“Why can't they come up with a program that teaches people how to get high and go to work”: Structural vulnerability, personal substance use and recovery goals, and substance use treatment among sexual and gender minority persons (SGMP) in Los Angeles, California
This qualitative study of sexual and gender minority persons who inject drugs in Los Angeles reveals that effective substance use treatment requires integrating harm reduction with structurally competent services that address social isolation, financial insecurity, and patient-centered goals, rather than relying solely on traditional abstinence-focused models.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
For many people, the path to recovery from drug use is imagined as a straight line: stop using completely, stay away from the substance forever, and rebuild a life. This view assumes that the primary battle is internal, fought against a chemical dependency that must be defeated through sheer will or strict rules. However, a growing body of research suggests that for many, this picture is incomplete. It often ignores the messy, difficult reality of a person's daily life, where the drive to use drugs is tangled up with a lack of money, the threat of homelessness, and the pain of being treated as an outcast by society. When people are struggling to find a safe place to sleep or a way to pay for food, the idea of stopping drug use entirely can feel impossible, or even counterproductive to their survival. This tension between what treatment programs demand and what people actually need to survive forms the backdrop for a new study exploring how sexual and gender minority people navigate addiction and recovery in Los Angeles.
The study, conducted by researchers at several universities, focused on a specific group: people who were assigned male at birth and identify as sexual or gender minorities, such as gay, bisexual, or transgender individuals. These researchers wanted to understand why so many people in this community use drugs at high rates but often fail to find or stay in treatment programs that work for them. Instead of just asking about the drugs themselves, the team sat down with fifteen people for long, open conversations. They listened to stories about how these individuals used substances, what they hoped to achieve by using them, and what happened when they tried to get help. The goal was to see the problem not just as a medical issue, but as a human one, shaped by the environment and the structures of society that surround these people.
The people who shared their stories described a complex relationship with their drug use that did not fit the simple "good versus bad" narrative often found in treatment centers. For some, the goal was not to stop using drugs entirely, but to use them in a way that felt controlled and intentional. They wanted to use substances to manage anxiety or connect with others without letting the drugs take over their lives or prevent them from working and caring for their families. One participant, who wanted to become a software engineer, explained that they wished they could use drugs recreationally, like someone might enjoy a glass of wine at a party, without it becoming a necessity that ruined their ability to function. Another person stopped injecting heroin after seeing a friend nearly die from an overdose, not because they wanted to stop using drugs altogether, but because they wanted to avoid the specific danger of needles and the shame of the visible scars they left behind. For these individuals, recovery meant finding a way to use less, or use differently, to stay safe and keep moving forward with their lives.
However, the standard treatment programs available to them often made these goals impossible. The researchers found that many participants felt that treatment centers were out of touch with their real lives. These programs frequently demanded total abstinence as a condition for help, ignoring the fact that many participants were struggling with homelessness, unemployment, and a lack of basic resources. One participant described a situation where they had lost their job and their home, and the idea of entering a program that required them to stop using drugs immediately felt unrealistic. They asked a question that cut to the heart of the disconnect: why can't there be a program that teaches people how to use drugs and still go to work? They envisioned a "function program" that would help them maintain their daily routines and income while managing their drug use, rather than forcing them to choose between survival and sobriety. When programs ignored these structural struggles, participants often felt that the treatment was not for them, or that it was setting them up to fail.
The experience of seeking help was often marked by feelings of shame and punishment rather than support. Several participants recounted stories where they were forced into treatment by the courts to avoid prison, only to be kicked out of the program for minor rule violations. One person, who had been sober for nearly five years in a residential facility, was asked to leave simply because they had come out as transgender and the facility could not or would not support their transition. Another participant was discharged after a romantic relationship with another resident, losing their housing and support system in the process. These experiences taught them that the rules of these programs were often rigid and unforgiving, prioritizing compliance over the person's well-being. Similarly, many found the group therapy sessions common in programs like Alcoholics Anonymous to be emotionally overwhelming. Being forced to share their deepest traumas and struggles in front of a crowd made them feel exposed and ashamed, driving them away from the very help they needed.
Despite these negative experiences, the study found that recovery was possible when the approach changed to meet the person where they were. Participants spoke positively about programs that addressed their basic needs first. When treatment included help with finding housing, securing food, or connecting with family and friends, people were more likely to stay engaged. One person described how their grandparents, who drove them to a facility and brought them small comforts like cigarettes, made the difference between giving up and continuing. Another found success in a program that used a "therapeutic community" model, where they could see a therapist weekly and receive medication for mental health while living in a structured environment. Others appreciated programs that offered financial incentives for staying clean, not as a bribe, but as a way to build a safety net and feel supported. These successful models shared a common thread: they treated the person as a whole, acknowledging that drug use is often a response to difficult life circumstances, and they offered a path forward that respected the individual's goals and dignity.
The researchers concluded that to help people in this community, treatment must change. It needs to move away from a one-size-fits-all demand for total abstinence and toward a more flexible, supportive approach. This means offering care that is not judgmental, that addresses the immediate crises of housing and money, and that allows people to make their own decisions about their recovery journey. It involves integrating different types of help, such as therapy, medication, and social support, into a single, cohesive plan. By focusing on the structural vulnerabilities that drive drug use—like poverty, isolation, and discrimination—rather than just the drugs themselves, treatment can become a tool for building a better life, rather than a barrier that keeps people out. The study suggests that when people feel safe, supported, and respected, they are far more likely to find a way to reduce the harm in their lives and move toward a future that feels within their reach.
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