Terminology note: Studies in this field use a variety of terms to refer to sexual and gender minoritised people, who are often described under the umbrella term ‘LGBTQ+’ (lesbian, gay, bisexual, trans, queer/questioning and others). Here, where studies are cited, the terminology from the original paper has been preserved (e.g. LGB, LGBT or LGBTQ+ people). For clarity we have opted to use the term ‘patient(s)’ throughout this paper, although acknowledge other terms (e.g. ‘service user’, ‘client’) may be preferred depending on context.
Rationale
Sexual minority individuals include lesbian, gay, bisexual, queer and other people whose sexual attractions, identities and behaviours are non-heterosexual. Among the range of health inequities faced by this group, Reference McDermott, Nelson and Weeks1–Reference Zeeman, Sherriff, Browne, McGlynn, Mirandola and Gios3 there are significant disparities in addiction problems. Sexual minority people have a higher prevalence of drug and alcohol use, and drug and alcohol use disorders, compared with heterosexual people. Reference Drabble, Midanik and Trocki4–Reference Plöderl and Tremblay10 They are more likely to have their addiction problems untreated, Reference McCabe, West, Hughes and Boyd11 or if they do enter treatment services, they often enter with more severe substance use disorders than their heterosexual counterparts. Reference Cochran and Cauce12 Within-group inequities also exist: bisexual people tend to have more severe addiction problems than gay and lesbian people, Reference Cochran and Cauce12,Reference Schulz, Glatt and Stamates13 and may also struggle more with accessing drug treatment services. Reference Fisher, Reynolds, D’Anna, Hosmer and Hardan-Khalil14 Minority stress theory is the leading explanatory mechanism for these disparities, Reference Meyer15–Reference Lehavot and Simoni18 and experiences of discrimination potentiate drug and alcohol use, and use disorders. Reference Meyer15,Reference Slater, Godette, Huang, Ruan and Kerridge19,Reference Keyes, Hatzenbuehler and Hasin20
Addiction treatment services can significantly impact drug- and alcohol-related morbidity and mortality. However, engaging and retaining sexual minority people in treatment may be challenging. In general, sexual minority people frequently experience negative healthcare encounters, Reference Robinson21–Reference Adley, O’Donnell and Scott24 and may fear homophobic/biphobic discrimination or abuse within services. Reference Bartels, Tseung-Wong, Crisp and Brown22,Reference Clark, Jewell, Sherman, Balthazar, Murray and Bosse23 They tend to receive poorer-quality care than heterosexual people, Reference Khan, Plummer, Hussain and Minichiello25–Reference Kneale, Henley, Thomas and French28 which may result from heterosexist bias among healthcare staff. Reference Cochran, Peavy and Cauce29 Concerns about services lacking sexual minority-specific knowledge and ‘cultural competence’ may also be barriers to access. 30–Reference Keogh, Reid, Bourne, Weatherburn, Hickson and Jessup32
For sexual minority people, therefore, their increased health needs are often not matched by their rates of health consultation. There is significant unmet need, or a ‘treatment gap’, as a result of barriers to healthcare access. Reference Whaibeh, Mahmoud and Vogt33,Reference Floyd, Pierce and Geraci34 In the addiction context, sexual minority-targeted or specialised treatment services are one response to this, and may have better outcomes than non-targeted services. Reference Green and Feinstein35,Reference Senreich36 There is a body of both qualitative and quantitative literature addressing addiction treatment access by sexual minority people, and to our knowledge, this is the first review to examine it systematically.
Objectives
We aimed to answer the question ‘What are the barriers and facilitators to accessing drug and alcohol addiction treatment services for sexual minority people?’. We expected that sexual minority people would experience unique barriers and facilitators to accessing addiction treatment based on their sexual minority status (e.g. homophobia from treatment providers). There may also be general barriers and facilitators, (e.g. around health insurance status), which may be more likely to affect sexual minority people than heterosexual people because of the socioeconomic disparities driven by their minority status.
Method
This review was prospectively registered in PROSPERO (identifier CRD42021244006), and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann and Mulrow37
Eligibility criteria
The target population was adults who identify as gay, lesbian, bisexual, queer or other sexual minority; and have accessed addiction treatment services, have tried to access addiction treatment services, want to access addiction treatment services or would benefit from accessing addiction treatment services. Services could include statutory health services, private services and third-sector providers that provide specialist, structured interventions for drug and/or alcohol addiction.
Studies were included if they were published in English, reported on adults (>80% of participants in study aged ≥18 years), reported on the population defined above (or included findings from health professionals or service providers, which were relevant to the study aims), and reported on barriers and/or facilitators to access for addiction treatment services. We included qualitative, quantitative and mixed-methods primary research studies. We excluded unpublished studies, conference abstracts, editorials, reviews, case reports, comment pieces, news articles and books. A list of the inclusion and exclusion criteria is provided in Supplementary Table 1 available at https://doi.org/10.1192/bjp.2026.10589.
Information sources
A systematic search was performed using the Medline, PsycINFO (via Ovid), CINAHL (via EBSCOHost), Web of Science and Sociological Abstracts (via ProQuest) databases (searched since inception). Reference lists of included studies were also searched to identify any additional relevant studies that were not captured by the search strategy.
Search strategy
The search strategy (A + B + C + D) combined MeSH terms/subject headings and keywords relating to the following constructs: A: sexual minorities, B: addiction, C: treatment service, D: barriers and facilitators.
The full syntax is given in Supplementary Table 2. The initial search and data extraction was performed on 25 April 2021, and searches were re-run on 20 October 2024 before the final analysis, to identify and extract data from any additional studies published since the original search. A final search was run on 18 April 2025 before submission for publication.
Selection process
EPPI Reviewer Web software (version 4.12.0.0 for macOS; Institute of Education, University of London, UK; https://eppi.ioe.ac.uk/EPPIReviewer-Web/home) was used for initial screening, which allowed automated de-duplication. Initial screening of titles and abstracts was performed by the first author, Reference Higgins and Thomas38 with 10% independently checked by the second author to ensure reliability. Screening decisions were recorded in EPPI Reviewer Web. All articles that appeared to meet the inclusion criteria were included for full-text screening. The first and second authors then independently screened full-text articles against the inclusion criteria and Mixed Methods Appraisal Tool 2018 version (MMAT-2018) screening questions. Reference Hong, Pluye, Fàbregues, Bartlett, Boardman and Cargo39 Decisions were recorded in a Microsoft Excel file. Any decisions where agreement could not be reached were discussed with the other authors for arbitration.
Data collection process
For included studies, the first and second authors independently extracted key variables and rated the quality of the included studies, using the MMAT-2018. The data items extracted are presented in Supplementary Table 3.
Study risk-of-bias assessment
This systematic review used the MMAT-2018, which allows a unified scoring of qualitative, quantitative and mixed-methods studies, resulting in a six-point rating of each study’s quality (zero ‘yes’ answers = poor quality, five ‘yes’ answers = very good quality). The first and second authors independently rated studies and recorded decisions in a Microsoft Excel file. In the case of any rating discrepancies that could not be resolved by discussion, arbitration was sought from the other authors.
Effect measures
Barriers and facilitators to accessing addiction treatment services were classified by the first and second authors into dimensions of accessibility according to the model from Levesque et al. Reference Levesque, Harris and Russell40 This model defines access as ‘the opportunity to reach and obtain appropriate health care services in situations of perceived need for care’. It includes five ‘service-side’ factors (approachability, acceptability, availability and accommodation, affordability and appropriateness) and five corresponding ‘patient-side’ factors (ability to perceive, ability to seek, ability to reach, ability to pay and ability to engage).
Synthesis methods
Individual barriers and facilitators were summarised by the first and second authors, in discussion with the other authors, into overarching themes for presentation. For example, the specific barriers ‘could not afford to pay the medical bill’ and ‘having no money to access detox services’ were summarised into the theme of ‘unable to afford medical bills/pay for addiction services’. A narrative synthesis was conducted in line with the guidance found in Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Reference Popay, Roberts, Sowden, Petticrew, Arai and Rodgers41
Results
The PRISMA flow diagram (Fig. 1) summarises the results of the search and screening process.
Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
Study characteristics
Of the 62 included studies, the majority (n = 38) were from the USA, Reference Cochran, Peavy and Cauce29,Reference Allen and Mowbray42–Reference Nieder, Schachter and Ajayi78 with eight from Canada, Reference Goodyear, Mniszak, Jenkins, Fast and Knight79–Reference Israelstam86 five from the UK, Reference Bourne, Reid, Hickson, Torres-Rueda, Steinberg and Weatherburn87–Reference Smiles, O’Donnell and Jackson91 three from Australia, Reference Copeland and Hall92–Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 two from Singapore Reference Tan, Phua, Tan, Gan, Ho and Ong95,Reference Tan, Wong, Chen, Chan, Bin Ibrahim and Lim96 and one each from Peru, Reference Brown, Vagenas, Konda, Clark, Lama and Gonzales97 South Africa, Reference Parry, Petersen, Dewing, Carney, Needle and Kroeger98 France, Reference Aslan, Lessard, Lebouché, Bichard, Loze and Laussat99 Germany Reference Graf, Dichtl, Deimel, Sander and Stöver100 and Ireland. Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 There was also one global survey. Reference Flores, Santos, Makofane, Arreola and Ayala102 Supplementary Table 4 summarises the characteristics of the included studies, and Supplementary Table 5 summarises the detailed results of the MMAT-2018 quality assessment. Quality of the included papers (32 qualitative, 26 quantitative and four mixed methods) was variable. Many of the quantitative studies relied on convenience sampling with a high risk of non-response bias, and failed to account for potential confounders of the findings. Qualitative studies were typically rated as higher quality, reflecting the utility of qualitative approaches for answering the research question, although some did not justify findings with reference to the collected data. All of the mixed-methods studies had some quality issues. Excluded studies are summarised in Supplementary Table 6.
Service-related barriers to access
A summary table of results can be seen in Supplementary Table 7.
Approachability
Approachability in Levesque et al’s model is the idea that a service ‘exists, can be reached, and [can] have an impact on the health of the individual’. Reference Levesque, Harris and Russell40 Several studies identified services lacking specific expertise and provision around LGBTQ+ addiction issues (for example, not providing for sexual minority patients’ specific sexual/mental health needs, or having no available services which could address sexualised drug use or methamphetamine use). Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Hussen, Camp, Jones, Patel, Crawford and Holland68,Reference Hellman, Stanton, Lee, Tytun and Vachon74,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Israelstam86–Reference Ralphs and Gray88,Reference Smiles, O’Donnell and Jackson91,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94,Reference Graf, Dichtl, Deimel, Sander and Stöver100 Services failing to provide information to patients about how drug support services work and how they can help was reported by two studies. Reference Tomkins, Vivancos, Ward and Kliner89,Reference Tan, Phua, Tan, Gan, Ho and Ong95 In some health systems, fragmentation of services means patients end up ‘knocking on several doors’, ‘falling between the gaps’ or being inefficiently ‘cycled’ between organisations or service pathways before they are able to access the specific treatment they need. Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference McGaughey, Richardson and Vera90,Reference Graf, Dichtl, Deimel, Sander and Stöver100 One study reported that because there were no available in-patient facilities for methamphetamine detoxification, methamphetamine-using men who have sex with men (MSM) were deliberately consuming excessive alcohol to render them eligible for a detox admission. Reference Hussen, Camp, Jones, Patel, Crawford and Holland68 Several studies in this review focused on chemsex, which is the use of specific drugs (‘chems’, usually crystal methamphetamine, gamma-hydroxybutyrate/gamma-butyrolactone and synthetic cathinones such as mephedrone) by MSM or LGBTQ+ people to facilitate or enhance sexual activity. Reference Stuart103 Chemsex participants felt that addiction services were set up for alcohol or non-chemsex drug users rather than for chemsex, Reference Ralphs and Gray88,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 a finding echoed in a study about drug service staff experiences. Reference Smiles, O’Donnell and Jackson91
Acceptability
Acceptability relates to ‘the cultural and social factors determining the possibility for people to accept aspects of the service’. Reference Levesque, Harris and Russell40 We have chosen to classify studies that reported on explicit harm to sexual minority patients here, acknowledging that such harm is unacceptable. Multiple studies reported explicit harassment, discrimination, bullying, threats, violence or abuse toward sexual minority people within services. Reference Cochran, Peavy and Cauce29,Reference Braine43,Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Washington and Brocato57,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Senreich75,Reference Travers and Schneider80 Examples of this range from a lesbian patient being raped by a male staff member, claiming he would make her heterosexual, Reference Travers and Schneider80 to patients being denied treatment because of their sexual identity. Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69 In addition, several studies reported staff failing to protect sexual minority patients from hostility, overt homophobia, attacks, sexual violence or abuse from non-sexual minority patients in treatment settings. Reference Braine43,Reference Hall48,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Senreich75,Reference Travers and Schneider80,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81 Explicit negative or stigmatising attitudes of service staff toward sexual minority patients were reported by 12 studies; Reference Gorman, Barr, Hansen, Robertson and Green46,Reference Hall48,Reference Washington and Brocato57,Reference Willging, Harkness, Israel, Ley, Hokanson and DeMaria58,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Senreich75,Reference Travers and Schneider80,Reference Barbara85,Reference Israelstam86,Reference Smiles, O’Donnell and Jackson91,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 for example, perceiving drug-using MSM as ‘difficult’ patients Reference Gorman, Barr, Hansen, Robertson and Green46 or staff explaining that they did not ‘condone’ homosexuality. Reference Travers and Schneider80 Inadequate training/clinical supervision of staff around LGBTQ+ issues, or staff holding inaccurate information/myths/stereotypes about LGBTQ+ people (for example, that homosexuality is caused by sexual abuse Reference Travers and Schneider80 ), was reported by nine studies. Reference Cochran, Peavy and Cauce29,Reference Gorman, Barr, Hansen, Robertson and Green46,Reference Hall48,Reference Hussen, Camp, Jones, Patel, Crawford and Holland68,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Hellman, Stanton, Lee, Tytun and Vachon74,Reference Travers and Schneider80,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Smiles, O’Donnell and Jackson91 One study reported that drug services having a ‘poor reputation’ was a potential barrier. Reference Conner, Lamb and Dermody66
Six studies described that disclosure of sexual minority status when accessing or already in treatment negatively affected subsequent service provision. Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Senreich75,Reference Travers and Schneider80 Other barriers included heteronormative assumptions made on intake forms and during treatment (e.g. assuming that a woman must have a husband, or only talking about heterosexual relationships in treatment groups). Reference Hall48,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Travers and Schneider80,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 Three studies reported that services had a lack of insight into the unique needs of sexual minority mothers, Reference Hall48,Reference Matthews, Lorah and Fenton73,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 and one study reported services not including the partners of gay/lesbian people in ‘family’ programmes. Reference Matthews, Lorah and Fenton73 Two studies reported that the abstinence-only focus of services was a barrier; Reference Gorman, Barr, Hansen, Robertson and Green46,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67 for example, not taking into account the importance of sexualised drug use. Reference Gorman, Barr, Hansen, Robertson and Green46 For people involved with chemsex, stigma around accessing needle exchanges and services (because they are associated with opiate drug users) was reported as a barrier. Reference Ralphs and Gray88 One study also described organisational tensions between non-specialist and specialist LGBTQ+ programmes within the same service. Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53
Availability and accommodation
This dimension of access relates to factors such as geographic location, opening hours, appointment mechanisms, models of care and staff capacity. Here, studies reported on specific barriers perceived by sexual minority patients such as inconvenient opening times (e.g. only 9am–5pm), Reference Allen and Mowbray42,Reference Conner, Lamb and Dermody66,Reference Ralphs and Gray88,Reference McGaughey, Richardson and Vera90 geographical unavailability of services (e.g. outside main city areas), Reference Underhill, Morrow, Colleran, Holcomb, Operario and Calabrese56,Reference Conner, Lamb and Dermody66,Reference Nieder, Schachter and Ajayi78,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 and problems with childcare provision at services. Reference Hall48,Reference Israelstam86 Two studies reported waiting lists as a barrier (e.g. 6 months for a gamma-hydroxybutyrate/gamma-butyrolactone detox), Reference Conner, Lamb and Dermody66,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 and two studies reported that low numbers of sexual minority patients led to isolation within treatment programmes, or restricted provisions of sexual minority-only services. Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54 One study reported that the finite/limited resources of services were evident (e.g. not giving naloxone to non-injecting drug users). Reference Goodyear, Mniszak, Jenkins, Fast and Knight79 Staff feeling unable to accommodate the specific needs of sexual minority patients, Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54 and the type of treatment sexual minority patients wanted not being offered Reference Haney49 were also reported as barriers. The effect of rurality versus urbanicity on unmet alcohol and substance use disorder treatment need was examined by one paper, with mixed findings depending on different subgroups and no clear overall trend. Reference Dyar and Morgan62
Affordability
Affordability-related barriers included health insurance not covering the cost of addiction treatment, Reference Haney49 a lack of economic resources preventing access to appropriate addiction-related medical services, Reference Gorman, Barr, Hansen, Robertson and Green46 low-cost or free addiction treatment programmes not being available in certain regions Reference Flores, Santos, Makofane, Arreola and Ayala102 and underfunded services being unable to pay for additional staff, rooms or specialist training. Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53
Appropriateness
The ‘appropriateness’ dimension of access relates to the fit between services and patients’ needs. Here, ten studies reported missed opportunities by services and staff to address or explore important LGBTQ+ issues (such as trauma, coming out, sexual health, sexualised drug use and sexual violence). Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Washington and Brocato57,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Travers and Schneider80,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Smiles, O’Donnell and Jackson91,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 Several studies reported service staff were negative/awkward about, or lacking knowledge about, the topic of sexuality and sexual practice,s Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Washington and Brocato57,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Hellman, Stanton, Lee, Tytun and Vachon74,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Israelstam86,Reference Smiles, O’Donnell and Jackson91,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 and that there was an inappropriate under-focus on sexuality (e.g. never mentioning it, or deflecting the topic even when patients explicitly linked substance use to the stresses associated with being sexual minority). Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Travers and Schneider80,Reference Israelstam86,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 Some examples of specific negative experiences include staff ‘outing’ patients without consent and breaching confidentiality; Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Travers and Schneider80 instructing sexual minority patients to hide their sexuality for the sake of non-sexual minority patients in groups; Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54 paternalistic, confrontational or coercive consultation styles; Reference Hall48,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69 silencing patients who brought up chemsex-related topics; Reference Tan, Phua, Tan, Gan, Ho and Ong95 staff stating that bisexuality did not exist; Reference Travers and Schneider80 staff not understanding the topic of sexual identity and motherhood; Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 and staff believing that sexuality-conversion therapy was effective or practising conversion therapy to try and make patients heterosexual. Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Travers and Schneider80 However, an inappropriate over-focus on sexuality could also be problematic, and make patients feel misunderstood or ‘different’ (e.g. insisting homosexuality must be the cause of addiction problems). Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Travers and Schneider80 One study reported that services did not acknowledge or address intersectionality (e.g. race/ethnicity and sexuality), Reference Hall48 and one study reported that services were only targeting a middle-class clientele rather than patients with higher needs. Reference Braine43
Service-related facilitators to access
Approachability
A variety of facilitators to access were reported. First, multiple studies reported on the creation, provision or importance of sexual minority-specific services or treatment pathways, including specific needs assessments. Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Rowan, Jenkins and Parks76,Reference Nieder, Schachter and Ajayi78,Reference Israelstam86,Reference Ralphs and Gray88,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94,Reference Aslan, Lessard, Lebouché, Bichard, Loze and Laussat99 For existing services, several studies reported on outreach to the sexual minority community to facilitate access (e.g. via smartphone hook-up apps, pop-up services, discussion groups, social networks, gay club nights/fetish venues and commercial sex areas). Reference Braine43,Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50,Reference Kanouse51,Reference Ralphs and Gray88,Reference Tomkins, Vivancos, Ward and Kliner89,Reference Graf, Dichtl, Deimel, Sander and Stöver100 Several studies mentioned clear referral pathways into addiction services (e.g. following crisis hospital admission, from sexual health services and from public assistance services), Reference Braine43,Reference Ralphs and Gray88,Reference Graf, Dichtl, Deimel, Sander and Stöver100,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 and for the provision of referral pathway options beyond the criminal justice system. Reference Ralphs and Gray88 Six studies mentioned the creation of visibly LGBTQ+ safe/friendly environments (e.g. having LGBTQ+ positive waiting-room literature, or displaying Pride flags or rainbow stickers). Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Rowan, Jenkins and Parks76,Reference Barbara85,Reference Smiles, O’Donnell and Jackson91,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 Some study participants reported that they would prefer to access specialist drug services within sexual health clinics (e.g. because they were trusted as gay-friendly), Reference Bourne, Reid, Hickson, Torres-Rueda, Steinberg and Weatherburn87,Reference Tomkins, Vivancos, Ward and Kliner89 or endorsed the idea of holistic ‘one-stop shop’ services which could address addiction, sexual health and mental health concerns in an integrated way. Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81 One study advocated for training medical staff (particularly in sexual health and HIV care) in identification and referral of chemsex participants into services. Reference Ralphs and Gray88 Three studies recommended or reported on addiction service staff having knowledge of other local support services to facilitate onward referrals. Reference Rowan, Jenkins and Parks76,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Smiles, O’Donnell and Jackson91 Partnership working (e.g. between addiction, sexual health and emergency services, criminal justice agencies, housing providers and LGBTQ+ organisations) is one way to achieve this. Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82,Reference Ralphs and Gray88,Reference Graf, Dichtl, Deimel, Sander and Stöver100 Publicity around drug support services directed at MSM was mentioned by one study, Reference Tomkins, Vivancos, Ward and Kliner89 and one study on pharmacotherapy for alcohol use disorder recommended improved information provision around this, using the language of harm reduction. Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50
Acceptability
Seeing an openly LGBTQ+ healthcare professional, managerial and organisational support of diversity within drug services, and services recruiting LGBTQ+ staff Reference Green47,Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Hellman, Stanton, Lee, Tytun and Vachon74,Reference Rowan, Jenkins and Parks76,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82,Reference Smiles, O’Donnell and Jackson91,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 were reported facilitators that enhance the acceptability of services. Fourteen studies mentioned the importance of positive, caring, affirmative or non-judgemental attitudes from service providers (e.g. staff empathising with the difficulties of homophobia, taking time to ensure patients felt comfortable, being able to openly discuss gay sexuality or acting as LGBTQ+ allies), Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Senreich75,Reference Rowan, Jenkins and Parks76,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82,Reference Barbara85,Reference Bourne, Reid, Hickson, Torres-Rueda, Steinberg and Weatherburn87,Reference Tomkins, Vivancos, Ward and Kliner89,Reference McGaughey, Richardson and Vera90,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94,Reference Graf, Dichtl, Deimel, Sander and Stöver100,Reference Flores, Santos, Makofane, Arreola and Ayala102 which can be facilitated through staff training (including for non-clinical staff) and policies about sexual minority patients. Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 Three studies reported on the importance of ‘cultural humility’ or ‘horizontal approaches’ from service providers, involving critical self-reflection and positioning the patient as the expert in their lives. Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference McGaughey, Richardson and Vera90 Two studies recommended intake forms/processes using inclusive, open-ended language regarding sexuality and gender, and allowing non-disclosure of sexual minority status. Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 Services that can be used anonymously may facilitate access in countries with sanctions around drug use or sexual minority status. Reference Tan, Wong, Chen, Chan, Bin Ibrahim and Lim96 Two studies also reported on staff at needle exchange programmes providing informal referrals to less LGBTQ+-hostile service environments, or acting as sources of solidarity. Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69 One study recommended the inclusion of LGBTQ+ people in service development (e.g. formulating non-discrimination or staff vetting policies), Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69 and another recommended staff explicitly let patients know that their service is LGBTQ+-positive at their first contact. Reference Barbara85 Positive LGBTQ+ community feedback can enhance the reputability of services. Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94
Availability and accommodation
Practical measures such as the establishment of evening and weekend drug clinics, offering alcohol treatment groups in non-clinical settings and improved service provision in city centres Reference Saulnier55,Reference Ralphs and Gray88 were reported. Three studies also reported on locating services strategically in LGBTQ+ community areas or areas of high need (e.g. a needle exchange in the gay village, drop-in recovery services near where alcohol is sold). Reference Saulnier55,Reference Ralphs and Gray88,Reference Tomkins, Vivancos, Ward and Kliner89 For existing services, gender neutral bathrooms may be a facilitator to access. Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53 One study on factors associated with high access to substance misuse treatment programmes for MSM found these typically correlated with high access to HIV risk reduction and education, medical care, mental health services and a high education level, Reference Flores, Santos, Makofane, Arreola and Ayala102 which can all function as facilitators. When asked to rate the relative importance of drug service design characteristics, the availability of one-to-one support in addition to counsellor-led group counselling; long-term, open-ended support; and support located close to home were rated highly by methamphetamine-using MSM. Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82 One study noted the importance of having a separate treatment facility or separate unit/area within a service for sexual minority patients. Reference Rowan, Jenkins and Parks76
Affordability
One study reported on drop-in community recovery centres offering cheap or sliding scale payments as a facilitator to access. Reference Saulnier55
Appropriateness
Nine studies reported on the importance of holistic, intersectional or ‘whole person’ approaches to treatment (e.g. incorporating sexuality, substance misuse, housing and social support, subsistence needs, mental health, culture and spirituality) Reference Hall48,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Washington and Brocato57,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Rowan, Jenkins and Parks76,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82,Reference McGaughey, Richardson and Vera90 to enhance the appropriateness of services. Providers ‘meeting the client where they are at’ (e.g. reflecting patients’ own language and identity labels, or offering flexibly tailored treatment) Reference Forenza and Benoit45,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Rowan, Jenkins and Parks76 can also help, in addition to professionals having specific knowledge, education and ‘cultural competence’ about issues relevant to sexual minority healthcare (e.g. methamphetamine use, coming out challenges, societal homophobia, links between drug use and sexual practices). Reference Gorman, Barr, Hansen, Robertson and Green46,Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Washington and Brocato57,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Rowan, Jenkins and Parks76,Reference Nieder, Schachter and Ajayi78,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82,Reference Barbara85,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 Open, non-judgemental questioning about gender and sexual preference during intake processes for new patients was reported as a facilitator, Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53,Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 with service providers acknowledging sexuality as an important component of identity without assuming it is the cause of a patient’s problems. Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Rowan, Jenkins and Parks76,Reference Pennay, McNair, Hughes, Leonard, Brown and Lubman93 Matching patients to therapists with their preferred sexual and/or gender identity, Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53 and staff using a warm, hopeful consultation style that preserves the patient’s decision-making power Reference Hall48,Reference Rowan, Jenkins and Parks76,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81 were also reported facilitators. Two studies mentioned the importance of approaches which are trauma-informed and sex-positive, Reference Washington and Brocato57,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69 one mentioned services being inclusive of HIV education and advocacy, Reference Washington and Brocato57 and two others reported on the ability to link patients to wider support programmes (e.g. a sexual minority women’s group) Reference Mericle, de Guzman, Hemberg, Yette, Drabble and Trocki53,Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81 as facilitators to access. Provision of relevant harm reduction supplies (e.g. clean needles) can also be a facilitator. Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82,Reference Graf, Dichtl, Deimel, Sander and Stöver100
Patient-related barriers to access
Ability to perceive
Complementary to the dimension of access of approachability, ‘ability to perceive’ includes patient-related factors such as health literacy, health beliefs, trust and expectations. Included studies reported barriers such as ambivalence around drug/alcohol use or reluctance to change, Reference Allen and Mowbray42,Reference Green47,Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50,Reference Willging, Harkness, Israel, Ley, Hokanson and DeMaria58,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Parry, Petersen, Dewing, Carney, Needle and Kroeger98,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 not seeing drug/alcohol use as a problem or serious problem, Reference Allen and Mowbray42,Reference Goodyear, Mniszak, Jenkins, Fast and Knight79,Reference Tomkins, Vivancos, Ward and Kliner89,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94,Reference Parry, Petersen, Dewing, Carney, Needle and Kroeger98,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 and negative beliefs around addiction or its treatment (e.g. feeling ‘I should be strong enough to handle this alone’, not believing that ‘alcoholism’ is a treatable condition, or feeling that gamma-hydroxybutyrate/gamma-butyrolactone users were treated inadequately by services). Reference Allen and Mowbray42,Reference Conner, Lamb and Dermody66,Reference Brown, Vagenas, Konda, Clark, Lama and Gonzales97,Reference Parry, Petersen, Dewing, Carney, Needle and Kroeger98,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 Several studies reported that patients did not know that addiction treatment was available/existed, Reference Allen and Mowbray42,Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50,Reference Conner, Lamb and Dermody66,Reference Goodyear, Mniszak, Jenkins, Fast and Knight79,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94,Reference Brown, Vagenas, Konda, Clark, Lama and Gonzales97 did not know where or how to access services, Reference Haney49,Reference Conner, Lamb and Dermody66,Reference Goodyear, Mniszak, Jenkins, Fast and Knight79,Reference Parry, Petersen, Dewing, Carney, Needle and Kroeger98 were not sure if they would be eligible for treatment Reference Conner, Lamb and Dermody66 or felt that the type of treatment they wanted was not offered from services. Reference Haney49 Two studies reported participants not believing addiction treatment was appropriate to their needs, Reference Hall48,Reference Goodyear, Mniszak, Jenkins, Fast and Knight79 and three studies reported on concerns about other drug users, or rehabilitation itself, triggering relapse. Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Goodyear, Mniszak, Jenkins, Fast and Knight79,Reference Parry, Petersen, Dewing, Carney, Needle and Kroeger98 One study of MSM noted that greater frequency of methamphetamine use, and greater frequency of sexualised use, was associated with an increased perceived difficulty of accessing support. Reference Card, McGuire, Bond-Gorr, Nguyen, Wells and Fulcher84 Normalisation of drug/alcohol use among sexual minority people/peers can also be a barrier to individuals perceiving the need to access services. Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 For lesbians specifically, a sense of being ‘different and isolated’ can lead to them feeling that conventional healthcare is not designed for their needs. Reference Hall48
Ability to seek
Studies reported barriers such previous unsuccessful attempts to access or utilise treatment, Reference Allen and Mowbray42,Reference Parry, Petersen, Dewing, Carney, Needle and Kroeger98,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 fears or embarrassment about discussing addiction or treatment, Reference Allen and Mowbray42,Reference Conner, Lamb and Dermody66,Reference Matthews, Lorah and Fenton73 apprehension about discussing sexualised drug or alcohol use, Reference Senreich75,Reference Goodyear, Mniszak, Jenkins, Fast and Knight79,Reference Bourne, Reid, Hickson, Torres-Rueda, Steinberg and Weatherburn87,Reference Tomkins, Vivancos, Ward and Kliner89 and fears of others’ opinions on learning about a person’s addiction problems. Reference Allen and Mowbray42,Reference Matthews, Lorah and Fenton73 Fear of stigma owing to sexual minority status, alcohol/drug use (particularly injecting) or addiction treatment itself was also reported. Reference Hall48,Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50,Reference Underhill, Morrow, Colleran, Holcomb, Operario and Calabrese56,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Sucaldito, Tanner, Mann-Jackson, Alonzo, Garcia and Chaffin70,Reference Matthews, Lorah and Fenton73,Reference Senreich75,Reference Rowan, Jenkins and Parks76,Reference Goodyear, Mniszak, Jenkins, Fast and Knight79,Reference Barbara85,Reference Israelstam86,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94–Reference Tan, Wong, Chen, Chan, Bin Ibrahim and Lim96 People are worried about involuntary admission to hospital if services are accessed, Reference Allen and Mowbray42 and for lesbian women particularly, there are fears that children will be taken into care if they enter treatment services. Reference Hall48 Three studies reported on concerns that being given pathologising labels (e.g. ‘alcoholic’), might compound the social stigma already experienced by sexual minority patients. Reference Forenza and Benoit45,Reference Hall48,Reference Israelstam86 For Black non-gay identified men who have sex with men and women, there may be specific barriers to seeking treatment related to cultural constructions of masculinity. Reference Forenza and Benoit45 One study described barriers to methamphetamine treatment for Black MSM as a racialised problem, caused by exposure to poverty, inadequate education and few resources compared with White MSM. Reference Hussen, Camp, Jones, Patel, Crawford and Holland68
Women experiencing lifetime high-risk drug use were more likely than moderate- or low-risk users to report that they had wanted but had not received professional support. Reference Corliss, Grella, Mays and Cochran44 For services that are difficult to physically access, an increased commitment is needed to attend. Reference Underhill, Morrow, Colleran, Holcomb, Operario and Calabrese56 In the Singaporean context, fear of incarceration/criminal sanctions for drug use or gay sex, or being reported by staff to drug law enforcement agencies, were barriers to service access. Reference Tan, Phua, Tan, Gan, Ho and Ong95,Reference Tan, Wong, Chen, Chan, Bin Ibrahim and Lim96 One USA study also reported not accessing services because of fears of legal ramifications. Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 There were also several studies reporting on differences in barriers to access comparing women versus men, or sexual minority subgroups. Compared with gay men, bisexual men were reported to have both a decreased Reference Hodges, Goings, Vaughn, Oh and Salas-Wright63,Reference Krasnova, Diaz, Philbin and Mauro65 and increased Reference Roth, Cui, Armstrong, Rich, Lachowsky and Sereda83 likelihood of drug treatment utilisation, and an increased likelihood of alcohol treatment utilisation. Reference Micale, Brubaker, Richardson and Acquavita71 Compared with a matched cohort of heterosexual men, sexual minority men ≥50 years old had a lower rate of in-patient drug treatment utilisation, and compared with heterosexual women, sexual minority women ≥50 years old had a higher rate of in-patient drug treatment utilisation. Reference Rowan, Frimpong, Li, Chaudhry and Radigan72 Black bisexual women had higher odds of reporting a treatment gap for both specialty drug, and alcohol services (compared with Black bisexual men, gay men and lesbian women), and Black gay men had worse odds of experiencing a drug specialty treatment gap than Black bisexual men. Reference Rice, Anderson-Carpenter and Ellis59 Latina sexual minority women were less likely to access substance use treatment services compared with White sexual minority women. Reference Jeong, Veldhuis, Aranda and Hughes77 Compared with sexual minority men, sexual minority women with probable alcohol use disorder were less likely to have this diagnosed by a professional, and less likely to attend substance use-related appointments. Reference Batchelder, Stanton, Kirakosian, King, Grasso and Potter60 For gay/lesbian-specific treatment units, a focus on White men can mean that they are perceived as less welcoming for women and ethnic minority people. Reference Rowan, Jenkins and Parks76
Ability to reach
One study reported that Black lesbian and bisexual women had less social support to help with accessing alcohol treatment than for heterosexual women, Reference Mays, Beckman, Oranchak and Harper52 and another study noted that services may only be accessible by car, meaning that patients may need to pay others to drive them. Reference Underhill, Morrow, Colleran, Holcomb, Operario and Calabrese56 One study of MSM reported that family members could be a barrier to treatment entry, for example by trying to force them to do so, creating resistance to the idea. Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67
Ability to pay
Included studies reported barriers such as sexual minority patients being unable to afford medical bills/pay for addiction services, or concerns about the potential costs. Reference Allen and Mowbray42,Reference Gorman, Barr, Hansen, Robertson and Green46,Reference Underhill, Morrow, Colleran, Holcomb, Operario and Calabrese56,Reference Conner, Lamb and Dermody66 For some specific treatments, such as medications for alcohol use disorder, there may be concerns around cost/benefits ratio of medications. Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50 Two USA studies also noted problems with obtaining health insurance, which may be dependent on employment. Reference Underhill, Morrow, Colleran, Holcomb, Operario and Calabrese56,Reference Nieder, Schachter and Ajayi78
Ability to engage
Studies reported factors such as sexual minority patients not wanting to engage with services, or wanting to continue alcohol/drug use, Reference Allen and Mowbray42 not having time to attend a service, Reference Conner, Lamb and Dermody66 difficulty in keeping appointments during periods of heavy substance use Reference Underhill, Morrow, Colleran, Holcomb, Operario and Calabrese56 and difficulty staying sober because of being unable to enjoy sex without drugs. Reference Gorman, Barr, Hansen, Robertson and Green46 Feelings of isolation or alienation (i.e. as a minority within predominantly heterosexual) services or therapeutic groups limited their success. Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Senreich75,Reference Rowan, Jenkins and Parks76 For specific treatments, such as medication for alcohol use disorder, studies reported concerns around the burden of treatment, and fears that it might negatively impact enjoyment of alcohol. Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50,Reference Brown, Vagenas, Konda, Clark, Lama and Gonzales97 Three studies reported concerns with confidentiality when accessing services. Reference Conner, Lamb and Dermody66,Reference Matthews, Lorah and Fenton73,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 Mistrust in healthcare providers was reported (e.g. patients feeling that healthcare providers have negative/pathologising attitudes or inadequate knowledge, or they have to educate their healthcare providers about LGBTQ+-related issues). Reference Hall48,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Barbara85,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 Perhaps consequently, sexual minority people feel the need to present in a heteronormative manner, Reference Travers and Schneider80 or censor/not disclose their sexuality. Reference Senreich75,Reference Barbara85,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 This led to difficulties discussing sexual practices or identity in therapeutic relationships, or fearing that staff members cannot ‘relate’ to sexual minority patients. Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Senreich75,Reference Barbara85,Reference Tomkins, Vivancos, Ward and Kliner89,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 Drug and alcohol treatment may be unsuccessful or less successful if someone feels unable to disclose their sexuality or sexual practices. Reference Senreich75,Reference Barbara85,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 Patients fearing homophobia, shaming, rejection or abuse based on their sexual identity within treatment settings is a significant barrier to engagement. Reference Penn, Brooke, Mosher, Gallagher, Brooks and Richey54,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Senreich75,Reference Rowan, Jenkins and Parks76,Reference Israelstam86,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94
Patient-related facilitators to access
Ability to perceive
Patient-related facilitators to access included knowledge of addiction support services and treatment options (e.g. pharmacological treatment of alcohol use disorder), Reference Hsiang, Jennings, Matheson, Hern, Euren and Santos50,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 and peer advocates and LGBTQ+ networks helping patients to understand their addiction problems and promoting treatment. Reference Braine43,Reference Willging, Harkness, Israel, Ley, Hokanson and DeMaria58,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67 Patients involved in chemsex were motivated to access services when they perceived it to be detrimental, or to avoid related financial, housing or employment crises. Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94
Ability to seek
No reported facilitators were found.
Ability to reach
Signposting and referral to services through LGBTQ+ community contacts, networks, peer advocates, family and friends can act as facilitators to access Reference Braine43,Reference Willging, Harkness, Israel, Ley, Hokanson and DeMaria58,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 and at least for MSM, use of substance misuse treatment programmes is positively associated with connection to the gay community. Reference Flores, Santos, Makofane, Arreola and Ayala102 Family support was viewed as important for successful treatment, Reference Brown, Vagenas, Konda, Clark, Lama and Gonzales97 and gay/lesbian people being able to bring ‘whoever you want to be considered family’ into family meetings as part of treatment was a facilitator. Reference Matthews, Lorah and Fenton73 Sexual minority individuals with a history of criminal legal system involvement were also more likely to utilise drug treatment than sexual minority individuals without this history. Reference Ramakrishnan and Gonzales64
Ability to pay
One study noted that providing alcohol use disorder treatment for a nominal fee seems to allow for more buy-in with the idea of treatment. Reference Brown, Vagenas, Konda, Clark, Lama and Gonzales97 A Canadian study reported on patients using private services (paid for directly or by insurance) even when free public healthcare was available, because of faster access or needing expertise not available in the public health sector. Reference Blanchette, Flores-Aranda, Bertrand, Lemaître, Jauffret-Roustide and Goyette81 For MSM, it was important that other participants in drug treatment be in similar financial situations to themselves. Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82 One USA study reported that state addiction treatment funding could be used to access an LGBTQ-specific treatment centre. Reference Nieder, Schachter and Ajayi78
Ability to engage
For sexual minority women, one study reported that having specialist women-only services is associated with greater likelihood of completing treatment. Reference Copeland and Hall92 In addition, having specialist female-only or lesbian-only groups allows sexual minority women to discuss specific relevant issues (e.g. sexual harassment and gender roles). Reference Saulnier55,Reference Israelstam86 For gay and lesbian patients, being able to ‘work though shame to self-acceptance’ was a facilitator to engagement and successful treatment. Reference Matthews, Lorah and Fenton73 Five studies reported on the focus of treatment being use reduction or harm reduction rather than abstinence, or allowing patients to set their own goals, Reference Saulnier55,Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82,Reference Brown, Vagenas, Konda, Clark, Lama and Gonzales97 as a specific facilitator. For individuals with mild or moderate alcohol problems, they may be more likely to engage in a group in a non-clinical setting, Reference Saulnier55 and peer support around gamma-hydroxybutyrate/gamma-butyrolactone use was particularly helpful for MSM. Reference Joyce, MacNeela, Sarma, Ryall and Keenan101 Building opportunities for socialising, self-expression, community connection and mutual support (particularly with other sexual minority people) within treatment facilitates engagement. Reference Viera, Sosnowy, van den Berg, Mehta, Edelman and Kershaw67,Reference Matthews, Lorah and Fenton73,Reference Senreich75,Reference Rowan, Jenkins and Parks76,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82 Two studies reported on the importance of sexual minority role models who were in recovery from addiction themselves; both other patients and staff. Reference Matthews, Lorah and Fenton73,Reference Freestone, Xiao, Siefried, Bourne, Ezard and Maher94 In one study, both sexual minority and heterosexual participants reported that their top addiction recovery facilitators were friends, community and network; family and children; and 12-step programmes such as Alcoholics Anonymous. More sexual minority than heterosexual participants cited spirituality, education and loss (e.g. of identity, loved ones, agency) as facilitators to recovery. Reference Bernier, Foley, Salomaa, Scheer, Kelly and Hoeppner61 In five studies, having other treatment participants who identify as sexual minority or LGBTQ+ was helpful. Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69,Reference Matthews, Lorah and Fenton73,Reference Senreich75,Reference Rowan, Jenkins and Parks76,Reference Card, McGuire, Berlin, Wells, Fulcher and Nguyen82 Three studies cited the importance of being able to be honest and open about the specific context of sexuality and addiction for treatment success. Reference Matthews, Lorah and Fenton73,Reference Senreich75,Reference Rowan, Jenkins and Parks76
Discussion
Interpretation of findings
This review highlighted a disparate range of potential, perceived and enacted barriers and facilitators to accessing addiction services. As we hypothesised, both barriers specific to the sexual minority community and generalised barriers were identified. Although not seeking to quantify the prevalence of different barriers/facilitators, nearly a third of included papers reported explicit physical and sexual violence, threats, abuse and discrimination toward sexual minority patients, or negative attitudes from staff members. These findings accord with a 2016 systematic review about LGBT access to health services. Reference Alencar Albuquerque, de Lima Garcia, da Silva Quirino, Alves, Belém and dos Santos Figueiredo104 Stressors such as these ‘get under the skin’ of sexual minority people, Reference Hatzenbuehler16 and may lead to identity concealment, expectations of rejection, hypervigilance to potential threats and internalised stigma. Reference Meyer15 These in turn result in negative psychological and physical outcomes. Reference Flentje, Heck, Brennan and Meyer105–Reference de Lange, Baams, van Bergen, Bos and Bosker110 Discrimination is also likely to compound the effects of traumatic life events, which are experienced by sexual minority people at higher rates Reference Tyler and Schmitz111,Reference Marchi, Travascio, Uberti, De Micheli, Grenzi and Arcolin112 and are associated with addiction. Reference Konkolÿ Thege, Horwood, Slater, Tan, Hodgins and Wild113
Abuse of patients in health settings is in stark opposition to principles of compassionate, equitable and trauma-informed healthcare. Reference Homes and Grandison114 In this context, fearing stigma from services, as reported by 14 of the included studies, may not be unjustified. These findings may reflect the fact that most of the included studies were conducted in the USA, where public attitudes toward sexual minority may be more negative than in Western Europe, Reference Poushter and Kent115 and where there are variable (and worsening) legal and policy protections between states. Reference Akré, Rapfogel and Miller116,Reference Choi117 Despite reporting across five decades, findings from older papers are repeated in newer studies. For example, both a study from 1989 Reference Hellman, Stanton, Lee, Tytun and Vachon74 and one from 2024 Reference Paschen-Wolff, DeSousa, Paine, Hughes and Campbell69 reported treatment staff lacking specific LGBTQ+ expertise, and highlighted the benefits of having openly LGBTQ+ staff; and papers reporting on explicit harassment, discrimination, bullying, threats, violence or abuse toward sexual minority patients had publication dates fairly evenly spread between 1994 and 2024. We could not identify clear temporal trends in identified barriers and facilitators.
The results of this review suggest that staff demonstrating caring, non-judgemental acceptance of sexual minority patients may be the most helpful facilitator to service access. However, tackling homophobic/biphobic or prejudiced attitudes and behaviours may be a necessary first step. Evidence-based approaches to this include intergroup contact (e.g. a session for heterosexual staff run by LGBTQ+ people), experiential learning approaches and exercises to encourage empathy and perspective-taking. Reference Morris, Cooper, Ramesh, Tabatabai, Arcury and Shinn118–Reference Cramwinckel, Scheepers and van der Toorn120 Even when healthcare workers are not prejudiced, they may have limited education on LGBTQ+-related issues. Reference Parameshwaran, Cockbain, Hillyard and Price121,Reference Marshall and Cahill122 There is evidence that ‘cultural competency’ training can improve knowledge, clinical and interpersonal skills, and attitudes toward LGBTQ+ people. Reference Yu, Flores, Bonett and Bauermeister123
Several studies reported ambivalence around or reluctance to address addiction problems, or that they were not perceived as a serious issue. This finding may speak to the relative importance and positive role of drug and alcohol use for the sexual minority community. Historically, gay bars may have been the only safe spaces to meet, and drug/alcohol use may be linked to identity formation, community connection, sexual fulfilment or active resistance to (heterosexual) norms. Reference Hakim124–Reference Pienaar, Murphy, Race and Lea127 The increased prevalence of addiction problems among sexual minority people may also mean that these are ‘normalised’ within this community. Reference Ahmed, Weatherburn, Reid, Hickson, Torres-Rueda and Steinberg128 Treatments or public health interventions should acknowledge that reducing or discontinuing drugs/alcohol may therefore be more complex for sexual minority patients compared with heterosexual patients.
Strengths and limitations
The search criteria were deliberately broad to ensure maximal retrieval and inclusion of studies, and synthesising quantitative and qualitative findings is a strength. However, the vast majority of included studies are from high-income countries, limiting the generalisability of findings to low- and middle-income countries. Findings around affordability and the practical aspects of access also need to be contextualised within differing health systems, which vary widely between countries in terms of policy and financial support (e.g. from public health systems free at the point of access, to private or insurance-based systems). This review only includes studies published in English, and unpublished or grey-literature results were not included, limiting its comprehensiveness. There is a large, related body of literature around the attitudes of treatment providers toward sexual minority patients, Reference Eliason129 which we did not include if these were not specifically conceptualised as barriers. It is likely that negative attitudes of addiction healthcare practitioners contribute to the negative experiences of sexual minority people.
A further limitation may be varying technical or cultural terminologies around sexual minorities. For example, in non-Western countries, sexual and gender minorities may be considered less separately than in Western countries, Reference Mukhopadhyay, Blumenfield, Harper, Gondak, Brown, Gonzalez and McIlwraith130 and included papers used differing definitions of sexual minorities (e.g. sexual behaviour versus self-defined identity). This review did not explicitly address the experiences of gender minorities, although many of the identified studies included trans or other gender-minority participants. We also chose to focus on specialist addiction services. Sexual minority people are likely to seek support with addiction problems from other services. These may include primary care, general mental health services and third-sector or mutual aid organisations; experiences of accessing these were not addressed by this review, and may differ from our findings.
Of the included studies, around half reported entirely or mostly on men, around a quarter reported entirely or mostly on women, and around a quarter were a more evenly mixed sample. The majority of studies focused on gay and lesbian participants, with a smaller number of bisexual participants, and only a very few studies that explicitly included queer or ‘other’ non-heterosexual sexual minority people. Of the articles that reported racial/ethnic identity, White participants were the largest group in the majority of studies. Individuals with multiple marginalised identities may face intersecting health and social challenges, Reference Turan, Elafros, Logie, Banik, Turan and Crockett131,Reference Crenshaw132 which may potentiate barriers to treatment, and so this is a limitation of the applicability of the published research.
Future implications
Although there is significant between-country variation, people with addiction problems tend to be underserved by available treatment services. Reference Connery, McHugh, Reilly, Shin and Greenfield133 Global attention to reducing treatment gaps in addiction problems may be expected to reduce generalised barriers, although it is still possible that for any given generalised barrier, its effect may be more significant on sexual minority than on heterosexual patients because of their increased marginalisation. Sexual minority people are also a heterogenous group with diverse needs, and differing access barriers and facilitators for different sub-groups (e.g. gay men versus queer women). The findings imply a range of potential solutions to tackle the identified barriers. These vary from simple interventions (e.g. creating a visibly LGBTQ+ welcoming environment, staff training to address knowledge and attitudes), to more complex organisational interventions (e.g. establishing sexual minority-specific services, or service provider competency frameworks), to wider policy and social changes (e.g. legal equalities protections for sexual minority people, improved funding of public addiction services).
Future research, ideally using representative rather than convenience samples, may wish to focus on the relative importance of different identified barriers for sexual minority individuals, and understand how these vary by orientation, gender identity, racial/ethnic identity and country of origin. Implementation or intervention studies may wish to identify what works in practice to address barriers and facilitate access, with attention to local cultural and healthcare contexts.
Supplementary material
The supplementary material is available online at https://doi.org/10.1192/bjp.2026.10589
Data availability
Search syntaxes are provided in the online supplementary material.
Author contributions
M.H. contributed to study conceptualisation, methodology, literature search, screening, data extraction and data analysis, and wrote the original draft of the manuscript. B.C. contributed to study screening and data extraction, and reviewed and edited the manuscript. C.D. contributed to study conceptualisation, supervised the study and reviewed and edited the manuscript. K.R. and E.R. supervised the study and reviewed and edited the manuscript.
Funding
M.H. is funded by the Medical Research Council (MRC) Addiction Research Clinical Fellowship (reference MR/N00616X/1). B.C. is funded by an Academic Clinical Fellowship from the National Institute for Health and Care Research (NIHR) (reference ACF/2019/21/009). E.R. is funded by an NIHR Advanced Fellowship (reference NIHR302215). The views expressed in this review are those of the authors and do not necessarily represent the views of the MRC, NIHR or National Health Service.
Declaration of interest
E.R. and C.D. are members of the British Journal of Psychiatry Editorial Board, although they did not take part in the review or decision-making process of this paper. The other authors have no conflict of interest to declare.
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