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Addiction is Different in the Gay Community — So Recovery Needs to Be, Too

Lola* got addicted to heroin while partying with her lesbian friends in New York City during the 1990s, some of whom were addicts, some not. “I met really hardcore users that had been through terrible rejection and abuse from family,” she says. But the idea was to have fun, not to medicate their homophobia traumas: “Going out to clubs and being high was part of the culture.”

Gay “culture” has taken a great deal of blame for the high statistics on LGBT substance problems, which are estimated to exist overall at more than twice the nine percent rate in the general population. And it’s true that a certain watering hole mentality has persisted long past the time when being gay was illegal and the only place to meet was over a warm beer in an undisclosed location. (Vodka merchants, among others, have targeted this persistent tradition.)

A Specific Set of Problems

Drug-taking certainly has its LGBT (lesbian, gay, bisexual and transgender) angles too: In the past decade or two, lots of gay and bisexual men have gotten hooked on crystal meth. This problem is linked to continued high rates of HIV infection—both as cause and effect. And now even cell phone dating is linked to heavy drug use. Meanwhile, problematic alcohol use is extra high among lesbians and bisexual women—although interesting new findings suggest that civil rights advances might sober some women up.

“Internalized homophobia” is the psychological term for the way anti-gay stigma can dig deep, and problematic substance use only makes it worse.

Researchers point to a combination of traumas, some experienced during childhood and others along the way. “Internalized homophobia” is the psychological term for the way anti-gay stigma can dig deep, and problematic substance use only makes it worse. Psychiatrist R.P. Capaj described this painful cycle after studying it among gay men, lesbians and bisexuals during the mid-’90s: “The use of mood-altering substances temporarily relieves but then reinforces this self-loathing in the drug withdrawal period…leading to a worsening of self-esteem.”

Measuring long-term changes in people’s lives is quite another thing, however, and there has been scant funding for larger-size studies tracking LGBT health over a significant period of time—whether about substance use or anything else. And we mustn’t forget the damage done by psychiatry’s insistence on branding homosexuality as a mental illness well into the 1970s. What’s more, the first studies on LGBT substance use were pretty useless because they were based on skewed information: In the 1970s and ’80s, too many survey participants were enrolled via bar stools.

It wasn’t until 2000 that the federal government officially pronounced sexual orientation to be a major factor contributing to disparities in the health of Americans. (That US Department of Health and Human Services’ agenda paper was named “Healthy People 2010,” recently displaced by “Healthy People 2020”.) And it’s only now that large-scale, longer-term data is becoming available, in both the US and the UK. The best investigations into LGBT health so far have been in the area of HIV prevention and treatment, specifically among gay men, although that was a long time coming as well.

Rates of HIV infection, attempted suicide, drug and alcohol abuse, and smoking among transgender and gender non-conforming people speak to the overwhelming need for…transgender-sensitive recovery programs.

Transgender people with substance use disorders are the least studied of all, and the least catered to in treatment. “Rates of HIV infection, attempted suicide, drug and alcohol abuse, and smoking among transgender and gender non-conforming people speak to the overwhelming need for…transgender-sensitive recovery programs,” a major health care survey urged in 2010. But even by attending the growing network of 12-step meetings in LGBT community centers around the country, few have found effective ways to target transgender addicts and get them into recovery.

Syndemics Theory

One of the most successful proposals for understanding LGBT addiction has been “syndemics” theory, which posits a witches’ brew of problems feeding off of each other.

Medical anthropologist Merrill Singer first proposed the idea in the mid-’90s, when he connected high AIDS rates among inner city Hartford residents to a mutually reinforcing mix of poverty, bad health care, family instability and drug-related violence. Later, Singer studied syndemics specifically among gay men. And in 2008, epidemiologist Ron Stall began developing these ideas further.

Stall, now working out of the Center for LGBT Health Research at the University of Pittsburgh, has looked closely at the nexus of gay men’s high rates of childhood sexual abuse, depression, partner violence and so-called “polydrug abuse.”

The problem of bullying in schools for this population has been in the news: A 2011 survey found 82 percent of LGBT youth had problems with it. But harder to measure are family mistreatment and the effects of observing that certain typical adult experiences are just not open to you—like marriage or military service, until recently, for instance, or being allowed to lodge an official complaint if you are discriminated against. (Until 2003, 15 states outlawed sodomy, and in 2014 there is still no federal law against firing someone simply for being gay.)

It’s a matter for debate whether rates of substance use disorders are affected by changes in LGBT public policy. “I actually don’t think so,” says Joe Disano, a substance abuse counselor at Center Recovery, part of New York’s Lesbian, Gay, Bisexual and Transgender Community Center. “The younger clients are out, loud and proud; it’s the older clients who deal a lot with internalized homophobia. I don’t think that gay marriage and all that stuff has increased or decreased drug use at all” among either group.

The younger clients are out, loud and proud; it’s the older clients who deal a lot with internalized homophobia.-Joe Disano

On the other hand, preliminary findings from a 2011 study interviewing lesbians and bisexual women before and after Illinois legalized civil unions suggest that rights laws can sometimes influence substance use. Tonda Hughes, a professor at the University of Illinois who was behind the study, says, “Sexual minority women interviewed after the bill’s passage reported lower levels of stigma consciousness—the belief that others view them in stigmatizing ways—perceived discrimination, depressive symptoms and lower levels of hazardous drinking.”

Not all of the study subjects reacted this way, however. “We found that these benefits were concentrated among Black and Latina women and women without college degrees,” says Hughes, suggesting that those lesbians and bisexual women who are “more marginalized” may benefit the most from these sorts of policy changes.

What’s clear is that for millions of LGBT Americans well into adulthood, a certain sort of damage may already have been done. One of Stall’s contributions was fingering the common adolescent boy experience of being perceived as not masculine in some way—“failing” at masculine socialization—and feeling bad about himself in a way that endures well after the baseball shaming is over. Stall and others have also argued that for all the benefits of leaving one’s small, homophobic childhood home town for the bright lights of a “gay ghetto,” such as New York City or San Francisco, there have been drawbacks too. Sometimes, they say, urban gay culture encourages drug and alcohol abuse.

Some of the differences are pure demographics: Tim*, a former crystal meth addict who is 45, guesses that “If you are hetero and still drinking or drugging and your friends are starting to settle down and have kids, that really makes your use stand out. But perhaps less so in the gay world when regular use can continue through one’s 30s and 40s.”

He found, along with a broad swath of American and European gay and bisexual men, that his crystal meth and alcohol use was intertwined with sex.

Tim became addicted in the early 2000s. He found, along with a broad swath of American and European gay and bisexual men, that his crystal meth and alcohol use was intertwined with sex. After quitting five years ago, he says, “I felt like I had to learn not only how to socialize without alcohol but how to have sex without any drugs, including pot and poppers.”

Drew*, 52, had a similar experience with crystal meth and alcohol: “For years, I didn’t have sex without being drunk or high.”

Drew says, “It’s a meth thing”—and there is no doubt that something is especially tenacious about the drug in this particular community. A decade after high rates of meth use got bad enough to attract mainstream attention and basic HIV prevention ideas had reached most of the LGBT community, research by psychologist Perry Halkitis suggests that even now, “use of inhalant nitrates and alcohol increased the odds of men engaging in unprotected receptive anal intercourse”—the HIV-riskiest kind. Disano, the Center Recovery counselor, guesses that 65 to 75 percent of his program’s clients are crystal meth addicts—“and they’re starting younger and younger.”

As Halkitis notes in the conclusion to a 2014 study of gay and bisexual men’s use of crystal meth, “One is left to wonder why this drug continues to wreak havoc in the population despite our efforts to address the addiction, and the community action that has evolved over the course of the last decade.”

Halkitis has observed the exponential, tinderbox-like power of syndemics in his research subjects and patients, and it’s an explanation that also resonates for researchers looking at substance use disorders among lesbians and bisexual women.

Ongoing Research and Hope

The federal National Institutes of Health (NIH) last year granted Tonda Hughes $2.7 million to investigate why lesbians and bisexual women are at such high risk of “hazardous drinking” (defined by the NIH’s National Institute on Alcohol Abuse and Alcoholism as more than seven drinks per week or more than three drinks per occasion for women). So far, Hughes has been able to link this heavy drinking to the experience of being “victimized” in more than one way. This goes for all sexual orientations, she says—it’s just that trauma is so frequent for people who grow up LGBT.

Ron Stall is especially interested now in the aspects of belonging to an LGBT community that boost people’s ability to recover from addiction, as opposed to encouraging problematic substance use. He sees evidence that this “resiliency” is strong among gay men—demonstrated, for instance, by their high rate of tobacco recovery during the second half of the ‘90s, and by their response to bias itself. “Gay men are very good at getting away from the homophobes,” Stall said in a recent talk. “‘I will not let you shame me!’ It’s different than pride. It operates at the level of the social.”

Groups including the National Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies (NALGAP) and the Gay and Lesbian Medical Association (GLMA) say that mainstream recovery professionals need to do better at specifically addressing issues of concern to LGBT addicts, as per a strong proposal that accompanied “Healthy People 2010.”

The Pride Institute in Minnesota has been doing this sort of work for 25 years; there are hundreds of gay-focused 12-step meetings out there now; and LGBT community centers all over the country offer one-on-one and group addiction counseling well beyond AA, NA and CMA (Crystal Meth Anonymous). Having said that, progress in the general recovery world remains far too slow.

Dr. Stall mentions faith communities and sports teams as two examples of the ways LGBT addicts get support and seek out alternatives to bar culture and dating on drugs. Also, he says, “There are lots of individual LGBT men and women who have done a very good job of finding support with their friendship networks, their families and partners.”

The stories of what works are so varied that the coming wave of higher-quality LGBT-focused substance use studies is more than welcome.

Drew, who has been sober now for five years after a relapse, says, “I went to a lot of gay meetings but I often prefer straight meetings. It’s about the program. Sometimes gay meetings can get a little distracting. While finding friends and peers is important, I hear the message better in straight meetings.”

When Lola, the ex-heroin addict, reviews the time since she was an active user, she says that some of her friends recovered in groups, while others did it on their own.

She herself went cold-turkey in Mexico—although with solid support. “Quitting and regaining my life are two different things,” she says. “The new friends I made while in Mexico made it all possible. To have absolute kindness and acceptance from good people made being there feel like a true life-saving time for me.”

Sally Chew is a lesbian journalist based in New York City. She has been an editor at Time Inc.’s as well as at Vibe, Out and POZ magazines. She has also authored a true crime book and worked as a wire-service reporter overseas.

*Name has been changed
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