For many years, it has been the general assumption that the incidence of alcoholism was much higher for gays and lesbians than in the heterosexual population.

Early studies reported that as high as 35% of gays and lesbians were "excessive or problem drinkers" vs. five percent of heterosexuals. (Saghir and Robins, 1973)

Later reported estimates of alcohol use among homosexuals tended to remain at the 30% mark, vs. the 10% usually cited for the general population.

It was not until researchers began an investigation of the methodology of the early studies that important information began to emerge.

Samples for early research efforts were recruited largely in gay bars and their surroundings, given that these are one of the few public places where gays can feely socialize as a group.

However, heavy drinkers are also more likely to congregate in bars than are social drinkers or abstainers.

Additionally, bars are also a frequent venue for other drug use. For these reasons, early studies whose research protocols relied heavily on patrons of gay bars were at risk to overestimate the prevalence of alcohol and drug use among gay men and lesbians.

The onset of the AIDS epidemic afforded the opportunity for studies of more representative samples of the gay community.

When alcohol and drug usage was measured among a group of self-identified gay men living in 17 census tracts in San Francisco, the rate of heavy drinking was reported at 19 percent as compared to 11 percent of heterosexual men living in the same area. (Stall and Wiley, 1988)

Later studies (Cochran, Keenan, Schroeker, & Mays, 2000) concluded that population based studies of gay men do not reveal that problem drinkers comprise 30 percent of that group.

Others (Paul, Stall, & Bloomfield, 1991) suggested that it was as low as 9 percent.

A study (Cochran et al, 2000) of women age 18 to 50 years, recruited using a random sample of commercially listed households in San Francisco, found no significant difference between lesbians and heterosexual women in rates of alcohol consumption.

Bux (1996) concluded that lesbians and gays are less likely to abstain from alcohol used than the general population, that lesbian women appeared to be at higher risk for problem drinking than heterosexual women, and that gay men's risk for alcohol problems is comparable to that of heterosexual men, and that this is due to a decline in alcohol use by gays.

Due largely to lack of information, or widespread misinformation, on the part of both the general public as well as treatment providers, gays and lesbians who do seek treatment face unique challenges.

In a society that has variously regarded homosexual behavior as immoral, pathological, deviant, and/or criminal it is easy to understand the reluctance to openly identify and live a gay or lesbian lifestyle.

Cabaj (1999) and Bobbe (2000) suggest that the stresses associated with accepting oneself as gay plays a key role in the development of alcoholism.

The suggestion that there exists gay specific reasons for alcohol abuse implies that gay specific treatment programs might also be in order.

However , such programs are few and far between. Accessibility to gay specific programs is the first challenge gays and lesbians must overcome.

Homophobic attitudes (negative bias) among counselors and other treatment providers are the most common reason cited among gays and lesbians for not seeking help (Cochran, 2003).

If they choose to seek help, they may feel pressure to hide their sexual orientation. Because sexual orientation generally cannot be determined based upon one's appearance, the decision to conceal one's homosexuality can lead to a less than successful outcome, due either to neglect on the part of the provider to inquire about sexual orientation, or, assumption on the part of the provider that one size fits all.

A study by Raytek (1996) revealed that both gays and lesbians would prefer a counselor with the same sexual orientation. However, a survey of 36 New York treatment agencies found few or no gay staff members. Affirmative action policies do not cover gay men and lesbians. Therefore, few gay and lesbians clients were able to work with gay or lesbian counselors.

Shame and fear of rejection by counselors also causes reluctance among gays and lesbians to seek treatment. (Finnegan & Cook, 1984) Lesbians deal with not only fears of rejection due to their homosexuality, but also with other gender-biased negative attitudes.

Finally, a lack of understanding and acceptance of the gay alcoholic's chosen family leads to a reluctance to seek treatment. Gay men and lesbians are likely to have primary relationships which do not conform to the societal definition of a nuclear family system.

As gays and lesbians may be rejected by their families of origin due to their sexuality, friendship networks and other alternative support systems are of prime importance.

Failure to disclose one's sexual orientation due to fear of rejection may result in this important social support being hidden or ignored. Family week, a key component of most drug and alcohol treatment programs, may serve only to increase feelings of isolation and alienation.

Matthews, Lorah, & Fenton (2006) studied four gay men's and 6 lesbian women's experience of addictions treatment and recovery.

Ten themes emerged regarding their experiences.

1. Participants stressed the importance for counselors to address substance abuse and sexual orientation directly, rather than wait for clients to bring it up. Along the same lines, clients felt it important that counselors be knowledgeable about addiction and sexual orientation and how these two interact.

2. Participants felt most supported in meetings, groups, and events which were gay/lesbian specific. It was felt by the group that gay specific meetings increased the opportunity for finding sober role models. Such role models were felt to provide a sense of connection and identification, as well as a feeling of safety that one could share his/her sexual orientation.

3. The most intense theme centered on the issue of shame. Participants felt that treatment providers who were able to help them move through shame to self acceptance were the most effective. They pointed out that gays and lesbians carry not only the shame of addiction, but also the shame of their homosexuality. The ability to share these facts with another who maintained an attitude of acceptance was felt to be particularly healing.

4. On the heels of the shame issue came the fourth theme, that of the coming out process. All the participants reported struggling with whether or not they could safely come out to the staff and other residents of the facility. They all agreed that one cannot work an honest program if he/she are not real about who they are. This did not assuage the pain of the struggle experienced when getting honest about their sexual orientation.

5. The theme of sexual orientation and addiction and how they are interrelated speaks to the need for counselors to be cognizant of the role of alcohol and drugs within the gay community.

6. Participants talked about the high risk of suicide in the gay community, and all linked suicide to lack of acceptance as gay or lesbian. One man related that he had hospitalized himself for suicidal depression, and that the facility he entered addressed neither his addiction nor his sexual orientation.

7. All of the participants reported the need to feel that treatment was a safe space, where they could feel comfortable coming out to their counselors without fear of rejection or judgment. Some specifically looked for facilities that included sexual orientation in its non-discrimination statement. Others discussed that they would look at how other minorities were treated before coming out.

8. Participants stressed the need for treatment providers to be aware of their own internalized homophobia, and to be cognizant of their verbal and non-verbal cues of acceptance or rejection.

9. Participants cited the importance of the facility's understanding of family as it applies to their unique circumstances. Questionnaires regarding family involvement typically were reflective of families of origin or heterosexual unions.

10. The final theme was that the participants felt it was most helpful when facilities were all inclusive of both family of origin, lesbian or gay partners, and previous heterosexual relationships.

These themes carry some important implications for counselors. In order to be effective, counselors must be aware of their own attitudes and behaviors with respect to both addiction and sexual orientation.

Isrealstam (1988) surveyed counselors regarding alcoholism and homosexuality. Sixty percent of those surveyed stated that both homosexuality and alcoholism were "learned" behaviors!

Finnegan and Cook (1984) contend that counselors must be careful about when to focus on alcoholism and ignore sexual orientation, and when to focus on sexual orientation and the interplay between it and alcoholism.

They go on to suggest that the same defenses that enable the gay individual to survive in a world which is hostile to homosexuality might also serve to maintain denial of the alcoholism.

Both alcoholics and homosexuals use isolation and distancing in order to keep their secret from being revealed, and these behaviors may lead to a powerful defensive structure.

Finnegan and Cook finally maintain that counselors must examine their own attitudes, become acquainted with healthy gay men and lesbians to dispel their own myths and stereotypes, and be willing to discuss the subject of sober sex.

Beaton (1976) concluded that straight therapists can be effective with gay and lesbian clients if trust is established and emphasis is placed on all types of problems rather than sexual orientation only.

Finally, counselors must be ever cognizant of the potential impact they may have on gay/lesbian clients, as the counselor may be the only person the client has shared with, and his/her response will carry huge importance.

Some clinical considerations follow. Admission and referral forms frequently do not include questions about a client's sexuality, and many homosexual clients are regarded as heterosexual when their treatment plans are created.

Group therapy is undesirable for homosexuals, particularly gay men, due to the possibility of hostility and rejection from heterosexual members. Male dominated groups present problems for all women.

In conclusion, gays and lesbians seeking treatment for alcoholism face the stigma not only of being alcoholic, but also of being gay. Counselor homophobia has the ability to create a long term negative impact on the client.

There is a time to focus on sexual orientation and a time to focus on alcoholism, and it is always important to understand the interplay of each upon the other.

Family programs must be all inclusive of the homosexual's chosen family, and mixed groups of heterosexual and homosexual clients are undesirable.

References

- Beaton, S. (1976). Treatment for gay problem drinkers. Social Casework, 57(5), 302-308.

- Bloomfield K. (1993). A comparison of alcohol consumption between lesbians and heterosexual women in an urban population. Drug and Alcohol Dependence, 33, 257-269.

- Bobbe, J. (2002). Treatment with lesbian alcoholics: healing shame and internalized homophobia for ongoing sobriety. Health & Social, 27(3), 218-223.

- Bux, D. (1996). Relapse and recovery in addictions. Journal of Studies on Alcoholism, 63 (1). 122-129.

- Cabaj, R. (1999). Substance abuse, internalized homophobia, and gay men and lesbians: Psychodynamic issues and clinical implications. Journal of Gay and Lesbian Psychotherapy, 3(3), 1-5.

- Cochran, B. (2003). Sexual minorities in substance abuse treatment. (Doctoral dissertation, University of Washington, 2004). Dissertation Abstracts International, 64, 5776.

- Cochran, S., Keenan, C., Schroeker, C., Mays, V. (2000). Estimates of alcohol use and treatment needs among homosexually active men and women in the U.S. population. Journal of Consulting and Clinical Psychology, 68(6), 1062.

- Finnegan, D., Cook, D. (1984). Special issues affecting the treatment of male and lesbian alcoholics. Alcoholism Treatment Quarterly, 1(3), 85-98.

- Isrealstam, S. (1988). Knowledge and opinions of alcohol intervention workers in Ontario, Canada regarding issues affecting male gays and lesbians. International Journal of Addictions, 23(3), 227-252.

- Matthews, C., Lorah, P., Fenton, J. (2006) Treatment experiences of gays and lesbians in recovery from addiction: a qualitative inquiry. Journal of Mental Health Counseling, 28(2), 111-133.

- Paul, J., Stall, R., Bloomfield, K. (1991). Gay and alcoholic: epidemiologic and clinical issues. Alcohol Health and Research World, (15)2, 151-161.

- Ratner, E. (1998) A model for the treatment of lesbian and gay alcohol abusers. Alcoholism Treatment Quarterly, 5(1-2), 25-46.

- Raytek, H. (1996). Addiction and recovery in gay and lesbian persons. Journal of Studies on Alcohol, 57(2), 217.

- Saghir, M., Robins, E. (1973) Male and female homosexuality: a comprehensive investigation. Baltimore: Wilkins and Wilkins.

- Stall, R., Wiley, R., Bloomfield, K. (1991). A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco men's health study. Drug and Alcohol Dependence, 22(1), 63-73.

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Photo: Fashion designer Marc Jacobs. In 2007, he was ranked as 8th on Out magazine list of "50 Most Powerful Gay Men and Women in America".

See article Marc Jacobs on his experience in rehab