Challenges of LGBTQ+ Clients during Group Therapy for Substance Use

This literature review examines substance addiction amongst lesbian, gay, bisexual, transgender, intersex, and questioning (LGBTIQ) youths and its relationship with both suicide ideation and suicide amongst LGBTIQ youths. To determine the relationship between substance addiction, suicide ideation and suicide, this piece examines different factors that influence substance addiction. This examination includes an evaluation of the socio-cultural stigma that LGBTIQ youths experience and how it may increase the risk of addiction. The review suggests LGBTIQ youths have a high degree of substance addiction, due to the prevalence of the different stressors that they experience. Stressors like impulsivity as measured by extraversion and neuroticism are also shown to contribute towards addiction (Livingstone et al., 2015). Substance dependency amongst the LGBTIQ is increased by the need to cope with external and internal factors as a result of their sexual orientation (Chaney et al., 2011). Drug use and substance addiction amongst the LGBTIQ youths may be increased by the need to cope with the isolation arising from discrimination and lack of social acceptance (Green & Feinstein, 2012). Substance addiction increases the likelihood of suicide and suicide ideation amongst LGBTIQ youths compared to their heterosexual counterparts (Russell & Fish, 2012). Moreover, the study by Russell and Fish (2012) suggest that the prevalence of prejudice, victimisation, discrimination and hate crime perpetrated towards LGBTIQ youths increases their risk of drug use and substance addiction, which adversely affects their mental health. Consequently, LGBTIQ youths are likely to engage in risky and antisocial behaviour, for example, risky sexual activities (Russell & Fish, 2012). The review proposes a number of recommendations that could be taken into consideration in minimising suicide ideation associated with substance addiction amongst LGBTIQ youths. They include increasing the level of social and family support to the LGBTIQ community. Structural implementation of these measures may reduce the risk of substance addiction.

• Introduction
• Internal sources of stress that may influence substance use and addiction
• Substance addiction and suicide ideation
• External & environmental factors and the relationship with substance use and addiction
• Substance addiction and the LGBTIQ youth's Psychological health
• Conclusion and recommendations
• References

Introduction

Modern society is characterised by a high level of diversity, particularly in relation to human sexuality. Keller et al. (2019) suggest that contemporary society is characterised by an increasingly high level of awareness of sexual orientation diversity. The lesbian, gay, bisexual, transgender, intersex and questioning (LGBTIQ) community and their supporters are intent on proving that one's biological sex orientation is not correlated with their sexual orientation or gender identity (Caputi et al., 2018). Nevertheless, a lot of effort needs to be invested to promote acceptance of LGBTIQ individuals in society. The limited level of societal and familial acceptance towards LGBTIQ youth may increase their likelihood of resorting to drug use, which according to Teesson et al. (2002) may lead to addiction.

Traditionally, addiction has been perceived as a learned behaviour or chronic disease. The behaviour may be learned from family or peers. Of the many theories of addiction, the Bio-Psycho-Social (BPSS) model seems most suited for this study. It recognises that social, biological and psychological factors all play a pivotal role in the causation of addiction (Skewes & Gonzalez, 2013). In developing treatment and prevention efforts therefore, it is important to consider all of these factors (Skewes & Gonzalez, 2013). Kelley, Schochet and Landry (2004) suggest that addiction entails the compulsion towards substance use, that results from an individual's loss of control on the behaviour over time despite the possibility of knowledge of the dangers associated with continued substance use.

Medically, addiction is classified as a chronic, progressive, and potentially fatal disease if left untreated (National Institute on Drug Abuse, 2007). The progressive nature of the addictive behaviour within an individual can be influenced by different factors that include the type of substance that an individual is taking, and an assortment of different environmental factors (Kelley, Schochet and Landry, 2004). Addiction impacts different aspects of an individual's health that include psychological, emotional, social, cognitive, spiritual, and social health. One of the effects of addiction may include the high risks associated with social-cultural stigma.

According to Schomerus et al (2015), stigma refers to an experience whereby one is deeply discredited because of his or her 'undesired' differentness. Secondly, Schomerus et al (2015) suggest that stigma leads to social isolation which limits an individual's interaction with other parties. As a result, the likelihood of individuals subjected to stigma developing a sense of belonging is severed (Schomerus et al., 2015). Stigma is identified as a major social stressor that increases the likelihood of an individual developing negative emotional reaction, a sense of hopelessness and social withdrawal (Keller et al, 2019). The social cultural stigma associated with substance addiction amongst LGBTIQ youths can therefore result in increased rates of suicide amongst such individuals (O'Donnell, Meyer & Schwartz, 2011).

Alternatively, according to Eckstrand and Potter (2017), stigmatisation refers to a situation whereby an individual is shunned, held in contempt or in some situations becomes socially invisible because of his or her socially disapproved status. Keller et al (2019) suggests that stigma can be evident in different forms that include emotional, behavioural or cognitive form. Stigma may increase the risk of an individual engaging in risky behaviour and substance addiction. The risk of SUBSTANCE USE amongst the LGBTIQ youths is considerably high because of development of the perception that one's status or condition results in an undesirable social status. The LGBTIQ youths may perceive their ‘different' sexual orientation as undesirable in society. As a result, LGBTIQ youths may also experience high levels of public stigma, which according to Eckstrand and Potter (2017), entails the endorsement of a particular form of prejudice towards a particular stigmatised group. Substance addiction may subsequently trigger their engagement in risky health behaviour (Keller et al., 2019). Additionally, the substance addiction may increase the risk of LGBTIQ youths suffering high levels of stigmatisation.

According to Deborah et al (2014), suicide ranks 10th amongst the leading causes of death globally and is the 3rd leading cause of death among youths aged between 10 and 24 years. Over 157,000 youths within this age bracket were reported to have sought health services from different emergency departments across the U.S. because of consequences associated with self-harm injuries and attempted suicide as a result of substance addiction (Deborah et al. 2014). As such, suicide is considered to be both a psychological and cultural issue hence making it a complex phenomenon (Poteat & Rivers, 2014). There has been a noticeable increase in suicide risk among LGBTIQ youths over the past few years. One of the factors behind this high rate of suicide may be SUBSTANCE USE hence leading to addiction (Huebner, Thoma & Neilands, 2015). Marshal et al. (2008) suggest that research over the past decade show that the SUBSTANCE USE amongst LGBTIQ youths starts from their young adulthood. Suicide as a result of substance addiction constitutes an area of concern for public discussion. Towards this end, various studies (e.g. Haas et al., 2011; Pflum et al., 2015) have singled out addiction as a key area of health concern for the LGBTIQ community, and in particular, young adults.

The number of LGBTIQ youths who are likely to have attempted suicide as a result of substance addiction is five times that of their heterosexual counterparts (Riley et al., 1999). The predisposition of LGBTIQ youths to addiction and hence suicidal ideation is increased by a number of different social environmental factors such as peer victimisation, depression, and physical use (Hatzenbuehler, 2011). Substance addiction amongst LGBTIQ youths may be due to the discrimination and harassment that they face because of their sexual orientation (The Marmot Report, 2010; Van Wormer, 2004). According to Weber (2008), individuals belonging to the LGBTIQ community are subject to unfair treatment by the wider community, their friends, family members and suffer loss of employment and promotion opportunities. In particular, LGBTIQ youths may be apprehensive of how society will react to their sexual orientation. Such fear is associated with negative mental health effects on LGBTIQ youths (Chaney et al., 2011).

According to Chaney et al. (2011), individuals categorised as LGBTIQ experience discrimination on different fronts, including accessing employment opportunities, housing and education. This discrimination may make LGBTIQ individuals feel isolated, which predisposes them to different mental health conditions such as generalised anxiety disorder and major depression. This may indicate an association between the fear of coming out as manifested in LGBTIQ youths and being discriminated against. Such fear may result in posttraumatic stress disorder, depression and substance use (Chaney et al., 2011).

Discrimination against LGBTIQ has far-reaching implications on their well-being. For example, discrimination in accessing employment may increases the LGBTIQ individual's level of poverty compared to that of heterosexual individuals (Quintana, 2009). Youth poverty has been identified as a major source of desperation amongst LGBTIQ youths. This may further increase the risk of LGBTIQ youths engaging in substance use. The findings by Chaney et al. (2011) are supported by McCann et al. (2013) who suggest that despite the increase in the number of LGBTIQ youths who have learnt to adjust to the prevailing society prejudices and developed positive coping mechanisms, a significant proportion of LGBTIQ youths still experience significantly high levels of tension, which may increase their stress because of their marginalised and stigmatised status. Existing literature shows the existence of a positive correlation between LGBTIQ youths, the level of individual stress and the likelihood of experiencing mental health problems within the LGBTIQ community (Cavalieri & Riley, 2012). Results showed a twofold increase in the rate of suicide attempts associated with development of substance addiction problems amongst bisexual and lesbian women (Cavalieri & Riley, 2012). Additionally, these individuals were characterised by a relatively high risk of developing substance use. The increased rates of substance use among LGBTIQ youths could be due to their shame-proneness which is in turn tied to substance use and internalised heterosexism (Hequembourg & Dearing, 2013). The likelihood of lifetime incidence of suicide was considerably high amongst bisexual and gay men (McCann et al., 2013). It may constitute one of the main challenges faced by LGBTIQ youths.

LGBTIQ youths are also faced with the challenge of questioning their individual sexual orientation in addition to falling victim to homophobic bullying at school, in the workplace and by society (Marston, 2015; Guasp, 2012). Bullying constitutes a form of harassment perpetrated by an individual towards another party over time hence causing them intentional harm and distress. In spite of the fact that substance use does not always result in addiction, Doumas, Midgett and Johnston (2016) suggest that addiction results in a considerable increase in the risk of the individual using drugs.

Bullying can have a profound negative impact on an individual's emotional, physical and social wellbeing, especially among young people (Marston, 2015). Previous studies suggest a growing rate of homophobic bullying of individuals characterised as LGBTIQ, over the past two decades (Rivers, 2011; Guasp, 2012). Recent studies from the UK (for example, McCabe et al., 2010) show that 55% of the LGBTIQ youths in the UK have at some point experienced homophobic bullying, for example, physical violence, verbal use, and offensive texts/or tweets. Similarly, findings of studies conducted in the US show that most schools are yet to establish a safe environment based on the students' sexual orientation. As a result, most LGBTIQ students in the UK experience bullying and harassment (McCabe, et al., 2010). This may exacerbate the stress and depression that LGBTIQ youths experience (Guasp, 2012).

The bullying and harassment that LGBTIQ youths encounter can also take the form of cyber-bullying. A report by Public Health England (2015) suggests that LGBTIQ youths are increasingly seeking social support and need for interaction with other people through different internet sites and other internet enabled technologies. The high rate at which LGBTIQ youths are turning to the internet in seeking support and interaction from their peers has been largely influenced by the idea that the internet provides an opportunity for LGBTIQ youths to safeguard their privacy and anonymity (Holt, 2009).

Legate, Ryan and Weinstein (2012) suggest that the internet provides individuals an opportunity for developing positive online relationships, which reduces their feeling of isolation. However, LGBTIQ youths tend to interact with strangers, which increases the risk of cyberbullying (Patchin & Hinduja, 2013). According to Nixon (2014), the cyberbullying experienced by youths' results in the development of isolation feelings, hopelessness and powerlessness, which is similar to being bullied face-to-face. Considering that individuals perpetrating cyberbullying are able to hide their identity, it is hard for LGBTIQ youths to identify their cyberbullies. As a result, the victims are forced to disconnect from online interaction, which increases the risk of developing feelings of isolation. It may be that LGBTIQ youths are already faced with excessive loneliness, which is why they yearn for online interaction (Legate et al., 2012). This subsequently may increase the risk of LGBTIQ youths resorting to substance use and hence addiction (Patchin & Hinduja, 2013).

Kulkin, Chauvin and Percle (2000) support the view that LGBTIQ youths who have experienced cyberbullying are twice as likely to attempt suicide compared to LGBTIQ youths who have not experienced cyberbullying. Weiderhold (2014) reported the case of Tyler Clementi, an 18-year-old student, who committed suicide by jumping from the George Washington Bridge after a video of him kissing his male college roommate, was posted online. This incident highlights the risk that cyber bullying poses to LGBTIQ youths. Cyberbullying may also be associated with poor mental health consequences. A study conducted by Weidehold (2014) involving 444 colleges, junior high and high school students showed that 45% of LGBTIQ students experienced cyberbullying and over 25% of them developed suicidal thoughts. This study showed that the likelihood of such individuals committing suicide is particularly high if such individuals develop drug use, hence increasing the risk of addiction to illicit substances (Weiderhold, 2014). Addiction to illicit substances is also correlated with the socio-cultural stigma and suicide ideation among LGBTIQ youths. Since LGBTIQ youths face a lot of prejudice and possible discrimination, they require health care and legislative support (Johnson et al., 2008).

Kelley et al's (2004) definition of drug use include the use of psychoactive drugs in a manner that results in serious interference with an individual's personal life interferences that include educational, spiritual, occupational, psychological and physical and social functioning. Substance use, therefore, impairs an individual's life (Kelley et al., 2004). Substance use may further result in risky and hazardous behaviour. Increased substance use is considered a moralised behaviour across most of modern society thus leading to substance addiction. Schomerus et al. (2015) suggest that individuals who use drugs are highly likely to be criminalised, perceived negatively and discriminated against. As such, the substance use amongst the LGBTIQ community increases the risk of the individuals experiencing perceived stigma. According to Flood, McLaughlin and Prentice (2013), the prevalence of perceived stigma may motivate individuals to resort to various stigma management strategies such as avoiding experience of stigma and trying to pass as heterosexuals. Nevertheless, perceived stigma may increase the risk of psychological distress, high risk of psychological and physical illness and limited behavioural options. Other stigma management strategies may include substance use (Flood, Mclaughlin & Prentice, 2013).

Perceived stigma may also hinder self-disclosure among LGBTIQ youths. This is the concept of 'coming out” or “self-disclosure of their sexual orientation or of their gender identity" (UCSF, 2019). A study conducted by Rosario et al. (2009) suggests a number of barriers that limit the likelihood of LGBTIQ youths coming out. The barriers identified include; concern about the confidentiality of their sexual orientation, fear of being judged by others, fear of being discriminated against, the preference to be self-reliant in regards to their sexual orientation, memories about past discrimination experiences, and the lack of confidence in seeking help about the issues that they might be experiencing (Ford & Jasinski, 2006). As a result, LGBTIQ youths are more likely to start using drugs at a younger age in comparison to their heterosexual counterparts (Corliss et al., 2010). Even among the LGBTIQ youths, differences are evident in respect to their use and use of addictive substances. Compared to gay, lesbian, and heterosexual youths, bisexual females who have developed the habit of patronising clubs have been found to be more likely to report a high rate of addiction of different drugs such as cocaine, ecstasy, and methamphetamine (Corliss et al., 2010). This may explain the prominent effect of drug use in this particular group (Parsons, Kelly & Wells, 2006).

Besides, LGBTIQ youths who identify as being romantically attracted to youths of the same sex may be at a higher risk of suicide attempts and ideation, which is linked to substance use. For example, the LGBTIQ youths are likely to develop depression relative to their heterosexual peers hence triggering their consumption of substances (Greenspan et al., 2011). Awareness of likely harm, coupled with own investment in harm reduction, contributes greatly towards strengthening of harm reduction strategies targeting the LGBTIQ community. According to Harawa, Williams and Ramamurthi (2008), the ‘sexually different' youths may resort to substance use as a maladaptive strategy aimed at improving their ability to cope with being categorised as LGBTIQ youths. Findings of a study conducted by Pienaar et al. (2018) suggest that the high prevalence rate of substance use amongst LGBTIQ youths is largely as a result of the stigmatised status that they experience because of their sexual orientation. This is evident in the form of discrimination and prejudice aimed at LGBTIQ youths and is hence a leading source of stress from this group of individuals (American Psychological Association, 2012). Such stress, along with the specialised needs of LGBTIQ youths, may drive them to the use of drugs.

Research aim and objectives

The aim is to examine how substance addiction increases the risk of suicide ideation and social-cultural stigma among LGBTIQ youths. The literature review also seeks to understand how substance addiction may create suicide ideation among LGBTIQ youths. In addition, the review will examine the social-cultural stigma that LGBTIQ youths around the world experience as a result of their substance addiction. The study will also assess whether the social-cultural stigma experienced by LGBTIQ youths around the world could lead to drug misuse and addiction. Finally, the study seeks to understand if the LGBTIQ club culture increases the risk of substance use and hence addiction.

Research questions

The study sought to answer the following research questions: What is the relationship between substance addiction and social-cultural stigma experienced by LGBTIQ youths? Are LGBTIQ youths more likely to experience social-cultural stigma on account of their substance addiction?

The study focuses on a number of areas that include examination of substance addiction amongst LGBTIQ youths and evaluation of the triggers of substance use among LGBTIQ youths. The study also investigates the correlation between increased substance use, use, addiction, increased risk of harm, suicidal ideation, and evaluation of the level of mental stability amongst the LGBTIQ youths. The research study makes recommendations on the areas of intervention that could be considered in order to minimise suicide and suicidal ideation that are associated with substance addiction.

Internal sources of stress that may influence substance use and addiction

The past few years have been characterised by a considerable increase in recreational drug use, especially amongst young adults (Marshal et al., 2008). Specifically, drug use has become an issue of concern especially amongst LGBTIQ youths because of the high risk of developing substance use (Marshalet al., 2008). substance use may result in the development of a behaviour whereby an individual becomes dependent on the particular substance as a way of escaping the negative feeling of their sexual orientation. Such feeling comes in the form of peer and family rejection, bullying, marginalisation, harassment, isolation, homonegativity, and fear (Zacharais, 2018).

Fear of coming out among the LGBTIQ

'Coming out' as it relates to the LGBTIQ, is a term used in reference to the individual's self-disclosure about their sexual orientation. For the majority of LGBTIQ people, ‘coming out' constitute an important milestone as far as the development of their sexual orientation is concerned (Rivers & Gordon, 2010). Nonetheless, this form of disclosure is largely linked to psychological, social and emotional dynamics, including fear of possible rejection, shame and the likely internalising of guilt by the LGBTIQ individuals who decide to disclose their status. As such, coming out could herald the development of poor health (Ryan et al., 2009). Findings of a study conducted in Ireland by Higgins et al. (2016) suggested that most of the country has experienced a considerable improvement in the rate of ‘coming out' amongst LGBTIQ youths. Higgins et al., (2016) study suggested that LGBTIQ youths start becoming aware of their sexual identity at age 12 years and start coming out at 16 years. Increase in the rate of coming out was largely associated with a high rate of acceptance by family and friends, and support from the community (Higgins et al., 2016). Moreover, coming out was also supported by the youths' acceptance of their sexual identity. The fear of possible stigma and discrimination after coming out may lead to depression, self-harm, and even suicidal thoughts (The Shaw Mind Foundation, 2016).

An individual's ethnicity and cultural background may further play a significant role in influencing development of suicidal ideation among LGBTIQ individuals. In spite of the fact that coming out is associated with the development of a positive feeling amongst LGBTIQ individuals, Balsam et al. (2004) suggest that some ethnic groups are less welcoming and accepting of LGBTIQ individuals. This view is supported by Legate, Ryan and Weinstein (2012) who suggest that coming out for the LGBTIQ individuals in an environment that is characterised by a considerably low level of support by the community, may increase their likelihood of experiencing rejection and stigma. LGBTIQ individuals living in such an environment may experience high levels of depression and anxiety. They are also more likely to experience suicidal thoughts (Balsam et al. 2004; Kulkin, Chauvin & Percle 2000; Morrow 2004). LGBTIQ individuals from black minority ethnic groups are more likely to experience isolation and discrimination while accessing health care services compared to their white peers (Balsam et al., 2004). Similarly, LGBTIQ asylum seekers tend to experience racism and legal challenges in accessing equal opportunity because of their sexual orientation (Morrow, 2004).

In particular, LGBTIQ asylum seekers may encounter discrimination in accessing housing. The Public Health England (2015) suggests that LGBTIQ youths in the UK are faced with a considerably high risk of being homeless. The Public Health England reported that approximately 62% of LGBTIQ youths in the UK were homeless and had attempted to commit suicide, compared to 25% of heterosexual youths. Being discriminated on account of one's sexual orientation can create feelings of depression and social isolation, which may trigger the risk of the affected individuals developing suicide ideation (Public Health England 2015). Specifically, LGBTIQ youths may be highly prone to self-harm and suicidal behaviour due to fear of how their families and the society might react when they discover their sexual orientation. Consequently, fear of coming out acts as a key driver for their risk of substance use and addiction (Rivers & Gordon, 2010).

Kecojevic et al. (2012) and McCabe et al. (2013) suggest that substance use exposes the LGBTIQ youths to risk of self-harm. The risk of substance addiction may be increased by familial rejection and lack of social support (Stevens, 2012). Moreover, LGBTIQ youths may be highly vulnerable to societal discrimination.

Due to societal discrimination, LGBTIQ youths may endure a lot of stress that often accompanies coming out, not to mention being rejected by their families and friends (Reed et al., 2010). This may drive LGBTIQ youths towards substance use. Internalised homophobia or transphobia could also drive them towards substance use, in addition to also being harassed both at school and in the workplace (Reed et al., 2010). Elsewhere, Edilma et al (2012) suggest that when the LGBTIQ individual realises that they are sexually different from their heterosexual peers, this is likely to trigger feelings of guilt and shame in them. As a result, they could be driven towards self-destructive and reckless behaviours, including drug use, suicide ideation and attempting suicide (Boekhout van Solinge, 1999). The decision by LGBTIQ individuals to ‘come out' or to disclose their sexual orientation in Ireland was also found to be strongly linked to depression and suicidality in this group (Flood, Mclaughlin & Prentice, 2013; Goffman, 2009). Additionally, negative family experiences are also associated with increased cases of suicidal distress in LGBTIQ youths. What this goes to show is that LGBTIQ youths who decide to ‘come out' could be highly predisposed to victimisation, bullying, discrimination, self-harm and suicidality relative to their heterosexual peers and increases the risk of substance addiction.

With regard to homonegativity or internalised homophobia, LGBTIQ youths may consciously or unconsciously internalise the stigmatised attitude directed towards them by society because of their sexual identities and behaviours (Paludi, 2010). substance use amongst the youths has become a leading problem that characterises the modern society. Flood, McLaughlin and Prentice (2013) suggest that lesbian and gay students are characterised by a considerably high risk of drug and alcohol use during their formative years.

A survey conducted by the US Department of Health and Human Services on substance use showed that over 16.6 million individuals aged 12 years and above were substance dependent (Cheng, 2003). Overall, evidence from Ireland and the world in general shows that substance use is substantially higher amongst the LGBTIQ compared to the general population (Abdulrahim et al. 2016). Drug use in Ireland has become a major problem amongst individuals aged between 15 and 64 years. It is estimated that the number of individuals aged 15-64 years who use drugs have increased from 2/10 in 2002/2003 to 3/10 in 2014/2015. Cannabis is the most commonly used illicit drug in Ireland (European Monitoring Centre for Drug and Drug Addiction, 2018). Jordan (2000) suggests that LGBTIQ individuals are characterised by a considerably high risk of developing substance use and substance addiction. Deacon et al. (2013) defines substance use as the occasional and social use of drugs and other substances. Findings of past studies show that LGBTIQ youths are characterised by a considerably high risk of developing substance dependency, for example to marijuana, alcohol and tobacco (Caputi et al. 2018). This view is further supported by Lea et al. (2013), who affirm that the likelihood of same-sex youths developing behaviour on alcohol and other illicit drugs is considerably higher when compared to their heterosexual peers.

Past studies according to Rukus, Stogner and Miller (2017), consistently show existence of a higher rate of substance use amongst the LGBTIQ community (Corliss et al., 2010; Cochran & Cauce, 2006; Hughes & Eliason, 2002; Littlefied, 2010). Health professionals working with the LGBTIQ community estimate that approximately 30% of the LGBTIQ youths use drugs and other substances compared to 12% of their heterosexual peers (Boon 2009). This finding is consistent with findings of a study conducted by the Crime Survey of England and Wales (CSEW), which shows that the number of gay and bisexual men in the UK who had developed drug use behaviour over the past year was 33% compared to 11% of the heterosexual men who had developed drug use behaviour over the same period (Home Office, 2014).

A study by Jordan (2000) on drug use amongst bisexual and gay youths in Minneapolis showed that 76% of the youths involved in the study were involved in alcohol use, 42% used marijuana, while 25% used crack cocaine. The study showed that the behaviour was mainly prevalent amongst the African American and Hispanic bisexual and gay youths (Jordan 2000). The high prevalence of drug use and substance addiction amongst the LGBTIQ is further illustrated by findings of a survey involving 59 schools in Massachusetts, USA (Jordan, 2000). According to the study, the gay, lesbian and bisexual students selected in the study were highly likely to develop addiction on 24 substances compared to their counterparts not characterised as LGBTIQ. The study further showed that the LGBTIQ youths had started abusing alcohol by the age of 13 years (Jordan 2000).

Jordan (2000) suggests that the probability of LGBTIQ individuals developing substance addiction is likely to be spurred by the prevalence of stressors amongst the LGBTIQ youths. Birkett, Espelage and Koenig (2009) suggest that the prevalence of daily stressors increases the risk of an individual becoming highly addicted to substances. For example, the prevalence of bullying and harassment towards the LGBTIQ youths may pressure them to resort to substance use and use in an effort to deal with problem of bullying (Birkett et al., 2009). LGBTIQ youths may engage in substance use as a way of coping with the internalised homonegativity, which relates to the shame and stigma that often accompanies their ‘different' sexual orientation (Flood, McLaughlin & Prentice, 2013). LGBTIQ individuals are prone to developing feeling of shame, which according to Greene and Britton (2013) entails a social emotion that is comprised of different negative feelings that may include mild embarrassment to severe feelings of humiliation. Individuals suffering from addiction are highly likely to experience self-esteem problems (Greene & Britton, 2013). The low self-esteem problem amongst LGBTIQ youths may be worsened by the feelings of guilt and shame about their sexual identity (Washton & Zweben, 2006).

The Public Health England (2015) supports the view that the process of developing identity amongst the LGBTIQ individuals can be considerably challenging and stressful because the individual is required to adopt to a non-traditional sexual identity, restructure their self-concept and to adjust one's relationship with society. The process of developing an LGBTIQ identity entails a complex process in that an individual is required to not only develop a personal and private identity but also requires 'coming out' so that society can understand one as an LGBTIQ individual (D'Augelli, 1994; Guerra, 2014).

In addition to coping with their sexuality, LGBTIQ youths may experience a challenge in that they have to negotiate their sexual identity in the school environment that is characterised by homophobia and heterosexism (Guerra, 2014). The Substance Use and Mental Health Services Administration (2001) supports the view that heterosexism resembles racism that is perpetrated towards an individual on the basis their sexual orientation, whereby their affection and emotional expression or sexual behaviour is stigmatised and denigrated. The prevalence of homophobic and heterosexist experiences increases the LGBTIQ individual's risk of depression and substance addiction (Guerra, 2014).

LGBTIQ youths may consider resorting to self-medication through substance use and use as a way of coping with the stress, marginalisation, anxiety and depression they face. Results of a 2013 study on HIV/AIDS showed that most of the HIV positive bisexual and gay young adults used marijuana as a way of relieving stress (Demant et al., 2013). The young participants argued that they used marijuana as a way of ‘making the problem go down', or forget their HIV status (Demant et al., 2018; Birkett, Espelage & Koenig, 2009). Flood, McLaughlin and Prentice (2013) suggest that stressors make LGBTIQ youths appraise their social environment negatively, or as a threat. In response to such an environment, Flood, McLaughlin and Prentice (2013) suggest that LGBTIQ youths respond to substance use in an attempt to suppress, reject, or deny their ‘different' sexual orientation.

Rukus, Stogner and Miller (2017) are of the view that a significant number of individuals belonging to the LGBTIQ community usually tend to hide their sexual orientation from the wider community because of the prevalence of homonegativity, which may be evidenced by the feeling of shame and the negative perception towards them. Society may develop negative attitudes towards homosexuals, which may affect the LGBTIQ youth's mental wellbeing. Moreover, the LGBTIQ youth's mental wellbeing may also be adversely affected by the prevalence of internalised homonegativity, which may arise from the LGBTIQ youth's lack of acceptance of their sexual identity. Findings of a study by Marshall et al. (2009) shows that the individual trajectory for substance use amongst LGBTIQ youths is considerably high compared to the heterosexual youths. Hence, LGBTIQ youths may develop addiction problems as a way of escaping from homonegativity and internalised homophobia (Weber, 2008).

The prevalence of a hostile social environment that LGBTIQ youths live in increases their risk of substance addiction and suicide ideation due to the stigma, discrimination, and prejudice that they face (Deborah et al. 2014). The minority stress theory holds that LGBTIQ youths are more predisposed to negative health outcomes on account of the frequent socially based stressors that they encounter. This could be in the form of victimisation and prejudice (Meyer, 2003). For example, LGBTIQ youths may be identified by heterosexual counterparts using discriminative and heterosexist language, for example, 'that's gay'. Elsewhere, Hatzenbuehler (2009) has also contributed to the debate on the minority stress theory suggesting that LGBTIQ people on account of the chronic stress they are subjected to, tend to be deficient in regard to their emotional regulation. Consequently, this may trigger negative mood states. In an attempt to deal with such negative effects, these individuals may resort to maladaptive coping behaviours like substance use (Cheung et al., 2010). For these reasons, there is need to take into account various psychosocial risk factors, for example, stress and depression, as well as protective factors in order to gain a better understanding of the development of negative health outcomes and substance addiction among LGBTIQ youths. This perspective is supported by Tobkes and Davidson (2017) who suggest that being an LGBTIQ individual does not cause substance addiction. On the contrary, it is the minority stress that the LGBTIQ individual experiences that causes substance use and addiction, largely because of the socially stigmatised identity (Ecstrand & Ehrenfeld, 2016). In respect to this, LGBTIQ youths may subsequently develop substance use and addiction as a way of coping with the feeling of being marginalised by society and depression. Rukus, Stogner and Miller (2017) suggest that substance addiction among LGBTIQ youths is highly likely to be developed from drug use in the quest to feel as part and parcel of the LGBTIQ subculture.

Padilla, Crisp and Rew (2010) are of the view that LGBTIQ youths may start patronising bars and clubs in the quest to socialize with other LGBTIQ youths. Such behaviour may push them towards drug use. Considering that LGBTIQ individuals are less likely to be bound by cultural standards or religious norms, their likelihood of resorting to substance use as a way of seeking acceptability amongst themselves is substantially high (Lampinen, McGhee & Martin, 2006). In light of this, lifestyle factors such as substance use have played a major role in increasing the risk of suicide within the LGBTIQ community (King et al., 2008).

This view is further supported by Boon (2009) who emphasises that the development of substance use and addiction by LGBTIQ youths may be increased by the need for cultural acceptance. Therefore, substance use among the LGBTIQ may be considered an important cultural issue by the LGBTIQ individual as a way of developing a sense of group belonging and personal identity (Green & Feinstein, 2011). Considering that LGBTIQ youths face a challenge with regards to being accepted by the community, they may experience pressure to use substances from their LGBTIQ peers, especially if their peers have developed substance use habits and addiction (Green & Feinstein, 2011).

There is need to understand LGBTIQ people's use of substances in terms of the prejudice, discrimination and stigma that they face. According to Boon (2009), prevalence of discrimination has made it considerably unsafe for LGBTIQ individuals to socialise. LGBTIQ individuals are thus left with a few options for socialising. In the face of such circumstances, LGBTIQ individuals tend to consider using substances as the only option for socialising with their LGBTIQ counterparts. Clinicians and researchers support the view that the need for affiliation amongst the LGBTIQ youths increases their likelihood of developing substance use (Green & Feinstein 2012).

Socialising amongst the LGBTIQ youths may be held in specialised venues, for example nightclubs and bars, whereby use of substances becomes normalised. As the major source of socialising amongst the LGBTIQ youths, bars play a major role in influencing the development of substance use and addiction amongst the LGBTIQ community (Chow et al., 2013). For example, LGBTIQ youths may start consuming alcohol as the readily available substance in such establishments (Chow et al., 2013). In light of this, it is proper to argue that substance use amongst LGBTIQ individuals is highly likely to be increased by peer pressure. Alternatively, Allen (2013) suggests that LGBTIQ youths may consider using substances as a tool of rationalizing their same-sex feelings. In addition to the above issues, Substance use and addiction amongst LGBTIQ youths may also be influenced by the individuals' specific sexual orientation. Bisexual and lesbian women are highly likely to develop alcohol addiction while bisexual/gay men are highly likely to develop illicit substance use problems (Green & Feinstein, 2012).

Over the years, the concept of stigma has been subjected to noteworthy modifications both in terms of characterisation and definition (Teliti, 2015). Stigma relates to a long-term trait or condition, a metaphorical or physical mark carried by a person. It is important however to note that the mark or attribute does not carry any meaning, but social interactions assist in assigning such meaning (Teliti, 2015). In the case of LGBTIQ youths, the attribute may be taken to imply that the bearer is a villain, criminal or a person who deserves the shame, social ostracism or condemnation that he or she is subjected to. In the case of LGBTIQ youths, this comes in the form of sexual stigma. This is the kind of stigma associated with homosexual identity, behaviour, or relationships (Teliti, 2015). Social stigma contributes towards the development of social expectations and roles for conduct. Such social expectations and roles are shared and understood by society, irrespective of their personal attitudes or sexual orientation. Consequently, this may lead to social exclusion.

A key attribute of social exclusions with respect to LGBTIQ youths is their marginalisation and invisibility. In other words, they are not fully appreciated as members of a society (Estivill, 2003). According to Rukus, Stogner and Miller (2017), individuals belonging to the LGBTIQ community are largely considered as outsiders by other members of the society. Consequently, such people have limited control over their individual destinies. Notwithstanding their personal attitudes, society may perceive the desires, acts and identities of the LGBTIQ youths as being bad, inferior, and immature in comparison with heterosexuality. Stigma has also been shown to “swallow”, literally, the entire identity of its bearer. This is because stigma deletes all the other qualities and attributes of an individual, in effect resulting in the social disapproval of such an individual (Yang et al., 2010). Moreover, stigmatised groups such as LGBTIQ youths have limited power in social standing. Consequently, they cannot access resources to the same extent as their heterosexual peers, but this is deemed “normal”. The engulfment of the LGBTIQ individual's identity increases their likelihood of developing substance use and hence the risk of addiction (Yang et al., 2010).

A combination of institutional and cultural factors contributes towards increased health disparities experienced by LGBTIQ youths. According to Eckstrand and Ehrenfeld (2016), such disparities seem to "stem from culturally sanctioned stigmatisation of sexual and gender minorities, beginning early in childhood" (p. 107). Bullying, as experienced either at home or in school, is linked to increased levels of depression and anxiety in LGBTIQ youths. This is in turn may be likely to trigger such maladaptive coping behaviours, such as substance use. This may subsequently translate into the development of addiction.

These youths may also use substances in a bid to reject feelings of being attracted to people of the same gender, or as a coping mechanism with the physical violence and antigay verbal violence directed at them (Ryan & Hunter, 2001). Reis and Saewyc (1999) undertook an in-depth assessment of eight population-based studies with a view to exploring the antigay harassment directed at people with same-gender sexual orientation, along with the well-being and safety of this group. Study participants consisted of sexual minority students drawn from various schools. Study findings pointed towards a reliable association between substance use and being harassed at school. Additionally, students who were harassed at school were also more likely to engage in such self-destructive behaviours as suicidal ideation (Reis & Saewyc, 1999).

Family or peer rejection further escalates substance use, and it also has the potential to disrupt their employment and educational opportunities (Eckstrand & Ehrenfeld, 2016). In their study, Díaz et al. (2001) report that family acceptance and support of LGBTIQ youths was linked to enhanced self-esteem and improved mental health of gay men who constituted the target population. Truselli (2013) suggests that disclosure to family members constitutes an integral step in supporting LGBTIQ youths to develop their sexual identity. There is a dearth of population studies that have sought to explore drug use among LGBTIQ youths and for this reason, it is very difficult to undertake comparable comparisons of this group with the general population (Dyer et al., 2012). Nonetheless, a range of studies indicate that LGBTIQ youths' resort to substance use at considerably higher numbers compared to their heterosexual peers (Hughes & Eliason, 2002). This could be an indication that strong push factors, for example, stress, depression, anxiety, and rejection by family, friends and the society are at play in terms of influencing LGBTIQ youths to experiment with drugs hence leading to development of substance use and addiction (Measham et al., 2011).

A study by Ryan et al. (2009) supports the view that family rejection amongst adolescents is positively correlated with substance use and use amongst the LGBTIQ community. In their study, Ryan et al. (2009) suggests that LGBTIQ adolescents who experience rejection from their parents are highly likely to develop substance use and addiction to illegal substances. Collectively, these factors add up to the health disparities that LGBTIQ youths have to endure across their lifespan. Rejection from family members may increase the likelihood of the LGBTIQ individual developing conflict with the other family members and society. In such an environment, LGBTIQ youths are likely to engage in different problem behaviours, for example, substance use (Hughes, Szalacha & McNair, 2010). Truselli (2013) suggests that the prevalence of problem behaviour amongst LGBTIQ youths is evidenced by their over-representation in juvenile detention centres, foster care homes and amongst the homeless youths.

In summary, substance use and substance addiction has become a major global health issue that the LGBTIQ community faces. The substance use and substance dependency amongst the LGBTIQ community may be triggered by a combination of diverse factors that include prejudice, stigmatisation, discrimination and isolation by the community, family, peers and friends.

The rate of substance use and addiction is considerably higher amongst LGBTIQ youths when compared to heterosexual youths. Amongst the factors that have been identified as contributing to an increase in substance addiction are the need to deal with the shame and stigma associated with same-sex attraction and coping with verbal and physical use. Lack of family support and acceptance has further resulted in an increase in the risk of LGBTIQ youths engaging in substance use, which constitutes a self-destructive behaviour.

Subsequently, LGBTIQ youths resort to substance use as a mechanism of coping with the situation they are facing. It means therefore that they are not merely victims of their circumstances but can actually play an active role in turning around the situation by embracing positive behaviour.

Substance addiction and suicide ideation

Suicide or taking one's life remains a complex phenomenon. An interaction of personal, neurobiological, familial, social-cultural and stressful events may also combine to trigger suicide. Statistics by the World Health Organisation (WHO) suggest that each year, nearly 1 million individuals across the globe are reported to have died by suicide (WHO, 2014). Suicide has remained a major health concern for both the developed and the developing countries (Liu & Mustanski, 2018). For example, in the US, suicide accounts for approximately 10.8 per 100,000 deaths and is ranked as the 3rd leading cause of death amongst youths in the country (Liu & Mustanski, 2018). Available epidemiological evidence shows that the risk of suicide follows a certain pattern, including the development of suicidal ideation, planning suicide and attempting suicide. Suicide ideation entails entertaining the thought that you can take your own life. Suicide planning entails making mental notes of the process you would undertake in ending your own life, while attempting suicide, involved actualising your suicide plan but you fail to die. The risk of suicide among LGBTIQ youths increases significantly during the adolescent phase (Legate, Ryan & Weinstein, 2012).

Considering the stigma associated with suicidal deaths, it is possible that a lot more adolescents attempt suicide than what is reported due to the stigma associated with such an act. Consequently, it could be underestimated (Katz, Bolton & Sareen, 2016). On the other hand, suicide ideation implies harbouring thoughts on how to commit suicide. Indeed, suicidal ideation is common among individuals experiencing depression or those who are undergoing a stressful situation. While suicidal ideation is, for the most part, a temporary thing, on certain occasions, it predisposes the individual to an increased risk of attempting suicide, if not addressed (Katz et al,. 2016).

For each reported case of suicide, many more individuals will have attempted suicide. According to the WHO (2018), a previous suicide attempt remains by far the leading risk factors for suicide in the general population. Suicide cases have been reported across the lifespan suggesting that all age groups are vulnerable. Each suicide not only affects the family of the victim, but also the community where he/she comes from, and the country at large. In 2016, suicide was identified as the second leading cause of death among youths aged between 15 and 29 years (WHO, 2018). Suicide remains a global phenomenon and is not just restricted to high-income countries. There has been a significant rise in the number of suicide cases reported in low-income countries as well. For instance, in 2016 alone, more than 79% of the global cases of suicide took place in both middle-income countries and low-income countries. Consequently, this calls for an in-depth multi-sectoral prevention strategy in order to curb the rising cases of suicide.

Such a prevention strategy starts with recognition of suicide ideation as a leading factor for the actual cases of suicide reported. For example, the findings of an epidemiological study conducted in the US revealed that nearly 17% of adolescents acknowledged that they had entertained suicidal thoughts in the past 1 year (Centre for Disease Control and Prevention, 2006). Similarly, a 2016 study in Ireland showed that approximately 60% of LGBTIQ individuals have seriously considered suicide over the past one year. The suicidal thoughts amongst LGBTIQ youths were largely motivated by their ‘different’sexual identity (Higgins et al., 2016). Furthermore, Kessler and Borges (1999) suggest that suicidal ideation rises significantly from the age of 12, which coincides with the entry into teenage years, and is at its highest in mid to late adolescent years. The relationship between suicide ideation and actual attempting suicide is strong. For instance, Nock et al. (2008) report that nearly 29% of all the individuals who experience suicide ideation go on to commit suicide. Nock et al. (2008) undertook a multi-national epidemiological study whose research findings indicated that the risk for attempting suicide tends to increase in the first year following the onset of suicide ideation, and more so among younger ideators. While a lot of effort has gone towards preventing suicide and offering treatment to those affected, there has been limited reduction in the rates of suicide ideation, implying that suicidal ideation aetiology calls for enhanced understanding (Nock et al., 2008).

The actual rate of suicide among LGBTIQ individuals is not known because it is not the norm to identify one's sexual orientation in one's death record (Waling & Roffee, 2017). In spite of this, surveys on suicidal ideation show that the suicidality amongst LGBTIQ community is considerably high. Developing togetherness between individuals is essential in shaping how individuals connect and interact with their peers. However, LGBTIQ individuals experience difficulty in achieving togetherness with other parties in the community because of their ‘different' sexual orientation (Waling & Roffee, 2017). According to Keller et al. (2018), LGBTIQ youths are characterised by a considerably lower level of social integration which increases their feeling of loneliness. This subsequently results in their inclination towards substance use and suicide ideation. In view of the low level of social integration amongst LGBTIQ youths, Waling and Roffee (2017) support the view that developing social support networks can result in significant reduction of the risk of victimisation, violence, substance use and suicide ideation experienced by LGBTIQ youths. This social support network should entail developing social bonds with different members of the society.

Suicide and suicidal ideation among the LGBTIQ community may also be triggered by incidents of victimisation and bullying. LGBTIQ youths face a considerably high risk of peer victimisation, which arises from being the target of aggressive behaviour by other youths (Higgins et al., 2016). Peer victimisation is considered to be one of the reasons that increase the incidence of suicide amongst the LGBTIQ community. King et al. (2018) support the view that even though peer victimisation does not in itself cause suicide, the experience of victimisation is an important predictor of negative psychological outcome amongst the youth. A study by Higgins et al., (2016) suggested that approximately 75% of LGBTIQ individuals in Ireland have been subjected to verbal use on the grounds of their sexual orientation over the past year, which constitutes a form of victimisation and harassment.

Suicide, suicide ideation and subsequent suicide attempts among the LGBTIQ community is considerably high in neighbourhoods that are characterised by a high level of hate crime, which refers to crimes that are motivated and perpetrated towards another party and/or his property on the grounds of prejudice of his or her personal characteristics such as race, gender or sexual orientation (Green, McFalls & Smith, 2001). LGBTIQ youths encounter incidents of hate crime as a result of their sexual orientation (Duncan & Hatzenbuehler, 2014). Examples of hate crimes that LGBTIQ individuals encounter include assault and battery, harassment and threat (Duncan & Hatzenbuehler, 2014).

In spite of the fact that some countries, for example the US, are characterised by a high rate of awareness and social acceptance of the LGBTIQ community, LGBTIQ youths still experience high levels of stress as a result of harassment, bias and discrimination, especially in countries where homosexuality is not accepted (Green et al., 2001). Discrimination occurs in different areas that include school, workplaces, places of religious worship, public accommodation and in accessing health care services (Birkett, Espelage & Koenig, 2009). For example, LGBTIQ individuals are discriminated against in religious institutions because of their sexual orientation. A study conducted in South Africa showed that LGBTIQ youths in the UK experience religious discrimination and stigmatisation (Mavhandu-Mudzusi & Sandy, 2015). The National LGBT Health Education Centre (2017) emphasises that the prevalence of anti-LGBTIQ attitudes within the society increases the risk of LGBTIQ youths developing substance addiction. The addiction problem may arise from different substances as a way of coping with their ‘different’sexual orientation, which may be spurred by internalised homophobia and homonegativity.

The prevalence of the different stressors as identified above increases the LGBTIQ youths' inclination to substance use. Findings from past studies such as Emslie, Lennox and Ireland (2017) suggest that LGBTIQ youths experience a considerably high risk of developing problem drinking, problem substance use and depression. According to Pompili et al. (2010), alcohol use has over the past years been consistently associated with a rise in cases of suicide. The reason behind the positive correlation between alcohol use and the high rate of suicidality includes the alcohol's disinhibition and impaired judgement. Findings of a stratified analysis by Silenzio et al. (1997) identified problem drug use, problem drinking and depression to be amongst the major factors that increase the risk of suicide ideation amongst LGBTIQ youths.

The report by the National LGBT Health Education Centre (2017) affirms that the rate of suicide among LGBTIQ youths is considerably high because of their substance use addiction. The report showed that the number of youths and teenagers who were reported to have attempted suicide as a result of substance addiction was 4.5 times higher compared to heterosexual youths. Over 42.8% of LGBTIQ youths were considered to have been seriously contemplating suicide largely because of substance addiction (National LGBT Health Education Centre, 2017).

According to Mereish, O'Cleirigh and Bradford (2014), LGBTIQ individuals experience a significantly high level of prejudices on the basis of their same-gender sexual behaviours and orientations. LGBTIQ youths are characterised as a high-risk group because they are exposed to a high a level of psychological distress and discrimination. The discrimination and prejudice that LGBTIQ youths experience have an adverse effect on the LGBTIQ's quality of life. This increases their predisposition to substance use and subsequently the risk addiction and suicide (Mereish, O'Cleirigh & Bradford 2014). McDermott et al. (2017) also echoed the sentiments of other researchers that LGBTIQ youths are highly predisposed to self-harm and suicide attempts. According to Haas, Eliason and Mays (2010), LGBTIQ youths are five to seven times more likely to be faced with a suicide risk compared to their heterosexual peers. The risk of suicide may be highly increased by substance addiction.

Drug and substance addiction and self-harm

Self-harm is a term used in reference to an array of behaviours in which a person deliberately inflicts injury on her or his body with no intention to cause suicide, or for non-socially approved reasons (Sarno, Madeddu & Gratz, 2010). The NICE Clinical Guideline (2012) defines self-harm as a form of self-injury, regardless of the intention or the level of suicidal aim. While self-harm consists of various behaviours, the most common ones include deliberate cutting, scratching or puncturing of one's skin, self-bruising, and pulling one's hair or skin, among others (Sarno et al., 2010). Most self-harming behaviours are described as being addictive on account of their "coercive” nature. Besides, self-harming behaviours have a “relieving" effect on the individual. Washburn et al. (2010) suggest that persons who partake in non-suicidal self-harm behaviour also have a strong desire for self-injury. Behavioural addiction is outlined by loss of self-control, along with the urge to carry on the behaviour even when an individual has experienced considerable negative outcomes.

While there is a dearth of literature on the link between self-harming behaviour and sexual orientation, existing research such as Chakraborty et al. (2011) indicate that individuals belonging to the LGBTIQ community are more predisposed to self-injury. Chakraborty et al. (2011) suggest that the number of LGBTIQ youths engaging in self-harm behaviour is on the rise in comparison with their heterosexual counterparts. According to Klonsky (2007), self-harming behaviour acts as a coping mechanism for LGBTIQ individuals, effectively shielding them against suicidality.

LGBTIQ individuals are more predisposed to self-harm in comparison with their heterosexual counterparts because of their high probability to substance addiction (McDermott, Hughes & Rawlings, 2016). In the same study, McDermott et al. (2016) established that LGBTIQ individuals were more predisposed to use in comparison to bisexuals. Consequently, LGBTIQ individuals were more likely to encounter negative feelings insofar as their sexual identity is concerned (Moller, Tait & Byrne, 2013). This discrepancy in terms of experience with self-harming behaviour can explain the minority stress theory as proposed by Meyer (2003). According to Meyer, this could be as a result of the extra distinctive prejudice facing bisexuals. According to McManus et al (2011), the high rise in cases of self-harm behaviour among the LGBTIQ community is primarily due to the fact that they keep questioning their sexual identify and hence resort to this behaviour which shields them from such thoughts. Similar sentiments have also been echoed elsewhere by Alexander and Claire (2004), who opine that despite acting as a coping strategy, self-harm behaviour also helps the sexual minority group deal with depression, as well as low self-esteem. The study indicates that contextual and social factors play a pivotal role insofar as the development of self-injury among LGBTIQ individuals is concerned. Despite the fact that LGBTIQ individuals may lead fulfilled and happy lives, they are actually at a higher risk of self-harm because of their incidence of substance addiction (Saewyc 2011). LGBTIQ individuals may engage in self-harm behaviour to fulfil several motives. They include a sense of relief from the anguish, as a form of escapism form the situation at hand, as well as a manifestation of feeling desperate (Brunner et al., 2007). The concept of self-harm is highly associated with suicidal behaviour amongst LGBTIQ individuals (Wong, Stewart & Lam 2007). In fact, they contend that suicidal behaviours occur on a broad-based spectrum that encompasses self-harm, suicidal ideation, suicide attempt, as well as actual suicide (Wong et al., 2007). On the other hand, other researchers identify self-harm and suicide attempts as being phenomenologically different behaviours aimed at fulfilling divergent purposes (Muelhlenkamp & Kerr, 2010). Accordingly, self-harming may be largely regarded as a coping mechanism with the potential to protect an individual against suicidality (Klonsky, 2007).

Considering the high incidences of self-harm and suicide ideation among LGBTIQ youths, the implication made is that this particular groups may have mental health inequality issues. The exact factors that trigger self-harm and suicide ideation among this group are not very clear (McDermott & Roen, 2016). However, hostility towards this group, discrimination and social stigma are some of the factors that contribute towards mental health inequalities in LGBTIQ youths. The observed increased rates of risk of suicide amongst LGBTIQ youths is linked to such factors as social isolation (Lehavot & Simoni, 2011), family or peer conflicts regarding gender or sexual identity, transphobic or homophobic use, failure to reveal gender or sexual identity, and early recognition of gender or sexual diversity among others (Austin, 2008).

In summary, LGBTIQ youths may be characterised by a considerably high rate of suicide ideation and suicide, which is exacerbated by substance use and use. The development of suicide ideation and subsequently the high rate of suicide amongst LGBTIQ youths are increased by different factors that include environmental and personal factors. The environmental factors identified include increased rate of prejudice, discrimination and stigma. The feeling of isolation and rejection experienced by LGBTIQ youths tends to pressure them into committing suicide (McDermott & Roen, 2016).

External & environmental factors and the relationship with substance use and addiction

LGBTIQ youths are characterised by a considerably high incidence of engaging in risky behaviour compared to their heterosexual counterparts (Nemoto et al., 2004). Flood, McLaughlin and Prentice (2013) suggest different risky behaviours amongst LGBTIQ youths that include binge drinking, tobacco use and illicit use of different substances. These behaviours increase the likelihood of LGBTIQ youths becoming addicted to the different drugs and substances that they use. The prevalence of substance addiction amongst LGBTIQ youths is increased by the prevalence of minority stressors amongst them as environmental factors (Flood, McLoughlin & Prentice, 2013). This assertion is further supported by findings of a meta-analysis involving LGBTIQ youths which showed that 90% of the youths are likely to use drugs (Keller et al., 2018). The rate of substance usage was high among bisexual youths, which was recorded at 3.4 times higher compared to the heterosexuals. Similarly, the rate of drug usage was recorded as 4 times higher amongst bisexual females compared to their heterosexual counterparts (Keller et al., 2019). While the study by Higgins et al. (2016) showed that 86% of the sexual minority individuals in Ireland reported drinking alcohol, 44% of the respondents reported that they had developed alcohol dependency problem while 10% of the respondents had developed severe alcohol drinking problem. Fifty-six percent (56%) of sexual minority youths had used substances for recreational purposes, especially the youths aged between 19 and 45 years (Higgins et al., 2016).

According to Weber (2009), the reasons behind the high incidence of substance use amongst LGBTIQ youths is largely under investigated. Among the many reasons that may explain the incidence of substance use amongst LGBTIQ youths is the fact that substance use tends to disconnect individuals from the feelings associated with their sexuality minority (Weber, 2009).

Substance use behaviour amongst LGBTIQ youths may be further increased by the fact that it enables them to develop feelings of social comfort by suppressing their feelings of low self-esteem. This view is supported by Adelson (2012) who suggests that substance use amongst the sexually minority youths is motivated by the need to relieve the painful experiences arising from shame, lack of a sense of belonging and guilt. LGBTIQ youths who use drugs experienced mood-altering behaviour attributed to these substances. However, Adelson (2012) argues that the capability of the drugs sustaining the individuals' self-esteem over the long term is limited. In some situations, LGBTIQ youths may experience a decline in self-esteem, especially during the substance withdrawal period. Substance use therefore increases the likelihood of LGBTIQ youths developing personality disorders, which according to Grant et al. (2011) arises from the poor treatment provided to individuals suffering from substance use and use. Grant et al. (2011) further suggests that personality disorders increase the risk of individuals developing multiple substance addictions. Findings of research conducted by McCabe et al. (2010) suggest that LGBTIQ youths are characterised by a considerably high risk of developing personality disorder.

A study involving a large sample of LGBTIQ individuals in a community showed that LGBTIQ individuals were two times more likely to develop substance use disorder, which is associated with decline in their personality. Gonzales and Henning-Smith (2017) suggest that most LGBTIQ youths who develop substance use disorder often seek treatment when their substance use problems worsen. According to Waling and Roffee (2017), sexual minority individuals suffering from substance use tend to experience comorbid or co-occurring psychiatric disorders such as depression and mental distress. As such, substance use and addiction amongst the LGBTIQ individuals leads to problem drug use, which subsequently translates into mental, physical and social harm for the individual (Baldvin et al., 2017; Bouris et al., 2010; Haas et al., 2010). The substance addiction that emanates from the social isolation increases the likelihood of the LGBTIQ youths developing suicide ideation.

It is important however to note that neither is substance use linked to one's LGBTIQ identity, nor is it the cause of substance use (Baldvin et al., 2017). As such, LGBTIQ individuals are likely to resort to substance use due to the same reasons as heterosexual individuals (Boon, 2009). Medley et al. (2016) report that LGBTIQ people are 2-4 times more likely to use such substances as alcohol, tobacco and other drugs, in comparison with the general population. Understanding substance use amongst the LGBTIQ youths should be undertaken in the context of the discrimination, prejudice and stigma that they experience. The Centre for Addiction and Mental Health suggest that the alienation and discrimination that LGBTIQ youths experience increases their level of stress, which pressures them to resort to substance use as a way of escaping such feelings (Centre for Addiction & Mental Health, 2006).

On the other hand, certain cultural factors contribute towards the noticeable high rates of substance use among the LGBTIQ individuals. An example of such cultural factors is limited non-bar-space. For a very long time, LGBTIQ individuals have made themselves invisible in regard to their socialising on account of the discrimination that they were subjected to. One of the few options available to them included parties and bars (Centre for Addiction & Mental Health, 2006). Consequently, the majority of the LGBTIQ individuals' may link socialising with substance use and use. Having bars as the main social outlet implies that LGBTIQ youths are more likely to develop the habit of regular use of drugs and alcohol, due to the peer setting (Scott & Priest, 2017). This means that the social crowd that the LGBTIQ youths are hanging out with tends to influence their behaviour negatively, such as their involvement in drug use (Johansen et al., 2013). On the other hand, the right social support acts as a powerful tool in enabling the LGBTIQ youths to maintain sobriety.

The media also plays a significant role in influencing substance use amongst the sexual minority, for example, by constantly portraying LGBTIQ youths regularly celebrating the use and use of substances (Marshal et al., 2008). The creation of such an image may result in normalisation of substance use and hence influence the use of such substances by the LGBTIQ individual. LGBTIQ youths may experience incidences of trauma arising from emotional and physical violence, which results in a further increase of their substance use.

The problem of substance addiction amongst the LGBTIQ community has been further exacerbated by political factors. Some countries have been characterised by a history of criminalising homosexuality. For example, homosexuality was considered illegal in Canada until 1969. As a result, LGBTIQ individuals experienced a significantly high rate of repression from the police (Hughes & Stevens, 2007). Cultural appearance is yet another reason that has contributed towards the high rates of substance addiction among LGBTIQ people, in comparison with the general population. LGBTIQ communities may tolerate being associated with substance use as this can be proof or manifestation of a group belonging and personal identity (Marshal et al., 2008). Fourteen individuals undertook a Toronto study involving minority bisexual and gay men attending clubs and circuit parties. The study findings revealed that some of the participants felt obliged or compelled to use drugs and especially so in cases where some of their friends were already using drugs (Husbands et al., 2004). LGBTIQ youths may also resort to drug use as a means of coping with social stigma directed at them. This view is supported by Boon (2009) who suggests that some individuals develop drug use and substance addiction as a method of coping with the stress associated with coming out. Different research studies have hypothesised on the correlation between stress and discrimination amongst the LGBTIQ community and a high rate of substance addiction (Rukus, Stogner & Miller 2017). Almeida et al. (2009) undertook a study to assess perceived discrimination among LGBTIQ youths on account of their sexual orientation. Research findings suggested that perceived discrimination was associated with increased development of depressive symptoms among study participants. Moreover, perceived discrimination was also associated with an increased risk of self-harm among study participants. There was also evidence of elevated suicide ideation, particularly in LGBTIQ males. Accordingly, Almeida et al (209) concluded that perceived discrimination may play a role in the development of emotional distress among LGBTIQ youths, further using them towards substance use.

Substance use and substance addiction amongst the LGBTIQ youths may increase their exposure to different problem behaviour associated with the behaviour. Examples of such problem behaviours include prostitution and engagement in frequent sexual encounters with multiple partners. Such behaviours may increase the risk of LGBTIQ youths suffering different sexually transmitted diseases, which may trigger suicide ideations (Bauer, Jairam & Baidoobonso, 2010). Findings of a study conducted by Rosario et al. (2009) show that women who have sexual intercourse with other women have an increased risk of becoming infected with sexually transmitted infections, for example, hepatitis B, which is associated with liver cancer, or human papillomavirus (HPV), compared to women who engage in sexual intercourse with men. The traumatic experience associated with sexually transmitted infections leads to increase in the probability of LGBTIQ youths developing substance addiction.

Rosario et al. (2009) further note that the probability of lesbians going for screening in order to determine whether they are infected with sexually transmitted infections is considerably low. Conversely, gay men are faced by a considerably high risk of suffering from oral, penile and anal cancer because of the strong relationship between the human papilloma virus and anal sex (Leonardi, Lee & Tans, 2011). The probability of infections with sexual transmission is considerably high if they do not use protection, for example, using a condom during sexual intercourse. Moreover, the likelihood of the LGBTIQ individual becoming infected may be worsened by substance use behaviour (Jordan, 2000). These illicit sexual behaviours amongst the LGBTIQ youths may trigger them to resort to substance use and substance use as a way of dealing with the negative consequences and hence addiction.

Findings from past studies show that LGBTIQ youths are characterised by an elevated risk of developing addiction. A study conducted by Rosario et al. (2009) suggest that approximately 30% of all individuals categorised as LGBTIQ are faced with the challenge of substance addiction. Among the common form of substances that the LGBTIQ community are likely to develop addiction are synthetic marijuana, steroids, cocaine, methamphetamine, inhalants, ecstasy, and prescriptions compared to heterosexuals (Caputi et al., 2018; Carrico, et al., 2010). Zacharias (2019) suggests that LGBTIQ youths are highly likely to combine different substances such as tobacco, alcohol and other substances i.e. polydrug use. As a result, the likelihood of LGBTIQ individuals developing addiction is estimated to be 2 to 4 times higher than that of the general population (Zacharias, 2018). This subsequently increases their risk of developing problem drug use.

Some of the common types of substances that have been identified and commonly used amongst LGBTIQ youths include, tobacco, alcohol, marijuana, opiates (heroin, oxycontin, Vicodin), prescription drugs (Ativan and Xanax) and Ecstacy (Zacharias, 2018). Zacharias (2018) suggests that LGBTIQ youths are 200% more likely to smoke compared to the heterosexual youths. In his study, Zacharias (2018) found that on average, the LGBTIQ individual smokes approximately 11 to 20 cigarettes daily. Similarly, 25% of LGBTIQ youths use alcohol while 63% of them have experimented with marijuana and ecstasy (Zacharias, 2018).

A study conducted in Australia showed that the country has experienced a considerable increase in the number of LGBTIQ youths using more potent substances such as crystal methamphetamine, commonly referred to as crystal meth. The use of crystal meth was found to be considerably higher amongst bisexual and gay men, compared to heterosexual men (Lea et al., 2017). Lea et al. (2017) suggests that there is a high probability of individuals who use crystal meth, developing addiction to the drug, which may result in such youths developing a heavier and regular use of the drug. Some LGBTIQ youths use different substances, for example, marijuana, in an effort to cope with mood disorders and anxiety arising from marginalisation, victimisation and discrimination (Bontempo & D'Augelli, 2002; McCabe et al., 2010). The self-medication behaviour may be increased by the LGBTIQ individual's desire to avoid the stigma that they might encounter in seeking medical care from professional healthcare services. This behaviour further affects the youth's quality of life (McCabe et al., 2010).

Aside from the problem behaviours that LGBTIQ individuals are likely to develop from substance use, Corliss et al. (2010) suggests that substance use by the LGBTIQ community is usually unregulated and illegal, which exposes them to the risk of illnesses and overdose. Substance use amongst the LGBTIQ community may further increase the risk of LGBTIQ youths experiencing criminalisation, stigmatisation, and discrimination, which may make them hesitant in seeking medical care (Corliss et al., 2010). Caputi et al. (2018) suggest that substance use amongst the LGBTIQ community is usually viewed to be a source of harm. LGBTIQ youths' use of different substances may be increased by the need to find social acceptance and community support. Therefore, academics and practitioners should view substance use amongst LGBTIQ youths in the context of their personal and social lives (Caputi et al., 2018).

Treating addiction among LGBTIQ youths

Reducing the likely harm that LGBTIQ youth may experience from substance use and addiction constitutes an important aspect of social and public health consideration. Success in treating addiction could be based on a multifaceted approach. First, governments could consider formulating interventions measures aimed at helping and supporting LGBTIQ youths to overcome the substance use problem (Rosario et al., 2009). This constitutes an important approach in reducing harm. Rosario et al. (2009) suggest that LGBTIQ youths who have developed substance use behaviour may prefer seeking treatment in institutions that are supportive of their sexuality. Such an environment may make them feel comfortable discussing issues related to their sexuality. In addition to this aspect, tailoring the substance addiction treatment program to the specific needs of the LGBTIQ individual is of fundamental importance in addressing the substance use problem. This arises from the fact that the treatment program is aligned with the specific addiction problem faced by an individual. For example, Rosario et al. (2009) support the perspective that the substance use treatment program should be designed in such a way that it aligns with the LGBTIQ youths' individual substance addiction problem.

Caputi et al. (2018) suggest that substance use by LGBTIQ youths may be specific to the stress experienced by the sexual minority group, which underlines the need of understanding the actual cause of the problem. The likelihood of the LGBTIQ client receiving quality care in respect to substance use is considerably high if such a program is tailored to the needs of the client. Training of service providers is another important issue that the health care providers could take into account in order to equip them with the requisite skills, knowledge and capability in responding to the problems posed by substance use amongst the LGBTIQ community.

Greene et al. (2018) and Taylor and Peter (2011) note that most healthcare providers, for example, nurses, physicians, and dentists, from whom LGBTIQ youths experience difficulty in providing health care, lack the proper knowledge on how to respond to the issues and challenges associated with their sexual orientation. Senreich (2010) supports the view that most LGBTIQ youths receive treatment and counselling from health care providers who do not have adequate knowledge on issues related to LGBTIQ individuals. Under such circumstances, LGBTIQ individuals may not be open with such support staff. The quality of support provided by such parties may not be sufficient for LGBTIQ youths in order to help them alleviate the substance use problem faced (Senreich, 2010). Training the healthcare providers may play an important role in addressing the health inequalities and health inequity that LGBTIQ youths experience in accessing health care. As a result, the quality of support given to LGBTIQ youths may increase substantially hence reducing their likelihood of engaging in substance use.

Another issue of importance in the delivery of health care to LGBTIQ youths. This includes ensuring that some of the parties involved in the health care service provision are LGBTIQ individuals themselves or supporters of the sexual minority rights (Lytle et al., 2014). Incorporation of these elements in the service provision is highly likely to increase the likelihood of LGBTIQ youths coming out because of the perception that confidentiality with regards to issues related to sexual orientation will be assured. In addition to the above support measures, the substance use programs could be comprehensive in that they could take into account the social, cultural, interpersonal and political dimensions that stimulate the likelihood of LGBTIQ youths using different substances.

In addition to healthcare providers, empowering social workers is another area of focus that could be taken into consideration in improving interventions to the LGBTIQ community. One of the issues that could be taken into account in improving the effectiveness of social workers includes training them on how to promote social justice towards the LGBTIQ individuals by targeting the communities structural, interpersonal, and intrapersonal dimensions of the stigma that LGBTIQ youths face. In respect to this, an empowerment-oriented social work course could be formulated (Logie et al., 2017).

Substance addiction and the LGBTIQ youth's Psychological health

LGBTIQ youths have increasingly become visible in society over the past decades (Joanna et al., 2009). One of the reasons that have contributed to their visibility includes the fact that they are increasingly campaigning for their rights (Joanna et al., 2009). In spite of the growing degree of visibility and level of social acceptance towards the LGBTIQ communities, there is a growing threat arising from the prevalence of the stigmatised identity (Joanna et al., 2009). One of the notable threats relates to the risk of substance addiction. This chapter examines substance addiction amongst LGBTIQ youths and its impact on their mental stability.

Increased social stigma of LGBTIQ poses a significant threat to their mental health (Russell & Fish, 2016). Hatzenbuehler (2009) suggests that experiences by LGBTIQ youths are not in themselves a cause of their psychological health problem. However, their psychological health is influenced by diverse stressors. One of the issues that may affect LGBTIQ youths' mental status includes their substance addiction. A study by Higgins et al. (2016) indicated a high level of mental instability amongst LGBTIQ youths in Ireland. Thirty-five percent (35%) of the LGBTIQ youths sampled suffered stress, while 42% of them experienced depression. The level of stress, depression, and anxiety was found out to be 4 times higher amongst the youths aged between 14 and 18 years (Higgins et al., 2016). The prevalence of diverse stressors experienced by LGBTIQ youths increases their predisposition to substance use and addiction. This may subsequently affect the LGBTIQ individual's mental health. According to the WHO (2014), mental health refers to an individual's state of wellbeing, which influences their capability in realising their full potential with regards to different aspects of life. It entails being productive at a personal and community level. Nonetheless, this definition raises a number of concerns or areas of controversy given that it views positive functioning and positive feelings as vital elements for mental health (Galderisi et al., 2015).

The level of mental stability for the LGBTIQ individual can be explained by the minority stress theory (Russell & Fish, 2016), which explains the relationship between sexual minorities (LGBTIQ) and their mental health. The theory proposes that the harassment, victimisation and discrimination that LGBTIQ individuals experience adversely affects their wellbeing and mental health (Russell & Fish, 2016). Findings of past studies on the subject (e.g. Larry et al., 2014) highlight existence of significant disparities between heterosexuals and the sexual minority group with regards to diverse diagnosable mental disorders and psychological symptoms, such as stress and depression, mood disorders, suicidal ideation, and post-traumatic stress disorder (Larry et al., 2014).

LGBTIQ youths experience significant mental health challenges, which emanates from the fact that they have to cope with different stressors that include the fact that they are a minority group, experience discrimination, violence and stigmatised identity (Hatzenbuehler, 2009; Fish & Pasley, 2015). As a result, the sexual minorities may be forced to employ maladaptive coping strategies such as substance use, which leads to addiction. Meyer (1995) and Flood, McLaughlin and Prentice (2013) undertook a study to determine minority stress facing gay men. Based on the study's research findings, it emerged that the mental health impact of chronic stress associated with their sexuality was a major contributor to the sexual minorities' poor mental health. Specifically, Meyer (1995) reported that expectations of being rejected, internalised homophobia and homonegativity as well as experiences with violence and discrimination were also linked to feelings of irrational guilt, demoralisation and suicidal ideation. Joanna et al. (2009) suggested that LGBTIQ individuals experience significant levels of chronic stress, anxiety, and depression.

Henning et al. (2013) suggest that depression is one of the common types of mental distress that LGBTIQ youths suffer from. The depression experienced by LGBTIQ youths largely goes untreated or under-treated. The level of depression amongst LGBTIQ youths is estimated to be 1.5 times higher compared to heterosexual youths (Szu-ying et al., 2017). Szu-ying et al. (2017) suggest that there are disparities with regard to the level of depression amongst the sexual minority groups depending on their ethnicity. For example, sexual minority groups of Indian and Chinese descent are characterised by a considerably high degree of mental resilience compared to New Zealand youths (Szu-ying et al., 2017). Nevertheless, the prevalence of stressors increases the risk of addiction hence negatively impacting the LGBTIQ youth's mental health.

A study by Thorsteinsson et al. (2017) involving over 500 LGBTIQ youths showed a positive correlation between sexual minority stress and their mental health. Findings of a community-based study Mustanski, Garofalo & Emerson (2010) on LGBTIQ youths show that 30% of the sexually minority youths experience a significantly high level of psychological distress. Mustanski, Andrews and Jae (2016) suggest that LGBTIQ youths experience stressors right from their childhood. The stress may arise from sexual use that they may have experienced during their childhood. Such experiences exacerbate the sexual minorities' mental health problems, increasing their probability of abusing illicit substances, which results in addiction.

Hein et al. (2013) suggest that the LGBTIQ youths experience hate-motivated rape in some instances. Such experiences are detrimental to their psychological wellbeing. It is estimated that LGBTIQ youths are highly likely to be subjected to sexual assault compared to the heterosexuals (Hein et al. 2013). Findings of a study involving 306 LGBTIQ adults showed that the highest level of post-traumatic stress disorder is experienced by the survivors of hate-motivated rape. This situation is not limited to the adults but is also experienced by LGBTIQ youths. The transgender group experience the greatest threat of assault and rape. A 2010 study involving 6,450 transgendered individuals showed that 12% of the respondents were victims of hate-motivated rape and were highly likely to develop substance addiction as a way of alleviating the mental stress suffered (Hein et al., 2013). The hate-motivated rape therefore tends to affect the victim's psychological wellbeing and may trigger substance addiction (Hein et al., 2013). The psychological stress associated with hate-motivated rape is high if it is perpetrated against male LGBTIQ youths compared to their female counterparts (Hein et al. 2013). In an effort to cope with the mental stress associated with sexual assault, LGBTIQ youths may consider abusing illicit substances.

Similarly, a study by the Australian National Survey of Mental Health and Wellbeing identified anxiety as one of the main mental disorders experienced by homosexual respondents selected for the study over the past 12 months (McNair & Bush, 2016). Stress remains a leading cause of substance use and it has also been singled out as a leading cause of relapse (National Institute on Drug Use, 2006).

LGBTIQ youths, on account of the numerous life stressors facing them, for example, harassment, victimisation and discrimination, are especially highly vulnerable to drug use compared to heterosexual youths (McNair & Bush, 2016). In fact, a close scrutiny of the lives led by LGBTIQ youths reveal that they are subjected to considerable stress, which is further complicated by the fact that this minority group have limited access to social support in comparison with their heterosexual counterparts (Hart & Heimberg, 2001). According to Hein et al. (2013), the presence of a support system creates a sense of safety and security amongst the LGBTIQ community. In spite of the fact that the support system does not eliminate the likelihood of the LGBTIQ individual experiencing victimisation, it results in less psychological distress in the event of one suffering such victimisation. Enhancing the quality of support provided to LGBTIQ youths may therefore constitute a valuable therapeutic intervention.

The mental distress faced by LGBTIQ youths may also arise from the fact that they may experience discrimination in accessing different amenities. For example, LGBTIQ youths may experience challenges in accessing health services partly because of the negative social beliefs on their sexual orientation. A study by Eady, Dobinson and Ross (2011) conducted in Canada showed that LGBTIQ individuals are perceived to be dishonest and promiscuous. Moreover, the study showed that most individuals do not consider bisexuality to be a legitimate sexual identity (Eady et al., 2011). The prevalence of such social beliefs hinders the ease with which bisexuals access health services. Such beliefs can lead to bisexuals experiencing stress, hence resulting in poor emotional wellbeing and mental health (Eady et al., 2011). Besides, LGBTIQ youths are frequently the victims of various types of victimisation, including harassment at school, their places of work, and within the community (Kosciw & Díaz, 2006).

The prevalence of stressors experienced by LGBTIQ youths may be categorised into external stressors, which arise from institutionalised and individual discrimination experienced by the LGBTIQ person, internalisation of the negative social attitude by the individual, and development of the perception that the individual will suffer victimisation and rejection on the grounds of their sexual orientation (Russell & Fish, 2016).

In view of the depression, stigmatisation and victimisation that LGBTIQ youths experience, their likelihood of developing a mental disorder is high (Russell & Fish, 2016). The conclusion of most studies conducted on mental health (e.g. Eskin et al., 2005) amongst the LGBTIQ community correspond with each other in that they support the perspective that the LGBTIQ community report a considerably high level of mood and anxiety disorders, emotional distress, self-harm, and suicide ideation (Eskin et al., 2005; Fleming et al., 2007; Fergusson et al., 2005; Marshall et al., 2011).

According to Hein et al. (2013), any violent victimisation that an individual may experience may result in devastating mental health consequences such as post-traumatic stress disorder, increased anxiety and depression. This may subsequently increase their probability of substance use, leading to addiction. In view of the fact that hate crimes are some of the most violent forms of victimisation that LGBTIQ youths have to deal with, their likelihood of developing addiction to different illicit substances cannot be ruled out (Hein et al., 2013). McCann et al. (2013) suggest that hate crime affects individuals in different ways, including a decrease in their self-worth. This subsequently results in the LGBTIQ individuals developing a feeling of disempowerment, feeling of inferiority, defeat, failure and unwanted exposure, which affects their mental health (Green & Britton, 2013).

Secondly, hate crime may have negative consequences on an individual's sense of personal invulnerability, and the perception of the world as a reasonable place to live in is negatively impacted. LGBTIQ youths may in some instances develop internalised homophobia, which entails a negative feeling about their sexual identity (Hein et al. 2013). Hein et al. (2013) suggests that there are different mental health consequences that LGBTIQ youths encounter; amongst them anger, a reduced sense of self-efficacy, internalised homophobia, sleep disturbances, development of a sense of self-blame, loss of trust for others and development of feeling of suicidal ideation (Hein et al. 2013; Johnson et al., 2008). In some instances, the poor mental health may cause LGBTIQ youths to be violent.

Psychological stress mainly arises from the discrimination and victimisation, fear of rejection and hate crime. Findings of a study conducted in 2014 showed that LGBTIQ individuals are highly likely to experience poor mental health because of stigmatisation and victimisation associated with their sexual orientation (Bariola et al., 2015). It is estimated that a significant proportion of LGBTIQ people living in societies in which they are subjected to high levels of prejudice and stigma die 12 years earlier than their LGBTIQ counterparts living in less prejudiced communities (Hatzenbuehler et al., 2014). The prevalence of poor mental health amongst the LGBTIQ community increases their frequency of substance use (Fish & Pasley, 2015). Currently, homosexuality is illegal in over 70 countries around the world. As such, the risk of LGBTIQ youths living in such countries experiencing poor mental health is considerably high.

In view of the fact that the school environment greatly impacts the LGBTIQ youth's mental stability, for example, because of victimisation, bullying and harassment from peers, LGBTIQ youths may develop problem drug use, which may lead to illicit drug and substance addiction. In light of this, the need for improving the school environment to be conducive for the LGBTIQ youths is essential (Flood, McLaughlin & Prentice, 2013). Guo et al. (2001) suggests the development of school connectedness as one of the strategies for enhancing social support towards LGBTIQ youths. School connectedness, according to Seil et al. (2014), entails the development of a school environment that is characterised by lower emotional distress, violence, eliminating substance use amongst the young adults hence limiting the risk of addiction. Developing school connectedness should further include supporting LGBTIQ youth develop a sense of belonging towards the school and the school environment, for example, by including LGBTIQ youths in school activities such as extracurricular activities (McNeely & Falci, 2004). Fostering school connectedness should further include supporting having teachers offer support to LGBTIQ youths. The rationale of this approach is supported by Rivers and Noret (2008), who suggest that staff support makes the students feel cared for. Such students depict better behavioural outcomes, for example, abstaining from abusing illicit substances and drugs.

In a study by LGBTIQ youths attending schools that have implemented antidiscrimination and anti-bullying laws against the LGBTIQ individuals reported a significantly lower incident of harassment and victimisation compared to their LGBTIQ counterparts attending schools where such protection was absent (Kosciw et al., 2014). By 2015, only the District of Colombia in the USA had implemented legal protection targeting LGBTIQ people, for example, the anti-bullying law (GLSEN, 2015). This indicates existence of a significant gap with regards to provision of protection of LGBTIQ youths in institutions. In addressing the high level of discrimination towards the LGBTIQ community, it is important for governments to consider undertaking legislative changes targeting the LGBTIQ community.

Needham and Austin (2010) undertook a study with a view to exploring variations in perceived parental support among LGBTIQ youths, relative to their heterosexual counterparts. From the study's research findings, it emerged that parental support moderately or completely mediated links between LGBTIQ youths on the one hand, and various risk factors such as suicidal ideation, depression and drug use, on the other hand. Parental rejection is associated with negative health outcomes (Ryan et al., 2009) and for this reason, there is the expectation that affirmation of LGBTIQ youths may be linked to positive adjustments and reduced behavioural health risks. Elsewhere, Resnick et al (1997) suggested that parental connectedness or support is associated with reduced levels of interpersonal violence, increased levels of psychological well-being, and reduced likelihood of partaking in such irresponsible behaviour as drug use and alcohol intake.

Research evidence confirms that family support constitutes a critical protective factor which translates into a positive mental health outcome because of improved self-esteem. Family support further results in reduced levels of depression, substance use and the likelihood of LGBTIQ youths developing suicidal ideation and behaviour (Trussell, 2017). Nevertheless, most LGBTIQ youths fear 'coming out' to their parents because of the perception that they will experience rejection because of their sexual identities (D'Angelli 2002; Rosario et al., 2009). Developing strong family bonds and promoting a supportive school environment can act as a protective measure that safeguards LGBTIQ youths from experiencing depression and development of suicidality thoughts.

Homma and Saewyc (2007) established that LGBTIQ youths of Asian American descent who perceived their families to be caring, tended to present with reduced levels of emotional distress, in comparison with their peers who did not believe they had caring families. A strong supportive relationship between a youth and his/her parents has been identified as a key indicator of long-term adjustment for such a youth in social settings (Chaplic & Allen, 2013). While the same argument could be extended to also include LGBTIQ youths (Nedham & Austin, 2010), a number of challenges are likely to hinder such relationships. In their study, Safren and Pantalone (2006) revealed that LGBTIQ individuals are likely to feel that they do not receive the social support they deserve in comparison with their heterosexual counterparts. Such perceptions are likely to be informed by the fact that LGBTIQ youths usually encounter distinctive developmental situations, in the sense that they are mainly brought up by people who differ from them with respect to their sexual orientation (Chaplic & Allen, 2013). Also, the homes where such individuals are raised do not support the LGBTIQ youths' identity development (Rosario et al., 2004).

According to Needham and Austin (2004), the increase in cases of poor mental health outcomes as experienced by LGBTIQ youths is in turn linked to limited support from the family environment that these individuals are exposed to. The realisation that not many LGBTIQ youths enjoy family support on account of their sexual orientation is in itself quite damaging (Rosario et al., 2004). The level of harassment at school and rejection at home tend to be higher among LGBTIQ youths who come out early in comparison with those who ‘come out' as adults (D'Augelli, Hershberger & Pilkington, 1998). Besides, Ryan et al. (2009) suggest that LGBTIQ youths who ‘come out to their families are more predisposed to higher rates of verbal and physical use by their families, which is in turn associated with increased rates of suicide attempts. According to Rosario et al. (2009), family rejection could result in distressing outcomes for LGBTIQ youths. This is because such rejection is linked to increased rates of substance use, suicidal ideation, engaging in unprotected sex, and committing suicide. Moreover, family rejection has also been shown to contribute greatly towards the increased rates of homelessness among this group (Coker, Austin & Schuster, 2010). However, Floyd and Stein (2002) suggest that ‘coming out' at a younger age implies that LGBTIQ youths tend to feel more comfortable with their individual sexual identity.

Duncan and Hatzenbuehler (2014) support the perspective that LGBTIQ youths living in communities characterised by LGBTIQ-motivated crimes tend to depict poor mental health. One of the issues that increases the risk of poor mental health includes the LGBTIQ youth's reliance on illicit substances as a way coping with the lack of community acceptance. As a result, the risk of LGBTIQ youths harbouring suicidal ideation and attempting suicide may be increased substantially. Conversely, LGBTIQ youths residing in communities that are supportive of LGBTIQ rights, for example, same sex marriage and freedom of registering same-sex organisations are not likely to develop risky behaviours such as problem drug use behaviours, substance use and subsequently suicidal ideation (DeCamp & Bakken, 2016).

In summary, LGBTIQ youths may be characterised by poor mental health, which arises from different internal and external factors. LGBTIQ youths may experience a significantly high levels of mental instability that arises from depression, anxiety, anger and post-traumatic stress disorder. LGBTIQ individual's poor mental health may be triggered by different factors such as rejection by family members and friends, prejudice, use, victimisation, genetics, and discrimination.

Moreover, the poor mental health experienced by the LGBTIQ community may also be increased by the prevalence of hate crime perpetrated towards them because of their sexual orientation. The poor mental health amongst LGBTIQ youths may be worsened by the lack of an effective support system. Most of the LGBTIQ youths may not be supported by their families, their colleagues, the government and society in general. As a result, LGBTIQ youths may tend to develop feelings of exclusion which affect their mental health. This subsequently may increase their predisposition to illicit substance use, hence leading to addiction. In respect to the internal and external stressors faced, the LGBTIQ youth's poor mental health, which may be exacerbated by drug use and substance addiction increases the likelihood of LGBTIQ youths committing suicide.

Conclusion and recommendations

Conclusion

The research literature review suggests that substance use and use amongst LGBTIQ youths increases the risk of developing an addiction problem (Bonnie, 2002). A number of factors appear to fuel addiction amongst LGBTIQ youths. The factors identified by different studies (Kelley, Schochet and Landry, 2004; Eckstrand & Ehrenfeld, 2016) as increasing the risk of addiction amongst LGBTIQ youths range from social and environmental to institutional factors. This current review of literature supports the existence of a positive relationship between substance addiction and the likelihood of LGBTIQ youths developing suicidal ideation (Eckstrand & Ehrenfeld, 2016). One of the reasons why addiction increases the risk of suicide ideation amongst the LGBTIQ youths may include the negative impact of substance addiction on an individual's mental health. The substance addiction that LGBTIQ youths develop is largely as a result of the negative societal reaction towards them, (for example, heterosexism, homophobia and transphobia), lack of support from family, friends and institutions, discrimination and social stigma (Bonnie, 2002). Drug use and substance addiction may therefore be identified as a leading problem experienced by LGBTIQ youths. The idea that LGBTIQ youths are victims of addiction is erroneous because they do have choices. Nonetheless, it is not likely they are under duress (Bonnie, 2002).

The risk of suicide is increased by the high probability of the addiction associated with the substance use (DeCamp & Bakken, 2016). Research shows that LGBTIQ youths are highly likely to develop illicit substance use compared to heterosexual youths. The development of substance addiction amongst LGBTIQ youths may be triggered by the prevalence of different stressors that the sexual minority group experience. Birkett, Espelage and Koenig (2009) identify stigma, prejudice, discrimination and use because of their sexual orientation as some of the stressors.

The discrimination, prejudice and victimisation against LGBTIQ youths may negatively impact the development of their self-identity. The stigma they experience may affect their probability of coming out because of the feeling of shame and negative perception towards them. In addition to this, LGBTIQ youths are in some instances considered as outsiders by the society because of their sexual orientation (Marshal et al., 2008). As a result, LGBTIQ youths tend to develop feelings of exclusion, which result in physical and emotional stress. In light of feelings of exclusion, stigmatisation and prejudice, LGBTIQ youths are highly likely to develop drug use and substance addiction in an effort to conform to the LGBTIQ subculture. For example, the LGBTIQ youths may start patronising bars in pursuit of a sense of belonging to the LGBTIQ community (Russell & Fish, 2016). As a result, the risk of LGBTIQ individuals developing substance use and substance addiction is increased. Development of substance use and addiction may also arise from the sexual minority individuals need to cope with the hate crime that may be perpetrated towards them because of their sexual orientation.

This review of the literature identifies the prevalence of discrimination as one of the factors that may increase the likelihood of LGBTIQ youths developing drug use behaviour and substance addiction. LGBTIQ youths may develop such behaviour as a way of socialising and in an effort to develop a sense of self-identity amongst the LGBTIQ community. The prevalence of substance use and substance addiction may increase the likelihood of the LGBTIQ individual developing suicide ideation. An increased rate of suicide amongst the LGBTIQ community may be further increased significantly by their substance use and substance addiction. One of the issues that have been identified as a significant contributing factor towards substance addiction and substance use and subsequently suicidal ideation is the prevalence of social-cultural stigma and prejudice towards the LGBTIQ youths. For example, the stigma affects LGBTIQ youths' mental wellbeing hence increasing their likelihood of developing drug use and substance dependency.

The LGBTIQ youths are faced with a high risk of self-harm, which is largely increased by the substance addictive behaviour that the LGBTIQ youths develop. One of the notable forms of self-harm that characterises the LGBTIQ youths includes development of suicide ideation and suicide (Marshall et al. 2008). The LGBTIQ individuals may be pressured to drug use and may become addicted by various stressors such as feelings of isolation by family, friends, and peers, which may arise from victimisation, use and discrimination by such parties. The anxiety, stress and depression arising from the social exclusion may increase the probability of the LGBTIQ youths developing substance use and substance addiction as a coping mechanism. In turn, the sexual minority may be pushed to drug use by the need to feel accepted by the society and to fit in within the sexual minority group.

The literature review further confirms that the risk of addiction amongst the LGBTIQ youths may be increased by other factors associated with their sexual orientation. Examples of such factors include sexual assault such as rape, harassment and physical violence. The literature shows that the LGBTIQ youths may in some instances be turning to the internet in an effort to 'come out' by seeking support from their peers. As a result, these youths may be increasingly exposed to cyber-bullying. Such incidences may affect the LGBTIQ youths psychologically if they do not access the necessary support. For example, the negative experiences may push the sexual minority to develop substance addiction and subsequently attempt suicide.

The current literature review confirms that LGBTIQ youths may be further characterised by poor mental health, which affects their mental stability. The poor mental health increases the LGBTIQ youths' inclination to substance use. Findings from the study show that the level of depression amongst LGBTIQ youths is estimated to be relatively higher compared to the heterosexual youths (Ryan &, Huebner, 2009). The depression may push the LGBTIQ youths to use illicit substances. The poor mental health amongst LGBTIQ youths mainly results from the different stressors in the environment where they live. The literature review supports that sexual minority communities may experience high levels of victimisation, marginalisation and stigmatisation which affects their likelihood of coming out. The lack of an effective support system, for example, family, cultural and social support directed towards the LGBTIQ community, negatively impacting their mental health outcome. The review further confirms that LGBTIQ youths may experience significantly high level of chronic stress, anxiety, and depression.

The absence of a support system affects LGBTIQ youths' sense of self-worth and self-esteem. In some instances, the youths may consider using drugs and developing substance addiction. The mental instability amongst the sexual minority youths is worsened by the fact that they are not able to access treatment because of discrimination by health service providers (Mustanski et al., 2010). Because of the numerous life stressors facing LGBTIQ youths, for example, harassment, victimisation and discrimination, they become highly vulnerable to substance use compared to the heterosexual youths. As such, their risk of developing suicide ideation and committing suicide may be considerably high. Substance addiction and drug use among LGBTIQ youths may increase their risk of suffering socio-cultural stigma. The high incidence of socio-cultural stigma may affect LGBTIQ youths emotional and psychological wellbeing and hence the risk of developing suicide ideation. The extensive disparities that LGBTIQ youths may experience for example are, mental health, suicidal ideation and substance use issues compared to their heterosexual counterparts. This underlines the need for health care professionals to consider taking into consideration the necessary precautions. In summary, the literature review underlines the existence of a positive correlation between substance addiction and suicide ideation amongst the LGBTIQ youths. The study confirms that substance addiction amongst the sexual minority youths may increase the level of social-cultural stigma that they experience.

Recommendations

In light of the fact that substance addiction may increase the risk of suicide and suicide ideation amongst the LGBTIQ youths, it is important for effective intervention measures aimed at safeguarding the LGBTIQ youths against developing substance addiction problems to be implemented. The intervention should largely focus on minimising the likelihood of LGBTIQ youths engaging in self-harm. The first intervention should entail improving the LGBTIQ youths' socio-political climate, which should encompass increasing the level of LGBTIQ acceptance by the community, the school environment and the neighbourhood.

One of the key areas of intervention in reducing substance addiction and hence suicide and suicide ideation includes reducing the prevalence of hate crime perpetrated towards LGBTIQ youths because of their sexual orientation. Governments across the world should implement hate crime prevention laws, which should, among other things, criminalise different acts of sexually motivated hate crime, for example, physical use towards LGBTIQ youth (assault or causing bodily harm/injury), and verbal use towards the LGBTIQ individual.

The rationale of criminalising hate crime is underlined by the fact that they are based on a particular motive. Hate crimes are highly likely to cause mental, physical and emotional injury to the victim compared to other types of crime. For example, hate crime towards LGBTIQ youths may be motivated by the intention to cause fear and to destroy or break the spirit of the LGBTIQ individual or group. To overcome the problem posed by hate crime, it is important for the community to be educated on the importance of accepting the LGBTIQ community as one of the key components of diversity in society. This move can play an important role in overcoming the stereotyping associated with LGBTIQ individual's sexual orientation. Educating the community on this front will significantly increase the likelihood of the LGBTIQ individuals in gaining a higher level of social acceptance. In addition to criminalising hate crime towards the LGBTIQ community, it is important for institutions to adopt a zero-tolerance policy of hate crime, discrimination, victimisation and prejudice towards the sexual minority. This move will play an important role in promoting the LGBTIQ youth's welfare hence minimising their probability of engaging in destructive behaviours such as drug use that increase the risk of addiction. Providing family, cultural, social and institutional support to LGBTIQ youths is another intervention that can result in significant reduction in the risk of substance addiction amongst the sexual minority. For example, by providing the necessary support, the likelihood of LGBTIQ youths developing substance addiction and hence suffering social cultural stigma will be reduced. At the family level, LGBTIQ youths should be supported by their nuclear and extended families. Support from the family may increase the likelihood of LGBTIQ youths coming out by disclosing their sexual orientation. As a result, the likelihood of such youths experiencing reduced minority stress as a result of the depression, anxiety and stress associated with their sexual orientation is significantly reduced.

Promoting social-cultural acceptance towards LGBTIQ youths is another issue that should be considered. Society should be encouraged to accept the various sexual orientations of the different members categorised under the LGBTIQ community as one of the key components of the cultural diversity that prevails in the society. By taking this aspect into consideration, lesbians, gays, bisexual, transgender, intersex and the questioning individuals may experience an increased level of social acceptance. Improving the support system at the family and society levels will result in creation of a feeling of acceptance for the LGBTIQ youth, which reduces minority stress. The support system may make the sexual minority develop a sense of self-forgiveness, to forgive others and forgive the situations that might have resulted in feeling of shame because of social stigmatisation. The overall impact is that the LGBTIQ's self-esteem may improve.

In recognition of the threat of health risk posed by substance addiction among LGBTIQ youths, it is important for stakeholders in the public sector to consider formulating policies aimed at addressing the threat. For example, policy makers should conduct research on substance use among the LGBTIQ community with the goal of gaining insight on how to foster the development of a supportive environment for the LGBTIQ individual. The policy makers should consider formulating research on how to help LGBTIQ youths avoid drug use and substance addiction. Another area that LGBTIQ youths require is formulating policy to reduce bullying. For example, learning institutions should formulate anti-bullying policies with the goal of reducing suicide and suicide ideation among the LGBTIQ community (Kull et al., 2016). Additionally, institutional support to LGBTIQ youths should further encompass the provision of training to the different stakeholders involved in public health matters. For example, public health care officials should be trained on issues related to coming out, and the stages that should be observed in assisting LGBTIQ youths to successfully come out.

It is also important for the public health practitioners to be provided with holistic training on the diverse issues that increase substance addiction amongst LGBTIQ youths. Adopting a holistic approach in training of health care providers may help in ensuring that practitioners are effective in addressing the challenges that range from LGBTIQ youth's mental health to discrimination, that tend to increase the risk of substance addiction and substance use. The intervention measures should further address the post-traumatic stress disorder that LGBTIQ individuals experience. Amongst the intervention measures that should be considered include integrating cognitive behavioural therapy, exposure therapy, and psychopharmacology. Such interventions can play an important role in addressing the poor mental health experienced by LGBTIQ youths because of their sexual orientation, which subsequently reduces the incidence of LGBTIQ youths developing substance addiction. This subsequently reduces the risk of the sexual minority youths developing suicide and suicide ideation. Observing the above proposed interventions will have a positive impact on the LGBTIQ individual's overall life satisfaction because of improved social support from family, friends, institutions, and colleagues.

The inclusion of a psychoanalytical approach to drug addiction among the LGBTQ youths is also recommended. In this case, psychoanalysis enables the drug user to confront the underlying issues they are faced with. Like all other interventions, psychoanalysis is also not 100% foolproof. As a matter of fact, none of the other above recommendations is 100% effective. Such an acknowledgment is crucial as it helps the therapist and the drug user to appreciate the fact that not all addicts can eventually recover. It is however hoped that the recommendations made above will contribute significantly towards improving the health and well-being of LGBIT youths. Further primary research in this area needs to be carried out.

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