Addiction in the LGBTQ Community
Like the pride flag that represents different colors, the LGBTQ acronym, which stands for lesbian, gay, bisexual, transgender, and queer or questioning, represents different groups of people with types of sexual orientation that belong to the minority of the population. However varied each group’s experience, and the individual experience within each group, one thing is certain – LGBTQ individuals have historically been oppressed, suppressed, vilified, and forced to the margins of society. Today, progressive efforts are being made to provide LGBTQ persons with equal rights, but the legacy of discrimination continues to inflict stress on members of this community. While choosing to abuse drugs is never a healthy decision, it may be an understandable one in view of the feelings of isolation and disempowerment that LGBTQ discrimination often instills in members of this group. As the Center for American Progress discusses, approximately 20 to 30 percent of the gay male and transgender community experience substance abuse compared to approximately 9 percent of the general population. Although this area requires further research, studies have found the following correlations between drug abuse and sexual orientation:
- Tobacco. Gay and transgender men have a tobacco intake rate up to 200 percent greater than heterosexuals.
- Marijuana. Gay men are 3.5 times more likely to use marijuana than heterosexual men.
- Amphetamines. Homosexual men are 12.2 times more likely to use amphetamines compared to men who are not gay.
- Heroin. Gay men are 9.5 times more likely to use heroin than heterosexuals.
- An estimated 25 percent of gay and transgender men abuse alcohol compared to 5 to 10 percent of the general population.
- Heavy alcohol use. Between 20 and 25 percent of lesbians and gay men are heavy alcohol users, compared to 3 to 10 percent of the general population
Social disapproval of LGBT status has played a direct role in the development of substance abuse in the LGBT community. Social discrimination, intolerance of LGBT lifestyle, and laws prohibiting LGBT conduct have limited the social outlets available to this community. Bars and nightclubs have long offered a safe haven; however, these social spots include exposure to alcohol and drugs that creates a risk of substance abuse and addiction. LGBT discrimination created a perfect storm for LGBT substance abuse.
Societal Factors in LGBT Substance Abuse
The high incidence of alcohol and other drug abuse in the LGBT community demands exploration. Despite earlier bias-riddled myths about the biology of homosexuality, scientists have concluded that there is no physiological link between sexual orientation and the formation of substance abuse or addiction. Rather, societal factors heavily contribute to the prevalence of substance abuse among LGBT persons. Such societal factors include:
- Coping/self-medicating. Facing constant discrimination, with little to no control over when or where it will occur, is highly stressful and can provoke LGBT members to turn to alcohol and other drugs to cope.
- Heterosexism. Non-heterosexual forms of behavior are highly stigmatized. Heterosexism, which posits itself as the superior form of sexual orientation, gives rise to rejection of homosexuality and can lead to workplace discrimination, being disowned by family, and hate activities in the form of threats, emotional abuse, humiliation, and, in some cases, murder. These factors each contribute an additional layer of stress to LGBT life.
- Treatment barriers. LGBT status may cause some members of this group to refrain from seeking services in order to avoid facing discrimination and discomfort in sharing intimate personal details. Early in treatment, an LGBT patient may not be certain she is in an environment that that will be compassionate and understanding. LGBT sensitivity is a necessary treatment component for this community.
- Targeted marketing. From a marketing and sales perspective, LGBT, like other groups, can be the subject of targeted marketing efforts. Alcohol and tobacco companies can readily exploit the connection some LGBT members have to bars and clubs.
- Black market targeting. The presence of LGBT individuals in the nightclub scene makes them a target for black market illicit drug dealers. Although this phenomenon is not the subject of mainstream research study methodologies, emergency room admissions and treatment program admissions make it clear that drug sales proliferate in clubs, and no doubt arise from targeting marketing efforts.
According to economics research, in 2010, LGBT buying power was estimated at $743 billion. Although research supports that gay men are likely to earn slightly less than heterosexual men, homosexual men often have more disposable income available to fulfill their personal wants. While gay parenting continues to rise, one contributing factor to greater disposable income is that same-sex couples are still less likely to have children than heterosexuals. In view of how drug abuse can be a self-medicating strategy to cope with the discrimination LGBT members routinely face in society, disposable income may only compound a drug problem simply because having money makes drugs all the more accessible.
LGBT Substance Abuse Treatment
At the research level, bias in the topic selection process presents another layer of complication in the field of LGBT addiction. LGBT substance abuse and treatment outcomes, as a research topic, may not be a priority in research efforts. Heterosexism/bias may be a factor in the under-research of LGBT substance abuse and addiction. Research would be impactful as the few research results that are available suggest that LGBT-tailored treatment programs do garner better results than non-LGBT methodologies. To the extent LGBT addiction research lags, especially in light of the prevalence of substance abuse in this community, effective treatment services will not be properly developed, and in turn not delivered to those LGBT persons in need of rehab services. LGBT persons may be among those most in need of treatment services, and yet some of the most inefficiently served. In a 2007 study of 854 substance abuse treatment programs, researchers found that only 62 centers included LGBT specific services (7.3 percent of the sample). Thirteen of the agencies exclusively provided services for the LGBT community. Half of the 62 service centers were concentrated in New York and California. Specialized rehab programs for the LGBT community involve different treatment factors compared to the general population, such as:
- The need for staff and counselors trained in, and sensitized to, LGBT life experiences such as social isolation
- Psychotherapy services that are equipped to deal with the double social stigma of sexual minority status and substance abuse or addiction
- An intake process that provides a safe, comfortable zone for LGBT patients to share their sexual orientation, whether they are “coming out” or have already come out
- Programs specifically responsive to LGBT needs to decrease the likelihood that LGBT patients will leave rehab before program completion
A 2009 research study found that homosexual men were less likely to complete drug treatment than heterosexual men, and further, they were more likely to leave treatment because they felt their needs were not being fulfilled. Such needs include addressing issues relevant to the LGBT community, such as HIV treatment and prevention counseling, sexual status discrimination, the need for legal and political advocacy and rights, grief and loss processing, and coping with rejection from family members and loved ones.
The treatment process also calls for sincerity and honesty. Not only must counselors and staff be sensitized to LGBT issues, but also truthfully believe in serving this community’s needs. Alienation can happen in invisible ways, such as on the level of language and attitude. Treatment vocabulary, like the services themselves, must reflect openness and acceptance of LGBT lifestyle. For instance, describing heterosexuals as “straight” could be interpreted to suggest that LGBT members are bent or imperfect. In short, counselors in the LGBT community will necessarily need to be vigilant of their own heterosexism, which may not be intentional but rather the product of living in a heterosexual-dominating society. A shift in thinking must precipitate the shift from providing services to the majority of the population to the LGBT community.
The American Psychiatric Association, until 1973, defined homosexuality as a mental illness.
Source: Pride Institute
HIV and Substance Abuse
Like the LGBT community overall, gay men face the stress of anti-gay bias and violence, heterosexism, and internalized homophobia, which can directly trigger substance abuse. Substance abuse and sexual activity can be a dangerous combination. For instance, using amphetamines can greatly enhance sexual desire, for up to 14 hours, but the prolonged period of sexual activity can increase the risk of HIV infection and exposure to other sexually transmitted diseases.
Risky behavior, including unprotected sex or sharing needles, not the fact of gay orientation itself, can cause a LGBT person to contract HIV. While the percentage of gay men in the population with HIV has steadily dropped, new cases always highlight the need for continued sex education and advocacy in this community. Substance abuse is a contributing factor of new HIV cases; according to studies of gay men who have engaged in unsafe sex, these men were reportedly much more likely to have unsafe sex after the consumption of alcohol and/or illicit drugs.
While public awareness of HIV focuses on HIV prevention, some people actively seek to contract this disease. There are stories of young gay youth who, having run away from home (likely for reasons associated with their sexual orientation status), develop a perverse economic incentive to receive HIV so that they may qualify for social relief programs including housing and disability benefits.
Drug treatment programs generally feature two main components: medication (as applicable, as in the case of using methadone treatment for heroin or other opioid withdrawal) and psychotherapy (including individual counseling, group help such as 12-step programs, and family therapy). In the case of substance abusers who are HIV positive (and this information may be learned for the first time in treatment), the following describes treatment components for LGBT individuals which may not apply to the general population:
- Medical treatment. Services from qualified providers (usually outside of the treatment center) who can treat HIV/AIDS, associated infections, care for any subnormal operation of the kidneys and liver, and in-depth dental care are needed.
- Neurological screening. In addition to a mental health screening, running the appropriate diagnostic tests to learn if there are any HIV-related neurological complications is needed.
- Nutritional support. Services that remedy dehydration and malnourishment, protein deficiency, vitamin and mineral depletion, distressed metabolism, anemia, and low weight may be necessary.
- Social services. This population may present in need of housing, income including disability, childcare, and medical insurance.
- Legal services. For instance, HIV-infected parents who are in treatment or too ill to care for their children may require legal counsel to petition a family court to appoint a guardian.
Although much of the literature on HIV and homosexuality focuses on gay men, lesbians also face an HIV risk. Although female-to-female HIV exposure is uncommon, lesbian injection drug users who share needles are at risk for HIV contraction. In addition, some women who self-identify as lesbians may continue to have sexual relations with men, or may be newly “out” and have a history of bisexuality or sex with men, which may have exposed them to HIV.
The transgender population does not necessarily distinguish itself from others based on sexual orientation, but on gender (including male/female behavioral norms, societal roles, and physical appearances). As scholars explain, sex is a biological fact whereas gender is a social construct that is individually performed. A San Francisco study of 519 transgender persons found a high rate of substance abuse among male-to-female and female-to-male individuals. The study further uncovered that there was a much greater likelihood of HIV infection among male-to-female participants, compared to female-to-male participants, with rates of 35 percent and 2 percent, respectively. It appears that irrespective of gender identification, the fact of male or female biology remains relevant to HIV contraction; for instance, unprotected male-to-male sexual conduct is risky, even if one or both of those males identifies as having a female gender.
A Note on Transgender Identity
The transgender population may present confusion to medical and addiction specialists. This identity touches on a host of sub-identities, including:
- MTF (male-to-female) and FTM (female-to-male) transsexuals undergo hormone therapy or sex reassignment surgery.
- Transgenderists assume (all of the time or only sometimes) the gender role of the opposite sex.
- Bigender individuals identify as female and male.
- Drag queens and kings dress up as the opposite sex, often with theatrical bravado, for occasions or events.
- Male and female impersonators perform and assume the clothing style of the opposite sex, usually for entertainment purposes.
It is important to note that none of these transgender categories actually make a declaration of sexual orientation, and no assumption should be made about a transgendered person’s preferred sexuality or the sex of a person with whom they would choose to have a romantic or intimate relationship.
LGBT Mental Health
In addition to substance abuse, LGBT persons face a risk of other mental health problems. According to different studies, compared to heterosexuals, lesbian, gay, and bisexual individuals experience higher rates of lifetime mood disorders, anxiety, and more suicidal thoughts (in the age bracket of 15 to 54 years old).
Among lesbians and gay youth, studies have shown that these groups experience higher rates of major depression. Among gay men, research has found that this group has a higher rate of persistent major depression. Overall, as studies show, homosexual men and women experience greater use of mental health services compared to their heterosexual counterparts. The psychotherapy process for substance abusers in the LGBT community may include a need for the therapist to have heightened attention in the following areas:
- At initial intake, before a therapist/patient bond has been formed, when an LGBT person may be “doubly closeted” because of self-perceived shame centering on drug abuse and homosexual orientation
- Different forms of transference in therapy, for instance, where a therapist has the same homosexual orientation as the patient, and the patient believes the therapist can therefore completely understand him
- The therapist experiencing countertransference, such as feelings of discomfort when the client discusses homosexual behavior which in turn limits the therapeutic benefit of the counseling
- Once the LGBT patient is abstinent, the eruption of emotions and insights centering on the LGBT experience, which the alcohol and other drugs were previously suppressing
- Helping an LGBT person to make life changes, such as picking new and health social outlets and developing good habits that do not involve spending time in bars or with drug-addicted friends
- Referral, as deemed necessary, to specialty LGBT rehab facilities that make an explicit commitment to being “gay friendly” or “gay affirmative” (lip service is not enough)
- Identifying 12-step programs that have a LGBT focus
Research in the area of LGBT substance abuse and addiction must develop further. Scientifically based findings contrary to negative stereotypes can help to thwart sexual orientation discrimination. As the LGBT community gains greater representation and legal rights, such as the right to marriage (decided state to state), a positive trickledown effect can occur whereby LGBT lifestyle, including access to specialized rehab services, can improve. As societal discrimination and oppression of LGBT status is a contributing factor to substance abuse, the improvement of social conditions for LGBT persons can help to stem the high prevalence of drug consumption in this community.
 Hunt, J. (Mar. 9, 2012). “Why the Gay and Transgender Population Experiences Higher Rates of Substance Use.” Center for American Progress. Accessed Oct. 11, 2014.
 Leible. A. (n.d.). “Why LGBT Treatment.” Pride Institute. Accessed Oct. 11, 2014.
 Hunt, J. “Why the Gay and Transgender Population Experiences Higher Rates of Substance Use.”
 Mooney, E. (Dec. 2011). “The Need for Specialized Programs for LGBT Individuals in Substance Abuse Treatment.” Southern Illinois University Carbondale. Accessed Oct. 11, 2014.
 Ibid, p. 12.
 Ibid, pp. 13 – 14.
 Ibid, p. 15.
 “A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals.” p. 81. (Last revised 2012). Substance Abuse and Mental Health Services Administration. Accessed Oct. 11, 2014.
 Ibid, p. 86.
 Ibid, p. 87.
 “Substance Abuse Treatment for Persons with HIV/AIDS” (Mar. 28, 2011). Substance Abuse and Mental Health Services Administration. Accessed Oct. 11, 2014.
 DeAngelis, T. (Feb. 2002). “New Data on Lesbian, Gay, and Bisexual Mental Health.” American Psychological Association. Accessed Oct. 11, 2014.
 “LGBT Mental Health Syllabus: Psychotherapy.” (n.d.). Group for the Advancement of Psychiatry. Accessed Oct. 11, 2014.