What’s Sex Got to Do With It? - Addiction in the GLBT Community
Social Work Today
By Kate Jackson
Vol. 4 No. 4 p. 14

GLBT sexual orientation doesn’t cause addiction, but it’s a major life issue that’s tough to ignore by either therapist or client in the addiction recovery process.

Although sexual orientation isn’t a factor in all cases of addiction among gay, lesbian, bisexual, and transgender (GLBT) individuals, it’s often an underlying factor in drug, alcohol, or tobacco dependency, as well as in process addictions such as compulsive spending or gambling. Sexual orientation clearly doesn’t cause addiction; however, experts suggest it may increase the vulnerability of individuals who are already predisposed to addiction.

According to Joe Amico, MDiv, CSAS, CAS, president of the National Association of Lesbian and Gay Addiction Professionals and community educator for Alternatives, a gay and lesbian treatment program, research points to a rate of addiction to drugs and alcohol three times higher in the GLBT community than in the general population (Amico and Nelson, 1997; Hellman, 1989). Addiction, explains Philip T. McCabe, CSW, CAS, mental health consultant in the Tobacco Dependence Program of the University of Medicine and Dentistry of New Jersey (UMDNJ) School of Public Health, is usually an acquired state by a predisposed person over a period of time. “If you have a person who’s biologically predisposed to an addiction, it doesn’t matter if they’re straight or gay,” he says. The increased risk, McCabe says, may be attributed to environmental and situational triggers, as well as to the social and emotional stressors linked to being homosexual in a heterosexist society. Similarly, while treatment and recovery issues may be the same for GLBT individuals as their straight counterparts, sexual orientation may influence therapeutic needs and outcomes.

Stress and Shame
Drug, alcohol, and tobacco dependency are more common among those attempting to avoid painful situations, says McCabe. “We do know from a mental health perspective that people who are not ‘out’ are more prone to depression, and people who are more prone to depression use substances to alleviate or self-medicate.” On the other hand, he notes, the coming-out process itself can be stressful, and individuals at various stages in that process may self-medicate as a coping strategy to deal with isolation or shame. “Nothing drives addiction like shame,” says Amico, who notes that in a heterosexist society, people grow up with the shame of not being what’s expected of them by their parents, family, and friends. As evidence, he points to statistics indicating that the highest percentage of teenagers who actually attempt or commit suicide are those struggling with sexual orientation issues.

Internalized homophobia, says Annmarie Agosta, MSW, LCSW, a private practitioner in Somerset, NJ, and clinician at UMDNJ, is so pervasive and difficult to work through that many individuals choose to self-medicate and numb their feelings so they don’t have to think about it. She says that those who are aware of their sexual identity at a very early age tend to have a great deal more internalized homophobia than those who come to this understanding later in life. “As they’re growing up, they’re more susceptible when they hear negative comments or hate words from people around them that they care about,” says Agosta. As their identities are being formed, she says, they may feel that because people around them are saying horrible things about them, there’s something intrinsically wrong with them. Adults who come out later in life, says Agosta, “already have an idea about who they are and where they stand in the world.”

Jim Stolz, MSW, LICSW, therapist with The PRIDE Institute, acknowledges that shame may play some role, but he questions the emphasis that’s frequently placed on it. “It’s dangerous when we go down that route because not everyone has shame,” he says. “People are quick to jump on the internalized heterosexism bandwagon, but a lot of GLBT people who have problems with addictions are perfectly fine with their sexuality. I don’t want to say it’s not a problem for people, but I think it’s dangerous when we automatically assume that it’s a problem. There may be issues with sexuality that create struggles, but it’s not necessarily a cause-and-effect relationship.”

The Bar Culture
Perhaps a simpler reason for an elevated risk of substance abuse and addiction among GLBT individuals is their exposure to the bar culture. “We have people who are trying to find out where they fit in the world,” says Stolz. “Every GLBT person pretty much grows up feeling very isolated in their thoughts and their feelings, and they’re trying to find a place where they can fit in, and the addiction world kind of welcomes anyone who’s willing to behave how they behave. It’s like a passport to acceptance.”

“Even though we have come to have so many other opportunities to socialize and interact, for many of our younger people, the bar is still seen as the mecca, the place to go, the place to be seen,” says McCabe. In addiction recovery work, he explains, clients are often encouraged to change “people, places, and things” to reduce temptation. “Yet for some gay people in rural areas, the club or bar scene might be their only real contact with the larger GLBT community,” he says. “They have to be able to balance their ability to remain abstinent and their ability to socialize in an environment where alcohol and drugs may be used.” Because of the closeted nature of much of the community, agrees Amico, people may feel extremely isolated, especially those who live far from cities with large GLBT communities. “San Francisco,” he notes, “has the Castro District, and New York City has Christopher Street,” but many cities have no geographic community. The only place GLBT people know where to find each other is in a bar. “It stands to reason that if the only place you know to go to meet other people like you is a bar, you’re going to be there more often.” Clearly, those with a propensity for addiction are increasing their vulnerability to addictions.

The bar culture is a challenge for those in recovery as well because the temptation is great to return to such places that may invite relapse. “It’s hard for a lot of gay men and lesbians who are addicted to imagine going back to a life without using because that’s the only way that they know to socialize and it’s become such a part of their identity,” says Agosta. A major concern for GLBT individuals in treatment programs, she says, is what they will do when they go home and can’t go to bars or clubs. “They’re afraid they’ll end up sitting alone at home getting depressed because they don’t know another way to connect with clean and sober gays and lesbians.”

Clients will often say they have to go to bars even if they’re in recovery because it’s their only opportunity to meet others. Amico acknowledges the difficulty but points to strategies. “Here in Phoenix, we don’t have a gay-identified neighborhood as in other large cities, but we have hundreds of organizations and several gay-identified churches.” Sometimes he tells clients to go to a gay church rather than a bar. They often reply that they’re not religious. “I’ll say I’m not asking you to sing, I’m not asking you to pray. You don’t have to do a thing except sit in a room with 100 other gay folks who aren’t there to use drugs or drink.” Another assignment he gives clients is to get local gay newspapers and list all the organizations and groups they’d be most interested in joining and then start attending. “It’s a way to start finding other gay folks that doesn’t necessarily revolve around drugs or alcohol.”

Treatment and Recovery
Treatment approaches, says McCabe, can range from gay-tolerant, gay-affirmative, gay-sensitive, gay-avoidant, gay-intolerant, or even abusive. The variety of treatment possibilities begs the questions: Is it possible to get adequate treatment without addressing issues of sexual orientation, and can closeted individuals truly explore their addictions in a meaningful way? Many experts suggest that if it’s not impossible, it’s at least more challenging. Amico is convinced that issues concerning one’s sexual identity more often than not must be addressed. He notes that clients typically go to heterosexist treatment centers and programs that are well-meaning but not informed about GLBT issues. “If the programs are gay-naive and clients don’t feel comfortable or safe, they won’t talk about their real issues. They relapse until finally someone helps them figure out what the real issues are.”

Programs, says McCabe, may be tolerant yet not inclusive. Sexual orientation may be seen to have no relevance to addiction and thus is not discussed. “That’s almost impossible to do,” he adds, “because homosexuality integrates into all components of our lives, not just our intimate relationships.” Another treatment model, he claims, may be sensitive to, but not affirming of, the role of sexuality. In this, issues of orientation are neither stressed nor repressed, but no special attention is paid to them. A truly gay-affirmative program, however, he explains, will have openly gay staff people, a statement in the policy or mission of sensitivity toward GLBT individuals, cultural sensitivity training for staff, and surroundings and materials that are sensitive to GLBT issues. Amico adds that staff should be trained to ask questions that are appropriate to gender and sexual orientation. The programs, furthermore, should offer a gay sensitivity or coming-out group that explores issues related to coming out at various stages of life. The needs, McCabe says, will be different for people in different situations, stages of life, and stages of coming out.

Some clients, says McCabe, are not going to come out, and clinicians need to respect that choice. However, he says, “they’ll need to develop coping strategies to deal with some of the related stressors of living a closeted life, such as fear of disclosure or discovery, conflict within the family or in the work site, and integrating a clean and sober social life with being closeted.”

“Addiction is addiction, and you can get treatment anywhere,” says Amico. “But I train counselors that people need to be free to talk about all areas of their lives.” Agosta agrees: “If a person is in treatment with a therapist, it’s completely counterproductive if they’re not able to be out to the therapist.” One’s sexual identity, she says, affects so many different areas of a person’s life and can cause a great deal of stress and pressure. “You can’t really get to the root of things unless you understand the whole picture,” says Agosta. Otherwise, she says, “it’s like putting a bandage on a huge infection.”

“I believe that people need to be in an open, honest treatment setting where disclosure is neither prohibited nor required but is allowed to be the client’s choice,” says Stolz. Furthermore, he says that not everyone needs to be in a gay program. “People can get perfectly good treatment in mainstream programs if they can be open and honest, although such programs are hard to find. While not everyone needs a gay treatment program, what they do need is good treatment where they can be themselves.”

Being GLBT-Affirming
“A lot of social workers think that just because they feel that they don’t have any prejudices that they can be empathetic with the client,” says Agosta. Therapists who want to work with GLBT clients, she suggests, “need to broaden their own personal lives in terms of having a diverse group of friends, acquaintances, and contacts.” To be effective as a therapist, she says, you must be somewhat familiar with the GLBT subculture, which isn’t something you can get from a book or conference. Social workers, in addition to attending continuing education programs, can learn a great deal simply by going out into the community, talking, and opening themselves up to learning more about the culture. For example, says Agosta, visiting community centers or attending meetings of Parents, Families, and Friends of Lesbians and Gays is helpful.

Amico says it’s also important to indicate that your practice is gay-affirming. For example, make sure that your intake forms show that you’re open to GLBT clients. “If the only options for marital status on your forms are married, single, divorced, or widowed, the gay or lesbian person that’s in a relationship may think gay and lesbian isn’t spoken here,” he says. “They have no category to check off and do not feel included.” Similarly, says Agosta, intake forms ask if a client is male or female. “There are plenty of clients out there that do not identify as either male or female,” she says. “They’re transgendered or they’re questioning or they choose not to label themselves.” GLBT clients, she asserts, are continually facing the assumption that everyone is straight. In that atmosphere, she says, clients, especially those with a lot of internalized homophobia, won’t be forthcoming because they have too much shame.

Also, an office environment can either welcome or discourage GLBT clients. Amico shares an office with two straight therapists whose clients are largely straight. Yet, placed in the waiting room are gay newspapers and magazines that let people know it is a safe place. “An office can have artwork or symbols such as pink triangles or rainbows, for example, and it lets clients know that ‘gay is spoken here,’” says Amico. These gestures, says Agosta, such as displaying a Human Rights Campaign equality symbol, are welcome signs that let clients feel the therapist is someone they can be honest with and are important in making clients feel more comfortable about disclosing. In the absence of an accepting atmosphere, Amico says, clients will not feel safe and will not reveal. Clients who have difficulties finding a comfortable and accepting treatment or therapy atmosphere, he says, can look for a gay program or request a gay-friendly therapist from their insurance company. “Many of the major managed care companies today have counselors who will self-identity either as gay or lesbian or at least indicate that they specialize in dealing with GLBT clients,” says Amico.

On one point the experts agree. If you have any doubt about your ability to work effectively with the GLBT client in addiction and recovery work, it’s crucial to refer the client to someone more accepting or experienced. “One of the underlying factors of being a social worker is understanding the therapeutic use of self,” says Stolz. “If you know that you’re not very good with this population, then you either need to work on that or not work with the population. If the therapists sense that their beliefs could get in the way, that they’re not adequately trained, or that they’re in any way conflicted with respect to GLBT issues, it would be damaging if they didn’t refer the client to more receptive or knowledgeable professionals.”

— Kate Jackson is a staff writer for Social Work Today.

References

Amico, J., & Neisen, J. (1997). Sharing the secret: The need for gay-specific treatment. The Counselor, 15(3), 12-15.

Hellman, R. E., et al. (1989). Treatment of homosexual alcoholics in government-funded agencies. Provider training and attitudes. Hospital and Community Psychiatry, 40(11), 1163-1168.

Resources

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

Alternatives
800-DIAL-GAY

Center for Substance Abuse Prevention Substance Abuse Resource Guide: Lesbian, Gay, Bisexual and Transgender Populations
www.health.org/referrals/resguides.asp?InvNum=MS489

Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgender Health
Gay and Lesbian Medical Association
www.glma.org/policy/hp2010/index.html

National Association of Lesbian and Gay Addiction Professionals
(Prevention Policy Statement)
901 North Washington Street, Suite 600
Alexandria, VA 22314
703-462-0539
www.nalgap.org

Preventing Alcohol and Other Drug Problems in the Lesbian and Gay Community
www.nalgap.org/LGBT.pdf

PRIDE Institute
800-54-PRIDE