About seven years ago, “Ramone,” 28, said he found himself in situations he “never could have imagined before.”

He moved to New York City from out of state without many personal connections or a job, and couch surfed from apartment to apartment.

At one point to pay the rent, he turned to working as an escort.

Then, on his 21st birthday, he learned he was diagnosed with HIV. Eventually, he found himself living in the city’s homeless shelter system.

Ramone, who did not wish to be identified by his full name, says that an undercurrent running through this period of transition and challenge was a reliance on substances.

While social and recreational alcohol and marijuana use were not significant hindrances to his day-to-day life, he says an addiction to crystal meth became a major roadblock to his ability to live what he called a “productive life.”

“Crystal meth was introduced to me by people who did not have my best interest at heart,” Ramone told Healthline. “I still keep in touch with some of these people to this day, every once in a blue moon they pop up. Of course, I think about ‘oh my gosh, I shouldn’t keep in touch with them.’ But they were there when I needed a place to stay, when I didn’t have anybody, any food, shelter. Unfortunately, they were there.”

Ramone’s experiences are not uncommon to the millions of people in the United States who live with addiction and substance use disorders.

The 2017 National Survey on Drug Use and Health reports that 18.7 million people age 18 or older had a substance use disorder in the United States. The same report found that about 3 in every 8 people struggle with a reliance on “illicit drugs,” about 3 in 4 live with alcohol use, while 1 in every 9 people deal with addictions to both drugs and alcohol.

Additionally, Ramone’s story might elicit nods of recognition from one particular segment of the population: LGBTQ people.

As a self-identified member of the LGBTQ community, Ramone’s experiences reflect the relatively high presence of these disorders among LGBTQ Americans.

Why are these issues so common in the greater LGBTQ community?

Numerous studies and work from counselors and advocates in the field have tried to answer this complicated question for years. From looking at the “gay bar” as a safe space for LGBTQ gatherings to cultural pressures that can leave people in this community particularly susceptible to substance use disorders, it’s a complicated, multi-faceted topic.

For Ramone, who is currently living a sober life, and others like him who identify as being LGBTQ, it’s a consistent struggle rooted in a range of deep-seated factors.

In January, research published in LGBT Health pointed to exceptionally high rates of substance use disorders among people in the LGBTQ community.

The research team out of the University of Michigan took a look at 2012-2013 data from the National Epidemiological Survey on Alcohol and Related Conditions-III. Out of the total 36,309 adults surveyed, about 6 percent fell under the category of “sexual minorities,” meaning they did not identify as heterosexual.

The researchers found that people who identified as being lesbian or gay were more than twice as likely as people who identified as heterosexual to have a “severe” alcohol or tobacco use disorder, while people who identified as bisexual were three times as likely to have this kind of substance use disorder.

Those who were unsure how to identify their sexual identity were five times as likely to have a substance use disorder than heterosexual people.

“We have known that LGB (lesbian, gay and bisexual) populations had higher prevalence of substance use, but this is the first study to document severity of the alcohol use disorders, tobacco use disorders, and drug use disorders based on diagnostic criteria (DSM-5) using a U.S. representative sample,” lead author Carol Boyd, PhD, RN, a professor at the University of Michigan School of Nursing, told Healthline.

Boyd explained that past studies were far less comprehensive. For instance, those conducting this kind of research would typically recruit gay men at bars and ask them about their drug and alcohol use.

She said some older studies would also only focus on alcohol and no other addictive drugs or substances.

However, what made this study unique was that it focused on alcohol, tobacco, and drugs.

Boyd’s study does have its blind spots. For instance, there are some glaring omissions from the LGBTQ acronym.

Boyd noted that her study did not examine members of the transgender community, calling it a “notable gap” in the research that “must be filled by future research.”

She added, “In the future, studies need to ask respondents about the sex they were assigned at birth, and whether this matches their gender,” she added.

While Boyd’s study did not examine substance use disorders in the transgender population, a few others have.

One recent study found that data from the 2013-2015 California Health Kids Survey (CHKS) showed transgender students were about 2 1/2 times more likely to use drugs like methamphetamines and cocaine than their cisgender peers.

Heather Zayde, LCSW, a Brooklyn-based clinical social worker and psychotherapist, told Healthline that for young people in the LGBTQ community, the potential for substance use disorders is very real.

“For these young people, there is the fear of fitting into a society that they may perceive is rejecting them,” Zayde said. “There has been lots of work moving in the right direction, with more acceptance of all people, but then there is messaging from the current presidency, for instance, where kids are hearing horrible things coming from leadership — it’s very hard, particularly for those kids who don’t fit in.”

She pointed out these young people are often afraid of not being accepted by those closest to them, from their families to their peers. For these kids, there is “no escape from that fear” of rejection, and oftentimes substances can become an easy “go-to” for them to help regulate their emotions.

June 2019 marks the 50th anniversary of the Stonewall Inn riots in New York City, a watershed moment in LGBTQ history that, in part, spurred decades of greater visibility and activism in the LGBTQ community.

Just blocks away from Stonewall, Joe Disano works as a substance abuse counselor at the Lesbian, Gay, Bisexual and Transgender Community Center (known as The Center) in New York City’s West Village neighborhood.

Disano said historically many LGBTQ people who felt they were “socially stigmatized” found safe havens in nightlife spaces and bars.

It’s something that New York City resident “Mark,” 42, who wished to not be identified by his full name, understands all too well.

Now living a full 2 1/2 years in recovery from drug and alcohol use, Mark, who is gay, remembers how it felt when he first started going out to gay bars as a young adult.

Originally from Cincinnati, Ohio, Mark said he first came out to himself as gay after he graduated from high school. He said his church had a gay activity group where young people could gather and feel safe, but as he got older, he gravitated to “where all the other gays were — the bar.”

“So, the next 20 years or so, all I knew was that if you are gay, you go to bars and clubs,” he told Healthline. “Over the years, you’re just trapped. You don’t have a choice. It’s like ‘you’re gay, here’s a bottle, here’s a bag.'”

He said now that he’s in recovery, he’s had the realization that a past social life that revolved solely around drugs and alcohol was one that helped him feel numb.

In Mark’s experience, going through life as a gay man meant dragging around the emotional baggage buried in his subconscious — anxiety and trauma from bullying and rejection.

He said he feels this is something that can cause many LGBTQ people like himself to turn to substance use in order to temporarily escape their pain.

“All people have some level of emotional pain that they carry, but I think being gay or queer, there are things we carry around. Like, there are other alternatives, but you don’t seek them out, you go to the club, you go to the bar, so I feel if that’s all you do, it’s really destructive,” he said.

For Mark all of this drinking and drug use spiraled into a sense of heavy depression, and got to a point where suicidal thoughts became “a consideration.”

He recalled how, after one particular weekend of clubbing, he decided to look for help. He went to a meeting at The Center in New York, and was struck by the fact he met other gay people who didn’t “want to get me drunk or drugged [and were just] trying to figure out a way out of this, too.”

Mark said one of his biggest challenges in wanting to live a life of sobriety was coming to terms with how “normalized” high levels of substance use became in his life and that his perspective was “skewed.”

For him, part of a living a sober life meant learning that some of the behavior he came to accept as part of a “typical” night out wasn’t necessarily the norm.

“For example, somebody overdosing on the dance floor, I would have thought it’s normal, like I had to re-learn it wasn’t normal for people to be overdosing and falling on their face, and going unconscious. It took me being in recovery to learn that ‘oh, that’s not normal,'” Mark said.

Now, Mark said he’s grateful for his new perspective and the ability to engage with people at a higher level without drugs or alcohol.

“The inner you doesn’t need to go get drunk every night,” he said of advice he would give his younger self. “It takes work to focus on ‘you.'”

Craig Sloane, LCSW, CASAC, CSAT, is a psychotherapist and clinical social worker who knows what is like to both help others through their recovery and seek help himself. As a self-identified gay man in recovery, Sloane said it’s necessary not to paint everyone’s experiences in a broad brush.

“Everyone is unique. You can’t pretend to know what everyone’s situation is like, but in a general way, I think that just having the empathy of the experience of knowing how difficult it is to ask for help, and having had the experience myself in knowing that recovery is possible, allows me to transmit a certain kind of hope,” Sloane said.

Professionally, he said he doesn’t share his personal history with the people he works with, but added that his experiences can help inform his understanding of what they are going through.

Sloane echoed Mark and Disano that growing up and coming into adulthood with an LGBTQ identity can leave some people with a certain level of anxiety and stress.

“The trauma associated with the social stigma of being LGBTQ, of living in a culture that, for the most part, is homophobic and heterosexist, is traumatic,” Sloane explained. “From the experiences of being bullied and being rejected by friends and family, those traumas unfortunately still are true in 2019. In many parts of the country, the safe spaces for queer people to go are bars, so social isolation certainly is one of the factors behind substance use disorders for LGBTQ people.”

He added that for members of the transgender community, in particular, rejection and isolation from peers and family can be high. All of these experiences contribute to “minority stress,” which Sloane defined as high levels of stress felt by groups that are marginalized, leaving many LGBTQ people susceptible to substance use disorders.

Dr. Alex S. Keuroghlian, MPH, the director of education and training programs at The Fenway Institute and assistant professor of psychiatry at Harvard Medical School, said that LGBTQ people seeking treatment might have difficulty finding an inclusive healthcare environment.

“Addictions treatment needs to be tailored for LGBTQ people,” he said. “We have to infuse minority stress treatment principles into evidence-based approaches. Providers have to tailor and address treatment to things like opioid use disorders among LGBTQ people, for instance.”

Additionally, he pointed out that medical providers need to understand exactly how the drivers for addiction are tied to minority stress.

Keuroghlian added that things have also improved in some ways, though more still needs to be done to make a more inclusive healthcare system. In fact, this fall, he said he has been asked to speak in Tennessee about addressing the opioid crisis in the LGBTQ community.

“Tennessee is a state where people might not expect to see interest in improving care in this area, but this kind of thing is happening all around the country, there’s great work being done that nobody hears about,” he explained.

Francisco J. Lazala, MPA, program coordinator, case management services at Harlem United, a community health center in New York City, said there are more LGBTQ young people out there who need housing and healthcare than the number of well-funded programs and services that can help answer their needs.

Lazala said Harlem United particularly serves young people of color and members of marginalized groups who come to him looking for support and safety.

Many of the young people he works with experience homelessness and addiction.

He said some stories are more encouraging than others.

The same week as his interview with Healthline, Lazala said a young woman he worked with came to see him. She had been living with an alcohol dependence in the past. She revealed that shortly after giving up alcohol, she discovered she had HIV.

“My heart just broke,” he said. “It’s sad to see these young people [hit these types of roadblocks and] there are few services for [HIV-]positive youth.”

Fifty years after Stonewall, Lazala noted it is ironic how places that used to be havens and safe spaces — like the West Village neighborhood near Stonewall and New York’s The Center — have become “gentrified,” and are less hospitable for young LGBTQ people of color seeking spaces that could keep them away from drugs and alcohol.

Ramone is very familiar with Lazala’s work. He came to Harlem United when he was experiencing homelessness and credits the services and support he found there with getting him back on his feet.

“I was hanging out with the wrong crowd, things got really bad in terms of finding myself doing drugs, hanging out with people who were selling drugs. All of a sudden, I was doing things I did not want to do. I wasn’t feeling loved, I wasn’t comfortable,” he said.

Of living with substance use, Ramone said it is important people know it’s not just a “stop and be done with it situation.”

“It’s an ongoing process,” he said. “Luckily, I have great determination.”

Mark said he’s happier since he can “access” more of himself now that he is in recovery.

“The recovery community is an increasingly growing community, a lot of queer people are waking up to it,” Mark said. “I think being gay is really special. It’s hard when you can’t tap into that specialness if you’re drunk. And in sobriety you get to tap into all of that, you get to work your soul and work through a lot of what we’re carrying around. It’s a really exciting place to be.”