUK�[YHUZ�ZWLJPÄJ�[YLH[TLU[�
modalities has improved treatment outcomes compared to programming 
[OH[�PZ�UV[�ZWLJPÄJ�MVY�[OL�3.);80(��WVW\SH[PVU��:LUYLPJO���������6UL�
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 
Z[YLZZ�MHJ[VYZ�^OPSL�PU�H�X\LLY�ZWLJPÄJ�[YLH[TLU[�MHJPSP[`�SLK�[V�WVZP[P]L�
V\[JVTLZ�HJJVYKPUN�[V�X\HSP[H[P]L�HUHS`ZPZ��Z\NNLZ[PUN�[OH[�YLWSPJHZ�
VM�Z\JO�TVKLSZ�TPNO[�IL�ILULÄJPHS��(KKP[PVUHS�L]PKLUJL�ZOV^Z�[OH[�
LGBTQIA+ individuals have lower completion and abstinence rates on 
average in substance use treatment than their cisgender, heterosexual 
WLLYZ��K\L�[V�H�SHJR�VM�HɉYTH[PVU�VM�[OLPY�ZL_\HS�VYPLU[H[PVU�PU�[YLH[TLU[�
�:LUYLPJO����� ���=HYPV\Z�HZWLJ[Z�VM�[OL�X\LLY�HUK�[YHUZ�L_WLYPLUJL�
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 

KATE ORCHARD



54  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

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), 
OLHS[OJHYL�WYV]PKLYZ�ZOV\SK�LUJV\YHNL�ZLLRPUN�V\[�3.);80(��ZWLJPÄJ�
groups.

0U�H�ÄYZ[�WLYZVU�HJJV\U[��1HPU����� ��KLZJYPILZ�[OLPY�L_WLYPLUJL�PU�
H�8\LLY�7LVWSL�VM�*VSVY�((�TLL[PUN�PU�[OL�:HU�-YHUJPZJV�)H`�(YLH!�
“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 
IHIISPUN�VM�JOPSKYLU��HUK�PU�[OL�JSHZWLK�OHUKZ�VM�X\LLY�WLVWSL�JOVVZPUN�
[V�ZH]L�LHJO�V[OLY¹��WHYH�������(�Z[\K`�PU�)YP[PZO�*VS\TIPH�YLÅLJ[LK�
[OL�ZLU[PTLU[��ÄUKPUN�[OH[�X\LLY�HUK�[YHUZ�TLU�[OV\NO[�[OH[�L]LU�
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 
JOHYNLZ�K\L�[V�\ZPUN�ZLY]PJLZ��-VY�L_HTWSL��`V\UN�X\LLY�HUK�[YHUZ�TLU�
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 
X\LLY�HUK�[YHUZ�WLVWSL�OH]L�OHK�H�SVUN�OPZ[VY`�VM�Z[Y\NNSL�^P[O�WVSPJL�
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 
PU�[OL�ÄLSK�ZOV\SK�JVUZPKLY�[OLZL�MHJ[Z�^OLU�Z[YP]PUN�[V�JYLH[L�TVYL�
accessible substance-use services.

BEST TREATMENT PRACTICES

;OL�MVSSV^PUN�ZLJ[PVU�WYLZLU[Z�H�JHZL�MVY�Ä]L�TVKLSZ�VM�JHYL�[OH[�
have been shown to improve treatment utilization and outcomes 
I`�JVUZPKLYPUN�Z[H[PZ[PJHS�KPɈLYLUJLZ�PU�Z\IZ[HUJL�\ZL�HTVUN�[OL�
LGBTQIA+ population, historical and cultural themes of the people, 

"SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD"



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   55   

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 
HTVUN�X\LLY�HUK�[YHUZ�WLVWSL��HKVW[PUN�OHYT�YLK\J[PVU�Z[YH[LNPLZ�
that account for cultural realities within the LGBTQIA+ community and 
putting into action means of crisis de-escalation outside of policing 
Z`Z[LTZ�HYL�YLX\PYLK�HJ[PVUZ�

BEHAVIORAL HEALTH INTEGRATION

According to the Integration Academy, "Integrated behavioral health 
care blends care in one setting for medical conditions and related 
ILOH]PVYHS�OLHS[O�MHJ[VYZ�[OH[�HɈLJ[�OLHS[O�HUK�^LSS�ILPUN¹��¸>OH[�PZ�
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, 
^OPJO�PZ�ZPNUPÄJHU[�NP]LU�JOHSSLUNLZ�^P[O�HJJLZZ�PU�[OL�[YHUZ�JVTT\UP[ �̀�
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 
HUK�ZLY]PJLZ�PU�3.);80(��ZWLJPÄJ�PU[LNYH[LK�ILOH]PVYHS�OLHS[OJHYL�PZ�
imperative in order to reduce the disproportionate risk of substance use. 
Fenway Health, a Boston-based LGBTQIA+-focused healthcare center, 
PZ�H�SLHKLY�PU�[OPZ�ÄLSK��-LU^H`�/LHS[O�WZ`JOPH[YPZ[�+Y��2L\YVNOSPHU��U�K����
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 
HɉYTZ�[OH[�[YLH[PUN�VWPVPK�\ZL�HUK�WZ`JOPH[YPJ�KPZVYKLYZ�ZPT\S[HULV\ZS`�
has positively impacted outcomes.

KATE ORCHARD



56  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

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 
3.);80(��JVTT\UP[`�ZWLJPÄJHSS`��2L\YVNOSPHU��U�K����*SPUPJPHUZ�ULLK�
to be aware of the minority stress model and implement a trauma-
informed framework that centers on the realities faced by people 
impacted by minority stress and that highlights the strengths of the 
3.);80(��JVTT\UP[`��2L\YVNOSPHU�L[�HS����������.P]LU�[OH[�X\LLY�HUK�
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

3PRL�PU�+Y��+LS�*HZ[PSSV�Z��������Z[VY`�HIV\[�[OL�SVULS`�YH[�PU�[OL�JHNL��
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. 
:\WWVY[PUN�PUKP]PK\HSZ�PTWHJ[LK�I`�TPUVYP[`�Z[YLZZ�HSZV�YLX\PYLZ�ILPUN�
[YH\TH�PUMVYTLK��0U[LNYH[LK�[YLH[TLU[�MVY�WLVWSL�^OV�OH]L�Z\ɈLY�
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 

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COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   57   

^OV�HYL�/0=�WVZP[P]L��;OL�Z[\K`�PTWYV]LK�HSS�[OYLL�V\[JVTL�TLHZ\YLZ!�
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

/HYT�9LK\J[PVU�0U[LYUH[PVUHS�KLÄULZ�OHYT�YLK\J[PVU�HZ�	WVSPJPLZ��
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 rights-
based 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 
JVTT\UP[PLZ�OH]L�OPZ[VYPJHSS`�SLK�LɈVY[Z�[V^HYK�OHYT�YLK\J[PVU��9PWSL`�
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 
Z[PJRLY�[OH[�ZH`Z�	Z\JR�K�����JHYY`�5HYJHU	��2\^HIHYH�)SHUJOHYK��������
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 
^OVSL�RP[�^HZ�Z\WLY�]PIYHU[�HUK�KPKU�[�SVVR�ZV�JSPUPJHS&�>OH[�PM�P[�^HZ�
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 
(WWHSHJOPH��[OLYL�PZ�UVIVK`�PU�[OL�YLNPVU�^OV�KVLZU�[�WSH`�H�YVSL	�
�>VYSSL �̀�U�K���WHYH������6U�X\LLYULZZ��[OL`�Z[H[L��	(Z�PM�ILPUN�X\LLY�PU�
Y\YHS�YLNPVUZ�PZU�[�PZVSH[PUN�HUK�VZ[YHJPaPUN�LUV\NO��[OL�HKKP[PVU�VM�[Y`PUN�

KATE ORCHARD



58  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

to recover only further exacerbates these experiences" (Worlley, n.d., 
WHYH������-VY�X\LLY�JVTT\UP[PLZ��[OL�NV]LYUTLU[�OHZ�ILLU�\UZ\JJLZZM\S�
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 

;OLYL�PZ�Z[PSS�SPTP[LK�NV]LYUTLU[�M\UKPUN�MVY�3.);80(��HɉYTH[P]L�
substance use-related services and higher substance user rates, help-
seeking 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"



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   59   

are certainly needed to support this vital issue, service models must 
additionally be rethought to best support LGBTQIA+ communities. 
,ɈLJ[P]L�TVKLSZ�^OPJO�TH`�YLK\JL�[OL�KL[YPTLU[HS�LɈLJ[Z�VM�TPUVYP[`�
stress on those in the LGBTQIA+ community who use drugs include 
PU[LNYH[LK�OLHS[OJHYL��[YH\TH�PUMVYTLK��3.);80(��ZWLJPÄJ�[YLH[TLU[�
models, cognitive behavioral therapy focusing on co-occurring PTSD 
and substance use disorder, harm reduction, and crisis intervention 
V\[ZPKL�VM�WVSPJPUN��0U�[OL�^VYKZ�VM�1HPU����� �!�

What might it look like to build models of care for alcohol abuse 
[OH[��PUZ[LHK�VM�Q\Z[�PUJS\KPUN�X\LLY�WLVWSL��ILNPU�^P[O�\Z�PU�
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)

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KATE ORCHARD



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"SMALL VICTORIES OF SURVIVAL IN A DEEPLY HOMOPHOBIC WORLD"


