Gender Identity and Sexual Orientation Interview Analysis

Substance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment
A Provider’s
Introduction to
Substance Abuse
Treatment for
Lesbian, Gay, Bisexual,
and Transgender
Individuals
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
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
All material appearing in this volume may be reproduced or copied without permission from the
Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance
Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
The material appearing on pages 12 and 13 is under copyright and reproduced herein with the
permission of the copyright holders. Before reprinting, readers are advised to determine the copy­
right status of all such material or to secure permission of the copyright holders.
This publication was developed by SAMHSA’s CSAT under purchase order 99M004228. Edwin
Craft, Dr.P.H., served as the CSAT Government Project Officer. Saul Levin, M.D., M.P.A., Access
Consulting International, Inc., served as the Project Director for the development of the original
draft document.
This document was edited and prepared for publication by CSAT’s Knowledge Application
Program (KAP) under contract number 270-99-7072 with JBS International, Inc., and The CDM
Group. Karl White, Ed.D., served as the CSAT KAP Government Project Officer.
The opinions expressed herein are the views of the authors and do not represent the official posi­
tion of CSAT, SAMHSA, or any other part of the U.S. Department of Health and Human Services
(HHS).
This publication may be ordered from SAMHSA’s Publications Ordering Web page at http://
store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and
Español). The document can be downloaded from the KAP Web site at https://www.samhsa.gov/
kap/resources.
HHS Publication No. (SMA) 12–4104
First printed 2001
Revised 2003, 2009, and 2012
Table of Contents
Foreword ……………………………………………………………………………………………………………………….. ix
Acknowledgments………………………………………………………………………………………………………….. xi
Executive Summary ……………………………………………………………………………………………………… xiii
Substance Abuse in the LGBT Community……………………………………………………………… xiii
Sexual Orientation and Gender Identity ………………………………………………………………….. xiv
Homophobia and Heterosexism …………………………………………………………………………….. xiv
Cultural Issues……………………………………………………………………………………………………… xv
Legal Issues ………………………………………………………………………………………………………… xv
Treatment Accessibility, Modalities, and the Continuum of Care………………………………… xvi
The Coming Out Process …………………………………………………………………………………….. xvii
Families of Origin and Families of Choice………………………………………………………………. xvii
Clinical Issues……………………………………………………………………………………………………..xviii
Related Health Issues ………………………………………………………………………………………….. xxi
Interpersonal Violence in the LGBT Community ………………………………………………………. xxi
Counselor Competence in Treating LGBT Clients …………………………………………………… xxii
Administrative Issues…………………………………………………………………………………………… xxii
Training and Education………………………………………………………………………………………… xxii
Alliances and Networks ………………………………………………………………………………………..xxiii
Conclusion ………………………………………………………………………………………………………….xxiii
SECTION I: OVERVIEW
Chapter 1—An Overview for Providers Treating LGBT Clients…………………………………………..1
Introduction …………………………………………………………………………………………………………….1
Substance Use and Abuse in the LGBT Community ……………………………………………………1
Definition of Terms and Concepts Related to LGBT Issues …………………………………………4
Estimates of the Number of LGBT Individuals …………………………………………………………….5
Homophobia and Heterosexism ………………………………………………………………………………..6
How Heterosexism Contributes to Substance Abuse ………………………………………………….8
Perspectives on Homosexuality ………………………………………………………………………………..8
Perspectives on Bisexuality…………………………………………………………………………………….10
Sexual Orientation Over Time …………………………………………………………………………………10
Assessing Sexual Orientation………………………………………………………………………………….11
Life Cycle Issues …………………………………………………………………………………………………..11
Summary ……………………………………………………………………………………………………………..14
Chapter 2—Cultural Issues in Working With LGBT Individuals………………………………………..15
Introduction …………………………………………………………………………………………………………..15
iii
Table of Contents
Definitions of Terms……………………………………………………………………………………………….15
Cultural Competency Overview ……………………………………………………………………………….16
General Issues in Cross-Cultural Treatment ……………………………………………………………..18
Dimensions of Culture ………………………………………………………………………………………….. 19
Introduction to the LGBT Community and Culture ……………………………………………………..19
Ethnic Minority Groups …………………………………………………………………………………………..22
Summary ……………………………………………………………………………………………………………..27
Chapter 3—Legal Issues for Programs Treating LGBT Clients ………………………………………..29
Introduction …………………………………………………………………………………………………………..29
Protecting the Confidentiality of LGBT Individuals in
Substance Abuse Treatment Programs …………………………………………………………………30
Discrimination Against LGBT Individuals ………………………………………………………………….35
Do LGBT Individuals in Substance Abuse Treatment
Have Any Legal Protections?……………………………………………………………………………….39
Recommendations…………………………………………………………………………………………………44
Resources…………………………………………………………………………………………………………….45
Chapter 4—Overview of Treatment Approaches, Modalities, and Issues of
Accessibility in the Continuum of Care ………………………………………………………………..49
Introduction …………………………………………………………………………………………………………..49
Approaches…………………………………………………………………………………………………………..50
Levels of Care ………………………………………………………………………………………………………50
Continuum of Care ………………………………………………………………………………………………..51
Accessibility ………………………………………………………………………………………………………….51
Specific Issues………………………………………………………………………………………………………53
Modalities……………………………………………………………………………………………………………..56
SECTION II: CLINICIAN’S GUIDE
Chapter 5—The Coming Out Process for Lesbians and Gay Men…………………………………….63
Introduction …………………………………………………………………………………………………………..63
What the Coming Out Process Means for Counselors ……………………………………………….63
Stage Models of Transforming an Identity ………………………………………………………………..64
Stage One: Identity Confusion ………………………………………………………………………………..65
Stage Two: Identity Comparison ……………………………………………………………………………..65
Stage Three: Identity Tolerance ………………………………………………………………………………66
Stage Four: Identity Acceptance ……………………………………………………………………………..66
Stage Five: Identity Pride ……………………………………………………………………………………….66
Stage Six: Identity Synthesis ………………………………………………………………………………….67
Recovery Issues for Lesbians and Gay Men …………………………………………………………….67
Chapter 6—Families of Origin and Families of Choice …………………………………………………….71
Introduction …………………………………………………………………………………………………………..71
Family of Origin …………………………………………………………………………………………………….71
Family of Choice and Relationships …………………………………………………………………………73
Parenting Issues……………………………………………………………………………………………………73
iv
Chapter 8—Clinical Issues With Gay Male Clients …………………………………………………………..81
Introduction …………………………………………………………………………………………………………..81
Being Male and Being Gay……………………………………………………………………………………..83
Gay Male Social Life ……………………………………………………………………………………………..84
Alcohol and Drug Use and Sexual Activity………………………………………………………………..85
Gay Male Life Cycles and Relationships…………………………………………………………………..86
HIV/AIDS: Loss and Grief……………………………………………………………………………………….86
Table of Contents
Chapter 7—Clinical Issues With Lesbians……………………………………………………………………….75
Introduction …………………………………………………………………………………………………………..75
Destructive Myths and Stereotypes………………………………………………………………………….76
Clinical Issues With Substance-Abusing Lesbians……………………………………………………..77
Counselors’ Responsibilities……………………………………………………………………………………77
Chapter 9—Clinical Issues With Bisexuals ……………………………………………………………………..89
Introduction …………………………………………………………………………………………………………..89
Myths …………………………………………………………………………………………………………………..90
Professional Biases Versus Research ……………………………………………………………………..90
What Counselors Need To Know About Bisexual Clients……………………………………………90
Psychosocial Issues ………………………………………………………………………………………………91
Counseling Strategies ……………………………………………………………………………………………91
Chapter 10—Clinical Issues With Transgender Individuals ……………………………………………..93
Introduction …………………………………………………………………………………………………………..93
Definitions …………………………………………………………………………………………………………….94
Research Into Substance Abuse and HIV Among Transgender Individuals…………………..96
Clinical Issues in Substance Abuse Treatment With
Transgender Individuals………………………………………………………………………………………97
Chapter 11—Clinical Issues With Youth ………………………………………………………………………..101
Introduction …………………………………………………………………………………………………………101
Alcohol and Drug Use in LGBT Youth…………………………………………………………………….102
Stigma, Identity, and Risk……………………………………………………………………………………..102
Abuse and Homelessness…………………………………………………………………………………….104
Assessment and Treatment…………………………………………………………………………………..105
Chapter 12—Related Health Issues……………………………………………………………………………….107
Introduction …………………………………………………………………………………………………………107
Gay and Bisexual Men …………………………………………………………………………………………108
Lesbian and Bisexual Women……………………………………………………………………………….108
Transgender Individuals ……………………………………………………………………………………….109
Common Barriers to LGBT Individuals Receiving Adequate Health Care ……………………109
Common Mental Health Issues That LGBT Individuals May Face ……………………………..110
Interpersonal Violence in the LGBT Community ………………………………………………………110
Assessment ………………………………………………………………………………………………………..111
Interventions ……………………………………………………………………………………………………….112
v
Table of Contents
Chapter 13—Counselor Competence in Treating LGBT Clients ……………………………………..117
Introduction …………………………………………………………………………………………………………117
Counselor’s Professional Responsibility………………………………………………………………….118
Helping Clients Heal From the Negative Effects of
Homophobia and Heterosexism………………………………………………………………………….119
Practical Suggestions for Providing Competent Treatment ……………………………………….120
Treating LGBT Clients in the Criminal Justice System ……………………………………………..121
SECTION III: PROGRAM ADMINISTRATOR’S GUIDE
Chapter 14—Policies and Procedures …………………………………………………………………………..127
Introduction …………………………………………………………………………………………………………127
Strategies and Recommendations …………………………………………………………………………127
Chapter 15—Training and Education …………………………………………………………………………….135
Introduction …………………………………………………………………………………………………………135
Issues To Consider………………………………………………………………………………………………136
Strategies……………………………………………………………………………………………………………136
Addressing the Six Components Effectively…………………………………………………………….137
A Training Model …………………………………………………………………………………………………140
Chapter 16—Quality Improvement and LGBT Clients…………………………………………………….143
Introduction …………………………………………………………………………………………………………143
A Framework for Functionally Defining Quality ………………………………………………………..144
Collecting Baseline Data ………………………………………………………………………………………145
Monitoring Progress …………………………………………………………………………………………….146
Evaluating Outcomes …………………………………………………………………………………………..149
Chapter 17—Using Alliances and Networks To Improve Treatment
for Lesbian, Gay, Bisexual, and Transgender Clients ………………………………………….151
Introduction …………………………………………………………………………………………………………151
Rationale for Alliance Building and First Steps ………………………………………………………..151
The Impact of Managed Care on Behavioral Health and LGBT Individuals …………………152
Concerns About Managed Care Organizations………………………………………………………..157
Advocacy Efforts and Partnerships To Improve LGBT Care ……………………………………..159
LGBT Provider Networks………………………………………………………………………………………160
Chapter 18—Recommendations ……………………………………………………………………………………163
Introduction …………………………………………………………………………………………………………163
Recommendations for Research ……………………………………………………………………………163
Recommendations for Clinicians ……………………………………………………………………………164
Recommendations for Training ……………………………………………………………………………..165
Recommendations for Administrators …………………………………………………………………….165
vi
Appendix A—Glossary of Terms ……………………………………………………………………………169
Appendix B—References ……………………………………………………………………………………..173
Appendix C—Acronyms ……………………………………………………………………………………….193
Appendix D—Studies on LGBT Substance Abuse …………………………………………………..195
Table of Contents
SECTION IV: APPENDIXES
vii
Foreword
The Center for Substance Abuse Treatment
(CSAT) of the Substance Abuse and Mental
Health Services Administration (SAMHSA) is
pleased to present A Provider’s Introduction to
Substance Abuse Treatment for Lesbian, Gay,
Bisexual, and Transgender Individuals.
This publication was developed through a
systematic and innovative process in which
clinicians, researchers, program and
administrative managers, policymakers, and
other Federal, State, and independent experts
were brought together for a series of intensive
sessions. These individuals reviewed and
discussed current administrative and clinical
practices for treating substance-abusing
lesbian, gay, bisexual, and transgender (LGBT)
individuals and then wrote and edited the
resulting document. The goal of this process
was to improve and advance substance abuse
treatment for a community of individuals
whose health care needs are often ignored,
denigrated, or denied.
This document seeks to inform administrators
and clinicians about appropriate diagnosis
and treatment approaches that will help ensure
the development or enhancement of effective
LGBT-sensitive programs. Serving as both a
reference tool and program guide, it provides
statistical and demographic information,
prevalence data, case examples and
suggested interventions, treatment guidelines
and approaches, and organizational policies
and procedures.
This publication focuses on the two most
important audiences for successful program
development and implementation—clinicians
and administrators. Section I provides an
introduction for both audiences and includes
information on sexual orientation, legal issues,
and treatment approaches and modalities from
an LGBT standpoint. Section II is written for the
practicing clinician. It offers further information
on clinical issues of LGBT clients; an introduc­
tion to strategies and methods for improving
current services to LGBT individuals; and steps
for starting LGBT-sensitive programs. Section
III, developed for program administrators, pro­
vides an overview of the issues that need to be
addressed when developing an LGBT program
or when expanding current services for LGBT
clients. It offers the data needed to build a
strong foundation for a program, including an
organizational mission and policies and
procedures. It provides resources and
strategies for working with managed care
organizations and building alliances and coop­
erative arrangements to coordinate efforts on
behalf of LGBT individuals so that members
of the LGBT population can promote self-help
programs within their own communities.
Besides increasing awareness of the need for
LGBT-sensitive treatment services and help­
ing all those involved in the treatment process
become more aware of LGBT issues, this
document also serves an important public
health function. For example, the convergence
of HIV, hepatitis, and substance abuse is a
major concern that has not been adequately
addressed in LGBT communities, especially
ix
Foreword
regarding the availability of vaccines for
hepatitis A and hepatitis B. Educating LGBT
people about these vaccines, the importance
of vaccination, and strategies for preventing
hepatitis C infection is a responsibility of all
health care providers, not just substance
abuse treatment professionals.
This publication is the result of the
collaboration of many contributors, and CSAT
gratefully acknowledges the dedication, time,
talent, and hard work that the writers and
reviewers have brought to this publication.
Pamela S. Hyde, J.D.
Administrator
Substance Abuse and Mental Health Services Administration
Peter J. Delany, Ph.D., LCSW-C
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
x
Acknowledgments
This publication was developed by the Center
for Substance Abuse Treatment of the
Substance Abuse and Mental Health Services
Administration in conjunction with many subject
area experts. These experts are identified at
the beginning of each chapter. CSAT acknowl­
edges the contributions of Edwin Craft, Dr.P.H.,
M.Ed., LCPC, who served as Project Officer;
Saul Levin, M.D., M.P.A., Access Consulting
International, Inc., who served as Project
Director; and Roxanne Kibben, M.A., LADC,
NCAC II, who served as Project Manager for
the development of this publication. The coordi­
nators for the Program Administrator’s Section
were Ednita Wright, Ph.D., and Roxanne Kibben.
The coordinator for the Clinician’s Section was
Joseph Neisen, Ph.D. In addition, appreciation
goes to Diann P. Fahey, Triumph Technologies,
Inc., who served as Production and Logistics
Coordinator for this publication. The Project
Officer also acknowledges the important contri­
butions to this project by Kevin Mulvey, Ph.D.,
Karl White, Ed.D., and Lynne McArthur, Barbara
Fink, Nancy Hegle, and Mary Beth Hatem
and other staff on the Knowledge Application
Program contract.
Appreciation is also extended to the Steering
Committee, which served as an advisory
committee to the editors and writers. The
Steering Committee consisted of those
referred to above, as well as:
E. Bernard Anderson, Jr., M.S., M.A.,
NCAC, ICADC, C.C.S.
Michael Browning
Patricia Hawkins, Ph.D.
Dominique Rosa Leslie
Therissa Libby
Victor Martinez
Maria Morfin, M.A.
José Martin Garcia Orduna
Candace Shelton, M.S., CADAC
Frank Y. Wong, Ph.D.
Additional appreciation is extended to the
following constituency organizations that partici­
pated in the development of this document:
AIDS Action Boston
AIDS Project of Los Angeles
Gay and Lesbian Medical Association
Gay Men’s Health Crisis
Howard Brown Clinic
Human Rights Campaign
Lesbian and Gay Community Service
Center of New York City
National Association of Alcohol and
Drug Abuse Counselors
National Association of Lesbian and
Gay Addiction Professionals
National Association of People With
AIDS
Northwest AIDS Foundation, Seattle,
Washington
San Francisco AIDS Foundation
Whitman-Walker Clinic
Many Government agencies also participated
in the development and review of this
document. These agencies included:
Health Resources and Service
Administration, HIV/AIDS Bureau
Immediate Office of the Secretary, U.S.
Department of Health and Human
Services
National Institutes of Health,
National Institute on Drug Abuse
and National Institute on
Alcohol Abuse and Alcoholism
xi
Acknowledgments
xii
Substance Abuse and Mental Health
Services Administration,
Center for Substance Abuse
Treatment and Center for
Substance Abuse Prevention.
Appreciation is also extended to the many
field reviewers who provided valuable
comments:
E. Bernard Anderson, Jr., M.S., M.A.,
NCAC, ICADC, C.C.S.
Elizabeth Anello
Sandi Armstrong, LCSW
Rodger Beatty, Ph.D., L.S.W.
Anthony R. D’Augelli, Ph.D.
Michele (Mickey) Eliason, Ph.D.
Norma Finkelstein, Ph.D.
Sharon L. Gottovi, M.A., L.P.C., LMFT,
CSAS
Tonda L. Hughes, Ph.D., R.N.
Jerry Jenkins, M.A.C., NCAC II
Michael W. Kirby, Jr., Ph.D.
Katherine M. Kranz, LICSW, LCDP
Wayne T. Lang, M.D.
Theresa Lemus, R.N., LADC
Cameron Lewis
Emilia Lombardi
Kevin McGirr, R.N., M.S., M.P.H.
Kathryn Miller, Ph.D.
Greg Millett, M.P.H.
William R. Olcott
Barbara Ann Perina, CASAC, NCAC I
Mel Pohl, M.D.
Ben Price, C.S.W., C.P.S.
David W. Purcell, J.D., Ph.D.
Steve Riedel, M.S.Ed., C.D.C. III
Karen Glass Sarraga, M.S.W., C.S.W.
Peg Shea
Steven Shoptaw, Ph.D.
Ruth Slaughter
Thurston Smith, NCAC I
Ken South, M.Div.
Jacque Stock
Susan B. Sulzman, C.S.W, M.A.C.,
CASAC
Mary Ellen Tinsley
Mike Wagner, M.A.C.
Executive Summary
This publication presents information to
assist providers in improving substance abuse
treatment for lesbian, gay, bisexual, and
transgender (LGBT) clients by raising aware­
ness about the issues unique to LGBT clients.
Sensitizing providers to these unique issues
will, it is hoped, result in more effective
treatment and improved treatment outcomes.
Effective treatment with any population
should be sensitive and culturally competent.
Substance abuse treatment providers,
counselors, therapists, administrators, and
facility directors can be more effective in treat­
ing LGBT clients when they have a better
understanding of the issues LGBT clients face.
With this knowledge, treatment providers can
reexamine their treatment approaches and take
steps to accommodate LGBT clients.
Substance Abuse in the LGBT Community
Precise incidence and prevalence rates of
substance use and abuse by LGBT individuals
are difficult to determine for several reasons:
• Reliable information on the size of the LGBT
population is not available.
• Epidemiologic studies on alcohol and drug
abuse rarely ask about sexual orientation.
• Research studies cannot be compared
because of inconsistent methodologies.
Studies indicate that, when compared with the
general population, 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. Some
studies have found that approximately 30
percent of all lesbians have an alcohol abuse
problem (Saghir et al., 1970; Fifield,
DeCrescenzo & Latham, 1975; Lewis,
Saghir & Robins, 1982; Morales & Graves,
1983). Studies that compared gay men and
lesbians with heterosexuals have found that
20 to 25 percent of the gay men and lesbians
are heavy alcohol users (compared with 3 to
10 percent of the heterosexuals studied) (Stall
& Wiley, 1988; McKirnan & Peterson, 1989;
Bloomfield, 1993; Skinner, 1994; Skinner
& Otis, 1994; Hughes & Wilsnack, 1997).
Marijuana and cocaine use has been found
higher among lesbians than among heterosex­
ual women (McKirnan & Peterson, 1989).
Although LGBT persons use and abuse alcohol
and all types of drugs, certain drugs seem to
be more popular in the LGBT community than
in the majority community. Studies have found
that gay men and men who have sex with men
(MSM) are significantly more likely to have
used marijuana, psychedelics, hallucinogens,
stimulants, sedatives, cocaine, barbiturates,
and MDMA (methylenedioxymethamphet­
amine) and are much more likely to have used
“poppers” (Woody et al., 1999; Stall & Wiley,
1988). Party drugs, such as MDMA (also
known as ecstasy or X-T-C), “Special K” or
ketamine, and GHB (gamma hydroxybutyrate),
are increasing in popularity among some seg­
ments of the LGBT population. Party drugs are
often used during circuit parties and raves, and
they can impair judgment and result in risky
sexual behavior (Ostrow et al., 1993). Abuse
of methamphetamine has increased dramati­
cally in recent years (Drug Abuse Warning
Network, 1998; Derlet & Heischober, 1990;
Morgan et al., 1993; National Institute on Drug
Abuse, 1994; Gorman, Morgan & Lambert,
1995; CSAT [Center for Substance Abuse
Treatment], 1997b) among some segments
of the LGBT community. HIV and hepatitis C
infections are linked with methamphetamine
use (CDC [Centers for Disease Control and
xiii
Executive Summary
Prevention], 1995) and can lead to significant
dependence and addiction. Some LGBT meth­
amphetamine users inject the drug,
putting them at risk for HIV, hepatitis B,
and hepatitis C.
Sexual Orientation and Gender Identity
Understanding the appropriate terminology
is essential to understanding LGBT clients.
Sexual orientation, sexual behavior, gender
identity, and gender role are different concepts.
Sexual orientation is the affectional or loving
attraction to another person. Heterosexuality
is the attraction to persons of the opposite
sex; homosexuality, to persons of the same
sex; and bisexuality, to both sexes. Sexual ori­
entation can be considered as ranging along
a continuum from same-sex attraction only
at one end of the continuum to opposite-sex
attraction only at the other end. Sexual
behavior, or sexual activity, differs from sexual
orientation and alone does not define someone
as an LGBT individual. Sexual identity is the
personal and unique way that a person
perceives his or her own sexual desires and
sexual expressions.
Biological sex is the biological distinction
between men and women. Gender is the
concept of maleness and masculinity or
femaleness and femininity. Gender identity is
the sense of self as male or female and does
not refer to one’s sexual orientation or gender
role. Gender role describes the behaviors that
are viewed as masculine or feminine by a
particular culture. Transgender individuals are
those who conform to the gender role expec­
tations of the opposite sex or those who may
clearly identify their gender as the opposite of
their biological sex. In common usage,
transgender usually refers to people in the
transsexual group that may include people who
are contemplating or preparing for sexual
reassignment. A transgender person may be
sexually attracted to males, females, or both.
xiv
Sexual orientation and gender identity are
independent variables in an individual’s
definition of himself or herself. How an
individual learns to acknowledge, accept, and
then act on a sexual orientation that is different
from that of the majority is shaped by cultural,
religious, societal, and familial factors.
Transgender clients face a somewhat similar
challenge in coming to terms with a gender
identity that differs from their biological gender.
An LGBT individual differs in the effect of
sexual orientation on self-definition and in the
degree of affiliation with other LGBT persons.
LGBT people and homosexual behavior are
found in almost all cultures and throughout
history. Homosexuality was considered a
mental illness until 1973 when the American
Psychiatric Association dropped the classifica­
tion of homosexuality as a mental illness. It is
now considered a normal variation of human
sexual and emotional expression, allowing, it
is hoped, a nonpathological and nonprejudicial
view of the LGBT community.
Homophobia and Heterosexism
Having a general understanding of heterosex­
ism and homophobia is important for substance
abuse treatment providers working with LGBT
individuals. Heterosexism and homophobia
describe the forms of bigotry against LGBT
people. Heterosexism resembles racism or
sexism and denies, ignores, denigrates, or
stigmatizes nonheterosexual forms of
emotional and affectional expression, sexual
behavior, or community. Homophobia is
defined as the irrational fear of, aversion to,
or discrimination against LGBT behavior or
persons. Internalized homophobia describes
the self-loathing or resistance to accepting an
LGBT sexual orientation and is an important
concept in understanding LGBT clients.
It is likely that all substance abuse treatment
programs have LGBT clients, but staff
members may not realize that they are treating
How Heterosexism Contributes to
Substance Abuse
Heterosexism can affect LGBT people by
causing internalized homophobia, shame, and
a negative self-concept (Neisen, 1990, 1993).
Some LGBT individuals may resort to sub­
stance abuse to cope with the negative feelings.
Counselors and clients should recognize that
these effects result from prejudice and discrimi­
nation and are not a consequence of one’s
sexuality. It is not surprising to find that many
LGBT individuals in therapy report feeling iso­
lated, fearful, depressed, anxious, and angry
and have difficulty trusting others. It is argued
that the stigma and resulting tension of being a
member of a marginalized community such as
the LGBT community cause some members of
the marginalized community to manage these
additional stressors by using mind-altering
substances. Substance use, especially alcohol
use, is a large part of the social life of some
segments of the LGBT community.
women report same-gender sexual behavior
since puberty; 8 percent of men and 7.5 per­
cent of women report same-gender desire;
and 3 percent of men and 1 percent of women
report a homosexual or bisexual identity. The
data on the number of transgender people are
more limited. In addition to understanding a
client’s ethnic background, counselors should
keep in mind how the client’s culture views
LGBT individuals and the effect this viewpoint
has on the client. Each ethnic minority group
has norms and values about LGBT members
and behavior. Providers may be helpful to a
client if they remember these multilayered, and
sometimes opposing, influences on the client.
For the LGBT person from an ethnic or racial
minority, coping with one’s sexual orientation
takes place amid a tangle of cultural traditions,
values, and norms. LGBT persons of color
cope with trying to fit into the gay and lesbian
communities in the face of racism and
discrimination. For some, the added burden
of these issues makes finding a comfortable
place in society even more complex and diffi­
cult. Major ethnic minority groups in the United
States react differently to issues of sexual
orientation. It is important for the provider to
assess how an LGBT client from a minority
group feels about his or her culture. Some
may be alienated from their culture, whereas
others may be supported by it.
Executive Summary
LGBT clients. Most treatment programs do not
ask about sexual orientation, and many LGBT
people are afraid to speak openly about their
sexual orientation or identity. LGBT clients
cannot anticipate the reaction they will receive
when mentioning their sexual orientation.
Cultural Issues
Legal Issues
Culturally sensitive treatment often results in
more effective treatment. A lively debate in the
LGBT community continues about what com­
prises LGBT culture. LGBT people are from
all cultural backgrounds, ethnicities, and racial
groups; can be any age; can have attained any
educational or income level; and live in all
geographic areas in the United States.
The size of the LGBT community is not known.
Reliable data are difficult to obtain. Michaels
(1996) thoroughly analyzed the limited
available data and estimated that, in the United
States, 10 percent of men and 5 percent of
Although Federal and a number of State stat­
utes protect recovering substance abusers
from many forms of discrimination, LGBT
individuals are not afforded the same
protections in many areas of the country.
Disclosure of one’s sexual orientation can lead
to employment problems or the denial of hous­
ing and social services. LGBT individuals may
lose custody of their children if their sexual
orientation becomes known during a custody
dispute. Even in those States that have
enacted statutes prohibiting discrimination on
the basis of sexual orientation, LGBT
xv
Executive Summary
individuals have sometimes been denied
protection. LGBT individuals regard protecting
information about their sexual orientation and
substance abuse histories as critically
important. Programs that treat this population
must be particularly sensitive about
maintaining clients’ confidentiality, because the
consequences of an inappropriate disclosure
can be devastating. Programs can safeguard
information about clients’ substance abuse
histories and sexual orientation status by:
identity, he or she may be harboring the effects
of society’s negative attitudes, which can result
in feelings of doubt, confusion, fear, and sor­
row (Diamond-Friedman, 1990). The client may
have had problems in traditional health care
systems and may distrust health care
professionals, requiring extra sensitivity
from substance abuse treatment providers
(Mongeon & Ziebold, 1982).
• Respecting clients’ confidentiality and
establishing a written policy that ensures that
information about their sexual orientation is
confidential and that prohibits disclosure of
such information to anyone outside the
program without their consent
Due to homophobia and discrimination against
LGBT individuals, some may find it difficult or
uncomfortable to access treatment services.
Substance abuse treatment programs are often
not equipped to meet the needs of this
population. Heterosexual treatment staff
members may be uninformed about LGBT
issues, may be insensitive to or antagonistic
toward LGBT clients, or may falsely believe
that sexual identity causes substance abuse or
can be changed by therapy. These beliefs by
providers become barriers to treating the LGBT
client.
• Cautioning clients to think carefully about
how self-disclosure information will be
received and whether their privacy will be
respected before disclosing their sexual
orientation to others
• Educating staff members and clients about
regulations affecting LGBT persons in their
jurisdiction
• Encouraging clients to conduct a legal
inventory of their employment, marital, and
parental statuses and assess what steps
they might take to protect themselves and
their rights.
Treatment Accessibility, Modalities, and the
Continuum of Care
Substance abuse treatment for an LGBT
individual is the same as that for other types of
clients and primarily focuses on stopping the
substance abuse that interferes with the
well-being of the client. It differs in the need for
the client and counselor to address the client’s
feeling about his or her sexual identity and the
impact of homophobia and heterosexism. Even
if the LGBT client is candid about his or her
xvi
Accessibility
Modalities
Some issues arise when treating LGBT clients
using typical treatment modalities for groups,
couples, or families. Groups should be as inclu­
sive as possible and should encourage each
member to discuss relevant treatment issues
or concerns. Other clients in therapy may have
negative attitudes toward LGBT clients. Staff
members should ensure that LGBT clients are
treated in a therapeutic manner and should tell
other clients that homophobia will not be toler­
ated. It should be the LGBT client who decides
whether to discuss issues relating to his or her
sexual orientation in mixed groups. Providing
individual services eliminates the mixing of
heterosexual and LGBT clients in treatment
groups and decreases the likelihood that
heterosexism/homophobia will become an
issue. However, in a mixed group led by
trained and culturally competent staff members,
his or her efforts to maintain recovery. LGBT
clients may live in an environment that is not
conducive to recovery (e.g., they have a part­
ner or roommate who is actively using or their
social life revolves around bars and parties).
Levels of Care
The term “coming out” refers to the
experiences of some, but not all, gay men and
lesbians as they explore their sexual identity.
There is no correct process or single way to
come out, and some LGBT persons do not
come out. The process is unique for each
individual, and it is the choice of the individual.
Several stages have been identified in the pro­
cess: identity confusion, comparison,
tolerance, acceptance, pride, and identity
synthesis (Cass, 1979).
LGBT substance abusers should be assessed
to determine the range of services and levels
of care they require. Knowledge of the type
and amount of a drug used by a client, the
danger of a medically complicated withdrawal,
the difficulty of withdrawal, and the impact of
social and psychological stressors helps a
counselor determine the level of care a client
needs. Whatever the planned treatment, the
level of care should match the client’s needs.
Continuum of Care
The continuum of care refers to services
provided in addition to program services and
services received after discharge such as
followup and monitoring activities, outreach,
recruitment, and retention. The types of ser­
vices offered for LGBT clients may differ
because of the health status of the clients or
their partners; their living arrangements; the
type and stability of their employment; their
level of comfort about their sexual orientation;
and their previous experience with service pro­
viders and service systems.
Discharge Planning
Specific concerns related to discharge plan­
ning include an analysis of the client’s social
support, living arrangements or environments,
employment status, type of employment, and
ongoing issues related to his or her sexual
orientation or identity. Possible support sys­
tems include the client’s family of origin and
family of choice, partner, friends, and others
and should focus on individuals who support
The Coming Out Process
Executive Summary
LGBT clients may have a powerful healing
experience by gaining acceptance and support
from non-LGBT peers. Family and
couple counseling can be difficult because of
alienation owing to the client’s sexual identity.
Often, LGBT couples are not treated with sen­
sitivity, and support is not offered to partners.
When developing a plan and treating LGBT
clients, providers should consider which stage
the client is in. To be most helpful, counsel­
ors need to recognize a client’s comfort level
with his or her feelings about his or her sexual
identity and treat the client accordingly. A
client who is uncomfortable with his or her
sexual identity may not want to attend LGBT
Alcoholics Anonymous (AA) meetings or
discuss feelings about sexual orientation.
However, these meetings could be helpful for a
client who is more comfortable with his or her
sexual identity. A provider may do harm if he or
she forces openness by questioning a client’s
sexuality before the client is ready. As with
many decisions, a provider can best serve his
or her clients by assuming little and gauging
the best form of care for reducing the client’s
fears and anxiety.
Families of Origin and Families of Choice
Providing support for LGBT clients and their
families is a significant element of substance
abuse treatment. Like other clients, LGBT
individuals in treatment are involved in
multidimensional situations and come from
xvii
Executive Summary
diverse family backgrounds. A family history
and a review of the dynamics of the family of
origin are part of a thorough biopsychosocial
assessment. Questions should be asked with
sensitivity. An LGBT client may have
unresolved issues with his or her family of
origin stemming from the family’s reaction to
the disclosure of his or her sexual identity. A
negative and intolerant reaction can have a
devastating effect on the LGBT individual.
Family dynamics are important in working
with LGBT individuals, and counselors can
put their understanding of these dynamics
to work in counseling LGBT clients and their
families. An LGBT client may have close
connections to what is called a family of
choice—a legal spouse or unrelated individu­
als who support and care about the client.
A support group that works with families of
origin is known as PFLAG (Parents, Families
and Friends of Lesbians and Gays).
Substance abuse counselors need an
understanding of the dynamics of LGBT
interpersonal relationships. This understand­
ing includes awareness of the internal and
external problems of same-sex couples and
the diversity and variety of relationships in
the LGBT community. Although many
individuals have a life partner, others are
single or in nontraditional arrangements.
Providers need to be aware of their own
biases when working with individuals who
find themselves outside the cultural norm of
a heterosexual, monogamous, and legally
sanctioned marriage.
Many LGBT individuals are parents and have
children from a heterosexual marriage, have
adopted children, or have children through
some other means. Substance abuse treat­
ment providers should expect to work with
increasingly more LGBT clients who are
parents, either as part of a couple or as single
parents, and should consider parenting issues
during treatment and discharge planning.
xviii
Clinical Issues
Lesbians, gay men, bisexuals, and
transgender individuals have unique
difficulties. Unless counselors carefully
explore each client’s individual situation
and experiences, they may miss important
aspects of the client’s life, which may affect
recovery. Many factors contribute to the
prominent role of substance use and abuse
in LGBT people. Legal prohibitions against
LGBT behavior and discrimination have lim­
ited LGBT people’s social outlets to bars,
private homes, or clubs where alcohol and
drugs often play a prominent role. Growing
up in a society that says they should not exist
and certainly should not act on their sexual
feelings, LGBT clients may have internal­
ized this homophobia. Relapse prevention
requires an understanding of the social life
many gay men will return to after discharge
from treatment, whether as part of the singles
circuit party group or as part of a same-sex
couple raising children. For lesbians, the
party scene is generally not as intense.
LGBT people may be victims of antigay
violence and hate crimes such as verbal
and physical attacks. Some victims may turn
to alcohol or drug use. It is important that
substance abuse counselors obtain training
and education about interpersonal violence
and stigmatized client populations.
Clinical Issues With Lesbian Clients
Lesbians resemble other women in that their
patterns of substance use vary. However,
fewer lesbians than heterosexual women
abstain from alcohol; rates of reported alco­
hol problems are higher for lesbians than for
heterosexual women; and drinking, heavy
drinking, and problem drinking show less
decline with age among lesbians than among
heterosexual women (Hughes & Wilsnack,
1997). Risk factors for abusing alcohol
include relying on women’s bars for socializing
Clinical Issues With Gay Male Clients
In spite of growing acceptance of gay people,
social outlets for gay men still tend to be
limited. The “gay ghetto,” the section of town
where gay people feel comfortable, usually is
identified by the presence of gay bars. The
number of gay coffee shops, bookstores, and
activities that do not involve alcohol and drug
use is increasing, but gay bars and parties that
focus on alcohol and drug use are still very
visible elements of gay social life.
HIV/AIDS continues to be a major factor in
gay male life. The percentage of HIV-infected
people in the United States who are gay has
steadily dropped. But many gay men in
treatment may be HIV seropositive, have AIDS,
or have a sense of loss from losing friends.
For some gay men, sex and intimacy may be
disconnected. Substance use allows them
to act on suppressed or denied feelings but
makes it harder to integrate intimacy and sex.
In general, the stereotypical American male
can be described as powerful, independent,
emotionally reserved, and career motivated.
Males who do not fit this stereotype may have
trouble fitting in or feel uncomfortable. Many
gay men do, however, grow up different from
their heterosexual peers, and some have traits
more commonly associated with females.
Being effeminate is sometimes condemned in
the gay community, and this characteristic adds
to gay men’s shame.
Clinical Issues With Bisexual Clients
Bisexual identity is not necessarily defined
by sexual behavior. An assessment of a
self-identified bisexual client includes sexual
behavior and identity issues and the range
of psychosocial issues that may complicate
substance abuse treatment. The current
conceptualization of bisexuality is that it is a
sexual orientation. Providers may have biases
about bisexuals, believing that they are psy­
chologically or emotionally damaged, are
developmentally immature, or have a
borderline personality disorder, with changing
sexual behavior manifesting as a symptom of
poor impulse control or acting-out behavior.
Bisexuals may feel alienated not just from the
heterosexual majority but also from the lesbian
and gay community. Internalized biphobia may
result in a struggle toward self-acceptance.
Executive Summary
and peer support; the negative effects of
sexism and heterosexism; additional stressors
related to coming out or “passing” as
heterosexual; and the effects of trauma from
violence or abuse. The traumas experienced
by some lesbians may affect their behavior and
emotional state. One study reported that 21
percent of lesbians were sexually abused as
children and 15 percent were abused as adults
(Bradford, Ryan & Rothblum, 1994).
Clinical Issues With Transgender Clients
The psychiatric model views transsexualism
as psychopathological and classifies it as a
gender identity disorder. Many in the transgen­
der community disagree with this classification.
The little research available about the
prevalence of substance abuse in the
transgender community suggests extremely
high rates. Substance abuse among transgender people can involve multiple patterns of
abuse and multiple problems; treatment must
be multimodal to correspond to a client’s
particular pattern of abuse (Lewis, Dana &
Gregory, 1994).
Issues in substance abuse treatment
for transgender clients include societal
and internalized transphobia, violence,
discrimination, family problems, isolation, lack
of educational and job opportunities, lack of
access to health care, and clients’ low selfesteem. Many transgender people have had
negative experiences with providers of health
care, and they may be distrustful of providers.
xix
Executive Summary
Hormone therapy is an often overlooked
clinical issue. Hormone treatment is a standard
medical practice for transsexuals, and clients
may need assistance in maintaining regular,
legally prescribed hormone therapy while in
treatment for substance abuse. It is important
that both the clinician and the client under­
stand that hormone therapies can affect mood,
especially when taken improperly. Transgender
clients may face an additional risk from using
“street” or “black market” hormones. Because
testosterone must be injected, obtaining or
using needles may be relapse triggers for cli­
ents in early recovery.
Transgender clients may face issues with
inpatient treatment and placement in housing
and shelters. Logistics such as rest room use
and sleeping arrangements need to be sen­
sitive to both transgender clients and other
clients. Evidence suggests that transgender
individuals have a higher rate of exposure to
violence and discrimination than lesbians and
gay men, and such experiences can influence
a transgender client’s ability to complete and
maintain successful recovery from substance
abuse. Some transgender clients have been
prostitutes or sex workers, resulting in clinical
issues that can also block recovery if they are
not adequately addressed.
Cases involving transgender individuals
illustrate the need for staff to ask open-ended
questions regarding gender and sexual
orientation. In this way, those who are or are
perceived to be transgender persons are given
the opportunity to disclose this at their own
comfort level. These types of questions also
allow those whose transgender status is invis­
ible to disclose their status to the counselor if
they sense that he or she might have an
understanding of transgender issues.
xx
Clinical Issues With Youth
The available research on LGBT youth has
focused on lesbian and gay male adolescents;
little information is available on bisexual identity
development or transgender youth. Some
studies of gay youth show high rates of alcohol
and drug use (Remafedi, 1987; RothermanBorus, Hunter & Rosario, 1994), whereas other
studies show rates that are comparable with
those of adolescents in general (Boxer, 1990;
Bradford & Ryan, 1987; Herdt & Boxer, 1993).
LGBT youth use alcohol and drugs for many of
the same reasons as their heterosexual peers:
to experiment and assert their independence,
to relieve tension, to increase feelings of selfesteem and adequacy, and to self-medicate for
underlying depression or other mood disorders.
LGBT youth, however, may be more vulnerable
as a result of the need to hide their sexual
identity and the ensuing social isolation. As a
result, they may use alcohol and drugs to deal
with stigma and shame, to deny feelings for
persons of the same sex, or to help them cope
with ridicule or antigay violence. LGBT youth
have the same developmental tasks as their
heterosexual peers, but they also face addition­
al challenges in sorting out their sexual identity.
The age at which identity development and
coming out occurs is decreasing, with most
adolescents’ initial awareness of feelings for
someone of the same sex occurring at age 10;
first experiences with someone of the same
sex at ages 13 to 15; and initial selfidentification as lesbian or gay at ages 15
to 16 (D’Augelli & Herschberger, 1993; Herdt &
Boxer, 1993; Rosario et al., 1996). Adolescents
may not have developed the coping strategies
that LGBT adults have to contend with the
added stressors (Hunter & Mallon, 1999).
LGBT youth are at high risk for antigay vio­
lence such as physical attacks, verbal and
physical abuse, and harassment (D’Augelli &
Dark, 1995; Dean, Wu & Martin, 1992).
Youth of color and those who are openly or
stereotypically gay are more likely to be
LGBT clients overcome discomfort in seeking
health care when in recovery.
Related Health Issues
Gay and bisexual men who are sexually active
with multiple partners are at risk for contracting
STDs, HIV/AIDS, and hepatitis A and hepatitis B
through sexual contact. Hepatitis C also may be
spread by sexual contact, although transmission
via infected needles is probably a far more
significant route and is of concern to all injection
drug users. All clients should be screened for
hepatitis B and hepatitis C and referred for
hepatitis A and hepatitis B vaccinations.
An LGBT client may face a variety of additional
health problems when entering treatment. LGBT
clients in recovery have similar health concerns
and face many of the same physical and mental
health crises as other clients in recovery.
Many people who abuse substances have
co-occurring mental health disorders, such as
affective disorders, eating disorders, or other
psychiatric illnesses. Substance abuse clouds
good judgment and contributes to dangerous
behaviors that can lead to illness, such as
HIV/AIDS, sexually transmitted diseases
(STDs), hepatitis, and injuries. People who
abuse substances may have neglected their
health, and some may have been the victims
of domestic violence or hate crimes resulting in
posttraumatic stress disorder. When consider­
ing these factors, providers of substance abuse
treatment for LGBT clients should, as with any
client, screen for other health problems—for
possible co-occurring mental health disorders,
poor nutrition, poor dental care, liver disease,
STDs, HIV/AIDS, and sexual abuse. In this
way, substance abuse treatment providers can
assist their LGBT clients in accessing appropri­
ate medical care and treatment for their health
and mental health concerns.
LGBT individuals have been marginalized by
some health professionals, who historically
labeled an LGBT sexual orientation deviant or
pathological. As a result, LGBT individuals may
not disclose their sexual orientation to health
care providers (Cochran & Mays, 1988), and
many LGBT individuals, particularly transgen­
der individuals, may be reluctant to use main­
stream health care services. Their hesitation to
seek health care may result in late diagnosis
and poor treatment outcomes. The substance
abuse treatment provider may need to help
Executive Summary
victimized, and anecdotal reports suggest that
transgender youth may be at the greatest risk.
Knowledge about health concerns unique
to lesbian and bisexual women is limited.
Alcoholic women have more fatty liver disease,
alcoholic hepatitis, cirrhosis, and osteoporosis
than nonalcoholic women (Woolf, 1983). Many
lesbians have had heterosexual contacts
and are at risk for both pregnancy and STDs
(O’Hanlan, 1995). Lesbian and bisexual
women who use injectable drugs are at high
risk for hepatitis B, hepatitis C, and HIV/AIDS
and should be screened for these diseases.
Some lesbian and bisexual women are sex
workers and have been exposed to STDs, HIV,
and trauma. Transgender individuals have
many health concerns. One study showed a
35-percent HIV prevalence rate among
male-to-female (MTF) transgender individuals
and a 65-percent HIV prevalence rate among
African-American MTF transgender individuals.
Both MTF and FTM (female-to-male)
transgender individuals encounter risks related
to taking hormones.
Interpersonal Violence in the LGBT
Community
Little research has been done on the
relationship between substance abuse and
interpersonal violence in the LGBT community,
but it is estimated that interpersonal violence
occurs at the same rate in same-sex relation­
ships as in heterosexual relationships (Island &
xxi
Executive Summary
Letellier, 1991; Lobel, 1986). Rates of violence in
same-sex relationships range from 8 to 46
percent (Elliot, 1996). As with all their clients,
practitioners should assess their LGBT clients
for evidence of involvement in interpersonal vio­
lence and act appropriately.
Counselor Competence in Treating LGBT
Clients
LGBT clients can be found in all types of
treatment settings: residential, intensive
outpatient, outpatient, crisis intervention,
and the criminal justice system.
In the counseling competencies model, a
counselor should respect the client and his or
her frame of reference; recognize the impor­
tance of cooperation and collaboration with the
client; maintain professional objectivity;
recognize the need for flexibility and be willing
to adjust strategies in accordance with client
characteristics; appreciate the role and power
of a counselor as a group facilitator; appreciate
the appropriate use of content and process
therapeutic interventions; and be nonjudgmen­
tal and respectfully accepting of the client’s
cultural, behavioral, and value differences.
These best-practice methods are critical when
working with LGBT clients.
Administrative Issues
A substance abuse treatment program’s
commitment to promote sensitive care for
LGBT clients can be included in its mission
statement and administrative policies and
procedures. Providing staff training and
education on LGBT issues helps increase
awareness of the issues. A program’s policies
and procedures can address the inclusion of
LGBT issues in its advertising, community
relations, administrative and personnel policies,
training, and program design.
Adding LGBT issues to a quality improvement
program may be helpful as well. To furnish
quality treatment, providers should evaluate
their programs and collect appropriate
demographic data to establish baseline infor­
mation about LGBT clients. They should design
and implement appropriate client satisfaction
measures that provide specific feedback about
how well their organization is serving its LGBT
clients. Providers should develop better
LGBT-specific outcome data. The data should
include the numbers of clients served, overall
satisfaction results, and treatment outcomes
among identified LGBT clients as compared
with the general treatment population.
Training and Education
In the counseling competencies model, a
counselor is responsible for self-monitoring,
obtaining proper supervision, and adhering to
professional and ethical standards. Establish­
ing the proper ethos of care for LGBT clients
requires that counselors monitor themselves
and be aware of and work through their feel­
ings about LGBT clients. Counselors must be
aware of countertransference, the process of
counselors seeing themselves in their clients,
overidentifying with their clients, meeting their
personal needs through their clients, or react­
ing to a client because of their own unresolved
personal conflicts (Corey, 1991).
xxii
Training providers to sensitively serve LGBT
individuals may improve treatment outcomes.
Some options include sexual orientation sensi­
tivity training to promote better understanding
of LGBT issues, LGBT-specific training, and
educational programs to ensure that quality
care is provided. The comfort level, experience,
and competence of staff serving LGBT
individuals should be assessed before and
after training.
Conclusion
A substance abuse treatment program seeking
to improve care to LGBT individuals has many
allies throughout both the health care commu­
nity and the LGBT community. The program
administrator who effectively identifies and
works with his or her allies will have taken an
important step toward ensuring that his or her
program is successful. This cooperation will be
particularly important in building local support
to serve LGBT clients and to work effectively
with managed care organizations.
Because each client brings his or her unique
history and background into treatment,
furthering our understanding of individuals
different from ourselves helps ensure that
clients are treated with respect, while improving
the likelihood of effective substance abuse
treatment interventions. It is hoped that the
information in this publication helps providers
improve their ability to provide competent and
effective treatment. A substance abuse treat­
ment provider who is knowledgeable about the
unique needs of LGBT clients can enhance
treatment. A provider who understands and is
sensitive to the issues surrounding sexual and
gender identity, homophobia, and heterosexism
can help LGBT clients feel comfortable and
safe while they confront their substance abuse
and start their journey of recovery. It is hoped
that this volume will assist administrators and
clinicians in forming a better understanding of
LGBT people, their problems with substance
abuse, and the unique challenges they face
and that the knowledge providers gain from it
about designing programs for LGBT clients will
be used to create a more comfortable
treatment environment.
For managed care and other health care
provider networks to improve LGBT sensitivity,
their provider panels can include LGBT
providers and LGBT-sensitive providers. LGBT
programs may want to join provider networks
to ensure provision of culturally competent
services.
Executive Summary
Alliances and Networks
xxiii
SECTION I:
OVERVIEW
An Overview for Providers
Chapter 1 Treating LGBT Clients
Robert Paul Cabaj, M.D., San Mateo County Mental Health Services, San Mateo, CA
Michael Gorman, Ph.D., San Jose State University, San Jose, CA
William J. Pellicio, LICSW, LCDP, Addiction Technology Transfer Center of New England,
Brown University, Providence, RI
Dennis J. Ghindia, Ph.D., Rhode Island College School of Social Work, Providence, RI
Joseph H. Neisen, Ph.D., New Leaf Services for Our Community, San Francisco, CA
Introduction
What providers will learn
from this chapter:
• The epidemiology of
substance abuse among
the LGBT population
• The types of substances
abused
For substance abuse treatment providers to
deliver skilled care to lesbian, gay, bisexual,
and transgender (LGBT) clients, they need to
be aware of issues specific to the LGBT com­
munity. This chapter presents an overview
of the use and abuse of substances in the
LGBT community and a brief introduction
to the concepts of gender identity, sexual
orientation, homophobia, and heterosexism.
Substance Use and Abuse in the LGBT
Community
• Definitions of key terms
In a discussion of the epidemiology of
substance use and abuse among LGBT
individuals, the following two questions
are of interest to providers:
• Characteristics of LGBT
individuals
• What is the epidemiology of substance
use and abuse among LGBT individuals?
• How differences in LGBT
life experiences may
shape the substance
abuse issues
• Life cycle issues for LGBT
individuals
• Do LGBT individuals use or abuse more
substances than heterosexuals or the
general population?
Epidemiology is the study of the patterns of
disease and health problems in populations
and the factors that influence these patterns.
Prevalence refers to the number of people
in a given population who are affected by a
particular disease at a certain time; it is
frequently expressed in percentages.
Incidence refers to the number of new
1
An Overview for Providers Treating LGBT Clients
cases of a disease or condition, such as
alcoholism or drug abuse, in a given population
over a specified time (such as a year).
Rates of substance use and abuse vary from
population to population. The numerous
reasons for the varying rates include biological,
genetic, psychological, familial, religious,
cultural, and historical circumstances. The
LGBT population is similar to the general
population in that numerous factors predispose
its members to substance abuse. However,
some clinicians argue that the additional stigma
and resulting tension of being a member of a
marginalized community such as the LGBT
community cause some members of the
marginalized community to seek to manage
these additional stressors by using mindaltering substances.
The precise incidence and prevalence rates of
substance use and abuse by LGBT individuals
have been difficult to determine for several
reasons. Reliable information on the size of
the LGBT population is not available. Scientific
studies of LGBT individuals’ substance abuse
do not always clearly define the difference
between substance use and substance abuse,
making it difficult to compare studies. Many
studies have methodological flaws, such as the
use of convenience samples that only infer or
estimate substance abuse among the LGBT
population. However, several promising stud­
ies are under way that, it is hoped, will provide
additional information. The Substance Abuse
and Mental Health Services Administration’s
(SAMHSA’s) Center for Substance Abuse
Treatment (CSAT) will continue to report the
results of these studies as they are completed.
To provide background information for this
publication, the authors conducted a review of
the epidemiological literature, and 16 studies
were chosen to highlight the extent of
substance use or abuse problems in the LGBT
population. The table in appendix D, Studies
on LGBT Substance Abuse, presents a
2
comparison of the studies. Studies were
included if they focused on the LGBT
population and substance abuse but did not
focus primarily on the human immunodeficien­
cy virus (HIV). These studies are considered
classics and have been cited in numerous
articles about LGBT individuals’ substance
abuse. The summary is by no means
exhaustive; however, it provides the context
for exploring the issue and has implications for
future research.
Publication dates of articles about the selected
studies range from 1970 to 2000. Of the 16
studies, 10 focused primarily on substance
abuse in the lesbian population, 3 focused on
both lesbians and gay men, 1 focused
exclusively on gay men, 1 focused exclusively
on men who have sex with men (MSM), and
1 focused on transgender individuals. Eleven
of the studies used convenience samples, and
five used population-based data. Most of the
studies reported on alcohol use.
These studies generally state that gay men
and lesbians have greater substance abuse
problems than non-LGBT men and women. In
seven studies, comparisons between the LGBT
population and the heterosexual population
could not be made. Studies by Saghir and
colleagues (1970); Fifield, DeCrescenzo, and
Latham (1975); Lewis, Saghir, and Robins
(1982); and Morales and Graves (1983) found
that approximately 30 percent of all lesbians
have an alcohol abuse problem. Studies that
compared gay men or lesbians with hetero­
sexuals (Stall & Wiley, 1988; McKirnan &
Peterson, 1989; Bloomfield, 1993; Skinner,
1994; Skinner & Otis, 1996; Hughes &
Wilsnack, 1997) found that gay men and
lesbians were heavier substance and alcohol
users than the general or heterosexual popula­
tion. From these studies, it is clear that
substance abuse treatment is needed and
that providers need to know more about this
community to provide competent treatment.
Over the past several years, the concerns
about the epidemic of HIV-related conditions
have led to an increased number of studies of
both gay and bisexual men and injection drug
users. Although LGBT persons use and abuse
alcohol and all types of drugs, certain drugs
seem to be more popular in the LGBT
community than in the majority community.
Woody and colleagues (1999) compared a
convenience sample of MSM at high risk for
HIV who participated in a vaccine prepared­
ness study with a nationally representa­
tive sample of men from the 1995 National
Household Survey on Drug Abuse (NHSDA).
The study found that these MSM were 21 times
more likely to use nitrite inhalants. They were
also much more likely (four to seven times) to
use hallucinogens, stimulants, sedatives, and
tranquilizers than the men in the NHSDA
sample. The study also found that weekly use
by this MSM sample was 2 times more likely
for marijuana, cocaine, and stimulants and 33
times more likely for inhalant nitrites.
A study by Cochran and Mays (2000) found
that people with same-sex partners were more
likely to use substances than were people with
opposite-sex partners. Closer examination of
the data (Cochran et al., in press) comparing
MSM with heterosexual men and comparing
lesbians with heterosexual women showed little
difference between MSM and heterosexual
male substance abuse but showed that rates of
alcohol use were much higher for lesbians than
for heterosexual women. For example, lesbians
used alcohol twice as often in the past month,
were five times more likely to use alcohol every
day, were more than twice as likely to get
intoxicated, and were four times more likely
to get intoxicated weekly than heterosexual
women.
Another study of lesbians using self-reported
data stated that rates of alcohol use in the
lesbian population were higher than those in
the general population, but not as high as rates
in other studies, and that the most significant
predictor of alcohol use was reliance on bars
as a primary social setting (Heffernan, 1998).
Designer Drug Use
Abuse of methamphetamine, also known as
meth, speed, crystal, or crank, has increased
dramatically in recent years (Drug Abuse
Warning Network, 1998; Derlet & Heischober,
1990; Morgan et al., 1993; National Institute
on Drug Abuse, 1994; Gorman, Morgan &
Lambert, 1995; CSAT, 1997b), particularly
among gay men but also among male-to­
female (MTF) transgender individuals and,
increasingly, among some groups of lesbians.
What makes the current epidemic so discon­
certing is its relationship to the HIV epidemic
(Ostrow, 1996; Gorman et al., 1997).
Amphetamines and methamphetamine
currently are the most popular synthetic
stimulants in the United States, and abuse of
them can lead to significant dependence and
addiction. The drugs may be drunk, eaten,
smoked, injected, or absorbed rectally. They
have a half-life of approximately 24 hours.
They work by releasing neurotransmitters, and
users suffer the same addiction cycle and
withdrawal reactions as those suffered by crack
cocaine users. These substances increase the
heart rate, blood pressure, respiration rate, and
body temperature. They cause pupil dilation
and produce alertness, a sense of euphoria,
and increased energy. After prolonged use,
users often experience severe depression
and sometimes paranoia. They may also
become belligerent and aggressive.
An Overview for Providers Treating LGBT Clients
Types of Substances Abused
Methamphetamine use appears to be integral
to the sexual activities of a certain segment of
gay men, especially in some urban communi­
ties. The so-called party drugs, such as MDMA
(methylenedioxymethamphetamine) (also
known as ecstasy or X-T-C),“Special K” or
3
An Overview for Providers Treating LGBT Clients
4
ketamine, and GHB (gamma hydroxybutyrate),
are increasingly popular at dances and
celebrations, such as circuit parties and raves.
MDMA is a synthetic drug with hallucinogenic
and amphetamine-like properties. The effects
are reminiscent of lysergic acid diethylamide-25
(LSD). Ketamine, a white crystalline powder
that is soluble in water and alcohol, is a
dissociative anesthetic, a synthetic drug that
produces hallucinations, analgesia, and
amnesia and can cause euphoria. Users can
experience impaired thought processes,
confusion, dizziness, impaired motor
coordination, and slurred speech. Liquid X
(GHB) possesses euphoric properties, and
overdoses can cause electrolyte imbalances,
decreased respiration, confusion, and
hypertension, as well as seizure-like activity
and vomiting.
Party drugs can impair judgment and increase
sexual risk taking. Research has shown a
connection between use of nitrite and high-risk
sexual behavior (Ostrow et al., 1993), and
there is compelling evidence that HIV and
hepatitis C infections are linked with
methamphetamine use. Studies in several
cities indicate that gay and bisexual men who
used speed, alone or in combination with other
drugs, appear to have much higher seropreva­
lence rates than either heterosexual injection
drug users or gay and bisexual men who do
not use these drugs (Harris et al., 1993; Diaz
et al., 1994; Gorman, 1996; CDC [Centers for
Disease Control and Prevention], 1995; Hays,
Kegeles & Coates, 1990; Waldorf & Murphy,
1990; Paul, Stall & Davis, 1993; Paul et al.,
1994). This finding is particularly apparent for
individuals who inject these drugs and who
share needles or injecting equipment. Although
most LGBT meth users probably snort, ingest,
or smoke the drugs, a sizable number also
report histories of injection drug use. Within the
substance-abusing population in general, and
the LGBT population in particular, injection
drug users represent an often hidden and
stigmatized group. Public health efforts have
targeted mostly heterosexual injection drug
users of heroin. A number of injection drug
users inject methamphetamine, and a number
of these are LGBT individuals.
Information on the needle hygiene of
methamphetamine users or LGBT injection
drug users is lacking. Some HIV-positive
individuals appear to be self-medicating for
depression or specific HIV-related symptoms
by using methamphetamine because it reduces
lethargy, raises libido, and can be an
antidepressant. Mixing these drugs can be
dangerous, and some deaths have been
documented from using party drugs while
taking protease inhibitors.
Definition of Terms and Concepts Related
to LGBT Issues
Understanding how certain terms are used is
essential to understanding homosexuality. It is
important to recognize the difference between
sexual orientation and sexual behavior as well
as the differences among sexual orientation,
gender identity, and gender role.
Sexual orientation may be defined as the
erotic and affectional (or loving) attraction to
another person, including erotic fantasy, erotic
activity or behavior, and affectional needs.
Heterosexuality is the attraction to persons
of the opposite sex; homosexuality, to per­
sons of the same sex; and bisexuality, to
both sexes. Sexual orientation can be seen
as part of a continuum ranging from same-sex
attraction only (at one end of the continuum) to
opposite-sex attraction only (at the other end of
the continuum).
Sexual behavior, or sexual activity, differs
from sexual orientation and alone does not
define someone as an LGBT individual. Any
person may be capable of sexual behavior with
a person of the same or opposite sex, but an
individual knows his or her longings—erotic
It is necessary to draw a distinction between
sexual orientation and sexual behavior. Not
every person with a homosexual or bisexual
orientation, as indicated by his or her fantasies,
engages in homosexual behavior. Nor does
sexual behavior alone define orientation. A
personal awareness of having a sexual orienta­
tion that is not exclusively heterosexual is one
way a person identifies herself or himself as an
LGBT person. Or a person may have a sexual
identity that differs from his or her biological
sex—that is, a person may have been born a
male but identifies and feels more comfortable
as a female. Sexual orientation and gender
identity are two independent variables in an
individual’s definition of himself or herself.
Sexual identity is the personal and unique
way that a person perceives his or her own
sexual desires and sexual expressions.
Biological sex is the biological distinction
between men and women.
Gender is the concept of maleness and
masculinity or femaleness and femininity. One’s
gender identity is the sense of one’s self as
male or female and does not refer to one’s
sexual orientation or gender role. Gender role
refers to the behaviors and desires to act in
certain ways that are viewed as masculine or
feminine by a particular culture.
A culture usually labels behaviors as masculine
or feminine, but these behaviors are not
necessarily a direct component of gender or
gender identity. It is common in our culture to
call the behaviors, styles, or interests shown
by males that are usually associated with
women “effeminate” and to call the boys who
behave this way “sissies.” Women or girls who
have interests usually associated with men are
labeled “masculine” or “butch,” and the girls are
often called “tomboys.”
Transgender individuals are those who
conform to the gender role expectations of the
opposite sex or those who may clearly identify
their gender as the opposite of their biological
sex. In common usage, transgender usually
refers to people in the transsexual group that
may include people who are contemplating or
preparing for sexual reassignment surgery—
called preoperative—or who have undergone
sexual reassignment surgery—called
postoperative. A transgender person may be
sexually attracted to males, females, or both.
Transvestites cross dress, that is, wear
clothes usually worn by people of the opposite
biological sex. They do not, however, identify
themselves as having a gender identity
different from their biological sex or gender
role. The motivations for cross dressing vary,
but most transvestites enjoy cross dressing
and may experience sexual excitement from
it. The vast majority of transvestites are het­
erosexual, and they usually are not included in
general discussions about LGBT people.
Gender identity disorder (GID) was
introduced in the latest edition of the Diagnostic
and Statistical Manual of Mental Disorders
(DSM–IV) (American Psychiatric Association,
1994). Although GID is listed as a mental ill­
ness, most clinicians do not consider individu­
als who are confused or conflicted about their
biological gender and their personal sense
of their gender identity to be mentally ill.
Considerable work needs to be done to
augment the small amount of research
available on the development of a transgender
identity—that is, how a person becomes aware
of a sexual identity that does not match his or
her biological sex or gender role.
An Overview for Providers Treating LGBT Clients
and affectional—and which sex is more likely
to satisfy those needs.
Estimates of the Number of LGBT
Individuals
The true number of people who identify
themselves as LGBT individuals is not known.
Because of a lack of research focusing on the
5
An Overview for Providers Treating LGBT Clients
LGBT population and the mistrust that makes
many LGBT people afraid to be open about
their identity, reliable data are difficult to obtain.
The popular estimate that 10 percent of the
male population and 5 to 6 percent of the
female population are exclusively or predomi­
nately homosexual is based on the Kinsey
Institute data (Kinsey, Pomeron & Martin, 1948;
Kinsey et al., 1953) addressing sexual
behavior. Kinsey proposed the Kinsey Scale,
a continuum that rated sexual behavior on a
scale from zero to six. Zero represented
exclusive heterosexual behavior and six
represented exclusive homosexual behavior.
The survey reported that 37 percent of
American men had at least one homosexual
experience after adolescence; 5 to 7 percent
had bisexual experiences but preferred
homosexual ones; and 4 to 5 percent had
homosexual experiences exclusively.
These data illustrate how widespread male
homosexual behavior is, not necessarily the
number of gay men. The same research
indicated that the majority of those surveyed
reported behavior in a range Kinsey termed
bisexual. Again, the classification is based only
on reported behavior. For many minority popu­
lations, bisexuality—but not homosexuality—is
acceptable (or at least admittable on surveys).
For example, in the 1989 Centers for Disease
Control and Prevention 8-year review of
acquired immunodeficiency syndrome (AIDS)
cases among gay or bisexual men, 54.2 per­
cent of African Americans were reported to be
bisexual, 44.2 percent of Hispanics were
reported to be bisexual, and 11.3 percent of
Caucasians were reported to be bisexual.
Michaels (1996) thoroughly analyzed the
limited available data and concluded that
determining prevalence rates of sexual
orientations is extremely difficult because the
data are widely disparate. He estimates that in
the United States, 9.8 percent of men and 5
percent of women report same-gender sexual
behavior since puberty; 7.7 percent of men and
6
7.5 percent of women report same-gender
desire; and 2.8 percent of men and 1.4 percent
of women report a homosexual or bisexual
identity.
The data on the number of transgender people
are even more limited. Some psychiatric
literature estimates that 1 percent of the
population may have had a transgender
experience, but this estimate is based only
on transgender people who might have sought
mental health services (Seil, 1996).
Homophobia and Heterosexism
Having a general understanding of
heterosexism, homophobia, and antigay bias
is important for substance abuse treatment
providers working with LGBT individuals. Alport
(1952) defined prejudice as a negative attitude
based on error and overgeneralization and
identified the three interdependent states of
acting out prejudice as verbal attacks, discrimi­
nation, and violence. Verbal attacks can range
from denigratory language to pseudoscientific
theories and findings, which serve as a founda­
tion for discrimination and violence. Following
this theory, prejudice and discrimination against
LGBT individuals is formed, in part, by
misinformation such as the following:
• All gay men are effeminate, and all lesbians
are masculine.
• LGBT persons are child molesters.
• LGBT individuals are unsuitable for
professional responsibilities and positions.
• LGBT persons cannot have fulfilling
relationships.
• LGBT persons are mentally ill.
Once negative generalizations are formed
about a group of people, some members of
the majority group feel that they can treat the
Vermont) as seen in the passage of Federal
and State laws against same-gender
marriages
Heterosexism and homophobia are used to
describe the prejudice against LGBT people.
Heterosexism is a prejudice similar to racism
and sexism. It denies, ignores, denigrates, or
stigmatizes any nonheterosexual form of
emotional and affectional expression, sexual
activity, behavior, relationship, or socially
identified community. Heterosexism exists in
everyone—LGBT individuals as well as
heterosexuals—because almost everyone is
brought up in a predominately heterosexual
society that has little or no positive recognition
of homosexuality or bisexuality. Heterosexism
supports the mistaken belief that gay men—
because they are attracted to men—are in
some way like women, and lesbians, in turn,
are in some way like men.
• The enforcement of outdated sodomy laws
that are applied to LGBT individuals but not
applied to heterosexual individuals.
Homophobia, although a popular term, lacks
precise meaning. Coined in 1972 to describe
fear and loathing of gay men and lesbians, it
also has been used by gay men, lesbians, and
bisexuals to describe self-loathing, fear, or
resistance to accepting and expressing sexual
orientation (Weinberg, 1983). Antigay bias is
another phrase to describe the first concept,
and internalized homophobia is another
phrase for the latter. Internalized homophobia
is a key concept in understanding issues facing
gay men, lesbians, and bisexuals in substance
abuse treatment.
Examples of heterosexism in the United States
include the following:
• The widespread lack of legal protection for
individuals in employment and housing
• The continuing ban on lesbian and gay
military personnel
• The hostility and lack of support for lesbian
and gay committed relationships (except in
Examples of heterosexism in the substance
abuse treatment setting are as follows:
• Gay-bashing conversations
• Cynical remarks and jokes regarding gay
sexual behaviors
• Jokes about openly LGBT staff members
• Lack of openly LGBT personnel
• Lack of inclusion of LGBT individuals’ family
members or significant others in treatment
processes.
Substance abuse treatment providers should
remember that LGBT clients do not know the
reaction they will receive when mentioning their
sexual orientation. For example, public opinion
measures indicate that homosexuality is not
widely accepted. In 1996, Gallup Poll data
showed 50 percent of respondents reported
that homosexuality was unacceptable and only
45 percent found homosexuality an acceptable
lifestyle. In addition, Herek (1989) found that as
many as 92 percent of lesbians and gay men
reported that they have been the target of
threats, and as many as 24 percent reported
physical attacks because of their sexual
orientation.
An Overview for Providers Treating LGBT Clients
other group differently. As the acceptance of
negative stereotypes spreads, discrimination
and violence can result.
It is likely that all substance abuse treatment
programs have LGBT clients, but staff
members may not be aware that they are treat­
ing LGBT clients. Most treatment programs do
not ask about sexual orientation, and many
LGBT people are afraid to speak openly about
their sexual orientation or identity. Treatment
7
An Overview for Providers Treating LGBT Clients
programs also may not realize that they have
LGBT staff members, who can be a great
resource for treating LGBT clients.
How Heterosexism Contributes to
Substance Abuse
When treating LGBT clients, it is helpful for
providers to understand the effect of heterosex­
ism on their LGBT clients. The role of
heterosexism in the etiology of substance
abuse is unclear. Heterosexism instills shame
in LGBT individuals, causing them to
internalize the homophobia that is directed
toward them by society (Neisen, 1990, 1993).
Some LGBT individuals may use intoxicants to
cope with shame and other negative feelings.
Some LGBT individuals learn to devalue
themselves and value only heterosexual
persons instead. The negative effects of
heterosexism include the following:
• Self-blame for the victimization one has
suffered
• A negative self-concept as a result of nega­
tive messages about homosexuality
• Anger directed inward resulting in destructive
patterns such as substance abuse
• A victim mentality or feelings of inadequacy,
hopelessness, and despair that interfere with
leading a fulfilling life
• Self-victimization that may hinder emotional
growth and development.
Recognizing that heterosexism is a type of
victimization helps the counselor and client
draw a parallel with recovery from other types
of victimization, whether they are culturally or
individually based. It is crucial that counselors
and clients recognize that these effects result
from prejudice and discrimination and are not
a consequence of one’s sexuality. It is not
surprising to find that many LGBT individuals
8
in therapy report feeling isolated, fearful,
depressed, anxious, and angry and have
difficulty trusting others. Meyer (1993) reports
that the victimization of gay males in our
society results in mental health consequences
for individuals. A skilled substance abuse
treatment counselor should be attentive to the
negative effects that prejudice produces when
working with LGBT clients.
Perspectives on Homosexuality
Homosexuality, as a specific category, was
not described in the medical or psychiatric
literature until the early 1870s. The fledgling
psychoanalytic movement regarded homosexu­
ality as a topic of special interest. Sigmund
Freud believed a person’s sexual orientation,
in and of itself, did not impair his or her judg­
ment or cause problems, and Freud set a
positive tone when he supported homosexual
colleagues in medical and psychiatric societies.
Even so, European psychoanalytic
organizations did not welcome gay men and
lesbians as members in the early years of
psychiatry, and many American psychiatrists
and psychoanalysts promoted the attitude that
homosexuality was a mental disorder.
Bieber and colleagues (1962) proposed that
childhood influences and family upbringing
were responsible for producing male
homosexuality and described the classic
combination of a distant, uninvolved father and
an overinvolved mother. They did not consider
biology or genetics as playing a role. Other
psychoanalytic writing also refuted a biological
component to female homosexuality, seeing
it as caused primarily by early developmental
disturbances.
Alfred Kinsey introduced new perspectives
on homosexuality with his studies of sexual
behavior (Kinsey, Pomeron & Martin, 1948;
Kinsey et al., 1953). Although his studies have
been criticized for a variety of reasons, such
as poor sampling methods, the studies greatly
The psychologist Evelyn Hooker (1957) dem­
onstrated that no discernible differences exist­
ed between the psychological profiles of gay
men and those of heterosexual men, effectively
beginning the debunking of the theory
that homosexuality is a mental illness.
Psychiatrist Judd Marmor (1980) recognized
that homosexuality could not be explained in a
single dimension and helped support exploring
the biological, genetic, psychological, familial,
and social factors involved in the formation and
expression of a homosexual orientation.
In 1973, the American Psychiatric Association,
after extensive scientific review and debate,
stopped classifying homosexuality as a mental
illness. Homosexuality is now seen as a normal
variation of human sexual and emotional
expression, allowing, it is hoped, a
nonpathological and nonprejudicial view of
homosexuality as well as of LGBT people.
LGBT people and homosexual and bisexual
behavior are found in almost all societies and
cultures in the world and throughout history
(Herdt, 1996). But the degree of tolerance and
acceptance of them has varied considerably in
different periods of history and from country to
country, culture to culture, and community to
community. Anthropological studies that have
observed homosexual behavior in other
cultures may help put homosexuality in global
perspective and may contribute to understand­
ing some of the issues facing American LGBT
individuals who are from ethnic or cultural
minority groups, such as African Americans
(Jones & Hill, 1996), Asian Americans
(Nakajima, Chan & Lee, 1996), Latinos/
Latinas/Hispanics (Gonzalez & Espin, 1996),
and Native Americans (Tafoya, 1996).
The genetic and biological contributions to
sexual orientation have been studied
increasingly in recent years. Unfortunately,
the biological studies often grow out of the
confusion between sexual orientation and
gender identity. Many studies have tried to
demonstrate that physical traits in gay men
resemble those of women or have tried to
identify traits in lesbians that resemble those
of males. These views are based on the belief
that, if a man wishes to be with a man, he must
somehow be like a woman, and a woman
wishing to be with a woman must, in some
way, be like a man.
The Kinsey Institute has supported surveys
and studies of both sexual behavior and sexual
orientation and concluded that homosexuality
must be innate, that is, inborn, and is not
influenced developmentally by family
upbringing (Bell & Weinberg, 1978; Bell,
Weinberg & Hammersmith, 1981; Weinberg &
Williams, 1974). The studies noted the diversity
and variety of gay men and lesbians,
recognizing that there was no uniform way to
be or become gay or lesbian in our society.
Lesbianism and female homosexuality have
also been studied from a nonpathological
perspective. Magee and Miller (1998) reviewed
these efforts and found no psychodynamic
etiologies to female homosexuality and that
each lesbian is unique and without stereotypic
characteristics.
An Overview for Providers Treating LGBT Clients
increased Americans’ awareness of sexuality
and the range of sexual behavior.
Studies of intersexual people, that is, people
with sexually ambiguous genitalia or true
hermaphrodites, are often analyzed.
Hermaphrodites have both male and female
reproductive organs. These studies ultimately
are about gender role expectations and do not
contribute to our understanding of homosexual­
ity.
The most promising areas of study involve
genetics and familial patterns. Although the
gene has not been identified, Hamer and
Copeland (1994) have reported a linkage
on the X chromosome that may influence
homosexual orientation. The genetic and
familial patterns studied by Pillard, Bailey,
9
An Overview for Providers Treating LGBT Clients
and Weinrich and their colleagues (Bailey et
al., 1993; Bailey & Pillard, 1991; Pillard, 1996)
have demonstrated the most consistent and
verifiable data. Pillard found that gay men are
much more likely to have gay or bisexual male
siblings than heterosexual males—based on
the incidence of homosexuality—but are not
more likely to have lesbian sisters than are het­
erosexual males. Lesbians are more likely to
have lesbian sisters but are not more likely to
have gay brothers.
Sexual Orientation Over Time
Combined with other twin and heritability
studies, this research helps explain the
probable genetic substrate of sexual
orientation, with different genetic influences
for male homosexuality, male heterosexuality,
female homosexuality, female heterosexuality,
and, possibly, bisexuality. Although the
complex set of behaviors and feelings of homo­
sexuality could not be explained by a single
factor, a genetic basis seems to be the
foundation on which other complex biological,
familial, and societal influences work to shape
the development and expression of sexual
orientation (LeVay, 1996).
Perspectives on Bisexuality
Bisexuality has also existed throughout
recorded history. Freud believed in innate
bisexuality and that an individual evolves
into a heterosexual or a homosexual, rarely
a bisexual (Freud, 1963). Many bisexuals still
find themselves contending with this lack of
acknowledgment that a bisexual orientation
can be an endpoint in itself and not just a
st…

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