One research model that Greg alluded to as well is the syndemic theory. Syndemic theory suggests that the reason we see multiple health problems arise in the same population—and you mentioned substance use, but we could also talk about anxiety, or many of the other health issues we're referencing today—is a confluence of two things. One is a history of feeling stigmatized and feeling different. Sometimes when those feelings get internalized a form of coping becomes substance use. It also becomes a way to connect to other people.
In syndemic theory one of the suggestions is that these populations will get together in the same geographic space. That's what has happened historically with gays and lesbians and other sexual and gender minorities. We've gathered together in certain places so we could connect with one another in community. That means sometimes if there's already a high rate of substance use, that becomes a form of connection. It also decreases inhibitions. If I've been told all my life that my sexuality is wrong, I might feel a natural rejection when I see another man, but using substances helps to relieve some of that inhibition and some of that fear.
The other piece of syndemic theory is that because these populations or these groups who disproportionately experience these health outcomes may have been excluded historically from some health services, as we were discussing today, it just might take a little extra effort to reach them and bring them through the door, given that they might avoid going to the ER or they might avoid going to a health clinic because they're not quite sure how that provider is going to react to their sexuality.