Written by Summer Tao
There is robust evidence internationally (Glynn & van den Berg, 2017; Newcomb et al., 2019) to suggest that LGBTQ+ people bear a disproportionate burden of substance use disorders (SUD). This heightened prevalence of SUD results from a complex intermingling of factors including minority stress, increased poverty, and experiences of violence to name a few. The resultant mental health and material stressors invoked by these factors leaves LGBTQ+ people vulnerable to unhealthy coping mechanisms, including substance use. When substance use escalates to harmful levels, it is ordinary to seek treatment. Unfortunately, seeking treatment for substance use is a manifestly more difficult task for LGBTQ+ people due to a range of interlocking barriers that I will describe below.
I opened by mentioning robust international evidence to suggest that LGBTQ+ people endure a disproportionate burden of SUD. This is largely because South African data in this area is severely deficient. To date, there have been no comprehensive studies tracing the epidemiology of LGBTQ+ substance use in South Africa. LGBTQ+ people are instead relegated to off-hand mentions in other research, and much is said about this lack of data (Jobson et al., 2012). This first deficiency informs the problems that follow. Chiefly, changes to treatment procedure must be built on a scientifically robust basis. The absence of a large body of work in this area is therefore detrimental to improving treatment and practitioner training down the line. The lack of basic demographic data drives a lack of useful research on the problem’s prevalence and epidemiology. An absence of information on the scale of the problem hampers efforts to develop in-depth interventions through the denial of funding, and production of quality research. The absence of this quality research hampers safe and effective improvements to treatment and practitioner training. The resultant deficiencies in the healthcare system are felt most keenly by prospective LGBTQ+ clients suffering from SUD and searching for care.
LGBTQ+ people deal with a range of healthcare shortcomings solely as a result of their gender and sexual identities. These range from invasive questioning to direct denigration and discrimination (Scandurra et al., 2019; Müller, 2016) and as a result, contribute to a fear of healthcare institutions. Such are the experiences of LGBTQ+ people in healthcare that many seek out explicitly ‘queer-friendly’ healthcare providers (Hudak & Bates, 2018). The term ‘queer-friendly’ is telling, as it implies that standard healthcare is unfriendly by default, but even ‘unfriendliness’ is just a glib euphemism that hides the realities faced by LGBTQ+ people in healthcare: invasive questioning, data exclusion, ignorance and open derision (Cicero et al., 2019; Scandurra et al., 2019; Müller, 2016). In substance use treatment, this burden of discrimination is complicated by the often social nature of treatment. Where most healthcare takes place between a practitioner and a client, substance use treatment is often social and relies heavily on group and familial support for sustainable recovery. This reduced privacy can expose LGBTQ+ people to further discrimination that can impede their recovery.
The above is largely theoretical and academic, hovering high above the boots-on-the-ground world of practitioners and clients. I will describe some of the treatment experiences of LGBTQ+ clients in SUD treatment from existing research, both my own and that of my MA supervisor. These case examples are illustrative of the real-world consequences of research deficiencies into a vulnerable population. These accounts are drawn from my Master’s research and my Master’s supervisor’s work, both of which consisted of interviews with registered mental healthcare practitioners in South Africa.
Jacobs (2019) interviewed in the Eastern Cape and found a range of training deficiencies, and a demand for additional training in the treatment of LGBTQ+ people. Practitioners reported general unreadiness in treating LGTBQ+ clients, with one saying, “I have a client that happens to be gay and I don’t know how to deal with it and I don’t feel comfortable with it [his gayness].” Another practitioner is aware of practitioner misdeeds and says, “To be honest social workers and psychologists sometimes conduct themselves unethically because we are supposed to be non-biased and work with everyone, without any discrimination. However, in reality, we don’t so, I agree 100% that we need to sensitize people.”
The social nature of substance use treatment becomes detrimental to some LGBTQ+ people, as described by one participant who says, “…when they’re [LGBTQ+ people] admitted into the treatment programme they start to feel very uncomfortable. The bullying, judgement and stigmatisation the non-binaries experience at the hand of the other inpatients makes them feel alienated in the facility. That’s one of the reasons why we see fewer from the queergender community coming forward for treatment because they fear the stigma that comes with it.”
My research involved interviewing mental healthcare practitioners working in the Cape Town metropolitan area and found similar trends and concerns. Most notably, one participant recounted the challenge of strengthening familial support structures in substance use treatment when the family was a discriminatory factor in a client’s life. Of this they said, “Remember I told you about those family meetings we had? And then we have when the parent will refer to the patient by the wrong pronoun, you know? When I’ve been part of the previous discussion of “Mom, this is my pronoun”, ten minutes earlier, you know? So there’s just, like, no consideration for that, I suppose.” Another practitioner noted the burden of stigma and shame that LGBTQ+ people bear in relation to discriminatory families and said, “Lots of shame - I hate to say this, but sometimes more shame and guilt than someone who doesn’t have to go through the experience of having to come out, you know? To open up to their families like, ‘oh hey, I’m actually gay, and guess what I have a heroin problem.” So it’s almost like a double-whammy in some ways.”
These few interview excerpts are only a small slice of the healthcare realities faced by LGBTQ+ people in substance use treatment. Though this piece addresses substance use treatment specifically, many of the negative experiences described here are routinely experienced by LGBTQ+ people in other areas of healthcare. These obstacles are not solely attributable to practitioners and their (often self-reported) unreadiness, other clients or wider structures. Rather, they are a mix of many systemic failures, errors and actions which combine to make healthcare an ironically risky place for LGBTQ+ people. This is discrimination, ignorance and lack of care is not unique to healthcare, but the consequences in healthcare can be far more devastating. Systemic failure in other areas may lead to embarrassment, pain or loss of opportunity. Systemic failure in healthcare systems is at best, an obstacle in the way of a person’s right to a healthful life and at worst, directly life-threatening.
 Lesbian, Gay, Bisexual, Transgender, Queer and Other
 Though the extent of problematic substance use in LBGTQ+ South Africans it no understood, there is absolutely no evidence to indicate that their situation is substantially better than the norm.