Reconsidering the LGBT Substance Abuse Treatment Experience

Joey Mogul, Andrea Ritchie, and Kay Whitlock, authors of the 2011 book Queer Injustice: The Criminalization of LGBT People in the United States, propose that understanding the differentials in treatment for LGBTs in the justice system requires, “discarding the facile notion that all queers experience the stigma of criminalization and the criminal legal system in the same ways.  Queer engagement with law enforcement cannot be accurately described, much less, analyzed, as a stand-alone, generic “gay” experience because race, class, and gender are crucial factors in determining how and which queers will bear the brunt of violence at the hands of the criminal legal system.” [i]

The same holds true for queer engagement with the behavioral health treatment system; here too there is no prototypical “gay” experience because race, class, and gender play pivotal roles in access to services, quality of treatment, and outcomes.  Consider Lambda Legal’s Healthcare Survey: It found that a higher proportion of LGBT respondents who were people of color and/or low-income reported receiving discriminatory and substandard care.[ii]

In 2001 the Substance Abuse and Mental Health Services Administration released “A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals.”  This Introduction reviewed studies from the 1970s through the 1990s and concluded that “LGBT people are more likely to use alcohol and drugs, have higher rates of substance abuse, are less likely to abstain from use, and are more likely to continue heavy drinking into later life.”[iii]  Over the past decade the Provider’s Guide has been the basis for innumerable trainings on LGBT substance abuse across the country and the paramount resource for LGBT treatment providers.

A new report offers an updated appraisal of LGBT substance abuse in the intervening decade and also begins to untangle the otherwise “generic gay” treatment experience. This 348-page report titled “The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding” was released by The Institute of Medicine (IOM) in 2011 and examines the myriad physical and mental health needs of LGBTs, including substance abuse.  Bradley Jacklin, policy manager at the National Gay and Lesbian Task Force, stated, “This is historic.  This is the first time the federal government has laid out a blueprint of the health challenges facing the LGBT community.”[iv]

The IOM report was an eye-opening surprise for many. According to Robert Garofalo, an Associate Professor of Pediatrics at Northwestern University’s Feinberg School of Medicine and a member of the committee supervising the IOM report, “No matter what we looked at, there was a paucity of research in the available literature.”[v]  Gaps include:

·               Reliance on convenience samples

·               Most of the research focuses on adults, not youth

·               Most study participants live in large cities  (According to Garofalo, “We don’tknow what it’s like to be LGBT and live in rural Illinois or the suburbs.  There was no literature out there for us to pull from.”[vi])

·              Most of the research focuses on lesbians and gay men and comparatively little on bisexual and transgender individuals

·              Much of the research is based on white individuals, and people of color are  unrepresented

The report concluded LGB adults might have higher rates of smoking, alcohol use, and substance use than heterosexual adults. However, most research in this area has been conducted among women, with much less being known about gay and bisexual men. Very limited research has occurred with transgender individuals, though it indicates that substance use is a pressing concern for this population.[vii]

What does this mean for treatment providers?  Many LGBT subpopulations have been marginalized or ignored in research, and we simply don’t have the knowledge to guide our clinical work with these groups.  In fact, much of what we “know” about LGBT substance abuse is based on studies of white lesbians of middle-class (or above) income who are publically “out.”  The limitations are obvious and the ability to generalize these studies to all LGBTs is, at the least, questionable.