Multiple Identities, Multiple Challenges

Michael Shelton
Forward by Dana G. Finnegan and Emily B. McNally

352 pages
Paperback, $45.00 ISBN: 9781939594112
Hardcover, $85.00 ISBN: 9781939594129
E-book, $41.99 ISBN: 9781939594136

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In this new book, the successor to the classic in the field Counseling Lesbian, Gay, Bisexual, and Transgender Substance Abusers: Dual Identities by Dana G. Finnegan and Emily B. McNally, Michael Shelton reviews the empirical literature and synthesizes what we know about the prevalence of LGBT substance use, abuse, and treatment availability, emphasizing the need for affirmative therapeutic
practices. The principles of trauma-informed and culturally competent treatment/intervention are explained and assessed, as well as the challenges of minority stress and microaggressions experienced by the LGBT population. Separate sections focus on the sub-populations of lesbians, gay men, bisexuals, and transgender individuals. Separate chapters focus on LGBT youth, the elderly, family constellations and concerns, criminal justice issues, and rural LGBT substance abuse. This volume provides an introduction to the field that will be useful both as a primary textbook and as a handbook/reference for LGBT-focused and general substance-use disorder clinics and their administrators, clinicians, trainees, allies and volunteers.
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Dana G. Finnegan and Emily B. McNally

(since 3/22/17)


(since 3/22/17)
1. An Introduction to LGBT Substance Use DisordersFree Chapter

Until 1973, the goal for those seeking treatment for homosexuality was to decrease the intensity and frequency of homosexual thoughts, feelings, and behaviors while simultaneously increasing heterosexual thoughts, feelings, and behaviors. The removal of homosexuality from the DSM that year led to efforts to promote the physical and mental health of gay men and lesbians, including an understanding of the impact of substance use by these populations. Early studies found very high rates of substance use. Later methodological improvements cast doubt on the conclusions of early studies but still found elevated rates of substance use. Later studies came to the same conclusion for bisexual and transgender individuals.

Treatment is also problematic. While the majority of individuals with a substance use problem do not seek professional help, LGBT individuals’ reluctance to seek treatment often stems from a confluence of prejudicial treatment from health-care staff and a lack of knowledgeable providers.

2. Factors Leading to LGBT Substance Abuse

A health disparity is a particular type of health difference that is closely linked with social or economic disadvantage. One noted health disparity is the elevated rate of substance use among LGBT people. Research finds that there are common risk factors for the initiation of substance use, and that the more risk factors a person has, the greater the chance that taking addictive substances will lead to a substance use disorder. There are also LGBT-specific risk factors that compound an individual’s likelihood of developing a substance use problem; these include minority stress (including internalized heterosexism), experience of microaggressive behaviors, navigation of the coming-out process, and an LGBT culture deeply rooted in bars and clubs, where the use of alcohol and other substances is prevalent. These risks are further compounded when one is a member of more than one minority group.

3. Treatment of LGBT Substance Abuse

History is replete with treatments for substance use that had marginal results. Fortunately, new conceptualizations of treatments have better outcomes. LGBT substance users needing treatment will progress through the same sequence of intervention as the general population, receive the same pharmaceutical and psychosocial treatment protocols, and likely be referred to supportive self-help groups as well. Still, success requires culturally competent treatment.

Clinical environments demonstrating cultural competence reduce fear of discrimination, increase LGBT patients’ willingness to access care, and improve provider-patient communication about health concerns related to sexual orientation and/or gender identity. One manifestation of cultural competence in addressing LGBT groups is affrmative treatment, which is a way of helping sexual minorities move from shame to pride and undoing the damage of heterosexism and minority stress. Trauma-informed treatment recognizes the bidirectional relationship between trauma and substance use, acknowledges that many LGBT individuals experience trauma during their lives, and aims to prevent retraumatization during the treatment process. Support groups have a history of inclusion, but some LGBT individuals have had negative experiences with them. Helping LGBT substance users to locate welcoming twelvestep groups is important.


(since 3/22/17)
4. Trans People and Substance UseFree Chapter

The definition of transgender has become increasingly encompassing and inclusive, and society is slowly recognizing the existence of a diverse group of individuals who depart from traditional gender norms and identification. While studies of substance use by transgender individuals did not get under way in earnest until the late 1990s, they find strikingly high rates. Research also finds that many transgender individuals experience cumulative and catastrophic levels of minority stress, which can help to explain a high prevalence of co-occurring disorders.

Treatment providers often have little information and/or negative attitudes about transgender individuals; treatment facilities are often unprepared to work with members of this group. Successful treatment must factor in the unfortunately common experiences of discrimination, violence, stigma, poverty, co-occurring disorders, HIV, and other health concerns.

5. Bisexual Individuals and Substance Use

Bisexuality is defined as the capacity for emotional, romantic, and/or physical attraction to more than one sex or gender. Though research is unequivocal in its conclusion that bisexuality is a true sexual orientation and that this demographic makes up the largest single population within the LGBT community, the very existence of bisexuality is sometimes still questioned. Many bisexuals experience physical- and mental-health complications arising from a confluence of minority stress, lack of acceptance by lesbians and gay men, and insistence that one must be either gay or straight. The situation is even further complicated for those engaging in behavioral bisexuality, defined as men who consider themselves heterosexual but who engage in sex with men or express the desire to do so.

Programs that pride themselves on their competence in working, with LGBT people often have little expertise with bisexuals, and bisexuals typically receive treatment protocols tailored for lesbians and gay men. Treatment of bisexual individuals who engage in substance use must take into consideration concerns such as minority stress, double discrimination, and invisibility

6. Lesbians and Substance Use

Lesbians’ substance use patterns, etiology, risk factors, and treatment are influenced by their sexual-minority status. Alcohol use by lesbians has received the most scrutiny in the research, but lesbians also have elevated rates of nicotine and illicit drug use. Risk factors include minority stress, gender and biology, gender-specific microaggressions and aggression, co-occurring disorders, socialization patterns, and interpersonal dynamics.

From a historical perspective, substance abuse treatment was developed for adult men. Interventions for lesbians are thus hampered by the lack of research on female substance use in general. Though lesbians are more likely than heterosexual women to seek treatment for a substance use problem, research on lesbian substance use interventions and modalities is sorely lacking.

7. Gay Men and Substance Use

Though early studies that found extremely high rates of gay male substance use are now generally discounted, ongoing research continues to find elevated rates of substance use (including nicotine use) by gay men. However, these studies are often unclear as to whether participants are gay men, bisexual men, men who have sex with men (MSM), or a combination. The use of methamphetamine and club drugs is particularly elevated for gay men. Risk factors for abuse include minority stress, childhood sexual abuse, and other co-occurring disorders. Eating disorders and body image concerns may also play a role. The association between sexual activity and substance use has been frequently noted; it plays a role in HIV transmission, and HIV is particularly concentrated among gay and bisexual men and other MSM. All of these risk factors must be considered in the treatment process, and several recent efforts at gay-male-specific interventions are highlighted.



8. LGBT Youth and Substance Use

Adolescent substance use increases the risk of adult substance use problems, and LGBT youth present with a higher prevalence of substance use than their heterosexual peers. Risk and protective factors are related to the initiation and ongoing use of drugs, alcohol, and nicotine. LGBT youth experience a confluence of general and LGBT-specific factors. The latter include minority stress, the difficulties of the comingout process, family rejection, school and peer rejection, unhealthy coping strategies, histories of trauma owning to physical and sexual abuse, and homelessness. Several major providers have offered comprehensive recommendations for working with LGBT youth in clinical settings, and the role of family is highlighted. Also, substance abuse prevention strategies for LGBT youth are in development, including strategies focused on building resilience.

9. LGBT Elders and Substance Use

The older adult population is one of the fastest growing demographics in the United States. There is concern that as the baby boomer population ages there will be a marked increase in the number of older adults needing treatment for substance use concerns because this group historically presents with elevated rates of illicit substance use. Alcohol and prescription misuse are particular concerns. LGBT individuals are similarly expected to carry their earlier substance use patterns into their older adult years; others will develop a substance use problem as an elder after a lifetime of abstinence.

LGBT older adults often experience a culmination of risk factors for poor mental-health outcomes, including substance use. These risk factors include those that are generic for older adults in general and those that are LGBT-specific. However, there are few studies of older adult substance use treatment, and even fewer for LGBT older adults. Many among the latter group fear discrimination and rejection during treatment. Considerations during treatment include a lifetime of minority stress for many clients, inadequate support systems, co-occurring disorders, creating social networks that do not involve clubs and bars, the coming-out process as an older adult, and financial issues.

10. Substance Use and LGBT Family Constellations

Substance use disorders affect both the individual user and his or her family; consequences include eroding trust, boundary violations, financial concerns, interpersonal violence, and enabling behaviors. Family engagement of one form or another in treatment for substance use problems has a long history. It is now recognized that family therapy is an important modality for an individual with a substance use disorder, and family-systems theories are relevant when addressing the effects of substance use by one or more family members.

Research on family involvement for LGBT substance users is sparse, and there are additional issues that traditional families do not experience and rarely even consider that must be factored into treatment decisions. First, the definition of family is more expansive for LGBT members. Second, unresolved family-of-origin issues related to sexual orientation or gender identity are common. Third, the coming-out process and community disclosure might affect treatment. Finally, one or more family members might be struggling with their sexuality and/or gender identity. It appears that most prevailing models of family therapy can be tailored to LGBT family and couples’ dynamics.

11. LGBT Substance Users in the Criminal Justice System

There is a strong association between substance use and involvement in the criminal justice system. More than half of the arrests in the United States involve drug use, and almost half of federal prisoners are in detainment for a drug offense. Research consistently shows that participation in substance use treatment—while on probation, on parole, or incarcerated—reduces the risk of a return to criminal activity. However, the availability and quality of such treatment vary across the criminal justice system. Few people in the system receive any treatment at all.

LGBT individuals are involved in the criminal justice system at multiple levels, including through interactions with police, in the courts, in jails and prisons, and on probation and parole. It is unclear how many LGBT individuals are in the legal system for substance use-related charges or convictions; many, though, are dependent on underground economies involving illicit substances that lead to police involvement. Transgender women and LGBT people of color are the most likely to come into police contact. Research highlights the special problems they face: discrimination, harassment, violence, inadequate provision of treatment, a lack of knowledge regarding LGBT populations, and a lack of awareness of their presence in the legal system. Finally, while current substance abuse treatment for most in the criminal justice system is inadequate, sexual minorities are even less likely to have a positive treatment experience.

12. LGBT Individuals in Rural Environments

One quarter of the U.S. population lives in rural areas, and substance use— including illicit substances, alcohol, and prescription drug abuse—is not uncommon. Rural substance use treatment is stymied by a number of factors, including a paucity of treatment providers, transportation difficulties, a belief in self-reliance, and confidentiality issues. New treatment approaches are currently under development to meet the needs of rural populations.

While it is commonly believed that rural life is inhospitable to LGBT individuals, recent data inform us that many say they are satisfied living in these communities. Additionally, some LGBT urbanites are returning to their rural roots and others are relocating for the first time to rural areas for what they see as an improved quality of life. Those with a substance use issue may encounter the aforementioned challenges as well as negative views and misconceptions regarding LGBT individuals held by some treatment providers and a lack of knowledge regarding LGBT clients. There is a particular need for culturally competent treatment in rural areas.


Treatment Agency Self-Audit: Policy and Procedures

Treatment Agency Self-Audit: LGBT Employees

The Gay Affirmative Practice Scale





(since 3/22/17)


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