Addiction and Abuse in the LGBT Community
Today, there is greater awareness of gender and sexual orientation diversity than ever before in recorded history. While the LGBT community and its advocates are showing the world that one’s biological sex does not determine one’s gender identity or sexual orientation, there is still much work to be done to promote acceptance of these forms of diversity. Despite strides for greater public acceptance, marginalization of the LGBT community persist, especially for the transgender segment, and not only impacts the rate of substance abuse but may lead to a lack of research study in this area.
There is only limited research available from which to assess the rates of LGBT substance abuse as well as the specific needs of this group in treatment. However, the data available does provide insight into why this community may be at greater risk of substance abuse compared to the general population and how to best serve them in lgbt treatment centers.
Data on Drug Use in General and LGBT Populations
The National Survey on Drug Use in America provides extensive insight into different drugs of abuse and consumption patterns across the nation. The survey did not, as of the most recent survey year in 2013, provide focused information on drug use patterns in the LGBT community. However, the survey results provide greater context to LGBT statistics (provided later in this discussion).
For an understanding of drug use trends in the overall population, the following 2013 survey highlights are useful:
- In the 12 or older age group, 24.6 million Americans (9.4 of this demographic) used illicit drugs in the month prior to the survey, including marijuana, prescription pain relievers, and cocaine.
- Marijuana is the most commonly used drug; 19.8 million Americans in the 12-or-older age group used this drug in the month prior to the survey.
- In the year prior to the survey, 681,000 Americans, across all age groups, had used heroin.
- In the 12-or-older age group, approximately 22.7 million Americans were in need of treatment for alcohol or illicit drug use problem but only about 2.5 million received treatment at a qualified rehab center.
The LGBT community is composed of lesbians, gays, bisexuals, transgender males, transgender females, and individuals who identify as queer or questioning. Within this group, research outcomes may differ along the lines of age. According to Social Work Today, national research efforts demonstrate that drug abuse is twice as common among youths in the LGBT community compared to their non-LGBT peers. This trend is also true for the LGBT population on the whole. While the Substance Abuse and Mental Health Services Administration estimates that the rate of substance abuse is 9 percent in the general population, the LGBT rates are as high as 20-30 percent.
A review of some of the available research on the LGBT community and substance abuse indicates that studies often look at discrete groups under the LGBT canopy rather than this diverse group as a whole. For instance, the Center for American Progress provides insight into different rates of drug abuse among gay men and transgender individuals.
The Center notes that research efforts are relatively scarce in this area, but provides the following estimated information:
- Compared to heterosexual and non-transgender individuals, gay and transgender persons smoke tobacco at a 200 percent greater rate of consumption.
- Compared to 5-10 percent of Americans overall, 25 percent of gay and transgender individuals abuse alcohol.
- Men who have same-sex relationships are 3.5 times more likely to consume marijuana compared to men who do not have same-sex relationships. This group is 12.2 times more likely to consume amphetamines compared to men who do not have same-sex relationships. This group is also 9.5 times more likely to take heroin.
Regarding the lesbian population, one study surveyed 87 lesbians and 89 heterosexual women to reveal that the lesbian group had significantly higher rates of alcoholism (18 percent compared to 7 percent). Another study considered lesbian and bisexual women and found that this group was more likely than heterosexual women to use tobacco and drink heavily. The volume of research on females and substance abuse exceeds research on the lesbian and bisexual members of this group. While research on females and substance abuse must be assumed to include lesbian and bisexual females, the lack of differentiation between sexual orientations within this group is a missed opportunity for greater insight into the dynamic between sexual orientation and drug use.
According to Healthy People, a group that reviews nationwide research findings on public health, as of 2010, there were no studies that exclusively focused on bisexual individuals and substance abuse. Information about this group is generally incorporated into either lesbian or gay studies. Further, Healthy People notes that even the scant information that may exist about bisexuals tends to focus on men because funding opportunities in this area center on prevention of communicable diseases, such as HIV, which typically presents a greater risk for bisexual men compared to bisexual women.
Healthy People makes the insightful point that in view of the reality of finite funding for research, available resources tend to focus on sexual activities that present the greatest risk to public health rather than academic issues of gender and sexuality, despite how helpful this information would be from a prevention and treatment standpoint. In short, the minority status of members of the LGBT community in society carries over to priorities in research funding (however, this is not meant to suggest that there is bias against research of this group but rather a reflection of the reality that research resources are limited).
Understanding Transgender Issues
Our culture currently prefers a binary view of gender, with strict separations between male and female identities. But for people who identify as transgender, these conventional categories don’t fit their sense of identity. They may feel that the sex they were assigned biologically does not correspond to their inner nature, or that their sexual identity encompasses both male and female genders.
The term transgender embraces a spectrum of identities that defy our traditional cultural standards. Members of this community may identify themselves in a number of ways:
- Gender non-conforming
- Female to male (FTM)
- Male to female (MTF)
Although the transgender community is generally included under the same umbrella as lesbian, gay, and bisexual groups, gender identity should not be confused with sexual orientation. Transgender people may identify themselves as straight, gay, bisexual, or queer.
Because transgender identities defy social expectations of sexual behavior, people who identify as transgender face high rates of social discrimination, abuse, bullying, and deprivation. Drug and alcohol abuse are more common in this community than in the population as a whole; however, recovery resources that address the unique needs of transgender people are few and far between. One New York social worker was quoted online in The Fix as saying that in many cases, transgender individuals with substance abuse issues are so afraid of being misunderstood or discriminated against by social service agencies that they prefer to live secretly with their problems rather than seek help.
Removing the Stigma from Gender Nonconformity
Thanks to increased public awareness of the origins of transgender identity, this psychiatric community no longer classifies this state of being as a mental illness. The condition formerly known as gender identity disorder has been replaced with the term gender dysphoria in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA). The term gender dysphoria implies that the individual’s self-determined gender identity does not match the one assigned to him or her at birth — not that the individual’s gender identity is pathological.
The APA emphasizes that gender dysphoria is associated with a certain level of emotional distress and impairment of social or occupational functioning and is not to be equated with gender nonconformity. Gender noncomformity simply implies that an individual’s primary gender identity differs from the gender assigned at birth. Laura Jane Grace, a musician who has spoken out eloquently about her transition from male to female, described gender dysphoria to The Independent as “a misalignment, of being painfully self-aware on an existential-dread level that the way you are perceived by other people doesn’t match up with the way you perceive yourself inside.”
In spite of these new efforts to remove the social stigma of transgender identities, many Americans still hold negative views of gender-nonconforming lifestyles and sex reassignment surgery. Even in the fields of primary care, mental health, and substance abuse treatment, many professionals are still uninformed about transgender issues or view these individuals in a negative light.
A female-to-male patient of a publicly funded substance abuse treatment program in San Francisco, who asked to remain anonymous, says, “People like me are living with a double stigma: being transgender, and having a drug problem. Even in a city like this, which has hundreds of services for the gay and trans communities, I run into doctors and social workers who look shocked or disgusted when they find out I’m a genderqueer person with an IV drug addiction. They want to hand me a list of public health clinics and shoo me out the door as fast as possible. And this is San Francisco! Can you imagine what it’s like for some poor trans kid trying to get information on sex reassignment surgery or find rehab programs in Smalltown, USA?”
Substance Abuse in the Transgender Community
To date, there have been few research studies focusing on the rates of substance abuse in the transgender community, and most studies have focused on the relationship between substance abuse and sexually transmitted diseases. According to the 2010 National Transgender Discrimination Survey Report on Health and Healthcare, the rate of HIV infection is four times higher in the sample population than in the general population, partly because of IV drug abuse. Much of the substance abuse that occurs in the transgender community can be attributed directly to social discrimination – 26 percent of survey respondents stated that they had used or were currently using alcohol or drugs specifically to cope with the social stigma of gender nonconformity.
Rates of substance abuse increase among transgender persons who work in the sex industry or sell drugs for a living. Out of the survey respondents who held underground or illegal jobs, 19 percent reported that they were currently using drugs or alcohol to cope with the effects of abuse or discrimination, and 36 percent reported that they had done so in the past. Job loss and job discrimination are two of the other most common reasons that transgender people abuse drugs or alcohol or attempt suicide.
Common Drugs of Abuse
A review of a sample of research available on drug use and the LGBT community demonstrates that much of the focus is on alcohol and club drugs. Regarding alcohol consumption, as mentioned earlier, members of the lesbian community tend to drink alcohol more than heterosexual females. In the case of club drugs, most studies focus on gay men. For example, one NYU study centered on gay and bisexual men; the study noted that the five most common drugs of abuse in the club scene among study participants were ecstasy, ketamine, crystal meth (“Tina”), GHB, and cocaine.
LGBT status may not be a significant factor in the specific type of drug selected for abuse. For this reason, it can be helpful to know that the most common illicit drugs of abuse in the population in general are marijuana, methamphetamine, cocaine, and opiates/opioids (including prescription pain relievers and heroin). The LGBT community is at just as much risk as the greater population for abuse of the most prevalent drugs.
Substance abuse trends in the transgender community are similar to those in the general LGBT population; however, some studies of urban populations show a preference for alcohol, marijuana, cocaine, and meth. Marijuana was one of the most common drugs of abuse among both female-to-male (FTM) and male-to-female transgender persons (MTF), with 64 percent of FTM individuals reporting use of this drug, and 43 percent of MTF individuals reporting its use. In the same study, 30 percent of female-to-male respondents said they had used speed, and 21 percent had used cocaine. Alcohol, one of the most widely available and frequently abused substances in the general population, is widely used among transgender individuals in an effort to cope with the stress of discrimination, harassment, and social exclusion experienced by this community.
Why Are LGBT Substance Abuse Rates High?
Due to a lack of comprehensive research in this area, there may be a significant amount of conjecture around why LGBT status can dispose a person to a greater risk of drug abuse. There is a general consensus that in addition to biology, substance abuse involves environmental and social factors. There is also a general consensus that even in spite of major advancements in LGBT rights (such as the Supreme Court’s decision that lesbian and gay individuals may marry in each and every state), LGBT is not a neutral status. For instance, LGBT status remains politically charged, and LGBT individuals are vulnerable to hate crimes and other forms of abuse.
According to LGBT advocates and researchers, substance abuse may be a coping method that some LGBT individuals employ in face of the “minority stress.” LGBT status can expose individuals to a range of prejudices that can affect life basics, including relationship recognition and employment opportunities. In addition, LGBT status can create a disincentive to seek healthcare treatment due to an actual or perceived insensitivity on the part of care industry providers. Seeking treatment, whether in the form of drug recovery or other services, necessarily involves revealing personal details of one’s history, which could be challenging for a member of the LGBT community.
There is also another layer to increased risk of substance abuse. It is well established that the LGBT community has often found solace in the bar and club scene, as this scene has been traditionally more accepting. Tobacco and alcohol businesses exploit the LGBT consumer market through targeted marketing efforts in bars and clubs. This for-profit behavior seems particularly exploitative in view of the fact that LGBT-owned or LGBT-friendly bars and clubs are typically intended to be safe havens for LGBT individuals. In addition, as the National Association of Lesbian and Gay Addiction Professionals (NALGAP) notes, funding for gay community services, cultural events, and “gay pride” parades often comes from tobacco and alcohol industry sponsors.
Factors Underlying Transgender Substance Abuse
Statistics on the challenges faced by transgender people are disturbing. Transgender individuals face discrimination on a social, political, and occupational level. Statistics show that they have higher rates of poverty, homelessness, drug and alcohol addiction, incarceration, and suicide attempts than the general population. The National Transgender Discrimination Survey indicates that:
- Extreme poverty, defined as living on an income less than $10,000 per year, was four times more common in the transgender population.
- Unemployment was more common in the transgender community, with 26 percent of survey respondents reporting that they had lost a job due to their transgender identity.
- Job discrimination affected nearly half (46 percent) of the respondents, either in the form of not being hired, losing a job, or being denied a promotion.
- Homelessness was more common in the transgender population. Nearly 20 percent had experienced homelessness at some time in their lives because of their identity, while 11 percent had been evicted from a home or apartment, and 29 percent had been turned away from homeless shelters.
- Physical and sexual assault plagues the transgender community, who are often the targets of hate crimes, robbery, and harassment. Out of those who responded to the survey, 61 percent stated that they had been the victims of physical assault, while 64 percent had been the victims of sexual assault.
- Bullying occurs at higher rates in children and teens who do not conform to cultural gender norms. Seventy-six percent of respondents in kindergarten through 12th grade had been bullied or harassed at school because of their gender-nonconforming identity.
- Suicide attempts are higher among transgender individuals, with 41 percent of respondents stating that they had tried to commit suicide at some time in their lives versus 1.6 of the general population.
Not surprisingly, this degree of discrimination creates high levels of stress. People with gender-nonconforming identities often live in fear of being harassed, bullied, assaulted, or robbed. They may hide their nonconforming identity from the general public in order to hold down a job or maintain a social role, while constantly worrying about being “outed” by friends or acquaintances. Because of the frequency of job discrimination against transgender persons, many are forced into underground jobs in the sex industry or drug dealing, where substance abuse is common.
In their personal lives, many transgender people lack a strong support network. They may be cut off from their families and may have few close friends who know about their gender identity. Social isolation, depression, loneliness, and anxiety often lead to substance abuse and increase the risk of self-destructive behavior or suicide.
“My 12-Step group has been my life support system,” says a woman who asked to be called Kristina. A singer and crossdresser, Kristina performs in one of San Francisco’s transgender clubs under the stage name Kriss Kross. She used to work as a prostitute while selling drugs to support her habit; now she is able to stay sober with the help of her recovery group. “No one in my family has spoken to me for over 15 years, since I came out as queer,” Kristina says. “The members of my group are my family, my friends, my lifeline. Going to meetings isn’t just how I stay sober, it’s how I stay connected to people who care. Straight folks, even gay folks, don’t really understand how cut off we are in the trans community.”
Positive LGBT Portrayals in Film
Film has a universal quality that can help viewers to separate from their immediate environment and be transported into the storyline, both for entertainment and educational purposes. In terms of stories involving a strong LGBT perspective, the following films are exceptionally insightful:
- A Single Man (2009)
- Milk (2008)
- Boys Don’t Cry (1999)
- Stonewall (1995)
- High Art (1988)
The following documentaries are particularly enlightening regarding the history of LGBT rights and certain struggles, such as with the HIV epidemic:
- Call Me Kuchu (2012)
- Stonewall Uprising (2010)
- We Were Here (2011)
- Paris Was a Woman (1996)
- The Times of Harvey Milk (1984)
As the National Association of Lesbian and Gay Addiction Professionals (NALCAP) discusses, public education is a main key to improvements in the relationship between the LGBT community and substance abuse. NALCAP advises that the following actions can be taken to increase public awareness and sensitivity to the LGBT community, which would in turn positively impact substance abuse trends:
From a drug use prevention and treatment standpoint, barriers to entry have potentially serious consequences. It is important to note that an LGBT individual’s hesitance, if any, to receive treatment can stem from a generalized anxiety about bias rather than any concrete negative experiences with a particular recovery center. The bias LGBT individuals experience in society as part of their individual histories is a factor to take into account when designing treatment services for members of this community. Substance abuse treatment involves disclosing personal details about one’s drug use experiences, and an LGBT individual may need to be encouraged to overcome any concerns or fears around sharing relevant personal information.
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LGBT-Focused Recovery Groups
The availability of recovery groups largely depends on the local community, but at least two national organizations feature LGBT meetings: Special Interest Meetings through Narcotics Anonymous (NA) and Gays and Lesbians in Alcoholics Anonymous (GAL-AA). GAL-AA maintains a searchable website for meetings, whereas the best practice to find an NA-LGBT meeting is to search postings and offerings for local NA meetings (and numerous locales list ongoing LGBT-based meetings). Ongoing attendance at 12-Step or other group recovery meetings is a staple of an effective aftercare program.
For transgender individuals, fitting in at LGBT 12-Step meetings may be more challenging. Even in groups that are dedicated to supporting the gay, lesbian, and bisexual communities, transgender people may encounter mixed messages about whether they are welcome. The AA saying “the women with the women and the men with the men” refers to the group’s traditional separation of the sexes at meetings. This mindset leaves transgender members in the position of having to justify their presence at a meeting when the sex on their birth certificate does not match their gender orientation.
Sara, a genderqueer person, overcame an initial resistance at 12-Step meetings by focusing on the spiritual aspect of recovery. “AA taught me discipline and connected me to my spiritual life,” she told The Fix. “My sexuality is connected to my human life, and my spiritual life connects me to my higher power, which gives me the feeling that it’s all gonna be okay. I have access to that spiritual life and no one can take that access from me.”
Rehab services that are sensitive to LGBT issues necessarily entail astute listening skills. Although individuals in the LGBT community share collective concerns, there is no one-size-fits-all approach to recovery treatment for members of this community. It is also important not to be lulled into a false sense of equality within this community. For instance, bisexual and transgender individuals may experience marginalization within the gay and lesbian community, and their needs may be especially underrepresented and undertreated.
During a thorough intake process at a rehab center, a counselor will learn about the specific needs of an incoming LGBT client. If admission is appropriate, a multidisciplinary team will then work together to create a tailored treatment plan for the client.
LGBT clients may have layered personal and medical histories, including being the victim of domestic violence or hate crimes, being estranged from family, having a dual diagnosis, or being positive for a sex-related or drug use-related disease. However layered an incoming LGBT client’s needs may be, treatment is available at every turn and can offer a path to a brighter future.
Challenges to Treatment for Transgender Individuals
In healthcare, as in other areas of their lives, most transgender individuals have had at least one experience being discriminated against or inadequately treated; as a result, many do not trust the medical community and may reluctant to seek out care for mental health concerns or substance abuse issues. They may be worried about confidentiality or having their identity inadvertently revealed by a care provider or therapist. Professionals who work with transgender individuals need a high level of compassion, sensitivity, and respect for this community.
Another barrier to treatment is the lack of education about transgender issues in the recovery community. Even in rehab programs that are supposedly specialized for transgender individuals, medical needs like hormone therapy are not always met. Clinical staff and therapists often do not understand the medical needs or risks of this community, and they may hold cultural misconceptions about transgender people that interfere with personalized care. According to the National Transgender Discrimination Survey, over half of transgender individuals have had to educate their medical providers about transgender care.
Faced with isolation, rejection, or harassment, many transgender clients isolate themselves and eventually leave treatment before completing a rehab program. In an article published in Substance Abuse, Prevention and Policy, a transgender woman known as Julia stated that although the staff members at her treatment center were generally supportive and treated her fairly, many of the counselors did not understand her gender identity. In spite of these misunderstandings, Julia had a positive experience with her treatment team; however, other clients abused her verbally and ostracized her.
“I had a lot of support from the staff,” Julia was quoted as saying, “but with the other clients, it was really difficult. I mean, everybody in the whole unit is talking about me … ‘cause I’m the only transgender. I ended up isolating myself, locked in my room 24 hours a day … it’s like this isn’t dealing with your addiction.” Julia ended up leaving her treatment program, not as a result of the staff’s lack of support, but because of the harassment and rejection she faced from her colleagues. Other transgender clients in the same qualitative study reported leaving their treatment program because counselors had tried to pressure them to conform to conventional gender standards, or because they had faced physical or verbal violence from other clients.
Many of these problems stem from ignorance of the needs of transgender individuals, as well as from social prejudices. Educating substance abuse treatment professionals about the nature of transgender identities can help to create a safer, more positive environment for these clients, many of whom are currently living with the effects of substance abuse rather than risking the negativity and hostility that they may find in treatment.
By contrast, clients who feel accepted by staff and peers in treatment reported having good experiences and were more likely to complete the rehab program. A participant, Rielle, described her treatment in positive terms: “Their staff was knowledgeable around trans people, the terminology … I was put in on a women’s side as I requested, and when it came time to doing the groups I was obviously put with the women versus with the men. I did everything that the women did. I wasn’t excluded from anything. I shared a room with another female and it was good.”
Transgender Treatment Needs
The recovery needs of transgender persons are often combined with those of the LGBT community; however, the needs of transgender individuals are unique. Transgender individuals may need medical services, such as hormone therapy or gender reassignment surgery, to make the transition to their chosen gender. However, providers cannot assume that all gender-nonconforming individuals are in search of medical or surgical interventions. Some members of this community do not feel the need to take these steps.
Substance abuse treatment for transgender people begins with the admission phase. In order to provide sensitive, compassionate, and effective recovery services, the needs of transgender clients must be assessed and clearly identified in the beginning. This goal can be accomplished through the use of screening instruments — questionnaires, tests, or interview questions — designed specifically for the transgender community. Clinicians and therapists working in rehab must have specialized training in working with the transgender community. With these tools, the treatment team can develop culturally sensitive care plans that reflect the client’s chosen identity, rather than requiring the person to conform to the gender assigned at birth.
A strong support system has been identified as one of the most significant protective factors against relapse in substance abuse treatment. A gender-nonconforming person who has been alienated from family and who has little support in the community will have a higher risk of relapsing after completing a rehab program. A treatment program for transgender people must identify individuals who need support and help them build a network of resources, including professional therapists, aftercare groups, 12-Step programs, and LGBT organizations within the community.
Perhaps the most crucial components of a transgender-friendly treatment program are sensitive and compassionate treatment team members and a no-discrimination policy that takes a strong stand against abuse or discrimination of any kind. Like any other group trying to overcome addiction, transgender individuals need a supportive, safe atmosphere where they can pursue recovery while developing new coping strategies and building a support network of empathetic individuals.
Resources on Substance Abuse in the LGBT Community
- Center of Excellence for Transgender Health: Housed at the University of California, San Francisco, this center is dedicated to providing innovative programs that meet the health needs of transgender individuals throughout the country. Education, research, preventive health care, and public policy are among its chief concerns. The Center’s website offers many educational and legal resources for transgender individuals and for health providers seeking education or information about transgender issues.
- GLBT National Help Center: This national hotline provides free, confidential support to gay, lesbian, bisexual, and transgender individuals and their supporters. Peer volunteers across the country are available 24 hours a day to answer questions about substance abuse, mental health, safe sex, sexual identity, and other concerns. In addition, the GLBT National Help Center maintains a large database of resources, including information on support groups, social connections, student groups, gay-friendly professional organizations, therapists, and counselors.
- NALGP (The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and their Allies): Founded in 1979, this membership organization is dedicated to the prevention and treatment of addiction within the LGBT community, with an emphasis on overcoming social and political barriers to recovery. Its website provides access to articles, resources, and contact information for addiction professionals and for individuals seeking help for substance abuse.
- National Center for Transgender Equality: Based in Washington, DC, this social advocacy organization supports the rights of transgender individuals at the state, local, and federal levels. Its goal is to promote justice for transgender persons and public awareness of their needs by actively seeking policy change. The Center’s website includes valuable information about transgender issues, as well as access to social and legal resources for the community.
- Parents, Families and Friends of Lesbians and Gays (PFLAG): Founded in 1972, PFLAG has grown into one of the largest national support organizations for the families, friends, and allies of the LGBT community. This group encompasses many local chapters that promote education, advocacy, and support for the gender nonconforming community.
- Substance Abuse and Mental Health Services Administration (SAMHSA): Lesbian, Gay, Bisexual, and Transgender: SAMHSA, a government agency that promotes education and treatment for substance abuse and mental illness, provides a list of resources on substance abuse in the LGBT community, including behavioral health resources, national survey reports, information on federal initiatives, and more.
- org: Staffed by transgender people supporting transgender people, this free telephone hotline offers help to individuals experiencing a gender identity crisis. The primary goal of the Translifeline is to prevent self-harm and suicide; however, volunteers are available to help anyone seeking support or answers about gender identity issues: “If you are not sure whether to call us or not, then please call us.”
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