Nelson J. Tiburcio, PhD
Chief Executive Officer, The SASSI Institute, 201 Camelot Lane, Springville, IN 47462, USA; Tel. 800-726-0526; Fax: 800-546-7995; E-mail: research@sassi.com
In 2015, the Children and Youth Services Review, using 15,425 high school students from across the United States of America (USA), suggested possible reciprocal paths between substance abuse and violent behavior.1 The study measured the effects of traditional and cyberbullying victimization on suicidal thinking, suicidal planning, and suicide attempts, mediated by violent behavior, substance abuse, and depression. In addition, a correlation between bullying and substance use (C-statistic=0.78; Odds Ratio (OR): 1.72; 95% Confidence Interval:1.58-2.03), and suicidal ideation (OR: 7.78; 95% Confidence Interval: 3.05-19.90) was found to exist.2,3 Risk behaviors during adolescence have been shown to enhance the likelihood of negative health outcomes in later life.4 Further to this, and not surprisingly, as adolescents age, depression, and substance abuse patterns increase. Thus, these patterns suggest that pathways to increased substance use disorders (SUD) begin early in adolescence.
Because research is still in its infancy, it is not yet possible to establish long-term trends in substance use and SUD prevalence in the adult Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) populations.5 Similarly, research is currently limited on rates of SUD among transgender populations, although existing research shows that transgender individuals are more likely to seek SUD treatment than non-transgender populations.6 A research study on lesbian, gay, and bisexuals (LGB) showed that racial/ethnic minority individuals experienced minority stress due to both their sexual identity and race/ethnicity and may be at elevated substance use risk; disparities were consistently greater in magnitude for Black and Hispanic LGB women compared with White LGB women.7 Research has shown that among teens, transgender children and adolescents have higher-levels of depression, suicidality, self-harm, and eating disorders than their non-transgender counterparts.8,9 Other research examining a phenomenon known as “faking good”, where individuals intentionally misrepresent prior drug use in the hopes of such use not being discovered, demonstrated that the substance abuse subtle screening inventory for adolescents (SASSI-A3) tool effectively identified these individuals; see Tiburcio et al10 for a more thorough review of this phenomenon. The SASSI screening tool was designed to identify individuals in need of further evaluation for SUD, including individuals who may be unable or unwilling to acknowledge their substance misuse, and over the years has proven quite useful as part of an overall assessment for detecting and treating substance use disorder among various populations.11 This is particularly important for LGBTQ adolescents who may come from diverse ethnic backgrounds such as Black/African American, Asian, or Hispanic, and who may be struggling with substance use but are hesitant to seek help, as the SASSI can provide a non-judgmental and confidential way to identify and address these issues.12 For more than a quarter century, it has been postulated that substance misuse has such a devastating impact because it is often not identified in its early stages.13
Many LGBTQ individuals experience confusion, alarm, fear, and discomfort at the thought of being “outed” because of their sexual preference(s). LGBTQ teens are not inherently prone to suicide risk, but the stigmatization and isolation by society because of their sexual orientation or gender identity places them at higher-risk for psychological and emotional issues, including suicidal ideation and ultimately suicide.14 As the LGBTQ population has grown and become more vocal and mainstream in recent years, coupled with the advent and proliferation of social media during this time, bullying, ostracizing, and social isolation have become even more common among teen members of these groups, and their mental health and well-being are put at risk by policies that seek to restrict their access to appropriate health care and inclusion at school.15 A report by Walls et al16 discussed the elevated risk (nearly 10%) of partner violence for LGB questioning and transgender high school students, with the highest risk among those who are both LGB and transgender. Adolescents who report partner violence are also more likely to be struggling with bullying, depression, and suicidality. These phenomena have, in turn, led to a greater spread and staggering numbers of suicides (both accidental and intentional) among those who seek solace in illicit substances.4,9 Bullying and substance use are oftentimes interrelated. In their systematic review and meta-analysis of 13 cross-sectional studies, Valdebenito et al17 confirmed a very strong association between bullying perpetration and substance use (Odds Ratio: 2.82; 95% Confidence Interval 1.97-4.02; z=5.71; p<0.001). Due to the negative consequences, it is clear that bullying among LGBTQ youth is associated with substance misuse.18
We participated in a recent Parent Teacher Association (PTA) meeting at a local high school and some of these issues were discussed with parents of teens that have witnessed some of these shaming episodes and their perspectives on what they witnessed and discussed with their spouses and others in their social circles and how that compared to some of the anecdotal information provided by their non-LGBTQ teen offspring. Both cases were reported anonymously and voluntarily; no names were used, and we adhered to the highest standards of respecting the anonymity and confidentiality of the parents and teens.
Bullying, Shaming and LGBTQ
One male parent indicated to us that he had several conversations with his three sons about being bullied or bullying someone themselves. He summarized that, although his sons had not experienced such episodes, they had witnessed others engaging in the practice. One of his sons even got into a physical altercation by coming to the defense of one of his friends who was being bullied. This incident resulted in the victim (14-years-old) being taunted about his small stature and “effeminate mannerisms”. In addition to being called a “midget” and an “elf ”, among other disparaging terms, he was physically pushed around by two bigger classmates. The bullying stopped eventually but resulted in the victim feeling so ashamed of his stature that he had to seek professional help. The male parent reported that the victim’s father had confided that his son was even resorting to “drinking liquor from the liquor cabinet” as a result of how badly he felt after these episodes. Statistics indicate that the reasons for being bullied reported most often by students include physical appearance, race or ethnicity, gender, disability, religion, and sexual orientation.19 Additionally, 59.5% of LGBTQ students feel unsafe at school because of their sexual orientation, 44.6% because of their gender expression, and 35% because of their gender.20 Peer victimization of all youth was less likely to occur in schools with bullying policies that are inclusive of LGBTQ students.21
One female parent we spoke to reported that she had to coax her daughter to not engage in social media platforms, eventually getting to the point that she had to take her daughter’s cell phone away because of her conduct. She had witnessed that her daughter and some of her friends were taunting a classmate on various social media platforms. They called her names such as “being butch” or “being a boy in disguise”. Other articles have reported that these behaviors may eventually lead to emotional and psychological trauma and, in some cases, substance abuse, or, as was the case with the male referred to earlier, alcohol abuse.19 As discussed earlier, an association exists between bullying and suicide-related behaviors, but this relationship is often mediated by other factors, including depression, violent behavior, and substance abuse.2,4
Bullying against LGBTQ teens doesn’t always come from their peers, but from the government as well, in the form of legislation targeting them. From January to May of 2023, 45 of the 50 states in the USA have proposed anti-LGBTQ laws, and at least 45 have passed, with many targeting youths by banning gender-affirming care, placing restrictions on which restrooms they can use at school, and forbidding classroom discussions on sexual and gender identity.22 This is particularly harmful to mental health for a population that is already at high-risk. A non-profit group specializing in LGBTQ youth suicide prevention said that LGBTQ teens reported that just hearing about laws like these were harming their mental health.13
Within the school environment, Gower et al23 found that students attending schools with more supportive LGBTQ climates reported lower odds of relational bullying victimization, physical bullying perpetration, and sexual orientation-based harassment compared to students in schools with less supportive LGBTQ climates. They further found that sexual orientation did not moderate these relationships, indicating that LGBTQ-supportive practices may be protective for all students, regardless of their sexual orientation. Thorough investigations of this sort indeed foster a non-hostile environment where school-wide efforts to create supportive climates for LGBTQ youth as part of a larger bullying prevention strategy may be one productive and proven method to address this phenomenon if anti-LGBTQ laws that restrict what schools can and cannot do are struck down or not passed. The most recent school climate survey in the U.S. found that 81.8% of LGBTQ students surveyed reported feeling unsafe in school.24 If these laws continue to be passed, that number will grow even higher in the coming years.
One study reported that non-binary respondents skewed younger than binary respondents when it came to hazardous drinking, so it may be possible that the discrepancy can be attributed to developmental life stage rather than gender or gender identity.25 Identifying as LGBTQ is not in and of itself a risk factor for substance misuse, SUD, or future SUD. However, the stress placed on LGBTQ teens by a judgmental and homophobic society, especially through anti-LGBTQ laws, contributes to the high number of cases of substance misuse. Thus, educating society on ways to support and have compassion for LGBTQ youth will likely reduce substance misuse in this population and help create inclusive and safe environments.
Previous studies on how non-binary people who use drugs are an underserved group at high-risk of harm concluded that clinicians should be trained in trans-affirmative language and practice, that development and implementation of specialist substance use disorder interventions for trans and/or non-binary people are needed, and a greater effort to include trans people in sexualized drug use research is needed as well.20 There are several useful tools and resources available from the National SOGIE Center and the Center of Excellence on LGBTQ+ Behavioral Health Equity and their partners that can help providers show up as affirming supporters and allies for their clients available at https://attcnetwork.org/ centers/attc-network-coordinating-office/celebrate-pride-monththese-important-tools-national-sogie. 26
Findings from an additional study illustrated the need for gender-based, anti-stigma policies and programs to be established within existing addiction treatment programs, and as recommended by the parents within the PTA group, schools and programs must establish transgender and/or LGBTQ-specific treatment programs.18 Future thorough empirical studies of these phenomena will hopefully provide a more profound understanding of the issues these individuals encounter. Our collective goal should be to further discussions of these encounters, and document these in order to achieve a more informed, sensitive dialogue of the most efficacious ways of treating members of these group(s), and providing the emotional and psychological support that has become so very necessary.
The authors declare that they have no conflicts of interest.
1. Reed KP, Nugent W, Cooper RL. Testing a path model of relationships between gender, age, and bullying victimization and violent behavior, substance abuse, depression, suicidal ideation, and suicide attempts in adolescents. Children and Youth Services Review. 2015; 55: 128-137. doi: 10.1016/j.childyouth.2015.05.016
2. Gaete J, Tornero B, Valenzuela D, et al. Substance use among adolescents involved in bullying: A cross-sectional multilevel study. Front Psychol. 2017; 8: 1056. doi: 10.3389/fpsyg.2017.01056
3. Skapinakis P, Bellos S, Gkatsa T, et al. The association between bullying and early stages of suicidal ideation in late adolescents in Greece. BMC Psychiatry. 2011; 11. 22. doi: 10.1186/1471-244X-11-22
4. Durand V, Hennessey J, Wells DS, et al. Bullying and substance use in children and adolescents. Journal of Addiction Research and Therapy. 2013; 4: 158. doi: 10.4172/2155-6105.1000158
5. Substance Abuse and Mental Health Services Administration. 2020 National Survey on Drug Use and Health: Lesbian, Gay, & Bisexual (LGB) Adults (Annual Report). 2022. Website. https:// www.samhsa.gov/data/report/2020-nsduh-lesbian-gay-bisexual-lgb-adults. Accessed April 5, 2023.
6. Keuroghlian AS, Reisner SL, White JM, Weiss RD. Substance use and treatment of substance use disorders in a community sample of transgender adults. Drug Alcohol Depend. 2015; 152: 139-146. doi: 10.1016/j.drugalcdep.2015.04.008
7. Schuler MS, Prince DM, Breslau J, Collins RL. Substance use disparities at the intersection of sexual identity and race/ethnicity: Results from the 2015–2018 National Survey on Drug Use and Health. LGBT Health. 2020; 7(6): 283-291. doi: 10.1089/ lgbt.2019.0352
8. Connolly MD, Zervos MJ, Barone CJ, Johnson CC, Joseph CLM. The mental health of transgender youth: Advances in understanding. J Adolesc Health. 2016; 59(5): 489-495. doi: 10.1016/j.jadohealth.2016.06.012
9. Business Bliss Consultants FZE. Effect of Bullying on Substance Abuse. 2018. ukdiss.com. Website. https://ukdiss.com/ examples/effect-bullying-substance-abuse-8363.php?vref=1. Published December 13, 2019. Accessed April 29, 2023.
10. Tiburcio NJ, Baker SL, Hanauer, M. Detecting “Faking good” with the adolescent substance abuse subtle screening inventory-SASSI-A3: A clinical response to alcohol & other drug use minimization among teens. Alcoholism Treatment Quarterly. 2019; 38(3): 356-363. doi: 10.1080/07347324.2019.1696155
11. Lazowski LE, Geary BB. Validation of the adult substance abuse subtle screening inventory-4 (SASSI-4). European Journal of Psychological Assessment. 2019; 35(1): 86-97. doi: 10.1027/1015- 5759/a000359
12. Baker S. SASSI Network Blog. How the SASSI can be a Useful Tool in the LGBTQIA+ Community. 2023. Website. https://sassi. com/blog-post-90/. Accessed May 18, 2023.
13. Miller FG. SASSI: Application and assessment for substance-related problems. Journal of Substance Misuse. 1997; 2: 163-166. doi: 10.3109/14659899709084630
14. The Trevor Project. Facts About LGBTQ Youth Suicide. 2021. Website. https://www.thetrevorproject.org/resources/article/ facts-about-lgbtq-youth-suicide/. Accessed May 19, 2023.
15. Substance Abuse and Mental Health Services Administration. Moving Beyond Change Efforts: Evidence and Action to Support and Affirm LGBTQI+ Youth. 2023. Website. https://store.samhsa.gov/product/moving-beyond-change-efforts/pep22-03-12- 001. Accessed May 20, 2023.
16. Walls NE, Atteberry-Ash B, Kattari S, Peitzmeier S, Kattari L, Langenderfer-Magruder L. Gender identity, sexual orientation, mental health, and bullying as predictors of partner violence in a representative sample of youth. Journal of Adolescent Health. 2019; 64(1): 86-92. doi: 10.1016/j.jadohealth.2018.08.011
17. Valdebenito S, Ttofi M, Eisner M. Prevalence rates of drug use among school bullies and victims: A systematic review and meta-analysis of cross-sectional studies. Aggressive Violent Behaviors. 2015; 23: 137-146. doi: 10.1016/j.avb.2015.05.004
18. Marshal MP, Friedman MS, Stall R, et al. Sexual orientation and adolescent substance abuse: A meta-analysis and methodological review. Addiction. 2008; 103: 546-556. doi: 10.1111/j.13600443.2008.02149.x
19. National Center for Educational Statistics. Student Reports of Bullying: Results From the 2017 School Crime Supplement to the National Crime Victimization Survey. 2019. Website. https://nces. ed.gov/pubs2019/2019054.pdf. Accessed May 20, 2023.
20. Kosciw JG, Greytak EA, Zongrone AD, Clark CM, Truong NL. The 2017 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Youth in Our Nation’s Schools. 2018. New York, NY: GLSEN. Website. https:// www.glsen.org/sites/default/files/2017-10/GLSEN-2017-National-School-Climate-Survey-NSCS-Full-Report.pdf. Accessed May 23, 2023.
21. Hatzenbuehler ML, Keyes KM. Inclusive Anti-bullying policies and reduced risk of suicide attempts in lesbian and gay youth. J Adolesc Health. 2013; 53(10): S21-S26. doi: 10.1016/j.jadohealth.2012.08.010
22. Campoamor D. Trans Kentucky teen reacts to new anti-LBGTQ law: ‘I wish we could just be kids’ Today. 2023. Website. https://www.today.com/health/news/trans-kentucky-teen-antilgbtq-law-mental-health-rcna77700. Accessed May 24, 2023.
23. Gower AL, Forster M, Gloppen K, et al. School practices to foster LGBT-supportive climate: Associations with adolescent bullying involvement. Prev Sci. 2018; 19: 813-821. doi: 10.1007/ s11121-017-0847-4
24. Kosciw JG, Clark CM, Truong NL, Zongrone AD. The 2019 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Youth in Our Nation’s Schools. 2020. Website. https://www.glsen.org/sites/default/ files/2021-04/NSCS19-FullReport-032421-Web_0.pdf. Accessed May 24, 2023.
25. Reisner SL, Hughto JM. Comparing the health of non-binary and binary transgender adults in a statewide non-probability sample. PLoS One. 2019; 14(8): e0221583. doi: 10.1371/journal. pone.0221583
26. Weeks A. Celebrate Pride Month with these important tools from the National SOGIE Center & partners. 2023. Website. https://attcnetwork.org/centers/attc-network-coordinating-office/celebrate-pride-month-these-important-tools-national-sogie. Accessed June 6, 2023.
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