23. Prevalence of and interventions for mental health and alcohol and other drug problems amongst the gay, lesbian, bisexual and transgender community: A review of the literature

 EXECUTIVE SUMMARY

This report summarises a vast literature in relation to gay, lesbian, bisexual and transgender (GLBT) people and both mental health and alcohol and other drug problems. Overall, we located more than 500 published papers. The report focuses on two aspects:
  1. The prevalence of mental health (MH) disorders, and alcohol and other drug problems (AOD) among GLBT populations; and
  2. Evidence regarding the effectiveness of interventions to redress MH and AOD problems amongst GLBT groups.
 
Prior to summarising the findings, we highlight some methodological constraints of the extant literature. Firstly, how sexual orientation is defined and measured varies considerably, and the terminology used to describe these populations also varies. Here we have chosen the acronym GLBT (gay, lesbian, bisexual and transgender). Other acronyms may include I (intersex) and Q (queer). In addition, the existing research literature on transgender populations in particular is relatively small, and although transgender is included in the acronym used in this report, much of the literature does not explicitly include transgender individuals in the samples.
 
The ways in which sexuality or sexual identity is defined and classified includes: self-identification (as gay, lesbian, bisexual etc.); through same sex attraction; or through same sex behaviour. Each of these definitions may identify different people, depending on how the questions are asked, and how respondents view their own sexual identity. Other terms, such as “men who have sex with men” (MSM) are also used in the literature. Because the terms and coverage vary between studies, not all studies can be directly compared in terms of prevalence or treatment effectiveness.
 
The second methodological constraint concerns the epidemiological literature. We chose to focus more on those studies that used recognised diagnoses (e.g. anxiety disorder, major depression, drug dependence) rather than other indicators of mental health or drug use. This is because many people may experience symptoms of mental health problems, or consume alcohol and other drugs, but this alone may not result in significant harm or impairment. The GLBT community is known to consume some substances at higher rates than heterosexual groups – we are not exceedingly concerned with this; rather the focus of this report is on harmful or problematic alcohol or drug use. Hence our attention to those studies that used diagnostic criteria, as the best available measure of problems.
 
As the report is concerned with the extent to which the GLBT population experiences problems at a higher rate than non-GLBT population, we have also focussed to a greater extent on those studies that have included a non-GLBT comparison group. Unfortunately, in the main these studies come from the United States, with only a small handful of studies from other countries. Therefore, many of the conclusions that are made within this report are based in large part on U.S. data. This does not necessarily invalidate the findings of this report, but is an important limitation. It is possible that the GLBT population in the United States exhibits different characteristics from that in Australia, or in other nations. Certainly, each nation has differing characteristics related to the epidemiology of drug use, which may influence the results. We have separately reviewed the Australian literature on prevalence rates, but as will be seen, at this point there are no published studies using diagnostic criteria (for mental health or drug use disorders) from an Australian population sample, aside from the original work we present herein.
 
Key findings in relation to prevalence of mental health disorders amongst GLBT
A majority of international and Australian studies have found that GLBT populations suffer from mental health disorders at a significantly higher rate than the heterosexual population. This finding occurs across both genders, and in both youth and adult populations.
  • In terms of anxiety disorders, the international literature (n=12 studies with a non-GLBT comparison group) demonstrates that GLBT people are more than twice as likely to have anxiety disorders. The majority of these studies find significantly higher rates in lesbian/bisexual women (with somewhat less strong findings for males). Australian studies provide less strong evidence, especially for lesbian and bisexual women, where anxiety disorders may be less common than in heterosexual groups.
  • In terms of depression and mood disorders, 14 of the 18 international studies examined here demonstrated higher rates amongst GLBT populations than heterosexual populations. This applied to both gay or bisexual men and lesbian or bisexual women, although the highest rates of depression were found for lesbian/bisexual women. Australian research confirms significantly higher rates of major depressive disorder in GLBT compared with non GLBT populations.
  • The evidence regarding suicidality examined here provides perhaps the clearest indication of increased risk amongst GLBT individuals. 25 of 28 international studies found a significantly higher prevalence of past suicide attempts among a GLBT population. Australian data on suicidality confirms that GLBT groups have elevated rates of suicidal thoughts, plans and attempts relative to heterosexual groups.
 
Key findings in relation to prevalence of AOD disorders amongst GLBT
Whether examining the prevalence or frequency of alcohol or other drug use, or the presence of diagnosed alcohol or other drug use disorders, the research indicates that GLBT individuals are likely to be at greater risk.
  • In relation to tobacco, 12 of 15 international studies found significantly higher rates of tobacco use among GLBT populations. A number of studies showed that bisexuals in particular (of both sexes) had the highest rates of tobacco use. The limited Australian research also suggests a higher prevalence among GLBT.
  • In relation to alcohol, in the international literature, 9 of 13 population studies found significantly higher rates of alcohol use disorders among GLBT populations. However, when studies divided the sample by gender, few found a difference between heterosexual and non-heterosexual men, whereas differences between heterosexual and non-heterosexual women were more common. The highest rates of alcohol disorders were found in lesbian and bisexual women. Australian research has shown elevated rates of alcohol consumption, but non-significant differences in alcohol use disorders between GLBT and non GLBT.
  • For illicit drugs, across both drug use and diagnosed drug use disorders, a majority of international studies showed significantly higher prevalence among GLBT compared to heterosexual populations. Particular sub-populations of gay/bisexual men are likely to use particular drugs to a greater extent. These drugs include stimulants such as methamphetamine, and also inhalants. Bisexual women appear to be the heaviest users of illicit drugs, notably cannabis. Australian research, using diagnosable drug use disorders found higher rates of drug abuse and dependence in the GLBT group; however this difference was not statistically significant.
 
Risk factors
  • A number of potential factors as to why GLBT individuals use alcohol and other drugs to a greater extent, or face higher rates of psychological disorders than the heterosexual population, have been identified.
  • Many, but not all of these risk factors for psychological disorder (for instance, victimisation) can apply equally to GLBT and heterosexual groups. However in many cases these factors are experienced to a greater extent by the GLBT population. In addition, there are other risk factors which may apply exclusively to this population, such as homophobic abuse, or issues surrounding sexual orientation disclosure (“coming out”).
  • Factors that may account for higher mental health or alcohol and other drug problems include: self-identification; relationship status; relationships with family and friends; residential context; “coming out”; abuse and victimisation; and stigma, minority stress and discrimination. Many of these factors are likely to be inter-related; for example the process of “coming out” may have implications for relationships with family and friends.
  • Each of these contributes towards further understanding the risk factors in the development of alcohol and other drug and/or mental health problems amongst GLBT populations.
 
Key findings in relation to intervention effectiveness amongst GLBT
  • Prevention is a priority with GLBT people; both AOD and MH problems are preventable, and interventions such as supportive counselling during adolescence are likely to reduce the risk of later mental health or substance misuse problems. Social marketing campaigns directed towards healthy lifestyles for GLBT have not been sufficiently evaluated to draw conclusions about effectiveness.
  • Preventing discrimination and stigma is an essential aspect of any comprehensive approach to reducing AOD and MH problems amongst GLBT. For example, there is a small but compelling literature that demonstrates the relationship between recognition of same-sex marriage and improved mental health status and reduced AOD problems. Measures which reduce the stigma and discrimination against GLBT people are likely to have powerful public health impacts.
  • GLBT people appear to access treatment for alcohol or drug problems at a higher rate than non GLBT people. For MH, we found no statistically significant differences in rates of treatment seeking, although the data indicate a trend towards higher MH treatment seeking amongst GLBT groups. The implications of this are obvious – all MH and AOD services should expect to see GLBT people within their services. This is a compelling argument for ensuring that services receive appropriate training and are well placed to provide care to this population group.
  • GLBT-specific services are those that are specially tailored for GLBT issues. Research has shown some superior outcomes with GLBT-specific services, especially for methamphetamine dependent users. GLBT-specific services provide positive role models, strategies for coping with stigma, tailored interventions for AOD and/or MH and are largely staffed by GLBT practitioners (which is a preference of many GLBT people).
  • While we can identify specific treatment needs for some GLBT, in the main GLBT treatment outcomes are the same as for non-GLBT people, and attention to sexuality-related issues in treatment does not appear to be essential, nor necessarily preferred by clients. This suggests we do not need 100% coverage of GLBT-specific services.
  • All AOD and MH services should however be GLBT-sensitive. This entails ensuring an adequately trained workforce, culturally appropriate services and a non-judgemental attitude by all staff across the service.
  • GLBT-sensitive services are essentially defined by being open, respectful and welcoming of GLBT clients, demonstrating an absence of discrimination or stigmatising attitudes and behaviours.
  • The variety of AOD and MH treatment interventions, such as CBT, motivational interviewing, 12 step programs and the community reinforcement approach have all been shown to be effective with GLBT individuals, in the context of a non-GLBT-specific service.
  • A diversity of service types is required. Not all GLBT clients want a GLBT-specific service. But they should expect and receive GLBT-sensitive services. On the other hand, some people will achieve better treatment outcomes (across both MH and AOD) in the context of a GLBT-specific service.
 
Future directions
Despite the substantial number of papers published in the area of GLBT, MH and AOD, many of the research reports are largely descriptive in nature, and the epidemiological studies with appropriate comparisons groups are small in number. Notably, Australian research which compares GLBT and non GLBT populations across mental health and alcohol and other drug problems is very small. We need more Australian research, with adequate sample sizes and preferably using diagnostic criteria, to assess the extent of differences. It also appears very important to concentrate research effort amongst bisexual populations, as this group appeared to experience more problems than the gay and lesbian groups. The few transgender studies that have been undertaken also suggest that this group may suffer from mental health disorders at a greater rate. However, to this point relatively little is known about the mental health of this population.
 
The research published to date on interventions to redress MH and AOD problems in GLBT populations is also somewhat small. There are some notable gaps, such as Australian treatment outcome studies, comparisons of GLBT-sensitive with GLBT-specific services, and no research on specific interventions such as pharmacotherapy maintenance for opioid dependence.
 
We hope this report will stimulate interest from the research community in pursuing such studies. More importantly, we hope this report provides direction for policy makers about improved services for GLBT. This includes changes such as the legalisation of same-sex marriage, the establishment of extensive training across all MH and AOD services to ensure GLBT-sensitive services are provided, and the continued support for specialist GLBT services to develop more appropriate and effective interventions for this population.