Gay, Lesbian, Bisexual, and Transgender Issues

Lesbian, gay, bisexual, and transgender (LGBT) people have patterns of substance use and abuse that differ from the general population and also require treatment services tailored to their specific experiences, that is, "culturally competent" services for sexual minority populations. It is also important to keep in mind that there are significant subgroup variations within the LGBT category.

There are three main differences between LGBT people and others that contribute to differences in substance use and abuse: (1) LGBT people face lifelong harassment, discrimination, social rejections, and increased likelihood of interpersonal violence due to their natural sexual and gender preferences; (2) LGBT people deal with sexual orientation and gender identity issues that significantly complicate personal development; (3) LGBT people tend to congregate in social enclaves or form social networks to find sexual partners, social support from compatible and accepting friends, and refuge from harassment and discrimination.

Many people turn to alcohol, tobacco, and other drugs to cope with emotional pain in its various forms. In any population, elevated rates of alcohol and other drug use and abuse are associated with lower levels of psychological well-being, such as depression, anxiety, and post-traumatic distress. LGBT people are no exception to this association. However, LGBT people live with Stressors and threats to their well-being that are unique to being LGBT. These include harassment, multiple social rejections (including the particularly emotional painful and psychologically consequential rejections some experience from family members, professional colleagues or workmates, close friends, and community leaders such as clergy and government), interpersonal violence, increased likelihood of child abuse, employment discrimination, housing discrimination, discrimination in receipt of public services, discrimination in parental custody or adoption procedures, and heterosexist belief systems that deny the acceptability of LGBT individuals as persons. Clearly LGBT people are at greater risk of substance use than the general population because they experience these stresses. These stresses are frequently experienced by the most visible subgroups: transgenders (who historically have experienced particularly debilitating rates of interpersonal violence and economic discrimination), gay men, and lesbians. Bisexuals are least likely to experience these types of Stressors.

The developmental path of a LGBT individual is more complicated and arduous than for a heterosexual individual. Richard A. Isay refers to becoming gay as a journey to self-acceptance. The phrase "coming out," used to refer to disclosing LGBT identity to others, expresses the fact that it must also be a journey to acceptance by others, a significant complication to individual development as well.

A concept frequently used to assess the level of internal difficulty the individual faces in this journey to self-acceptance is the notion of "internalized homophobia," a complex psychosocial phenomenon that can be characterized as decreased self-esteem caused by negative social messages about homosexuality and subconscious fears of homoerotic attractions produced by widely held but erroneous belief systems regarding such attractions. Everyone, LGBT or not, has some degree of internalized homophobia to deal with in their personality development. Among lesbian, gay, and bisexual individuals, numerous studies have linked elevated rates of alcohol and drug use to internalized homophobia. As with the external stresses of interpersonal violence, economic discrimination, and social rejections, transgenders are most likely to experience internal conflict and confusion in their journey to self-acceptance, given the extreme lack of knowledge of gender identity issues in the general population and the related extremity of social rejection of individuals with fluid, ambiguous, or transitioning gender. This puts them at high risk for substance abuse.

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