Alcohol abuse and dependence in the gay and lesbian populations
I. Introduction (slide 2)
- The problem:
- The prevalence of substance abuse and dependence is higher than in the general population.
- Gay identity formation may be linked to the increased prevalence.
- Few gay and lesbian clients enter treatment centers.
- Substance problems may be linked to unsafe sexual practices.
- Most treatment centers do not address the special needs of the gay and lesbian populations.
- Lesbians may have additional needs beyond that of the gay man including child related and domestic violence issues.
- Prevalence (slide 3)
- 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)
- 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.
- 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)
- 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)
- Possible etiologies of increased prevalence of substance abuse and dependence. (slide 4)
- At one time, male homosexuality was thought to cause alcoholism. (9)
- 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)
- 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)
- Societal/cultural factors have also been proposed. (slide 6)
- 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)
- Societal homophobia could lead to a higher degree of expression of the genetic potential for substance problems.
- 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
- Societal factors are the reason most gay/lesbian people give for
the increased prevalence of substance problems in the gay/lesbian
- Psychological factors may also be involved. (slide 7)
- 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.
- 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
- 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)
- Current treatment programs (slide 8)
- 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)
- 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
- HIV and alcohol abuse or dependence (slide 9, 10)
- In the United States, gay men constitute the highest population infected with HIV.
- New cases of HIV in the US are also found most frequently in the gay population.
- Although the data are mixed, alcohol use is probably associated with an increase in risky behavior.
- 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)
- The association between risky sex and alcohol has not been replicated in all studies. (20)
- Alcohol abuse and dependence may lead to poor compliance with HIV
medications resulting in drug resistance and premature progression of
- There is speculation that alcohol may increase the progression of the illness as alcohol may be an immune suppressant. (21)
- Special concerns of the lesbian alcoholic (slide 11)
- Few studies have specifically evaluated lesbian substance abuse and dependence.
- As compared to gay men, lesbians are more likely to have a lower income and to be parents.
- Lesbians have to deal not only with the prejudices against lesbians but also of women in general.
- There are very few lesbian specific treatment programs. (22)
- Some recommendations (slide 12, 13)
- Due to the high prevalence of substance abuse and dependence in the
gay population, gay clients should be routinely screened for substance
- Studies have shown that gay people can successfully be treated for alcohol abuse and dependence.
- 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)
- As with other minority groups, gay people might feel more comfortable in minority specific treatment centers.
- There is a shortage of gay specific treatment facilities but most major cities have such programs.
- If a gay facility is not available, a gay friendly facility is then recommended.
- Treatment may need to focus on both substance use disorders and on acceptance of homosexuality.
- Clients need to be evaluated for internalized homophobia, the adequacy of the support system, and the stages of coming out.
- Alcoholics Anonymous can be very helpful in the treatment of the gay alcoholic.
- You should remind clients that A.A. is not always as religious as many people think.
- Extending the powerlessness over alcohol concept to being powerless over being gay may be helpful.
- The 4th step, the moral inventory, may also be especially relevant to gay clients.
- Most cities have gay or gay friendly A.A. meetings, and A.A. has a pamphlet for the gay alcoholic.
- Many of the problems of the gay client in recovery will be the same as anyone in recovery.
- Clients must often give up old "using" friends.
- Clients must stay away from bars and other places at high risk for relapse.
- Clients must learn how be comfortable without alcohol or drugs.
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