Here is the research paper we talked about in episode 63: THE POT OF RECOVERY AT THE END OF THE LGBTQ RAINBOW (SORT OF)
School of Social Work, Salisbury University
SOWK 653: Substance Abuse Assessment And Intervention
Rebecca, MSW, LCSW-C
November 29th, 2020
The lesbian, gay, bi-sexual, transsexual, and queer (LGBTQ) community is a growing minority that we are still learning more about. As recently as 1973, homosexuality was still a diagnosable disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and even after it’s removal, was replaced with sexual orientation disturbance, another nod to being gay as fundamentally being wrong, which was not removed until 1987 (Drescher, 2015). The LGBTQ population was still considered to be undeserving of equal rights until 2015 when laws were passed legalizing same-sex marriage in the United States. Even now, there’s no assurance that those rights will continue to stand. With this in mind, it’s understood that the research and statistics about how substance abuse impacts this vulnerable, minority population is still in its infancy.
The most recent National Survey on Drug Use and Health (NSDUH) data, provided by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2020) states that 16.5% of LGBTQ adults had a substance use disorder (SUD). This is a much larger portion of the general population, which, according to SAMHSA data for the same year has been estimated as 6.5% who have had an SUD (2019). This means that an adult member of the LGBTQ population is more than 2 and a half times more likely to have had an SUD.
The NSDUH data lists alcohol as the most used drug of choice for the LGBTQ community, with over 64% of the population partaking (SAMHSA, 2020). Marijuana is also a commonly used substance by the population, with 37% of the population using marijuana. Alcohol Use Disorder (AUD) leads the misuse of drugs in the LGBTQ population, with around 12% of persons reporting having had an AUD, compared to around 6% of the overall population. There is also a high reporting of Opioid Use Disorder (OUD), with 9% of the LGBTQ population reporting misuse of prescription medication or some other opioid.
There does not seem to be any evidence that this population is more prone to any certain effects of substance use. The LGBTQ population is not biologically different from the total population, reducing the tendency for physiological differences. Due to the increased proportions of the LGBTQ population struggling with substance use, using substances would not create an isolated environment anymore than it would for any other individual.
Factors of Increased Substance Use
Risk factors are present for LGBTQ persons that are not there for the overall population. Alternatively, risk factors that are present in the overall population are increased due to the LGBTQ identification of an individual. Ryan, et al. (2010) looked at the connection of family acceptance to substance use. It was observed that family acceptance did serve as a protective factor for substance use in all populations. Further, since being LGBTQ is less accepted by people as a whole, there was less acceptance of LGBTQ youth by families, creating a risk factor greater than what the average person might face.
Hughes and Eliason (2002) also point out that many of the protective factors that assist in the overall populations ability to have less substance use are not as protective in the LGBTQ community, meaning that they are at increased risk of continued problems with substance use. Generally, age is a protective factor against substance use. As well, being a woman is usually a protective factor. In the LGBTQ community, these factors are not as protective. The percentage of lesbian women who have had a substance related problem in the last 12 months actually increases as they get older, the opposite of the total population.
Along with the loss of some protective factors and the higher risk factors, comes the increased stressors from discrimination that this population faces. McCabe, et al. (2010) posit that social stigma from being a member of the LGBTQ community, along with internalized homophobia, make this population more at risk than the typical population. The stigma of feeling judged every day, of feeling different, of possibly not even feeling that it’s safe to tell others about one’s true identity, all serve to further isolation, shame, and guilt, which in turn increases the chances of substance use.
While many people in the overall population look to find potential mates at bars and clubs, this might actually be more so in the LGBTQ community. There are many bars and clubs that act as hubs for socialization in the community, creating an atmosphere of substance use as a means for socialization.
The prevalence of school victimization also correlates to substance use. Huebner, et al. (2015) found that elevated levels of school bullying and harassment were tied to elevated levels of substance use, along with elevated risk of substance use. Up to 85% of LGBTQ adolescents reported verbal harassment in the school setting.
Researchers are starting to see correlation between cultural value shifts and substance use. While cultural changes happen slowly, it is becoming more acceptable in American society to be a member of the LGBTQ community. There is still a long way to go, but recent strides have made a stark difference between being “out” in 2020 versus being “out” in 1990. The SAMHSA (2020) data shows a large decrease in pain reliever misuse along with significant decrease in new and overall heroin users, suggesting that with more cultural acceptance, there could be a decrease in risk for the population.
There is a strong belief that outcomes of treatment would vary depending on one’s LGBTQ designation. There is little evidence, however, mostly due to very limited research and funding, that allows researchers to know what those differences might be, or how they might help to find the best, evidenced-based treatments for substance use problems in the LGBTQ population.
Less than one in eight treatment centers had a specialized treatment service available to assist persons in the LGBTQ community. Upon further inspection of these specialized services, Cochran, et al. (2007) found that 70% of them were not any different from the regular services offered. Further, only 7% of the centers that did offer LGBTQ specialty programs could actually name a service that was employed to address the LGBTQ population that was different from their typical treatment regimen. Furthering the problem is that when funding and interest does lead to actual research, it is almost always a lumped together group of LGBTQ, even though vast differences have been found between the members of this population.
An entire booklet has been published by SAMHSA (2012), titled A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals. At 228 pages and revised as recently as 2012, this sits as the definitive guide as to the best treatment approaches for treating substance use in the LGBTQ community. However, the treatment modality section covers only seven pages and can be summed up as “group might be difficult for LGBTQ if there is homophobia present.”
Stevens (2012) suggests that using feminist or queer theory in treatment could assist in taking into account issues that might be relevant to the LGBTQ community and provide more specialized treatment. Stevens further says that treatment could be assisted by specialized treatment centers for LGBTQ only. Finally, Stevens mentions taking on issues,such as stigma, minority stress, abuse, harassment, family rejection and lack of social support, that affect the LGBTQ population directly during the treatment process.
While statistics on the percentages of LGBTQ persons that go to 12 step recovery programs cannot be found, it can be postulated that these programs are used at the same rate by LGBTQ communities as the overall population. 12 step recovery programs lean toward a more open-minded view, making them a more accepting and tolerant place to begin with. Further, the list of meetings for Alcoholics Anonymous and Narcotics Anonymous both include LGBTQ specialty meetings, increasing the likelihood that persons of that orientation would feel welcomed, comfortable, and able to talk about their specific needs.
The LGBTQ population is often discriminated against by persons who claim it is a sin according to their religion. Often, this is the predominant religion in the United States, Christianity. These individuals claim that any form of relationship that is not specifically a man and a woman is immoral and persons who are in the LGBTQ community should not have equal rights.
The LGBTQ population is as marginalized, discriminated, and oppressed as any other minority in America. Even more so when these minority characteristics intersect. As examples, the LGBTQ community only gained entry into the military officially in 2011. Even now, that does not include the T portion though. As explained above, homosexuality was considered a mental illness until recently. The population only recently gained the ability to be married. This affected the ability to have medical coverage for many couples. Persons who identify as LGBTQ have lost jobs for no reason except that identification. Services have been withheld from persons who are part of the LGBTQ community.
Social workers believe in the value of social justice. It’s listed as one of the core values of the social work code of ethics (2017). It goes on to list challenging social injustice as an ethical principle, and basically the job of every social worker. As recently as one month ago, an organization in Texas voted to remove the protections for the LGBTQ population, and allowed social workers to deny persons who identified as LGBTQ. This was reversed later, but the LGBTQ community still needs advocates to attain equal treatment and rights.
This population still needs resources, as shown by this research paper, in the way of money to fund research to learn more about the unique challenges the LGBTQ community faces, and how to best handle them. With very little funding going to LGBTQ research, and the majority of that going towards AIDS related studies, very little is known about the effects of other issues, such as substance use, and how different risk and protective factors are present or needed, along with best practices for treatment. Policies are still needed to further prevent the discrimination that is faced by the LGBTQ population.
At a local level, advocacy is still needed to acquire some protections and freedoms for the LGBTQ population. Some example include the requirement of birth certificates to identify gender a difficult name change process for persons who identify as trans, not being fully protected from discrimination of private health care access, adoption laws, protections for family leave, and protective financial lending practices. If any bills that attempted to assist in gaining rights in any of these areas were to be presented to the local legislature, social workers could provide assistance by contacting their local legislators, along with going to the legislative hearing to let their support be shown.
I would love to learn more about providing services to this population. At this point, it seems that the only way to learn more about this population, what they need, and how they can be best served, is to work with this population and ask. While we know supportive groups of like minded people and normalizing the LGBTQ experience are both helpful, we know entirely too little about how to best help treat substance abuse, or anything else, in this population. I have seen the acceptance level of LGBTQ persons change drastically during my lifetime. With that, I have had to change and adjust as I learned more information. Hopefully we are nearing a point where we invest the resources to better understand how different approaches can assist different minority populations. For now, the best thing to do for this population is to work with them and listen. Look for ways that they are asking for something slightly different than the normal treatment approach. Try to gain insight into other ideas that might benefit this population, or meet a need that is going unmet.
As of this moment, I don’t feel particularly called to work with any certain population. No one cause has stood out to me as where my heart is, or my ultimate goal of helping lies. That being said, I find the idea of working with minorities in general, and the LGBTQ population in specific, very appealing. I love the idea of learning more about people to better understand where they are coming from and how the world could better accommodate all people. My hope is that through my learning more of others, I can take that out into the community as a whole in my interactions, and spread the information to more people, to increase understanding and acceptance of all.
I cannot currently think of how working with the LGBTQ popuation might be unappealing to work with. I do have a slight fear of interacting with a certain type of person that I have encountered in my life. I’ve struggled with interacting with persons who identify as something exotic. It could be my lack of understanding about the nature of it, but at times I’ve felt as if I didn’t know how to frame the conversation. So maybe the unappealing part is my fear of not understanding.
In general, I think I’m prepared to start working with this population. Many of the social work beliefs, such as acceptance of all, inherent dignity and worth, and equality, all tie into the ability to work with minority populations. As for getting better at working with this population, I think that only time spent in practice with the LGBTQ community will assist in that process. I can make sure to keep up with any new information and research that pertains to the population to assist in the effort to be competently informed with evidenced based practices.
As of right now, I’m currently unaware of any personal conflicts that might arise when working with this population. I do not have any history of issues dealing with the LGBTQ community. In my youth, it was much more acceptable to mock and belittle LGBTQ persons. I think that I am aware of the ways I internalized those messages from society, and have moved into different thinking. I’m sure there will be new understanding along the way, of how some of my behaviors could be microaggressions, some small way that I perpetuate marginalization of the community that I do not realize, but I will not be able to address them until I’m informed that they are there.
Anytime I am tasked with researching a topic, and therefore more educated on a topic, I gain in my awareness, my critical thinking, and my level of understanding. Previous to this paper, I had honestly never considered that the LGBTQ community might need a different treatment method, or any alternative therapy practices to assist in treatment of substance use. While I understood that some minority communities might need different resources for certain struggles, substance use disorder had seemed universal in my thinking, and therefore the treatment, while not always effective in its current state anyway, did not seem like it would need to be altered for any particular group of people. It can be easy as a white male to forget that others benefit from things different than what would work for me. I can walk into a treatment facility and assume that I will feel included in any group discussion. Or that my feeling of isolation and exclusion is the norm. I can overlook that minorities have extra challenges every day of being excluded even in the places that strive to be inclusive. I think this research paper has helped to make me more aware of my own tendency to forget that special populations probably need special methods of assistance. This can help in the sense that I can advocate and speak up about the need for more LGBTQ, and any minority, services in substance use treatment. It can also assist me in remembering that in my future practice, I hope to look for places where I can find ways to help marginalized populations feel included.
Cochran, B. N., Peavy, M., & Robohm, J. S. (2007). Do Specialized Services Exist for LGBT Individuals Seeking Treatment for Substance Misuse? A Study of Available Treatment Programs. Substance Use & Misuse, 42, 161–176. 10.1080/10826080601094207
Drescher, J. (2015, December). Out of DSM: Depathologizing Homosexuality. Behavioral Sciences, 5(4), 565-575. 10.3390/bs5040565
Huebner, D. M., Thoma, B. C., & Neilands, T. B. (2015, July). School Victimization and Substance Use among Lesbian, Gay, Bisexual, and Transgender Adolescents. Prevention Science, 16(5), 734–743. 10.1007/s11121-014-0507-x
Hughes, T., & Eliason, M. J. (2002, March). Substance Use and Abuse in Lesbian, Gay, Bisexual and Transgender Populations. The Journal of Primary Prevention, 22(3), 263-298. 10.1023/A:1013669705086
McCabe, S. E., Bostwick, W. B., Hughes, T. L., West, B. T., & Boyd, C. J. (2010, October). The Relationship Between Discrimination and Substance Use Disorders Among Lesbian, Gay, and Bisexual Adults in the United States. American Journal of Public Health, 100(10), 1946-1952. 10. 2105/AJPH.2009.163147
National Association of Social Workers. (2008). Preamble to the code of ethics. Retrieved May 4, 2008, from http://www.socialworkers.org/pubs/ Code/code.asp
Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010, November). Family Acceptance in Adolescence and the Health of LGBT Young Adults. Journal of Child and Adolescent Psychiatric Nursing, 23(4), 205-213. 10.1111/j.1744-6171.2010.00246.x
Stevens, S. (2012, February). Meeting the substance abuse treatment needs of lesbian, bisexual and transgender women: implications from research to practice. Substance Abuse and Rehabilitation, 3, 27-36. 10.2147/SAR.S26430
Substance Abuse and Mental Health Services Administration. (2012). A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES.
Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. (2019). Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health.
2018 National Survey on Drug Use and Health: Lesbian, Gay, & Bisexual (LGB) Adults. (2020). Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services.
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