The Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA) is pleased to present A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals.

This publication was developed through a systematic and innovative process in which clinicians, researchers, program and administrative managers, policymakers, and other Federal, State, and independent experts were brought together for a series of intensive sessions.

These individuals reviewed and discussed current administrative and clinical practices for treating substance-abusing lesbian, gay, bisexual, and transgender individuals and then wrote and edited the resulting document. The goal of this process was to improve and advance substance abuse treatment for a community of individuals whose health care needs are often ignored, denigrated, or denied.

This publication focuses on the two most important audiences for successful program development and implementation—clinicians and administrators. Section I provides an introduction for both audiences and includes information on sexual orientation, legal issues, and treatment approaches and modalities from a lesbian, gay, bisexual, and transgender standpoint. Section II is written for the practicing clinician. It offers further information on clinical issues of lesbian, gay, bisexual, and transgender clients; an introduction to strategies and methods for improving current services to LGBT individuals; and steps for starting LGBT-sensitive programs.

Section III, developed for program administrators, provides an overview of the issues that need to be addressed when developing an LGBT program or when expanding current services for LGBT clients. It offers the data needed to build a strong foundation for a program, including an organizational mission and policies and procedures. It provides resources and strategies for working with managed care organizations and building alliances and cooperative arrangements to coordinate efforts on behalf of LGBT individuals so that members of the LGBT population can promote self-help programs within their own communities.

Besides increasing awareness of the need for LGBT-sensitive treatment services and helping all those involved in the treatment process become more aware of LGBT issues, this document also serves an important public health function. For example, the convergence of HIV, hepatitis, and substance abuse is a major concern that has not been adequately addressed in LGBT communities, especially regarding the availability of vaccines for hepatitis A and hepatitis B. Educating LGBT people about these vaccines, the importance of vaccination, and strategies for preventing hepatitis C infection is a responsibility of all health care providers, not just substance abuse treatment professionals.

This publication is the result of the collaboration of many contributors, and CSAT gratefully acknowledges the dedication, time, talent, and hard work that the writers and reviewers have brought to this publication.

Joseph H. Autry III, M.D.
Acting Administrator
Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., C.A.S., FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration

Download A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals

PDF format, 588KB, 209Pages.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatments
www.samhsa.gov
Rockwall II, 5600 Fishers Lane, Rockville, MD 20857

Executive Summary:

This publication presents information to assist providers in improving substance abuse treatment for lesbian, gay, bisexual, and transgender (LGBT) clients by raising awareness about the issues unique to LGBT clients. Sensitizing providers to these unique issues will, it is hoped, result in more effective treatment and improved treatment outcomes. Effective treatment with any population should be sensitive and culturally competent.

Substance abuse treatment providers, counselors, therapists, administrators, and facility directors can be more effective in treating LGBT clients when they have a better understanding of the issues LGBT clients face.

With this knowledge, treatment providers can reexamine their treatment approaches and take steps to accommodate LGBT clients.

Substance Abuse in the LGBT Community

Precise incidence and prevalence rates of substance use and abuse by LGBT individuals
are difficult to determine for several reasons:

• Reliable information on the size of the LGBT population is not available.
• Epidemiologic studies on alcohol and drug abuse rarely ask about sexual orientation.
• Research studies cannot be compared because of inconsistent methodologies.

Studies indicate that, when compared with the general population, LGBT people are more likely to use alcohol and drugs, have higher rates of substance abuse, are less likely to abstain from use, and are more likely to continue heavy drinking into later life. Some studies have found that approximately 30 percent of all lesbians have an alcohol abuse problem (Saghir et al., 1970; Fifield, DeCrescenzo & Latham, 1975; Lewis, Saghir & Robins, 1982; Morales & Graves, 1983). Studies that compared gay men and lesbians with heterosexuals have found that 20 to 25 percent of the gay men and lesbians are heavy alcohol users (compared with 3 to 10 percent of the heterosexuals studied) (Stall & Wiley, 1988; McKirnan & Peterson, 1989; Bloomfield, 1993; Skinner, 1994; Skinner & Otis, 1994; Hughes & Wilsnack, 1997).

Marijuana and cocaine use has been found higher among lesbians than among heterosexual women (McKirnan & Peterson, 1989).

Although LGBT persons use and abuse alcohol and all types of drugs, certain drugs seem to be more popular in the LGBT community than in the majority community. Studies have found that gay men and men who have sex with men (MSM) are significantly more likely to have used marijuana, psychedelics, hallucinogens, stimulants, sedatives, cocaine, barbiturates, and MDMA (methylenedioxymethamphetamine) and are much more likely to have used “poppers” (Woody et al., 1999; Stall & Wiley, 1988). Party drugs, such as MDMA (also known as ecstasy or X-T-C), “Special K” or ketamine, and GHB (gamma hydroxybutyrate), are increasing in popularity among some segments of the LGBT population. Party drugs are often used during circuit parties and raves, and they can impair judgment and result in risky sexual behavior (Ostrow et al., 1993). Abuse of methamphetamine has increased dramatically in recent years (Drug Abuse Warning Network, 1998; Derlet & Heischober, 1990; Morgan et al., 1993; National Institute on Drug Abuse, 1994; Gorman, Morgan & Lambert, 1995; CSAT [Center for Substance Abuse Treatment], 1997b) among some segments of the LGBT community. HIV and hepatitis C infections are linked with methamphetamine use (CDC [Centers for Disease Control and Prevention], 1995) and can lead to significant dependence and addiction. Some LGBT methamphetamine users inject the drug, putting them at risk for HIV, hepatitis B, and hepatitis C.

Sexual Orientation and Gender Identity

Understanding the appropriate terminology is essential to understanding LGBT clients. Sexual orientation, sexual behavior, gender identity, and gender role are different concepts.

Sexual orientation is the affectional or loving attraction to another person. Heterosexuality is the attraction to persons of the opposite sex; homosexuality, to persons of the same sex; and bisexuality, to both sexes. Sexual orientation can be considered as ranging along a continuum from same-sex attraction only at one end of the continuum to opposite-sex attraction only at the other end. Sexual behavior, or sexual activity, differs from sexual orientation and alone does not define someone as an LGBT individual. Sexual identity is the personal and unique way that a person perceives his or her own sexual desires and sexual expressions.

Biological sex is the biological distinction between men and women. Gender is the concept of maleness and masculinity or femaleness and femininity. Gender identity is the sense of self as male or female and does not refer to one’s sexual orientation or gender role. Gender role describes the behaviors that are viewed as masculine or feminine by a particular culture. Transgender individuals are those who conform to the gender role expectations of the opposite sex or those who may clearly identify their gender as the opposite of their biological sex. In common usage, transgender usually refers to people in the transsexual group that may include people who are contemplating or preparing for sexual reassignment. A transgender person may be sexually attracted to males, females, or both.

Sexual orientation and gender identity are independent variables in an individual’s definition of himself or herself. How an individual learns to acknowledge, accept, and then act on a sexual orientation that is different from that of the majority is shaped by cultural, religious, societal, and familial factors.

Transgender clients face a somewhat similar challenge in coming to terms with a gender identity that differs from their biological gender.

An LGBT individual differs in the effect of sexual orientation on self-definition and in the degree of affiliation with other LGBT persons. LGBT people and homosexual behavior are found in almost all cultures and throughout history. Homosexuality was considered a mental illness until 1973 when the American Psychiatric Association dropped the classification of homosexuality as a mental illness. It is now considered a normal variation of human sexual and emotional expression, allowing, it is hoped, a nonpathological and nonprejudicial view of the LGBT community.

Homophobia and Heterosexism Having a general understanding of heterosexism and homophobia is important for substance abuse treatment providers working with LGBT individuals. Heterosexism and homophobia describe the forms of bigotry against LGBT people. Heterosexism resembles racism or sexism and denies, ignores, denigrates, or stigmatizes nonheterosexual forms of emotional and affectional expression, sexual behavior, or community.

Homophobia is defined as the irrational fear of, aversion to, or discrimination against LGBT behavior or persons. Internalized homophobia describes the self-loathing or resistance to accepting an LGBT sexual orientation and is an important concept in understanding LGBT clients.

It is likely that all substance abuse treatment programs have LGBT clients, but staff members may not realize that they are treating LGBT clients. Most treatment programs do not ask about sexual orientation, and many LGBT people are afraid to speak openly about their sexual orientation or identity. LGBT clients cannot anticipate the reaction they will receive when mentioning their sexual orientation.

How Heterosexism Contributes to Substance Abuse Heterosexism can affect LGBT people by causing internalized homophobia, shame, and a negative self-concept (Neisen, 1990, 1993).

Some LGBT individuals may resort to substance abuse to cope with the negative feelings. Counselors and clients should recognize that these effects result from prejudice and discrimination and are not a consequence of one’s sexuality. It is not surprising to find that many LGBT individuals in therapy report feeling isolated, fearful, depressed, anxious, and angry and have difficulty trusting others. It is argued that the stigma and resulting tension of being a member of a marginalized community such as the LGBT community cause some members of the marginalized community to manage these additional stressors by using mind-altering substances. Substance use, especially alcohol use, is a large part of the social life of some segments of the LGBT community. ...

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