Research has consistently demonstrated that young people who identify as lesbian, gay, bisexual, or queer (LGBQ) show greater levels of psychosocial risk than general cohorts of young people. Young people engaged with youth alcohol and other drug (AOD) services are some of the most marginalized of all young people. Hitherto research is yet to investigate if young people identifying as LGBQ fare worse in these psychosocial domains than their non-LGBQ co-clients within AOD services. This study compared outcomes for 103 matched pairs of LGBQ identified and non-LGBQ identified young people (N = 206) using youth AOD services in Australia from a youth needs census. The results indicated that youth identifying as LGBQ reported more family dysfunction; and had experienced more violent crime, sexual, physical, and emotional abuse; and accumulated trauma than the non-LGBQ group. They had significantly more substance related harms, greater polysubstance use, and greater severity in their substance use. The LGBQ group also demonstrated poorer psychological health, quality of life, and were more likely to report a history of mental illness, and non-suicidal self-injury according to their youth worker. Overall these data indicate a need to direct more support to this particularly at risk group of young people.