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Reducing the Risk and Prevalence of Cannabis Use Disorder in LGBTQ+ High Schoolers  
Axel Rivera-De Leon, Stanford ’23 

 
 
 
Abstract: Over the past few decades, the nature of cannabis in American society has changed 
dramatically. Cannabis is steadily increasing in potency and making a mainstream entrance into 
our society as it is gradually decriminalized and legalized around the country. With these 
changes comes a need to investigate the effects of the increasing reach of cannabis on 
adolescents. Particularly, high schoolers are at an age when they are slowly gaining autonomy 
and seeking to make adult decisions. Specifically, LGBTQ+ youth face injustice and inequity 
when it comes to housing, schooling, parenting, and medical care; all these factors combine into 
increased risk for cannabis use disorder (CUD) in LGBTQ+ youth. This paper will outline the 
ideal combination of protective factors and reduction of risk factors created through individual-, 
school-, and policy-level interventions that would hopefully reduce the risk and prevalence of 
CUD in LGBTQ+ high schoolers. 
 

Content warning: This paper discusses substance abuse, mental health, and discrimination. 
Readers are advised to take these into account before proceeding.  

 
 
 
 
 
 
 
 
 

 



Introduction 
 In 2021, we find ourselves at a turning point for cannabis legalization, prevalence, and 
normalization in American society. With decriminalization and legalization bills being debated 
and passed in state governments around the United States, cannabis is making a mainstream 
entrance into our society. Along with attitudes about cannabis, cannabis itself is changing. Over 
the past couple of decades, cannabis has decreased in price and increased in accessibility and 
potency from around 9% to 30% THC in the past 3 decades (Amiet et al., 2020). With the 
rapidly changing nature and presence of cannabis in modern society comes a need to assess how 
these changes impact and influence adolescents. 
 Adolescence is a time-period marked by experimentation, a fight for autonomy, and the 
pursuit of peer acceptance and the formation of a group identity (Medoff, Substance Abuse). 
Additionally, the adolescent brain undergoes neurobiological changes that contribute to 
emotional and behavioral changes; the prefrontal cortex, which is responsible for cognitive 
control and impulse inhibition, experiences a decline in serotonin and glucose metabolism. The 
amygdala, which is responsible for emotional processing and motivation, grows during puberty, 
particularly in males. These changing brain regions are also regions associated with addiction. 
(Medoff, Substance Abuse) 

Ultimately, a novel substance introduced into an adolescent’s brain chemistry has the 
potential to take advantage of their developing, manipulable brain. Trying a substance for the 
first time is daring and exhilarating, and this novelty stimulates the release of dopamine (Medoff, 
Substance Abuse). A literature review found stronger acute and chronic effects of regular heavy 
cannabis use during adolescence rather than heavy use during adulthood, suggesting the 
adolescent brain is particularly sensitive to cannabis. Specifically, the development of the 
endocannabinoid system may be disrupted, and synaptic pruning and white matter development 
may both be impacted, which may cascade into other negative cognitive and developmental 
effects (Lubman et al., 2015). 
 All these factors together create an ideal breeding ground for a substance use disorder in 
adolescents. Cannabis use disorder (CUD) is a diagnosis given to people with problematic 
cannabis consumption habits, defined as the inability to stop using cannabis despite its negative 
impacts on their health or social life. A 2020 research study analyzing data from the National 
Survey of Drug Use and Health from the Substance Abuse and Mental Health Services 
Administration found that adolescents aged 12-17 who began to use cannabis within the last 12 
months were significantly more likely to develop a cannabis use disorder than young adults aged 
18-25 who similarly began to use cannabis within the last 12 months (Volkow et al., 2021). This 
finding signals a faster transition to a substance use disorder in adolescence than in young 
adulthood and emphasizes the dire need for an early intervention.  
 Generally, the literature agrees that experiencing cannabis for the first time at a younger 
age is correlated with a higher risk of developing a CUD. CUD is consistently more prevalent in 
people who had an earlier first-time experience using cannabis; additionally in the cited study, at 
each 12-month period since first-time cannabis use, adolescents had significantly higher rates of 



CUD than their young adult counterparts (Han et al., 2018). When CUD takes a step further and 
becomes a multifaceted substance abuse disorder, called polysubstance use disorder in the DSM-
IV but dropped in the DSM-V in favor of diagnosing multiple individual substance use disorders, 
youth are put at risk for other health concerns. Youth with polysubstance use report worse 
physical and mental health, often engage in other risk behaviors, perform worse in school and 
have lower high school graduation rates, and are more likely to increase than decrease the 
number of substances used over time (Zuckermann et al., 2020). These findings further 
emphasize the urgent need to prevent adolescents from trying cannabis at an early age.    

LGBTQ+ youth are often subject to identity-based harassment and discrimination and 
thus face additional risks for developing CUD. LGBTQ+ youth are more likely to experience 
bullying, harassment, feelings of alienation, and assault (Prevost, 2021), and adolescents who 
have been physically or sexually assaulted are more likely to develop a substance use disorder 
(Human Rights Campaign Foundation). Data from the Youth Risk Behavior Surveillance Survey 
in 2017 found that LGB high school students used substances at significantly higher rates than 
their heterosexual counterparts (Kann et al., 2018). 

Transgender youth in particular face additional inequities and unique outcomes when it 
comes to the harms associated with cannabis use disorder and substance abuse in general. This 
population is often overlooked in terms of interventions and prevention. Moreover, transgender 
youth often face additional discrimination in healthcare and bullying at school, putting them at 
greater risk for poor social and health outcomes. An analysis of data from a gender clinic in Los 
Angeles found that 51% of clients reported lifetime suicidal ideation, and 30% reported at least 
one lifetime suicide attempt (Connolly et al., 2016). A 2019 study found that people with a 
substance use disorder have a risk of dying by suicide seven times greater than people without 
substance use disorders (The Trevor Project, 2020). While this statistic was determined for the 
general population, it can be safely assumed that transgender youth, who face higher rates of 
suicide attempts and death by suicide compared to their cisgender counterparts, would have 
compound risk associated with experiencing cannabis use disorder. This demographic should be 
properly screened and monitored for any comorbid increase in mood disorder symptoms, which 
would further increase their risk for a suicide attempt (Medoff, Self-Harm). 

Furthermore, it is unjust to discuss LGBTQ+ youth without underlining prevalence of 
homelessness in the population. Somewhere from 20 to 40% of unhoused youth identify as 
LGBTQ+ (Homelessness Policy Research Institute, 2019), and 2% identify as transgender (Los 
Angeles Homeless Services Authority, 2020), meaning that LGBTQ+ youth are 
disproportionately represented in the total unhoused youth population. Combining this with the 
racial demographics of unhoused youth, we find that systemic racism also causes LGBTQ+ 
people of color to be disproportionately affected by homelessness. Compounding with the health 
disparities associated with identifying as LGBTQ+, being unhoused puts LGBTQ+ youth at risk 
for negative health outcomes on a completely different scale, also opening them up to secondary 
health effects because of potential cannabis or other substance abuse. LGBTQ+ youth 
experiencing homelessness are more likely to use drugs and be HIV positive in comparison to 



the overall United States homeless youth population (Homelessness Policy Research Institute, 
2019).  

Additionally, the Covid-19 pandemic and social distancing guidelines may exacerbate 
solitude and other social risk factors for LGBTQ+ adolescents, increasing the likelihood of 
partaking in riskier cannabis use habits. A Canadian study administered an online survey to 
adolescents in 2020 and found that the frequency of cannabis use increased in adolescents from 
the 3 weeks before and after social distancing practices were put into effect (Dumas et al., 2020). 
Covid-19 and the subsequent stay-at-home orders put many into isolation, disrupting usual 
routines and limiting access to entertainment, resources, and socialization. For adolescents who 
use cannabis, they may be used to smoking in a social group setting, which would no longer be 
permitted under the stay-at-home order, pushing them to smoke alone. 

Moreover, smoking alone puts adolescents at new risk. Solitary cannabis use in 
adolescence is associated with more frequent cannabis use and more CUD symptoms with a 
weak association with continued CUD symptoms in young adulthood (Creswell et al., 2015). 
Many of these social users may have turned to solitary cannabis use during the pandemic as a 
source of entertainment and as a mechanism to cope with this newfound solitude, potentially 
pushing them towards developing a CUD.  

Solitary cannabis users have been found to open up to their parents about their personal 
problems less than social-only cannabis users (Ellickson et al., 2006), which may compound with 
the secrecy of not being open with one’s sexuality, creating a wide rift in knowledge and 
emotional connection between parents and their LGBTQ+ children. A longitudinal study 
following eighth grade solitary substance users found that these users had lower academic 
achievement and less understanding of the consequences of substance use, and this translated 
into poorer self-rated health and greater substance use problems by age 23 (Ellickson et al., 
2006).  
 Overall, the amalgamation of risk factors, health disparities, effects of systemic racism, 
and rapidly changing nature of cannabis in society has led to a disproportionate risk for 
LGBTQ+ youth to develop a CUD. With this in mind, we must call for a sweeping series of 
changes in policy, individual treatment, and societal attitudes to protect LGBTQ+ youth, 
particularly transgender youth and LGBTQ+ youth of color, from falling victim to CUD at the 
fault of our society.  
 This paper will focus on highlighting potential areas for intervention in three facets of 
adolescent cannabis use: monitoring, protective factors, and treatment. Substance abuse does not 
exist in a vacuum and should not be considered in isolation given the complex social and 
environmental risk factors that could make substance use a symptom of a greater issue rather 
than the predominant health issue itself. As a result, this paper will also consider some of the 
differential risk factors based on social determinants of health and highlight areas of health 
inequity in this issue. 
 
Individual-Level Interventions: Therapy and Medication Options  



 The literature on psychiatric medications to treat cannabis use disorder, particularly in 
adolescents, is extremely limited and with variable, sometimes even conflicting conclusions. An 
early literature review found that many of the typical pharmacotherapies used for other 
psychiatric disorders, such as “SSRI antidepressants, mixed action antidepressants, atypical 
antidepressants (bupropion), anxiolytics (buspirone) and norepinephrine reuptake inhibitors 
(atomoxetine),” provide little benefit in the treatment of CUD (Marshall et al., 2014). A 2021 
systematic review and meta-analysis of pharmacotherapies in the treatment of CUD in adults 
found some promising preliminary results but a lack of sufficient evidence to support the use of 
one specific medication in treatment (Bahji et al., 2021). Researchers must continue their search 
for an effective pharmacotherapeutic intervention for this vulnerable population. 
 However, due to the high association between CUD and Major Depressive Disorder and 
Generalized Anxiety Disorder, at least in adults, medication used to treat the comorbid mood 
disorder may be effective in reducing cannabis use in adults with CUD and a comorbid MDD or 
GAD diagnosis (Onaemo, Fawehinmi & D’Arcy, 2021). These already tentative results cannot 
be extrapolated to adolescents without further investigation. This same study in adults found that 
experiencing depressive symptoms significantly preceded increased cannabis consumption in the 
following month; however, the reverse pathway (i.e. increased cannabis consumption preceding 
greater depressive symptoms in the following month) was not significant, suggesting that 
treatment of an underlying mood disorder may alleviate heavy cannabis use (Onaemo, 
Fawehinmi & D’Arcy, 2021).  
 Additionally, empirical evidence supporting therapy options for adolescents with CUD is 
similarly limited. As of 2020, there were only two randomized control trials to test the efficacy 
of different therapy options – cognitive behavioral therapy (CBT), motivational enhancement 
therapy (MET), and multidimensional family therapy (MDFT) – in treating adolescents with 
CUD. Despite the shallow literature pool, both studies found that adolescents with CUD who 
underwent CBT, MET, and MDFT treatment, or a combination thereof, experienced significant 
decreases in cannabis use, with some even no longer meeting the criteria for CUD. 

However, both trials also resulted in high relapse rates at over 50% of participants 
experiencing at least one relapse episode after their course of treatment (Aguinaldo et al., 2019). 
The high rates of cannabis use reduction in response to these therapies combined with high 
relapse rates demonstrate a need to actively participate in therapy to reap its benefits. 
Additionally, adolescents who no longer meet the criteria for CUD are not considered “cured”; 
rather, they are always at risk of relapsing and returning to cannabis abuse. Consequently, 
adolescents with CUD, who are at continued increased risk of CUD and other substance abuse 
through young adulthood, should continue to be monitored even after receiving effective therapy 
treatment. 

Especially when discussing treatment options for LGBTQ+ youth, there are important 
limitations that may affect a LGBTQ+ youth’s access to certain treatments. This population is 
one marked by high rates of family rejection and experiencing homelessness, which would 
render MDFT inaccessible. Housed LGBTQ+ youth may still face rejection of their gender or 



sexual identity from their family, who may refuse to participate in MDFT. Despite the existence 
of free, low-cost, and/or online therapy options, unhoused LGBTQ+ youth may not be able to 
access therapy altogether due to financial, transportation, or technological limitations. Unhoused 
LGBTQ+ adolescents face the most risk, but also have some of the least access to treatment. For 
them, early prevention and education may be the deciding factor in development and 
advancement of a cannabis use disorder, creating a dire need for increased access to affordable 
therapy for LGBTQ+ youth. 
 Financial and situational feasibility must be considered for this population with greatly 
varying socioeconomic status. A randomized control trial found that MDFT was associated with 
higher costs and larger effects in treating adolescent CUD – demonstrating a potential gradient in 
access to and benefits reaped from treatment based on one’s financial, housing, and family 
situations. This trial, when including costs for delinquency associated with adolescent CUD, 
found that MDFT was ultimately the most cost-effective treatment (Goorden et al., 2016).  

 
Family-level Interventions: Acceptance, Knowledge and Skills, and Parenting Styles  
 Family support is a strong protective factor against a number of undesirable outcomes in 
adolescent development, including the development of a substance abuse disorder (Medoff, 
Substance Abuse). Adolescence is generally marked by a strong emotional need for acceptance 
from others, and this is especially true for acceptance from one’s family. Family acceptance is 
particularly important for LGBTQ+ teens, whose identity may come under significant scrutiny 
from their parents to the point of full rejection and being kicked out of their family’s home. The 
San Francisco State University’s Family Acceptance Project found that a LGBTQ+ youth’s risk 
of substance abuse decreases as their family’s acceptance of their LGBTQ+ identity increases 
(Human Rights Campaign Foundation).  

Furthermore, LGBTQ+ youth are more likely to experience stress in their relationship 
with their family as a result of their sexuality, either due to hiding their sexuality from their 
parents or some kind of negative parental response. Only 49 percent of LGBTQ+ youth in the 
Human Rights Campaign Foundation Youth Survey reported having an adult in their family they 
could go to for help, compared to 79 percent for non-LGBTQ+ youth (Human Rights Campaign 
Foundation). 

Additionally, parenting styles strongly influence outcomes in adolescents. A study 
analyzing data from the Transition to Adulthood survey, a longitudinal study with a focus on 
low-income families, found that adolescents who reported more acceptance and less 
psychological control from their parents were less likely to abuse substances and reported 
general positive well-being during the transition to young adulthood. Conversely, regardless of 
parental acceptance, higher levels of reported psychological control predicted subsequent 
substance use in the transition to adulthood (Lee, Beckert & Marsee, 2018). 
 Families and parents should also consider their own substance use and abuse history 
when considering their child’s risk for developing CUD, particularly as cannabis is increasingly 
legalized and prevalent in the United States. Family history of substance use and abuse is a risk 



factor for developing a substance abuse disorder (Medoff, Substance Abuse). Specifically, 
parental CUD is associated with adolescent cannabis use and low positive parenting, a known 
risk factor for adolescent cannabis use; parental cannabis use without CUD does not confer the 
same association (Hill et al., 2018). Parents with CUD may be inhibited from providing the 
positive parenting that is necessary for healthy adolescent development. 

 
School-Level Interventions: GSAs, Anti-Bullying Policies, and Administrative Support 
 School culture and experiences at school have the potential to augment risk factors to the 
already at-risk LGBTQ+ youth population or provide protective factors to deter substance abuse 
and potential development of a CUD. Gender- and sexuality-based bullying has been found to 
exacerbate cannabis use in LGBTQ+ adolescents (Coulter et al., 2018). Also, LGBTQ+ youth 
may underreport bullying for several reasons, including fear of disclosing their sexual or gender 
minority status to school administration. If LGBTQ+ youth experience identity-based harassment 
at school, the effectiveness of other interventions will be curtailed, demonstrating a dire need for 
anti-bullying protections specifically for LGBTQ+ youth at a school- and even state-level.   
 GSA clubs – Gay-Straight Alliances, or as named at some schools, Gender and Sexuality 
Awareness club – play a key role in shaping the culture of a school and attitudes towards 
LGBTQ+ students on top of providing potentially the only safe space for LGBTQ+ students at 
school. One prospective analysis found that fewer homophobic bullying events took place in the 
year following the formation of a GSA. This protective effect persists – the researchers noted a 
decrease in homophobic bullying from one year to the next after the formation of a GSA 
(Ioverno et al., 2016). Interestingly, this study found that this drop in homophobic bullying was 
independent of participation or lack thereof in GSA activities, suggesting that GSAs generally 
aim to shape the culture of schools into a safe climate for all LGBTQ+ students, not only active 
members of the GSA. Ultimately, this suggests that the presence of a GSA at a school is enough 
to be a protective factor against homophobic bullying and thus a protective factor against 
development of CUD (Ioverno et al., 2016). For LGBTQ+ youth, the mere presence of a GSA at 
a school signals acceptance and support from the school administration.  
 From an administrative level, a harm-reduction approach may curtail substance use in 
adolescents. Often, schools implement zero-tolerance policies, serving severe and potentially 
disruptive predetermined punishments in response to drug use, including suspension or expulsion 
from school. However, these zero-tolerance policies are often biased against LGBTQ+ youth and 
obstruct their recovery rather than deter drug use (Himmelstein & Bruckner, 2011). On top of 
this, adolescents with a higher frequency of cannabis use and earlier onset of cannabis use suffer 
from lower rates of high school graduation (Castellanos-Ryan et al., 2016). Enacting punishment 
on LGBTQ+ adolescents with CUD, who already face lower school performance and graduation 
rates, may only exacerbate these issues, disrupting their school achievement, sense of 
accomplishment, and potentially upsetting their parents and straining family relationships even 
further. 



 One example of an effective harm-reduction approach in a school setting is providing a 
punishment-free, motivational check-in for adolescent cannabis users as described in Walker et 
al. (2016). The researchers in this study created the Teen Marijuana Checkup, a school-based 
voluntary intervention offering the opportunity for adolescents unwilling to go to treatment to 
ask questions and express concerns about their cannabis use. This form of MET could be 
implemented in schools to provide an effective intervention for heavy cannabis users or 
adolescents with CUD who may be hesitant or unable to receive treatment. 
 General anti-substance use education and policies in place at a school may also indirectly 
aid LGBTQ+ youth. Ongoing education beginning before adolescence is an important tool in 
preventing adolescent substance abuse. Schools can practice refusal skills using role-play to 
protect the adolescents from succumbing to peer pressure (Medoff, Substance Abuse). The 
Popularity Socialization Hypothesis posits that popular adolescents play a significant role in 
modelling risk behaviors to less popular adolescents (Dumas, Ellis & Litt, 2020). Given that peer 
substance use is a risk factor for adolescent substance use (Medoff, Substance Abuse), 
preventing any student from initiating substance use may have cascading protective effects on 
LGBTQ+ youth. 
 
Community/Cultural-Level Interventions: City, State, and Medical Policies and Resources  
 Bringing in the federal government, the Substance Abuse and Mental Health Services 
Administration (SAMHSA) has a 24/7, free, confidential hotline that can connect youth to 
services. On a state policy level, SAMHSA has block grants which provide funding for substance 
abuse and mental health services to states that apply for a grant. States could advocate for 
receiving a block grant to fund LGBTQ-specific substance abuse treatment (Substance Abuse 
and Mental Health Services Administration). 
 LGBTQ+ youth have the additional stress of being their own advocates in their 
healthcare. If LGBTQ+ adolescents are not out to their parents or feel uncomfortable disclosing 
their sexuality to their healthcare providers, it may be difficult for them to share details about 
their sexual identity and experiences. This limited communication can lead to inadequate 
education, screening, and interventions, and thus, poorer healthcare outcomes (Hafeez et al., 
2017). Additionally, even if this information is disclosed, healthcare providers may not be 
adequately trained on the specific needs of the LGBTQ+ community (Hafeez et al., 2017).   
 Social media platforms play a huge role in shaping adolescents’ perception of the world 
and the content that they consume. California has a series of restrictions in place to minimize the 
marketing of cannabis to people under 21. However, adolescents may still be exposed to 
cannabis media and marketing through social media. A cross-sectional online survey of high-
school aged adolescents found that exposure to cannabis via social media was significantly 
associated with past-year cannabis use, and this association was increased with each additional 
platform that exposed adolescents to cannabis (Whitehill et al., 2020).  
 
Potential Outcomes and Limitations 



 LGBTQ+ experiences are incredibly unique – the LGBTQ+ community is not a 
monolith, as it comprises of people of all races, genders, socioeconomic statuses, housing 
statuses, family structures, etc. For the most privileged, non-minority, housed with a supportive 
family, high socioeconomic status LGBTQ+ youth, they may benefit greatly from the 
combination of these protective factors and treatment options. Conversely, a poor, person of 
color, high-school dropout, unhoused youth estranged from their family is incredibly at-risk, 
with so many possible combinations of factors in between. Still, though, risk factors alone do not 
determine whether cannabis use will evolve into full-blown CUD.  
 There also exists a lack of literature that relates queerness, adolescence, and cannabis use 
specifically. Many studies have confounding factors that rendered significant results insignificant 
when included in the statistical analysis. For example, adolescents commonly do not singly use 
cannabis; rather, they often experiment with alcohol and nicotine as well. The effects of repeated 
use of cannabis can be unclear since many cannabis users also drink alcohol, which has its own 
set of cognitive detriments. This is particularly true for LGBTQ+ teens, who face a number of 
unique stressors and risk factors.   

Furthermore, CUD in LGBTQ+ high schoolers is a rapidly changing issue due to the 
evolving nature of cannabis culture, and even cannabis itself, in society. As a result, research and 
treatment courses must play a game of catch-up with the increasing reach of more potent forms 
of cannabis. However, cannabis research is blunted and restricted by the United States Drug 
Enforcement Agency, which has limited researchers for decades to only using cannabis grown at 
the University of Mississippi under their contract with the National Institute on Drug Abuse 
(Wadman, 2021). This cannabis is typically low quality, sitting at just 6-8% THC, nowhere near 
representative of the 30% THC cannabis that an 18-year-old with a medical cannabis card can 
legally purchase and consume on any given day. As a result, much of the published literature 
does not reflect the current substance climate of our contemporary society. 
 
In Closing 
 In conclusion, the United States has much work to do in order to protect our LGBTQ+ 
youth from the growing reach of cannabis. A conglomerate of individual, familial, societal, 
political, and academic interventions is necessary to create the ideal environment for LGBTQ+ 
youth to avoid falling into the cannabis use to CUD to polysubstance abuse pipeline and the 
secondary health issues and social detriments associated with it. Research on the longitudinal 
effects of cannabis use and a potential psychopharmaceutical intervention must continue, and the 
medical community should understand the specific needs of the LGBTQ+ community and 
prepare itself for an increase in cannabinoid-induced conditions. As always, special attention 
should be paid to LGBTQ+ and trans youth of color, who face compounding minority stress. 
However, as attitudes towards the LGBTQ+ community change, policies and medical research 
advance, and LGBTQ-specific resources are developed, there is hope on the horizon for this 
vulnerable, glorious population.  
  



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