Structural determinants of tailored behavioral health services for sexual and gender minorities in the United States, 2010 to 2020: a panel analysis

Abstract

Background Research indicates that tailored programming for sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender, queer) people, compared to non-tailored programming, is effective for reducing the disproportionate health burden SGM people experience relative to the general population. However, the availability of SGM-tailored programming is often over-reported and inconsistent across behavioral health (i.e., substance use and mental health) facilities in the United States (U.S.). Methods Using panel analysis, the National Survey of Substance Abuse Treatment Services (N-SSATS), and the National Mental Health Services Survey (N-MHSS), this study examines structural stigma and government funding as two structural determinants affecting the availability of SGM-tailored programming in the U.S. Results Results indicated that from 2010 to 2020, reductions in structural stigma (i.e., increases in state-level supportive SGM policies) were positively associated with increases in the proportion of substance use treatment facilities offering SGM-tailored programming. This effect was significant after controlling for over-reporting of SGM-tailored programming and time- and state-specific heterogeneity. On average, the effect of reduced structural stigma resulted in approximately two new SGM-tailored programs in the short term and about 31 new SGM-tailored programs in the long term across U.S. substance use treatment facilities. Structural stigma did not predict the availability of SGM-tailored programming in mental health treatment facilities. Government funding was not significant in either data set. However, without correcting for over-reporting, government funding became a significant predictor of the availability of SGM-tailored programming at substance use treatment facilities. Conclusions Because SGM-tailored programming facilitates access to healthcare and the current study found longitudinal associations between structural stigma and the availability of SGM-tailored programming in substance use treatment facilities, our findings support claims that reducing structural stigma increases access to behavioral health treatment specifically and healthcare generally among SGM people. This study’s findings also indicate the importance of correcting for over-reporting of SGM-tailored programming, raising concerns about how respondents perceive the N-SSATS and N-MHSS questions about SGM-tailored programming. Implications for future research using the N-SSATS and N-MHSS data and for public health policy are discussed.

Characteristics of Outpatient and Residential Substance Use Disorder Treatment Facilities with a Tailored LGBT Program

“…28 It may very well be the case that geographic sociocultural views affect the availability of programs and services designed to support LGBT people along with policies. 11,12,25,29 Results from our analyses also found that community outreach as a programmatic characteristic is positively associated with providing LGBT-tailored programs at SUD facilities. Research suggests that engaging in community outreach to advertise LGBT-tailored programs can help raise awareness of the SUD treatment facilities providing these services.…”

“… 28 It may very well be the case that geographic sociocultural views affect the availability of programs and services designed to support LGBT people along with policies. 11 , 12 , 25 , 29 …”

“…One limitation may be the geographic breadth of the analyses. We focused on 4 regions; however, treatment facilities with LGBT services likely vary by state 25 and even regions within states, which may relate to urban and rural differences. Although the response rate and data inclusion for N-SSATS 2020 is high (88.4%), we could not examine differences between facilities that completed the survey and included in the data versus those that were not, which may present the potential for bias.…”

“…On a policy level, LGBT-friendly state-level policies are associated with an increase in the proportion of tailored LGBT programs across mental health and SUD treatment facilities. 25 Another study found that SUD treatment facilities with LGBT-tailored programs were more likely to be in the Northeastern region of the USA, offer flexible payment options, and be for-profit. 12 However, little is known about the differences between facilities that have tailored programs for LGBT individuals based on the level of care, including outpatient treatment and residential treatment.…”

Structural stigma and alcohol use among sexual and gender minority adults: A systematic review

“…Further, given the increasingly hostile policy landscape for gender minority people in particular, individual- and interpersonal-level interventions tailored for gender minority people, in addition to policy change, may be especially crucial. A recent study found that a decrease in structural stigma was longitudinally associated with an increase in SGM-tailored programming being offered at substance use treatment facilities ( Cascalheira et al., 2022 ), thereby illustrating the potential of multilevel approaches in addressing alcohol-related health inequities among SGM people. Finally, given the impact of structural stigma on alcohol use among SGM people, clinicians need to be aware of these inequities, incorporate conversations about alcohol use into care for SGM people, and be competent in providing care to SGM people.…”