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In the movement for gay and transgender equality, issues like marriage and workplace discrimination dominate media headlines as well as the time and attention of most advocates. The focus on these headline issues has been successful on some fronts in recent years, with the repeal of “Don’t Ask, Don’t Tell” and passage of the Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act, a hate crimes law that is inclusive of gay and transgender people. Other issues that impact the overall equality and wellbeing of gay and transgender people, however, don’t always garner as much attention.

Gay and transgender health is one of these issues. This issue brief examines the disproportionately high rates of substance use by gay and transgender people, which is a significant impediment to the health of this group. Although data on the rates of substance abuse in gay and transgender populations are sparse, it is estimated that between 20 percent to 30 percent of gay and transgender people abuse substances, compared to about 9 percent of the general population.

The stress that comes from daily battles with discrimination and stigma is a principle driver of these higher rates of substance use, as gay and transgender people turn to tobacco, alcohol, and other substances as a way to cope with these challenges. And a lack of culturally competent health care services also fuels high substance-use rates among gay and transgender people.

In order to lower these rates, our health care system needs to better meet the needs of gay and transgender people, and our government needs to advance public policies that promote equality for this population.

This issue brief explains why we see higher rates of substance use in the gay and transgender population, provides a brief overview of these rates, and makes recommendations that can help end antigay and antitransgender discrimination and reduce substance use rates.

Rates of substance use and abuse in the gay and transgender population

In this section we provide some topline numbers on substance abuse rates in the gay and transgender population. Note that there is little national data on gay and transgender people overall, so the statistics here are best estimates of these rates.

Tobacco

Gay and transgender people smoke tobacco up to 200 percent more than their heterosexual and nontransgender peers.

Alcohol

Twenty-five percent of gay and transgender people abuse alcohol, compared to 5 to 10 percent of the general population.

Drugs

Men who have sex with men are 3.5 times more likely to use marijuana than men who do not have sex with men.

These men also are 12.2 times more likely to use amphetamines than men who do not have sex with men.

They are also 9.5 times more likely to use heroin than men who do not have sex with men.

Factors leading to these rates of substance use and abuse

Gay and transgender people report higher rates of substance use than others due to three main factors.

First, many gay and transgender people live with a high level of stress that comes from social prejudice and discriminatory laws in areas of daily life such as employment, relationship recognition, and health care.

Second, a lack of cultural competency in the health care system discourages gay and transgender people from seeking treatment for substance abuse, and—if they do seek help—often leads to inappropriate or irrelevant services.

Finally, targeted marketing efforts by alcohol and tobacco companies exploit the con- nection many gay and transgender people have to bars and clubs as safe spaces for socializing and increase easy access to tobacco products and alcohol. Below, we look at each of these factors in turn.

Minority stress

Minority stress—the negative effects associated with the adverse social conditions experienced by individuals of a marginalized social group—is something gay and transgender people have to deal with every day. This stress is triggered by general social prejudice against being gay or transgender, as well as discriminatory laws and policies.

Antigay and antitransgender social prejudice stems from the belief that being gay or transgender is somehow wrong or bad. It can be expressed in subtle ways (for example, a receptionist at a pediatrician’s office asking a lesbian couple which of the pair is their child’s “real” parent), or it can be expressed in verbal and physical violence (two men holding hands getting taunted with antigay epithets or a transgender person getting jumped by a group of strangers).

Karen and Marcye Nicholson-McFadden of New Jersey understand this prejudice all too well. They are the parents of two children and have a civil union because same-sex marriage is not legal in their state. Whenever they visit the doctor or go to their children’s school, they are treated differently because they have to deal with people who don’t know what a civil union is, and they have to explain their family to the staff. Karen and Marcye regularly cross out items on government, school, and doctors’ forms to reflect their family structure. For example, a family headed by two moms often has to cross out “name of father” on forms.

Or take the 2010 case of a 14-year-old student at Nassau BOCES Career Preparatory High School in Hicksville, New York, was assaulted by four of his classmates who perceived him to be gay. The student was stomped and kicked by his classmates as they spewed antigay epithets at him on his bus ride home from school. The very next day the student was once again the subject of abuse as two of his classmates from the day before made antigay remarks toward him and slapped him across the face and head. His classmates were later arrested and charged with assault and harassment for their actions.

This kind of prejudice can force some gay and transgender people to avoid social settings or neighborhoods that might put them in harm’s way. The end result is higher levels of anxiety and fear of being attacked when doing something as simple as walking down the street. And this can lead them to use substances to ease this anxiety.

Discriminatory laws and practices are another source of minority stress that negatively impacts the gay and transgender population and can lead to drug and alcohol use. In particular, discrimination in employment, housing, relationship recognition, and health care are major areas of concern.

Discrimination in employment

It is currently legal in 29 states for gay and transgender individuals to be denied employment, fired, or discriminated against just because of their sexual orientation or gender identity. A recent article by the Center for American Progress reported that 43 percent of gay and 90 percent of transgender people have experienced discrimination and harassment on the job.

Workplace discrimination poses a real and immediate threat to the economic security of gay and transgender workers by leading to job instability, which affects a person’s ability to earn a steady income and have access to employer-provided health insurance. These issues not only impact the person who has been discriminated against but also threaten the well-being of other people (a partner, spouse, or children) who are financially dependent on that person.

Discrimination in housing

Having access to safe and stable housing is key to well-being. Fifty-six percent of gay individuals and 70 percent of transgender individuals, however, report experiencing some form of discrimination in housing based on their sexual orientation or gender identity. Being denied stable and affordable housing makes it much more difficult to maintain employment, access health care, and maintain a safe and stable family structure.

Discrimination in relationship recognition

The debate over marriage for gay couples has been a nationwide news story for nearly two decades now, with frequent and prominent stories in the press that elevate and perpetuate antigay stereotypes and sentiments. Hearing these attacks on a regular basis increases antigay social prejudice and its negative impact on gay people.

Further, only eight states and the District of Columbia allow marriage for gay couples, which means that most families headed by same-sex couples are currently barred from accessing the many public policies and programs that are designed to bolster a family’s economic security (child care tax credits, Social Security survivor benefits, employer-sponsored health insurance in many cases, and the ability to sponsor a partner for citizenship).

Discrimination in health care

A lack of access to affordable and culturally competent health care also contributes to gay and transgender minority stress. Gay and lesbian adults are roughly twice as likely as the general population to be without health insurance coverage, and rates of uninsurance are even higher for transgender and bisexual individuals.

Because our nation lacks a public health insurance system and individual coverage is currently prohibitively expensive, most insured people access coverage through their employers or their spouse’s employer. Unfortunately, widespread workplace discrimination prevents many gay and transgender people from having consistent access to health insurance through their employers. Furthermore, many workplaces do not provide health insurance benefits to same-sex domestic partners. When they do, the cost is higher for these couples, since they have to pay taxes on the insurance benefit, a cost that different-sex married couples do not incur.

Moreover, most private and public plans including Medicare, many state Medicaid programs, and plans sold through the Federal Employees Health Benefits Program specifically target transgender people with exclusions that deny coverage for transition-related care. Such exclusions are frequently expanded in practice to deny even basic health care services to transgender people.

Finally, as we discuss in more detail below, many health care providers are not trained to serve gay or transgender patients, which negatively impacts quality of care. These and other forms of discrimination work together to make life for gay and transgender people more expensive, complicated, and difficult. The end result is additional emotional stress and pressure for many people who are gay or transgender.

Cultural competency

Gay and transgender individuals may be hesitant to utilize health care services that can help them overcome substance abuse because they are aware of the likelihood of meeting health care professionals who are unaware of their specific needs or are outright hostile toward them. As a result, gay and transgender individuals may delay substance-abuse treatment or choose not to disclose their sexual or gender minority status, which not only hinders recovery but also undermines their overall health.

Many tobacco-cessation programs are not welcoming of gay and transgender people, for example. A number of these programs do not provide any outward indications that they are inclusive of gay and transgender people and their unique needs, thereby isolating some gay and transgender people who are already apprehensive because of previous experiences they have had accessing care. Given that many gay and transgender people smoke because of stress factors related to their sexual orientation or gender identity, they might not feel comfortable enrolling in these programs or, if they do enroll, the programs might not address the root causes of their addiction.

Socialization and marketing

Bars, clubs, and restaurants have traditionally been places where gay and transgender people can socialize and feel safe. In many of these venues, smoking and drinking remain popular. As a result, higher rates of smoking, drinking, and sometimes drug use occur in these environments.

Tobacco and alcohol companies have exploited gay and transgender social networks to aggressively market their products for decades. In the early 1990s tobacco companies surveyed gay men for branding choices, which resulted in a new program called Subculture Urban Marketing, or SCUM, which targeted minority gay men in San Francisco.

According to a fact sheet by the American Cancer Society, tobacco companies also appeal to the gay and transgender population through direct advertising in national gay and transgender magazines; indirect mainstream magazines with a high number of gay and transgender readers, at times with same-sex undertones; and sponsorships of events or organizations that support gay and transgender issues.

The fact sheet also states, “The [tobacco] industry focuses advertising and sponsorships on themes important to the [gay and transgender] community: liberation, individual- ism, social success, and acceptance.” Such targeted marketing campaigns exacerbate the higher rates of substance use in the gay and transgender population.

How to help

Below we discuss administrative and legislative recommendations whose implementation will help reduce the high rate of substance abuse within the gay and transgender population while helping advance overall gay and transgender equality.

Recommendations for the Department of Health and Human Services

As the Center for American Progress outlined last year, the Department of Health and Human Services, or HHS, can take a number of steps to reduce the rate of substance abuse within the gay and transgender population:

HHS’s agencywide priorities should include strong support for the efforts of the Substance Abuse and Mental Health Services Administration, or SAMHSA, to specifically address gay and transgender substance-use disparities through SAMHSA’s strategic plan, block-grant programs, cultural-competency initiatives, and other activities.

HHS should promote routine and ongoing cultural-competency training for medical and nursing students and other health professions students across the programs administered or supported by its operating divisions.

HHS should explicitly include gay and transgender cultural competence in the National Standards on Culturally and Linguistically Appropriate Services, or CLAS. The CLAS Standards, which are developed by the Office of Minority Health, offer health care organizations and individual providers guidance on making their services more culturally and linguistically accessible to patients from diverse backgrounds.

HHS should require any hospital, rehabilitation center, nursing home, or other facility receiving federal dollars to implement a comprehensive and high-quality gay and transgender cultural-competency training program for providers and other staff.

HHS should specifically recruit gay and transgender students and professionals for training initiatives focused on expanding and diversifying the health care workforce, including the National Health Service Corps, the U.S. Public Health Service, and pipeline programs administered by the Bureau of Health Professions.

HHS should adopt a boilerplate nondiscrimination policy for its programs and grants that prohibits them from discriminating against participants or prospective participants on the basis of sexual orientation or gender identity. Such a policy is part of the rule recently adopted by the Department of Housing and Urban Development.

Legislative recommendations

The following four pieces of federal legislation, if enacted, would substantially help address and eliminate the prejudice and discrimination that drive substance use disparities among the gay and transgender population:

Employment Non-Discrimination Act: The act would create federal protections against sexual orientation and gender identity discrimination at all federal, state, and local government agencies; employment agencies; unions; and private employers with 15 or more employees.

The act would create federal protections against sexual orientation and gender identity discrimination at all federal, state, and local government agencies; employment agencies; unions; and private employers with 15 or more employees. Housing Opportunities Made Equal Act: The act amends the Fair Housing Act to prohibit discrimination on the basis of actual or perceived sexual orientation and gender identity in housing sales and rentals, residential real-estate-related transactions, and brokerage services.

The act amends the Fair Housing Act to prohibit discrimination on the basis of actual or perceived sexual orientation and gender identity in housing sales and rentals, residential real-estate-related transactions, and brokerage services. The Respect for Marriage Act: The act would repeal the Defense of Marriage Act and allow the federal government to recognize legally married same-sex couples. This would allow same-sex couples to take advantage of more than 1,100 federal benefits and protections that are currently denied to them.

The act would repeal the Defense of Marriage Act and allow the federal government to recognize legally married same-sex couples. This would allow same-sex couples to take advantage of more than 1,100 federal benefits and protections that are currently denied to them. The Health Equity and Accountability Act: The act addresses a wide range of health disparities that affect the gay and transgender population, including disparities in health status, access to health care, and protection from discrimination in the health system. It also calls for greater data collection on sexual orientation and gender identity through federally supported health surveys and programs.

Conclusion

Reducing rates of substance use in the gay and transgender population will require both a short- and long-term strategy. In the short term substance-abuse treatment programs and services need to become fully culturally competent and able to effectively and appropriately serve gay and transgender people. Over the long term laws that discriminate against gay and transgender people, as well as persistent antigay and antitransgender prejudice, need to be addressed head-on and dismantled.

Ending the problem of disproportionately high rates of substance use in the gay and transgender population will take considerable time and effort. But working to end this problem—and promoting overall health for gay and transgender people and their families—will make hard-fought legal victories for equality more meaningful and sustainable. Addressing this problem is not easy, but it is a necessary step in the movement toward full gay and transgender equality.

Jerome Hunt is a Research Associate for LGBT Progress at American Progress.

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