Though the higher rate of substance use disorders (SUDs) among sexual minorities—whether lesbian, gay, bisexual, transgender, and/or queer (LGBTQ)—is well-documented (Hicks, 2000), clients benefit from Twelve Step meetings and group therapy settings specifically designated for their community. This has not been definitively established due to a lack of research in this area, though researchers such as MacEwan (1994) and Senreich (2009, 2010a, 2010b) have begun building the foundation. For clinicians looking for evidence-based recommendations to make to their clients, this presents a conundrum. Their intuition may tell them that SUD clients in the LGBTQ community would benefit from attending LGBTQ-friendly meetings and/or group therapy sessions, but a solid foundation of data has not yet been built. And as a cautionary note, a gay member of both traditional and LGBTQ-friendly Twelve Step meetings points out, sexual attraction can be a distraction, though this is an issue that would also confront heterosexual clients attending traditional Twelve Step meetings. The authors of this article are attempting to aid clinicians in this effort by conducting research inside Twelve Step meetings in St. Louis, Missouri, as well as performing a review of the literature to bring to light whether existing data suggest there are benefits to LGBTQ-friendly meetings and groups. Furthermore, the research that has been done on sexual minorities and SUD treatment offers a path for how future researchers may establish whether this should be considered an evidence-based treatment.
Qualitative Field Research
With the permission of facilitators of LGBTQ-friendly Twelve Step meetings at the Steps Alano Club in St. Louis, Missouri, one of the authors was allowed to sit in on Narcotics Anonymous (NA) and Crystal Meth Anonymous (CMA) meetings in February 2017. While inquiring about the statement on Steps Alano Club’s website stating that it is the current home of “. . . one of the oldest Gay Alcoholics Anonymous meetings in the nation, dating from 1974” (Steps Alano Club, n.d.), one of the leaders pointed us to a man we will refer to as Gary Smith. Smith agreed we could use his information as long as we refer to him by a pseudonym to protect his confidentiality. Many of the people who organized St. Louis’s gay-friendly Alcoholics Anonymous (AA) meetings died in the AIDS crisis or have moved, according to Smith (personal communication, April 17, 2017). When Smith was trying to get sober in the mid-1980s, he recalled having trouble initially finding the gay-friendly AA meetings the staff at a treatment center had told him about. He would show up at a home where the meeting was supposed to occur and no one would be there—the information was apparently outdated. Eventually he found his way to the Episcopal denomination’s Christ Church Cathedral in downtown St. Louis, where he was finally able to meet other members of sexual minority groups who were striving for sobriety.
In May 1984, Smith entered traditional AA (personal communication, May 2, 2017). But when he revealed his sexual orientation to his sponsor, the man abruptly walked out of Smith’s house and life forever (personal communication, April 17, 2017). Even years later, a researcher hears the lingering pain of that moment. Rejection by his heterosexual sponsor is what caused Smith to seek a gay-friendly meeting.
Smith began attending the gay-friendly AA meetings in August 1984 (personal communication, May 2, 2017) and felt much more at ease when he got a gay sponsor, remarking later that he felt he could “trust him” (personal communication, April 17, 2017). Smith began holding candlelight versions of gay-friendly AA meetings, in which members speak of their struggles in near darkness, and recalled everyone hanging out afterwards and playing “gay Monopoly.”
Having an LGBTQ social support group and learning to socialize without drugs or alcohol are important factors for resilience among sexual minorities (Callicott, 2012; Hicks, 2000). When one of the authors attended an LGBTQ-friendly NA meeting, a young community college student told him, without any prompting, that one of the factors keeping him sober was the new friends he made in the group. The young man remarked that they did simple things together like going out for pancakes (personal communication, February 17, 2017). It should be noted that this young man was seen later in the night holding hands with a young woman, so one should not make assumptions about the sexual orientation of people at these meetings. In fact, the candlelight NA meetings held late on Friday nights at Steps Alano Club is known for attracting young people who would not be considered sexual minorities. The authors hypothesize the nonjudgmental nature of these meetings may attract people outside the LGBTQ community who may feel safer sharing any details of their lives that they consider nonnormative. This is another area that would benefit from researchers inquiring into the sexual orientation of SUD clients (Flentje, Bacca, & Cochran, 2015).
SUD Prevalence in the Gay Community
The need for such research is great. An estimated 20 to 30 percent of gay and transgender individuals struggle with SUDs compared with 9 percent of the general population, according to researcher Jerome Hunt at the Center for American Progress (2012). The meta-analysis presented in his issue brief shows men who have sex with men (MSM) “are 9.5 times more likely to use heroin than men who do not have sex with men” (Hunt, 2012). In addition, Hunt points out, gay men are 12.2 times more likely to use amphetamines than heterosexual men. This is partly due to the “chem sex” or “party and play” phenomenon in the gay community, in which drugs like crystal methamphetamine, GHB/GBL, and mephedrone are used to enhance sexual pleasure and reduce fears of intimacy and engagement in same-sex intercourse (Bourne, Reid, Hickson, Rueda, & Weatherburn, 2014), but also has its origins in societal oppression (SAMHSA, 2012), which can result in individuals turning to substances as a coping method. SAMHSA (2012) researchers describe this societal oppression as resulting from heterosexism, which “resembles racism or sexism and denies, ignores, denigrates, or stigmatizes nonheterosexual forms of emotional and affectional expression, sexual behavior, or community.” The effect on a member of the LGBTQ community can be “internalized homophobia, shame, and negative self-concept” (SAMHSA, 2012). Hicks (2000) points out that homophobia can also result in self-directed anger, suggesting an area clinicians may want to explore with LGBTQ clients struggling with sobriety.
In addition, while the Internet has provided opportunities for LGBTQ people to meet online, the central gathering places offline still tend to be gay bars and nightclubs, part of what Bourne et al. (2014) call the “gay commercial scene,” describing it as the “infrastructure developed to facilitate the (socialization) of gay or bisexual men.”
Experiences in SUD Treatment
Despite all the evidence about why LGBTQ individuals use substances at higher rates, there are “not enough controlled studies to demonstrate (the) effectiveness” (Hicks, 2000) of SUD treatment services designed specifically for the LGBTQ community. According to Cochran, Peavy, and Robohm (2007), a significant majority of the nation’s SUD treatment agencies claim they offer them but, when prompted, less than 8 percent could identify a specific service they offer the LGBTQ community. For some LGBTQ individuals in treatment, staff members’ and peers’ negative attitudes about their sexual orientation manifest as active homophobia (Matthews, Lorah, & Fenton, 2006), which creates a barrier to clients getting healthy. In a survey of 104 gay or bisexual people who had been in substance abuse treatment in the previous six years, Senreich (2009) discovered that 57 percent regarded their sexual orientation as having negatively affected them in their treatment program. In another study, Senreich (2010a) found that “being gay/bisexual in LGBT-specialized treatment were both positive predictors of current abstinence and negative predictors of leaving treatment due to ‘needs not met/discharged’ in comparison to being gay/bisexual in traditional treatment.”
Experiences in Twelve Step Meetings
Like most SUD clients, members of the LGBTQ community are usually directed to Twelve Step meetings at some point in the treatment process. However, the perception that AA includes religious components may create a disconnect for LGBTQ individuals (Hicks, 2000). For example, five of AA’s Twelve Steps directly reference “God” or “Him” (Bittle, 1982), which can present a barrier to LGBTQ folks who have rejected organized religions that denounce homosexuality (Hicks, 2000).
However, Suprina (2006) found that many participants differentiated spirituality from religion. This differentiation enabled participants to develop a positive, personal relationship with a higher power that is independent of traditional religious denominations. This created a sense of belonging and served as a protective factor for the participants (Suprina, 2006).
Callicott (2012) also raises the issue of “pride” in the gay context—that is, feeling positive about sexual orientation and having made the choice to live authentically—and how it may be viewed as a character defect in the context of a Twelve Step program. This is another issue which may be handled differently in an LGBTQ-friendly Twelve Step meeting than a meeting facilitated by a heterosexual person or attended by a majority of people outside the LGBTQ community.
At one time, gays and lesbians were even discouraged from bringing up their sexuality, as it was believed it would cause a disturbance within the group or that it was not relevant to the recovery process (Green & Faltz, 1992; Lewis & Jordan, 1989). However, we now understand the importance of LGBTQ substance users having role models who are also members of the LGBTQ community and in recovery (Matthews et al., 2006). Like Gary Smith in St. Louis, who finally felt he could trust this process when he got a gay sponsor, LGBTQ role models provide safety and comfort, allowing those in the community to be themselves. It is through LGBTQ-friendly Twelve Step meetings that they can connect with possible sponsors and role models (Matthews et al., 2006).
However, there is a dearth of research into whether LGBTQ-friendly Twelve Step meetings are any more successful in keeping their members in recovery (Callicot, 2012). When researchers choose to query participants in SUD studies about their sexual orientation, much of the time it is because the study is directly related to HIV (Flentje et al., 2015). When Senreich (2009) researched abstinence among gay and bisexual men following treatment in traditional SUD programs, he found one-third of them were still using substances, compared with one-tenth of their straight brethren, despite attending Twelve Step meetings at the time they were surveyed. Senreich (2009) hypothesizes this is explained by the majority of gay and bisexual participants in his study reporting “at least some negative experiences in treatment due to their sexual identity.”
The SUD treatment field would benefit from more research being conducted specifically into the effectiveness of LGBTQ-friendly Twelve Step meetings. There is anecdotal evidence that participants feel as though LGBTQ-friendly meetings are an essential component to their recovery. However, much of the existing research lacks empirical evidence surrounding the impact that LGBTQ-friendly Twelve Step meetings have on sustained recovery and whether these groups prove any more effective when compared with traditional Twelve Step groups. One avenue to achieving this involves asking questions regarding sexual orientation and gender identity in federal research conducted on SUD treatment (Flentje et al., 2015).
Implications for Social Work
Through analysis of previously completed research, it is clear that the issue of SUDs within the LGBTQ population is multifaceted. This issue is a result of decades of systematic discrimination coupled with continuous barriers to treatment directly linked to the stigmatized status LGBTQ individuals hold. The role of social work in combatting this problem involves working towards destigmatization at the macro, mezzo, and micro levels. From advocating for LGBTQ rights and conducting research on this issue to providing culturally competent services, social workers can play a large role in gaining control over this pervasive issue.
Individuals in the LGBTQ population report that their social service providers do not always administer culturally sensitive services. This is a factor that has been shown to drive clients out of treatment, leading to increased substance use issues. In order to combat this trend, it is recommended that increased training on LGBTQ issues be provided to those in the helping professions. Many organizations encourage employees to seek such training or attend events that promote knowledge about cultural awareness, but it is rare that these types of trainings are mandated. Education is the key to improving services, especially when those in the helping profession are not always aware of what they do not know. Workshops and trainings that delve into the ethical and supportive concerns associated with working with minority group clients are essential in taking steps towards breaking down the discrimination and stigma experienced by all minority populations, including the LGBTQ population.
Research also repeatedly demonstrates that systematic discrimination, coupled with the persistent stigma tied to the LGBTQ community, directly contributes to both the high prevalence of SUDs and the difficulty accessing adequate treatment experienced by this population. In order to reduce the suffering currently experienced, work must be put toward combatting the stigma at a societal level as well as at the professional level. Efforts to educate young people in school settings about cultural acceptance serve to solidify accepting viewpoints prior to a negative bias developing. This can be achieved in the form of educational workshops in addition to the creation of an inclusive school environment through supportive ally groups, the use of inclusive language schoolwide, and intentional bullying prevention initiatives. Combatting the effects of societal stigma felt by this population at a young age is recommended in order to reduce the likelihood of individuals in the LGBTQ population resorting to substances as a coping mechanism.
SUD clients in the LGBTQ community deserve safe, comfortable, inclusive environments for their Twelve Step meetings and group therapy sessions. Social workers, along with other members of multidisciplinary treatment teams, must never forget the ethical obligation to provide them.
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