Alcohol abuse and dependence in the gay and lesbian populations

I. Introduction (slide 2)

    1. The problem:
      1. The prevalence of substance abuse and dependence is higher than in the general population.
      2. Gay identity formation may be linked to the increased prevalence.
      3. Few gay and lesbian clients enter treatment centers.
      4. Substance problems may be linked to unsafe sexual practices.
      5. Most treatment centers do not address the special needs of the gay and lesbian populations.
      6. Lesbians may have additional needs beyond that of the gay man including child related and domestic violence issues.
    1. Prevalence (slide 3)
      1. Early work in the field estimated the rates of substance abuse and dependence in gay men to be greater than 30%. These samples probably oversampled heavy users. (1,2)
      2. Population-based samples of gay and heterosexual men in the mid 80ís found substantially higher rates of drug use among gay men than heterosexual men. This result was true for both urban and rural areas. (3,4,5).
      3. There is no clear consensus on the actual prevalence, as most of the studies have had methodological errors including poor or absent control groups, unrepresentative samples (e.g. gathered data from bars), failure to use uniform definitions or substance abuse and dependence, or of homosexuality, and the "closet factor". (6)
      4. Lesbians appear to have an equal prevalence of substance abuse and dependence as compared to gay men, and have a higher prevalence than heterosexual women. (7,8)
  1. Possible etiologies of increased prevalence of substance abuse and dependence. (slide 4)
    1. At one time, male homosexuality was thought to cause alcoholism. (9)
    2. Alcoholism and substance abuse and dependence are not "caused" by any psychodynamic or personality factor alone, and the increased prevalence is most likely multifactorial involving biologic, societal/cultural, and psychological factors. (10)
    3. Biological factors include growing evidence that both alcohol abuse and dependence and homosexuality have some genetic component. (11) There is also speculation of a chromosomal link between sexual orientation and the propensity for substance abuse and dependence. This is unlikely as male and female homosexuality is thought to be different phenomena with differing familial patterns. There is an equal incidence of substance abuse between gay men and lesbians. (12) (slide 5)
    4. Societal/cultural factors have also been proposed. (slide 6)
      1. A possible increase in the prevalence of alcoholism in women since the beginning of the 20th century is an example of societal factors increasing substance problems. In the early 1900ís societal pressures discouraged women from drinking. As the social acceptability of drinking increased, more women drank increasing the exposure to alcohol related problems. (13)
      2. Societal homophobia could lead to a higher degree of expression of the genetic potential for substance problems.
      3. Additional factors involve other aspects of the environment. Significant exposure to bars, legal prohibitions on homosexual behavior, discrimination, hate crimes, and the failure of some in society to accept or acknowledge gay people has limited the types of social events to bars and other places where alcohol plays a prominent role.
      4. Societal factors are the reason most gay/lesbian people give for the increased prevalence of substance problems in the gay/lesbian population.
    1. Psychological factors may also be involved. (slide 7)
      1. Internalized homophobia might be an example. Gay children often grow up in a society that says that they should not exist and certainly should not act on their feelings. These societal feelings can be internalized. The conflict between what they feel and what they believe they should feel can cause psychological stress.
      2. Many gay and lesbian people have their first sexual experiences under the influence of alcohol. This might be a way to overcome the internal fear, denial, and anxiety about gay sex. Alcohol use and sexual behavior can be conditioned together so that the pattern continues.
      3. Self-acceptance of homosexuality may be important in the treatment of men who have problems with alcohol. One study found that self-acceptance was a key variable in the recovery of gay men. (14)
  1. Current treatment programs (slide 8)
    1. Studies in the 1970ís indicate that only a small percentage of gay and lesbian clients in treatment centers identify themselves as gay. This suggests that gays do not identify themselves as gay or do not go to treatment. (15)
    2. Workers in a mainstream drug and alcohol program in Canada and New York reported that they had relatively little knowledge of the special needs of gay and lesbians yet reported this knowledge would be very helpful. (16,17)
  1. HIV and alcohol abuse or dependence (slide 9, 10)
    1. In the United States, gay men constitute the highest population infected with HIV.
    2. New cases of HIV in the US are also found most frequently in the gay population.
    3. Although the data are mixed, alcohol use is probably associated with an increase in risky behavior.
      1. In one study men who never drank during sex were three times more likely to be in the cohort who had no sexual risk compared to those who combined sex with alcohol. (18,19)
      2. The association between risky sex and alcohol has not been replicated in all studies. (20)
    1. Alcohol abuse and dependence may lead to poor compliance with HIV medications resulting in drug resistance and premature progression of the illness.
    2. There is speculation that alcohol may increase the progression of the illness as alcohol may be an immune suppressant. (21)
  1. Special concerns of the lesbian alcoholic (slide 11)
    1. Few studies have specifically evaluated lesbian substance abuse and dependence.
    2. As compared to gay men, lesbians are more likely to have a lower income and to be parents.
    3. Lesbians have to deal not only with the prejudices against lesbians but also of women in general.
    4. There are very few lesbian specific treatment programs. (22)
  1. Some recommendations (slide 12, 13)
    1. Due to the high prevalence of substance abuse and dependence in the gay population, gay clients should be routinely screened for substance use disorders.
    2. Studies have shown that gay people can successfully be treated for alcohol abuse and dependence.
    3. The prevalence of substance abuse and dependence in the gay population might have decreased over the past ten years. There are unclear reasons for the decrease, but it may be due to increased acceptance of homosexuality, awareness of the problem, HIV education, or due to increased social outlets for gays and lesbians. (23)
    4. As with other minority groups, gay people might feel more comfortable in minority specific treatment centers.
      1. There is a shortage of gay specific treatment facilities but most major cities have such programs.
      2. If a gay facility is not available, a gay friendly facility is then recommended.
    1. Treatment may need to focus on both substance use disorders and on acceptance of homosexuality.
    2. Clients need to be evaluated for internalized homophobia, the adequacy of the support system, and the stages of coming out.
    3. Alcoholics Anonymous can be very helpful in the treatment of the gay alcoholic.
      1. You should remind clients that A.A. is not always as religious as many people think.
      2. Extending the powerlessness over alcohol concept to being powerless over being gay may be helpful.
      3. The 4th step, the moral inventory, may also be especially relevant to gay clients.
      4. Most cities have gay or gay friendly A.A. meetings, and A.A. has a pamphlet for the gay alcoholic.
    1. Many of the problems of the gay client in recovery will be the same as anyone in recovery.
      1. Clients must often give up old "using" friends.
      2. Clients must stay away from bars and other places at high risk for relapse.
      3. Clients must learn how be comfortable without alcohol or drugs.



  1. Fifield L, Latham J, Phillips, C: Alcoholism in the gay community: the price of alienation, isolation, and oppression. A project of the gay community services center, 1977.
  2. Lohrenz L, Connelly J, Coyne L, Sare K: Alcohol problems in several midwestern homosexual communities. J Stud Alcohol 39:1959-1963, 1978.
  3. Stall R, Wiley J: A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco menís health study. Drug Alcohol Dependence 22:63-73, 1988.
  4. Skinner WF: The prevalence and demographic predictors of illicit and licit drug use among lesbians and gay men. Am J Public Health 84:1307-1310, 1994.
  5. Skinner WF, Otis MD: Drug and alcohol use among lesbian and gay people in a Southern US sample. J Homosex 30:59-91, 1996.
  6. Bux, D. The epidemiology of problem drinking in gay men and lesbians: a critical review. Clin Psychol Rev 16:277-298, 1996.
  7. Saghir MT, Robins E, Walbran B, Gentry KA: Homosexuality IV: psychiatric disorders and disability in the female homosexual. American Journal of Psychiatry 127:147-54, 1970.
  8. Lewis CE, Saghir MT, Robins E: Drinking patterns in homosexual and homosexual women. Journal of Clinical Psychiatry 43:277-79, 1982.
  9. Israelstam S, Lambert S: Homosexuality as a cause of alcoholism: a historical review. Int J Addict 18:1085-1107, 1983.
  10. Israelstam S, Lambert S: Homosexuality and alcohol: observations and research after the psychoanalytic era. Int J Addict 21:509-537, 1986.
  11. Pillard RC, Weinrich JD: Evidence of familial nature of male sexuality. Arch Gen Psychiatry 43:808-812, 1986.
  12. Cabaj R, Stein T editors: Textbook of Homosexuality, APA press, 1996.
  13. Valliant GE: the natural history of alcoholism: causes, patterns, and paths to recovery. Harvard University Press, 1983.
  14. Kus RJ: Alcoholism and non acceptance of gay self: the critical link. The Haworth Press:25-41, 1988.
  15. Fifield L, Decrescenzo TA, Latham JD: Alcoholism and the gay community an analysis of gay alcohol abuse and evaluation of alcoholism rehabilitation services for Los Angeles County, 1975.
  16. Israelstam, S: Knowledge and opinions of alcohol intervention workers in Ontario Canada, regarding issues affecting male gays and lesbians: parts I and II. The International Journal of the Addictions 23:227-252, 1988.
  17. Hellman RE, Stanton M, Lee J, Tytun A, Vachon R: Treatment of homosexual alcoholics in government-funded agencies: provider training and attitudes. Hospital and Community Psychiatry 40:1163-1168, 1989.
  18. Donovan C, McEwan R: A review of the literature examining the relationship between alcohol use and HIV-related risk-taking in young people. Addiction 90:319-328, 1995.
  19. Stall R, McKusick L, Wiley, J: Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS. Health Education Quarterly 13:359-371, 1986.
  20. Weatherburn P, Davies PM, Hickson FCI: No connection between alcohol use and unsafe sex among gay and bisexual men. AIDS 7:115-119, 1993.
  21. Watson RD (ed): Cofactors in HIV-1 infection and AIDS. CRC Press, 1990..
  22. Nicoloff L, Stiglitz, E: Lesbian alcoholism: etiology, treatment, and recovery. Lesbian Psychologies, 283-293.
  23. Crosby MG, Stall RD, Paul JP, Barrett DC: Drug and alcohol and drug use have declined between generations of younger gay-bisexual men in San Francisco. Alcohol Dependence 52:177-182, 1998.
  24. Kus RJ: Alcoholics Anonymous and Gay American Men. J Homosex 14:253-276, 1987.