"Why can't they come up with a program that teaches people how to get high and go to work": Structural vulnerability, personal substance use and recovery goals, and substance use treatment among sexual and gender minority persons (SGMP) in Los Angeles, California.

Abstract

Introduction Sexual and gender minority persons (SGMP) report disproportionately high rates of substance use in the United States, yet relatively low rates of treatment access and initiation. In this study, we examined substance use treatment experiences among SGMP who inject drugs in Los Angeles, California. Methods We conducted 15 one-on-one qualitative semi-structured interviews with self-identified SGMP assigned male at birth. Eligibility included being assigned male at birth, reporting sex with men, and meeting at least one of the following: being a participant in either the NIH-funded mSTUDY or CANOP cohorts or reporting any opioid or injection drug use within the past two years. Data were collected at a community site associated with a syringe services program and LGBT+ service provider in Los Angeles, CA between May 2022 - February 2023. We employed inductive and deductive coding, using the intersectional risk environment framework and life course theory to develop our codebook and guide our thematic analysis. Results Participants described motivations to decrease their substance use in order to use drugs more intentionally and reduce stigma. Disordered use was linked to financial and material insecurity, which participants perceived as inadequately addressed by treatment programs. Experiences of shame, punishment, conditionality, and loss of support were common in treatment settings. However, patients reported positive experiences with programs that addressed structural vulnerabilities (such as social isolation and financial hardship) and integrated multiple therapeutic modalities into care. Discussion We found that participants view substance use recovery on a continuum that included reducing frequency and type of substance use and modifying routes of administration to reduce infection risk. These findings support integrating harm reduction-based therapeutic modalities into substance use treatment settings. Furthermore, our results emphasize how substance use treatment may be delivered to improve efficacy by 1) co-delivering structurally competent services, that address housing instability, social isolation, unemployment/underemployment, and professional development, 2) prioritizing patient directed, and centered care that incorporates harm reduction and shared decision making, and 3) providing integrated treatment that combines various treatment and therapeutic modalities to meet patients' most pertinent needs.