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There is a good deal of alcoholism and addiction in the gay community, but newer studies suggest that the incidence among younger homosexuals may be no greater than in the population at large. This article suggests that gay liberation in the 1970's may have spared male homosexuals now under 30 some of the misunderstanding, discrimination and hatred that drove older homosexuals to drink and drugs. It also suggests that older homosexuals may abuse drink and drugs to dull the pain of aging in an especially youth-oriented, beauty-driven homosexual culture.This article discusses some of the treatment issues specific to homosexuals who abuse alcohol and drugs, and suggests the use of gay special-interest 12-Step groups to assist in treating internalized homophobia and in making some of the lifestyle changes beneficial to homosexuals in recovery .
Substance abuse is endemic in the homosexual communities in the United States. Although the etiology of abuse in any given individual can be complex, there are certain themes which are frequently seen in the gay or lesbian addict, and require specialized treatment in recovery. Awareness of these special risk factors increases the chances of successfully treating a lesbian or gay addict. The author has chosen this topic because he is both homosexual and in long-term recovery from alcoholism.
American Psychiatric Association (1994) (the DSM-IV) lucidly groups all addiction to and abuse of substances into a single chapter: Substance Related Disorders. There is no single theory which accounts for why some people abuse substances and others don't (Straussner, 1993), but the presenting picture is essentially the same regardless of the substance.
In all probability, addiction (like so much mental illness) has a multifactorial etiology. Thus it must be viewed in a biopsychosocial framework. Straussner (1993) concludes that,
It may be best to view substance abuse as a multivariate syndrome in which multiple patterns of dysfunctional substance abuse occur in various types of people with multiple prognoses requiring a variety of interventions (p. 11).
Here are some of the predisposing factors:
1. the possibility of a biochemical or genetic factor in intergenerational transmission;
2. familial factors such as early separation from one or both parents early in life; inadequate parenting during childhood; physical or sexual abuse, or growing up in a family with multigenerational abuse of substances;
3. all of the psychological theories posit psychological factors in the development of addiction. For all the "insight" provided by these theories, none of them leads to any more effective intervention than the others. In fact, those willing to be straightforward on this subject admit that psychotherapy of any ilk is largely ineffective in treating active addiction. If the proof of the pudding is in the eating, it is then apparent that the following classic psychological bromides are wrong and/or irrelevant:
The addict uses the substance:
- as a substitute for unacceptable sexual or aggressive drives, as a substitute for the primal addiction to masturbation, or as a defense against homosexuality;
- as the result of a fixation in and a regression to the oral stage of development;
- in response to an underlying neurosis based on the conflict between dependence and anger, or
- as slow suicide (Straussner, 1993).
Other more modern theoretical perspectives focus equally ineffectively on poor ego development, pathological narcissism, or a deficiency in the sense of self (Straussner, 1993).
More useful theories for treating an individual in later-stage recovery suggested that,
- the addict attempts to medicate emotional problems such as depression, anxiety and anger;
- express dependency needs;
- compensate for feelings of inferiority and powerlessness, or
- relate to such things as low frustration tolerance, high level of impulsivity, or the inability to endure even low-level anxiety (Straussner, 1993).
Learning and behavioral theorists see addiction as a conditioned response; it produces a pleasurable high (perhaps very pleasurable in some, making them more willing to accept the negative consequences of indulgence) or relieves pain (as suggested above). Because children raised by addicted non-biological parents are at a higher risk of alcoholism than children raised by non-addicted non-biological parents, expectancy, modeling, imitation and identification may also predispose to substance abuse (Straussner, 1993).
4. environmental and cultural factors in general can play a role in the etiology of addiction, such as:
- availability of the substance (e.g., many soldiers became addicted to heroin in Vietnam because of  the high stress of war, and  the availability of the substance, but upon return to civilian life a large proportion of them ceased to have problems with drugs and alcohol);
- lack of rewarding alternatives in life (e.g., lack of decent living conditions or opportunity to earn an income, as might be experienced by persons living in a minority ghetto),
- influence of mass media, or
- social or peer acceptance of use of the substance.
Finally, regardless of the theory of addiction or the predisposition of the person to addiction, almost anyone who takes a mood-altering substance in large quantity for a long enough time will experience physical and/or psychological dependence (Straussner, 1993).
Etiology of alcoholism in homosexuals
People with a homosexual orientation are, of course, subject to all of the multiple risk factors for addiction discussed above. They also have some psychosocial predisposing factors common to all hated minorities, and some unique to the homosexual population. There are many different types of alcoholics; there are many different types of homosexuals, and there are even more types of alcoholic homosexuals (Nardi, 1982).
Common to all hated minorities is the damage done to self-image by the internalization of that hatred. Erikson (1959) asserts that it is impossible for any member of a hated minority to escape that internalized hatred.
Homosexuals are subject to unique stressors, as well. Starting in youth, sometimes as early as school age, sometimes before the homosexual himself is aware of any sexual orientation, he learns some of the dangers of being homosexual: public derision ("Joey is a fagot!"), discrimination ("We don't want a queer on the baseball teem"), and physical harm ("Hit the sissy again!"). The child may be rejected by her family implicitly (Mother overheard: "I'd rather my daughter be dead than be one of those lez-bines.") or explicitly (Father overheard: "You are a homo, you are not my son. Get out of my house.") (Savin-Williams, 1994). In later life he will face discrimination in the workplace and the possibility (only today less prevalent) of arrest and imprisonment for "unnatural acts." Rosario, Hunter & Rotheram-Borus (1992) note,
. . . the experience of being gay or bisexual in our society overwhelms any potential differences in social categories involving age, ethnicity, race, social class or geographical region of the country (p. 19).
The homosexual is unique among minorities in facing hatred and discrimination in that she usually has no role model, no positive example in her family, no loving parent who has gone through the same experience, to support her in her pain. Those discriminated against because they are (for instance) Jewish or African-American usually have families or communities for which this is a common problem. But gay youths are all too often rejected even by their families (Savin-Williams, 1994) and too seldom have yet found their supportive peers and communities.
Facing this external view of herself, no wonder that the homosexual internalizes this hatred and has difficulty with accepting her identity, building self-esteem, and expressing her sexuality. About 65% of all homosexuals seek therapy and give as a reason depression which is a result of adjusting to their homosexuality; of these, 50% started therapy between the ages of 18-21 (Diamond-Friedman, 1990).
In turn, these difficulties lead some to increase their consumption of alcohol or other drugs to aid in the coming-out process, or to medicate the anxiety or depression associated with concealing their identity or facing rejection from family and friends, discrimination in employment and housing, physical assault, arrest or imprisonment.
Colcher (1982) hypothesizes that homosexuals use substances to dull the pain of feeling "different and alone," to reduce "sexual inhibitions" relating to internalized homophobia, and to reduce the stress of the keen competition for good-looking sexual partners.
Nardi (1982) hypothesizes that homosexuals are more at risk of drinking to the point of addiction because the gay life style often revolves (or revolved in 1982) around gay bars, which have a history of permissiveness and protectiveness:
The absence of significant subculturally valued alternatives to drinking settings . . . contributes to the dependency on alcohol as an acceptable solution to feelings of anxiety, alienation and low self-esteem (p. 21).
Various older studies indicate that about one-third of all homosexuals will have a problem with substances at some time in their lives (Diamond-Friedman, 1990). In a more recent study, however, McKirnan & Peterson (1989) come to a strikingly different conclusion. Based on their very large (n=3,400) and well-controlled study, they criticize earlier studies as being biased for several reasons, not the least of which is that they were made in gay bars of the bar-going population. McKirnan & Peterson (1989, p. 549) found the following percentages of homosexuals reporting alcohol problems:
General Homosexual Population SampleAge Men Women Men Women
18-25 29 16 26 24
26-30 25 7 25 23
31-40 16 8 24 25
41-60 7 4.5 19 15
(overall) (16) (8) (23) (23)
Significantly, up to age 30 the homosexual men in the study show no higher incidence of alcoholism than men in the general population (although homosexual women show significantly higher levels). But after age 30, the high incidence of alcohol problems declines much less in the homosexual population than it does in the general population.
Why are older homosexuals at greater risk of alcoholism? The author has found no sufficient explanation in the literature. McKirnan & Peterson (1989) suggest that psychosocial or cultural variables in the homosexual population might be responsible for increased alcoholism in the later years. They hypothesize that homosexual men and women do not typically enter traditional marriages or childbearing roles as they age, are often not in mainstream occupations, and do not typically adhere to traditional sex roles, all of which encourage control of drinking. The author suggests that more significant than "encouraging the control of drinking," the functions of childbearing and childrearing may have a significant part in the emotional happiness and stability of the parents, being biologically ego-syntonic which, in turn, could relieve feelings of loneliness and lack of fulfillment which give impetus to drink.
Author suggests several other explanations as to why today's older gays have a higher rate of alcoholism:
Today's older homosexuals faced a more closeted life in their young years, with a much higher prevalence of the stressors discussed above. Gay liberation had not yet struck. They began drinking heavily earlier and, addiction being a disease most frequently progressing into middle age before being addressed, were addicted by their middle 30's. Thus, the higher rates of alcoholism in those over 30 shown by McKirnan & Peterson (1989) may be caused by an even higher incidence of alcoholism in the pre-liberation group, which is now in its 30's, 40's and 50's. That male homosexuals under the age of 30 should show no greater incidence of addiction may be a testament to the positive effects of gay liberation.
Another untested hypothesis which occurs to the author is that many older homosexuals (say, over 35) are faced with the daunting task of competing for lovers, friends, and sexual partners in the unrelentingly youth-oriented, beauty-driven gay culture. One of the major tasks of middle age for homosexuals is to reach acceptance that they are no longer able to compete for lovers or sexual partners on the basis of beauty (of which youth, in the homosexual population, is ordinarily a requisite), and accept that their sex and love lives may be substantially less fulfilling, or fulfilling in different ways, than when they were younger. Many homosexuals as they pass 35 turn increasingly to drugs and alcohol for solace and companionship.
Treating Addiction in Homosexuals
Addiction is like a fire; once started it becomes self-sustaining, and the first order of business for the fire fighter is to put out the blaze. Only later comes the search for the match. Similarly, treatment of the addict in early recovery is largely behavioral and cognitive: daily attendance at AA meetings provides (among other things) a support system and teaches the addict a number of techniques to avoid drinking/using, break old habit patterns of action and thinking, and reduce or manage the inevitable pain of withdrawal and recovery. Even psychodynamically oriented therapists now agree that focusing on the underlying causes of active addiction in an individual does not work to halt the addictive behavior (Colcher, 1982). Thus initially the sexual orientation of an addict is largely irrelevant to his treatment (Colcher, 1982), except (1) as it may cause legitimate concerns as to the treatment he may receive at the hands of a homophobic treatment staff, or may fuel his alcoholic denial that even an unbiased staff could help him, and (2) that the homosexual because of his lifestyle may be at special environmental risks to continued sobriety. In these cases, an addict should be referred to a gay-sensitive rehabilitation program, or to one of the gay special-interest groups of the 12-Step programs.
Internalized homophobia is common in gay alcoholics, and often a source of considerable pain and dysfunction. In the author's experience, addiction is most often initially driven by pain; thus it is important in recovery to reduce pain and stress wherever possible in the recovering alcoholics life and thus reduce the temptation for the alcoholic to self-medicate.
The alcoholic may be self-medicating anxiety, anger and depression relating to the internalized homophobia. In addition, a homosexual who has been taught by parents, church, school and society in general that homosexual lovemaking is forbidden, sinful, bad, sick, disgusting, and perverted, may use alcohol to medicate the anxiety which these negative thoughts provoke in him and thus allow him to engage in sex at all. And to the alcoholic contemplating abstinence, the prospect of not being able to have (or function in) sober sex can be a motivation to and justification for not staying sober.
Gay special-interest 12-Step programs (and, perhaps gay group therapy) can help the recovering alcoholic consciously work through internalized homophobia, and understand and reject for himself the destructive myths about homosexuality:
Most of these myths are counterproductive . . . since they are based on assumptions that all gay males are identical, are fixated at regressive levels, and can never achieve a "whole" and satisfactory life. Examples of these myths are: gay males are hysterical and dramatic, especially in dealing with conflict; gay male sex is compulsively driven sex; the treatment objective is a dyadic, long-term relationship; gay males are basically narcissistic; gay sex is basically masturbation; gay males are immature (fixated at pre-Oedipal stages, fixated at adolescence, manifesting the Peter Pan syndrome); gay men are totally sexually liberated; "something" will always be missing, in comparison with heterosexuality; gay intimate relationships cannot last and cannot mature; gays are "sad young men"; casual sex is empty sex; gay men are psychotic; gay men cannot obtain relatedness; and so on (Smith, 1982, p. 55).
In addition, strange though it might seem, in the gay special-interest meetings of 12-Step programs, gay men and women can learn (perhaps for the first time) to relate to other gay men and women in non-sexual ways, thus building healthy relationships based on other common interests. This may be especially important for older homosexuals, for whom the earlier, sexualized relationships may be undesirable, unfulfilling, and unavailable.
Whatever the etiology of an individual's addiction, successful long-term recovery requires him to come to terms with himself and his homosexuality, and to learn to cope with life. In the treatment of the gay alcoholic, the therapist must not only keep perspective on the client as an addict, but also as a homosexual, with all that may mean to that person in his biopsychosocial setting. This includes being aware of the special challenges discussed above of internalized homophobia and the related low self-esteem, a lifestyle in which alcohol, drugs and gay bars may be central, and the particular problems of aging in the homosexual community. Especially, older gay men need information and encouragement to find the joys which can be contained in the second half of life (Smith, 1982).
The therapist must be sensitive to the gay subculture and to subcultural changes. The therapist must also be aware of the developmental tasks, as described by Erikson (1959), that gay men face throughout their lives. For instance, the stage of generativity can involve more than just parenting. Twelve-Step groups give ample opportunity, through 12th-Step work for mentoring and nurturing others, and for utilizing that most noble of the ego defenses: altruism.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association.
Colcher, R.W. (1982). Counseling the homosexual alcoholic. Journal of Homosexuality, 7(4). 43.
Diamond-Friedman, C. (1990). A multivariant model of alcoholism specific to gay-lesbian populations. Alcoholism Treatment Quarterly, 7(2). 111.
Erikson, E. (1959). Identity and the Life Cycle. New York: Norton. 30. Quoted from Greene, R. & Ephross, P. (1991). Human Behavior Theory and Social Work Practice. New York: Aldine de Gruyter. 97.
McKirnan, D.J. and Peterson, P.L. (1989). Alcohol and drug use among homosexual men and women: epidemiology and population characteristics. Addictive Behaviors, 14. 545.
Nardi, P.N. (1982). Alcoholism and homosexuality: a theoretical perspective. Journal of Homosexuality, 7(4). 9.
Rosario, M., Hunter, J., & Rotheram-Borus, M.J. (1992). HIV risk acts of lesbian adolescents. Unpublished manuscript, Columbia University. Quoted from Savin-Williams, R.C. (1994). Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: associations with school problems, running away, substance abuse, prostitution and suicide. Journal of Consulting and Clinical Psychology, 62(2). 261.
Savin-Williams, R.C. (1994). Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: associations with school problems, running away, substance abuse, prostitution and suicide. Journal of Consulting and Clinical Psychology, 62(2). 261.
Smith, T.M. (1982). Specific approaches and techniques in the treatment of gay male alcohol abusers. Journal of Homosexuality, 7(4). 53.
Straussner, S.L.A. (1993). Clinical Work with Substance-Abusing Clients. New York: The Guilford Press.
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