Promoting sexual health in the LGBTQ community

Before we address the topic of sexual behavior in the lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) community, it is always important to clarify terms and “labels” to make the client feel safer while building trust and rapport.

Briefly, biological sex is the gender assigned at birth, usually by a doctor. Gender identity is one’s sense of self as predicated by societal and cultural norms, in terms of gender expression, and usually matches one’s biological sex. Transgender refers to people whose gender identity differs from the societal and cultural norms of the biological sex assigned at birth. Gender expression is the way one dresses and exerts one's own personality in an outward fashion, via body language, speech, clothing, etc. Finally, sexual orientation refers to which gender one prefers to have sexual or romantic relationships with. Another commonly used term is men who have sex with men (MSM), often used in some subcultures to identify men who are having sex with men and not utilizing the labels most often associated with this behavior (e.g., gay, bisexual, experimenting).

It is also important to keep in mind that transgender is not a sexual orientation or behavior, but rather a gender identity. Lastly, problematic sexual behavior is best described as out-of-control sexual behavior, lessening the stigma and judgment most LGBTQ clients are struggling with prior to seeking treatment. These terms may seem common, yet they are some of the main sources of trauma and pain fueling most of LGBTQ clients' out-of-control behavior.

Terms and labels associated with substance abuse are also important to note. However, “sex addiction” still remains outside the scope of consideration as a diagnosable disorder. The DSM-5 combined the categories of substance abuse and substance dependence into a single disorder where each is addressed individually, on a continuum from mild to severe. The DSM-5 cites that clinicians now must choose two or three criteria from a list of 11, which includes problems with law enforcement and drug craving that previously were not listed, in order to make a more inclusive substance use diagnosis. This helps to remove stigma and shame often associated with terms such as “addict” and “alcoholic,” and places more focus on behavior.

For the LGBTQ client struggling with substance use disorder symptoms and problematic sexual health issues, it is vital for the clinician to use nonjudgmental language to create a safe space for open discussion of the consequences from the out-of-control behavior that are causing the most harm.

In his new e-book Cracking the Erotic Code: Helping Gay Men Understand Their Sexual Fantasies, Joe Kort, PhD, speaks to the importance of a clinical approach that is LGBTQ competency based, affirmative to sexuality, and viewing sexual fantasy and arousal as resulting from an unconscious attempt to solve problems, not to re-create them. The label of problematic sexual behavior (or sex addiction) is focusing too much on the client having a “problem with sex,” whereas out-of-control sexual behavior is more conducive to solving problems together instead of stigmatizing or judging. This approach also allows for more open communication regarding sexually transmitted diseases, HIV, and the hepatitis C virus (HCV).

Any sexual health discussion must always include education on prevention and treatment of these important medical issues affecting many LGBTQ individuals, some in epidemic proportions. This is especially true with HCV, where according to the Centers for Disease Control and Prevention (CDC), gay and bisexual men are more at risk for HCV if they are involved in high-risk behaviors. Of people with HIV, 25% also have HCV.

It is crucial for clinicians to understand the importance of using appropriate and affirming language when discussing sexual practices, especially with non-white clients, who may not subscribe to any of the known or current labels around sexual practice or sexual orientation. Using wrong or offensive language not only retraumatizes LGBTQ clients, it might put them at further risk of continuing harmful and dangerous behavior due to not receiving the help they need and deserve.

Trauma and sexuality

In the past 30 years, there has been a profound shift in understanding the impact of trauma on individuals, families and society. Interpersonal violence, as well as intergenerational trauma, has a devastating impact on individuals, families, communities and society as a whole. The LGBTQ community faces violence and trauma every day.

Since 1996, the National Coalition of Anti-Violence Programs (NCAVP) has released national research reports on the ways in which LGBTQ and HIV-affected communities experience hate violence. In 2017, NCAVP recorded reports of a record-high 52 hate-related homicides of LGBTQ people. Twenty–two of these homicides were of transgender women of color.

The incidence of various other non-fatal assaults perpetrated against LGBTQ populations is not sufficiently collected in national data. The FBI reported in 2016 that there were 1,076 incidents involving lesbian, gay, bisexual or transgender people; it is important to note that reporting to the FBI is not mandatory and some victims might have been categorized by race, ethnicity or religion even if they were also LGBTQ. This collective trauma has a cumulative effect on the community.

Perhaps the most common emotional reaction to a trauma is feeling fearful and anxious. For many LGBTQ individuals, this level of anxiety is quite common. Often people self-medicate with substances or other problematic behaviors in an attempt to avoid unpleasant feelings. Sexual assault may more than double the risk of substance abuse for survivors. Clients, and sometimes counselors, may connect a history of trauma to one’s sexual identity (“Did this happen to me because I am gay?” or “Am I a lesbian because I was molested or a survivor of incest?”). These responses are typical for individuals who blame themselves for the abuse. Many gay men will tell themselves that, absent physical injury, “The abuse wasn’t that bad,” or engage in other rationalizations.

As a person enters into recovery, or stops using substances, intense feelings and memories will often occur. This can be very challenging for someone without proper support. LGBTQ individuals with a history of interpersonal violence need to receive substance use treatment in a safe and supportive environment that is both affirmative and trauma-sensitive. Addiction treatment, as well as some self-help models, can re-create traumatic experiences or trigger emotional reactions if services are not trauma-sensitive.

Sexual and relationship histories

A sexual history is important for all clients because it provides information that identifies high-risk behaviors that can lead to a relapse, an unintended pregnancy and/or a sexually transmitted infection. Taking a thorough sexual history can be a gateway for essential risk reduction counseling.

Many clinicians are concerned about their ability to take an appropriate and thorough sexual history with LGBTQ clients. Some clients can be reluctant to provide details about sexual behaviors. Individuals with multiple partners, married bisexuals or polyamorous persons might limit information out of concern for being judged. It is important that we avoid assumptions of heteronormativity or behaviors when conducting a sexual history. Do not assume that you know a patient’s gender identity, sexual orientation, sexual behaviors or number of partners. Instead, create an open and respectful dialogue when conducting a sexual history.

The book and movie Fifty Shades of Grey may have increased some awareness of the variations of sexual behavior for the general public, but it might not be a good representation of the experiences for others who engage in such sexual activities. Human sexuality can include a spectrum of activity, behavior, desire, fantasy, paraphernalia, and monogamous or polyamorous relationships.

Some individuals engage in sexual variations sometimes referred to as “kink.” “BDSM” is a variety of often erotic practices or role playing involving bondage, discipline, dominance and submission, sadomasochism, and other related interpersonal dynamics. While this is not exclusive to sexual minorities, it can raise certain issues in recovery.

Counselors might also be concerned about some activity indicating abuse in a relationship. There is a vast difference between domestic violence/abuse and BDSM. The latter often includes an agreement to maintain safe, sane, consensual and sober sex. Domestic violence, conversely, does not include consent. Sexual abuse is a misuse of power. These issues can occur in any relationship, so addiction professionals need to be able to provide resources should abuse become indicated.

The outcome of a successful sexual history interview will result in an improved clinician-client relationship and a treatment plan so that the client is fully informed and less likely to engage in high-risk behaviors. NALGAP, The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies advocates an inclusive integration of human sexuality and sexual health into treatment.

Sexual health refers to the ability to embrace and enjoy our sexuality throughout our lives. It is an important part of our physical and emotional health. The World Health Organization reminds us: For sexual health to be attained and maintained, the sexual rights of all people must be recognized and upheld.

A relationship history also must be discussed sensitively. When discussing relationship status, clinicians should avoid using terms such as “married,” “divorced” or “widowed,” which may not apply to all. Ask more open-ended questions in order to create a dialogue with the client, such as “Are you currently involved with anyone? How about in the past? How do you describe the relationship? Can you tell me more?”

A standard part of any assessment needs to include basic questions asked respectfully of all clients, such as “Are you sexually active? Are you active with men, women or both? Do any of your partners identify as transgender? How about in the past; were you active with men, women or both? Can you tell me more?”

Same-sex relationship styles

For generations, cultures have based their understanding of gender and relational intimacy on heteronormative interactions and relationships. As we have evolved into a new age of knowledge, acceptance and awareness, the focus has shifted. Research has begun to focus on attachment “styles” and how they affect same-sex relationships, as well as heterosexual relationships. One's relationship style, or attachment style, accompanied by a greater understanding of gender and how these “roles” were previously thought to impact relationships, can have a profound effect.

Where it was once believed that each gender carried specific behaviors and relationship styles, researchers are now leaning toward the belief that individuals' “roles” in relationships are more based on their social setting and early and continuous exposure to attachment. If a child is raised in an environment in which hugging and intimate acknowledgment is commonplace, one is more likely to reflect an affectionate relational style, regardless of gender. In previous generations, this “style” would be more associated with a feminine role, as women were categorized as the “caregivers.” Thus, it was thought that it was a natural inclination for women to be more hands-on. Now, through research and an ongoing evolution of knowledge, we can begin to see that this style is influenced by a predisposition to a nurturing environment and reinforced approval of affection.

When observing relationship styles among same-sex couples, the gender-as-relational approach can be easily brought to the forefront as a key component involved in the understanding of relational “roles” and “styles.” In contrast to a dichotomous view of men and women in relationships, a gender-as-relational approach recognizes “gender as dynamic and situational, with attention to differences among women and among men.”

Different relationship styles correlate with different experiences in love and different characteristics of romantic relationships, with three of the main styles being identified as secure, anxious/ambivalent and avoidant.

Embracing healthy sexuality

Whether to reduce inhibitions or heighten sexual desire, drugs are a common feature in LGBTQ cultural approaches to sex, and many LGBTQ individuals have never had sex without some form of mood-altering drug. Identifying safe, sane behavior is an essential task to maintain sobriety, and it can take various forms along a continuum of recovery.

Persons who are newly sober may choose (in fact, it is recommended) to abstain from sexual relations for some length of time. This provides a “grace period” during which they can focus on their recovery without the complications and risks of sex. When re-engaging with sex, individuals should identify behaviors that enhance healthy sexuality and avoid others that can threaten their recovery through activations of old rituals, triggers or other patterns. Such recovery plans take various forms depending on the needs of the individual (for example, masturbation but no sexual relations, or dating versus anonymous hookups).

Beliefs about sex and sobriety will affect recovery. Some might believe, for example, that sobriety leads to a life of boring, vanilla sex, or no sex at all. Others, especially those living with HIV/AIDS, might have used drugs to numb beliefs such as “I feel like damaged goods” and might need to work on issues of worthiness and self-compassion before they are able to engage in healthy sex in sobriety. Ultimately, embracing a firm belief that healthy sexuality and sobriety can co-exist is essential.

Developing sober sex and intimacy requires many steps, which vary depending on the individual. Some LGBTQ persons who used alcohol and other drugs to numb internalized homophobia or to disinhibit themselves might find that sex and sobriety are like a “second coming out,” complete with all the uncomfortable feelings and awkward scenarios. Others who used sex for validation will need to examine their issues of worthiness.

Stimulants are particularly damaging to the arousal template, our internal map of who and what we find attractive. The resulting persistent lack of sexual desire and its implications, which requires time and patience to heal, is detailed in David Fawcett's Lust, Men and Meth: A Gay Man's Guide to Sex and Recovery. Most newly sober individuals, especially those who have engaged in chemsex (combining stimulants, other drugs and sex) will need to grieve any remaining appeal of drug-fueled sexual behavior. Along with counseling and support groups, tools such as mindfulness, relaxation and conscious breathing can be useful in this process.

Managing sex in sobriety is fraught with complications. It is not uncommon to transfer addictions, such as engaging in a process addiction. Determining if and when to masturbate requires careful consideration, as does the use of pornography, which can be a powerful trigger. This is especially true for users of stimulants, which enhance visual sensitivity.

Loneliness is pervasive in the LGBTQ community and is often cited as a driver of addictive behavior, underscoring the importance of establishing a robust network of social connections in recovery. Other issues such as age, stigma and a lack of experience with sober sex and intimacy must be addressed on an individual basis.

Finally, technology in the form of hookup apps such as Grindr and Scruff has become common and can be very triggering. Clients should be urged, at least initially, to avoid apps and then work with their providers to reduce risk.

Assisting clients in embracing healthy sexuality requires that providers have strong self-awareness of their own beliefs and biases. Because LGBTQ clients are particularly sensitive to shame, any expressions of judgment, lack of empathy or unfamiliarity with sexual practices toward sexual minorities must be avoided. Issues of transference and countertransference should be consciously managed because they can easily lead to boundary violations. Finally, strong supervision facilitates not only better therapeutic practices but improved client outcomes as well.

Philip McCabe, CSW, is a health educator and LGBT Cultural Competencies instructor at Rutgers University, and serves as president of NALGAP, The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies. Mark McMillan, LMSW, is a behavioral health and addiction therapist with Joe Kort & Associates. Kristina Padilla, MA, LAADC, is director of education and director of business development at the California Consortium of Addiction Programs and Professionals. David Fawcett, PhD, LCSW, is a psychotherapist and sex therapist in Fort Lauderdale, Fla., specializing in gay men's health, especially addictions and HIV.

Join Us

Phil McCabe, Mark McMillan, Kristina Padilla and David Fawcett will present a workshop, Sexuality and Gender Diversity in Recovery, on Aug. 19 from 9 am to 3:15 pm at the National Conference on Alcohol and Addiction Disorders in Anaheim, Calif.