Family Rejection, Chosen Family and Recovery

For many LGBTQ people, family is complicated. Some families are supportive from the start. Some take time. Some reject a person outright when they come out or transition. And many LGBTQ people build a chosen family of friends, partners and mentors who show up when relatives do not.

All of that matters in addiction recovery. This guide covers what research says about family rejection and acceptance, how to bring chosen family into treatment, how family sessions work, how to set boundaries with relatives who are not safe, and where families can find support of their own.

What research says about family rejection

The best-known research here comes from the Family Acceptance Project at San Francisco State University, led by Caitlin Ryan. In a study published in Pediatrics, the team surveyed white and Latino lesbian, gay and bisexual young adults about how their families reacted to their sexual orientation during adolescence. Higher rates of family rejection during adolescence were significantly associated with poorer health in young adulthood, including higher rates of depression, suicide attempts and illegal drug use.

A follow-up study in the Journal of Child and Adolescent Psychiatric Nursing looked at the other side: family acceptance. Among LGBT young adults, family acceptance during adolescence predicted greater self-esteem, social support and general health, and was protective against depression, substance abuse and suicidal thoughts and behaviors. The project describes accepting behaviors as things like advocating for a child who is mistreated and supporting their gender expression.

Two points from this research are worth holding onto:

• Rejection is a risk, not a destiny. These studies show associations. Many people who faced rejection never develop a substance use problem, and many who do go on to recover.
• Families can change. The Family Acceptance Project reports that parents and caregivers can modify rejecting behavior once they understand the impact of their words and actions, and that even a little change in parental behavior appears to reduce risk.

Family rejection is one of the clearest examples of what researchers call minority stress, the extra strain that stigma puts on LGBTQ people. Our guide to minority stress and addiction explains how that stress connects to substance use.

How family history shows up in treatment

If family rejection is part of your story, it may come up in treatment whether you plan for it or not. Old conflicts can surface during detox and early recovery, when emotions run high. Feelings of shame, grief or anger may be tied to how family members responded when you came out or transitioned.

A good program makes space for that. The National Institute on Drug Abuse (NIDA) notes that treatment for LGBTQ people should address issues such as family problems, violence and social isolation, and that screening for co-occurring conditions such as depression is especially important. If depression, anxiety or trauma are part of the picture, look for dual diagnosis treatment that can address both.

Chosen family belongs in your recovery

Your support system is whoever actually supports you. For many LGBTQ people that means a partner, close friends, a former roommate, a sponsor or an older LGBTQ mentor, not only parents or siblings.

When you talk to programs, ask directly:

• Can the people I name as family take part in family sessions, visits and discharge planning, even if we are not related or married?
• Can I choose who is and is not contacted, and who receives information about my treatment?
• Can my partner be included regardless of gender?

You control who gets information. Federal rules known as 42 CFR Part 2 give substance use disorder treatment records extra privacy protection, and programs generally need your written consent to share them. Our guide to confidentiality in rehab explains how consent works, so you can include the people you trust and leave out the ones you do not.

How family sessions work

Many programs offer family therapy or family education as part of treatment. SAMHSA's Treatment Improvement Protocol on substance use disorder treatment and family therapy (TIP 39) exists to help providers understand how to include families in treatment and services. In practice, sessions may cover how addiction affects the whole household, how to communicate better, and how loved ones can support recovery without taking control of it.

For LGBTQ clients, a few questions help you decide whether and how to take part:

• Is the counselor comfortable with LGBTQ families? Ask how they handle a session where a parent misgenders you or criticizes your identity.
• Can sessions be paused or ended? You should be able to stop a session that turns hostile.
• Can you start with chosen family? Some people find it easier to work with supportive people first and decide about relatives later.
• Is it optional? Family work should never be a condition of treatment if contact with certain relatives is unsafe.

Our list of questions to ask an LGBTQ rehab includes more on how programs handle family involvement.

Setting boundaries with family

Recovery sometimes means protecting yourself from people you love. Boundaries are not punishment. They are the rules that keep you safe while you heal.

• Decide what you will and will not discuss. You can talk about your recovery without debating your identity.
• Plan for hard moments. If a phone call or holiday visit tends to end with you drinking or using, plan ahead: a time limit, a friend on standby, an exit plan.
• Limit contact if you need to. Stepping back from relatives who are hostile is a reasonable choice, temporary or longer term.
• Protect your information. If you are on a parent's or partner's insurance, statements may go to the policyholder. Under HIPAA you can ask a health plan to contact you in a specific way or at a different address, and the plan must agree if you say you would be in danger otherwise.
• Practice with your counselor. Role-playing a tough conversation in therapy makes it easier to hold the line in real life.

Support for families

If you are a parent, sibling or partner reading this, your attitude matters more than you might think. The research above suggests that acceptance is linked to better health and that even small changes in how families respond can help. Learning more is a good first step.

PFLAG is a national organization that supports, educates and advocates for LGBTQ+ people and their loved ones, with chapters across the United States and virtual meetings. It also offers free publications, including resources for families of trans and nonbinary loved ones. You can find a local or virtual meeting through its website.

For guidance on supporting someone through addiction specifically, read helping an LGBTQ loved one with addiction.

Finding a program that respects your family, chosen or not

Our directory lists programs that report a program or group for LGBTQ clients to SAMHSA. That is self-reported, so call and ask how the program involves partners and chosen family, and whether its family sessions are run by staff experienced with LGBTQ clients. Start with the national LGBTQ rehab directory or browse programs by state.

Your next steps

• Make a list of the people you want involved in your recovery, and the people you do not.
• Ask each program you are considering how it defines family and who can attend sessions.
• Sign consent forms only for the people you choose.
• Plan your boundaries with relatives before discharge, with your counselor's help.
• Line up ongoing support. Our guide to recovery support after rehab covers groups and community options.
• If you are in crisis or thinking about suicide, call or text 988.

Whatever your family looks like, you deserve people in your corner. Treatment is a good place to start building that circle.

Sources

• Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults (Pediatrics)
• Family acceptance in adolescence and the health of LGBT young adults (Journal of Child and Adolescent Psychiatric Nursing)
• Family Rejection of Lesbian, Gay and Bisexual Adolescents and Negative Health Outcomes (Family Acceptance Project, San Francisco State University)
• Substance Use and SUDs in LGBTQ* Populations (NIDA)
• TIP 39: Substance Abuse Treatment and Family Therapy (SAMHSA)
• Fact Sheet: 42 CFR Part 2 Final Rule (HHS)
• Model Notice of Privacy Practices for HIPAA Health Plans (HHS)
• PFLAG: Find a Meeting

Related guides

• Why LGBTQ-Specific Addiction Treatment Matters | LGBTQ Rehab
• Questions to Ask an LGBTQ Rehab Before You Enroll
• Transgender Rehab: Finding Addiction Treatment That Respects Your Gender
• Minority Stress and Addiction: How Stigma Affects Substance Use
• LGBTQ-Friendly vs LGBTQ-Specific Rehab: What's the Difference?
• Rehab for Gay and Bisexual Men: What to Look For

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