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
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