Until 1973, the goal for those seeking treatment for homosexuality was to decrease the intensity and frequency of homosexual thoughts, feelings, and behaviors while simultaneously increasing heterosexual thoughts, feelings, and behaviors. The removal of homosexuality from the DSM that year led to efforts to promote the physical and mental health of gay men and lesbians, including an understanding of the impact of substance use by these populations. Early studies found very high rates of substance use. Later methodological improvements cast doubt on the conclusions of early studies but still found elevated rates of substance use. Later studies came to the same conclusion for bisexual and transgender individuals.

Treatment is also problematic. While the majority of individuals with a substance use problem do not seek professional help, LGBT individuals’ reluctance to seek treatment often stems from a confluence of prejudicial treatment from health-care staff and a lack of knowledgeable providers.

The definition of transgender has become increasingly encompassing and inclusive, and society is slowly recognizing the existence of a diverse group of individuals who depart from traditional gender norms and identification. While studies of substance use by transgender individuals did not get under way in earnest until the late 1990s, they find strikingly high rates. Research also finds that many transgender individuals experience cumulative and catastrophic levels of minority stress, which can help to explain a high prevalence of co-occurring disorders.

Treatment providers often have little information and/or negative attitudes about transgender individuals; treatment facilities are often unprepared to work with members of this group. Successful treatment must factor in the unfortunately common experiences of discrimination, violence, stigma, poverty, co-occurring disorders, HIV, and other health concerns.