Researchers disagree as to the exact number of lesbian, gay, bisexual, and transgendered (LGBT) individuals living in the United States and other countries (Berger & Kelly, 1995). Furthermore, considerable disagreement persists about the prevalence, causes, and consequences of alcohol use and abuse among LGBT persons. Based on early and methodologically unsound studies, reports of alarmingly high rates of alcohol and other drug use within the LGBT population were published. More recent investigations have revealed lower rates of heavy drinking and fewer differences in patterns of use between LGBT and heterosexual groups.
Whether they drink more, the same, or less than heterosexuals, LGBT persons are subject to many of the same risks and consequences of use. In addition, they also encounter population-specific risks. When addressing alcohol use/abuse prevention and treatment issues, LGBT individuals deserve the same compassionate, informed responses as those given to other populations or groups. The goal of this module is to increase social workers' understanding of, and responsiveness to, the unique characteristics and concerns of LGBT individuals in relation to alcohol use, prevention, and treatment.
By the end of this module, learners should be able to:
A. Become familiar with culturally appropriate definitions of the terms lesbian, gay, bisexual, and transgendered, used to identify members of the LGBT community
B. Identify major limitations to current, empirical knowledge about alcohol use and problems within this population
C. Describe the prevalence and etiology of alcohol use within the gay and lesbian population as it is currently understood
D. Discuss barriers to prevention and treatment of alcohol problems within this population and ways that those barriers may be addressed
"Research tells us that lesbian, gay, bisexual and transgender people are more likely to smoke, drink, and use other drugs, than our non-LBGT peers. We're less likely to abstain and more likely to continue heavy drinking into later life. Does this mean that we have higher rates of addiction and other serious substance abuse problems? Who knows? As an oppressed and often invisible population, we don't even know how many of us there really are, much less what percentage of us fall into any category. Even these labels -"lesbian," "gay," "bisexual," "transgender"-are arbitrary and by no means acceptable to all of those we describe this way. But there is one fact we know for sure-and it doesn't require one cent of further research to confirm: there is an appalling and unacceptable absence of substance abuse services and competen-cies throughout the continuum of care-from research funding, to public education and other social marketing, to targeted prevention, to effective treatment-to meet the needs of America's LGBT women and men. It's up to us to change that." (NALGAP Board Member, June 2000, as cited on NCADI web page, http://www.health.org/features/lgbt/substance.htmll)
Sexual orientation and gender identity are complicated constructs that encompass multiple dimensions of an individual's experience. These dimensions include sexual attraction, behavior and fantasies, as well as emotional, social and lifestyle preferences and self-identification. Individuals whose present behavior or appearance is labeled by others as lesbian, gay, bisexual or transgendered may or may not agree with the assigned designation. Tremendous variability exists in the histories, behaviors, preferences, and self-identities of the men and women (including adolescents) to whom these labels are attached. There exists as much diversity among LGBT individuals in cultural background, ethnic or racial identity, age, income, education, and residence as exists within the general population.
With these qualifications in mind, it is generally accepted that:
- "Lesbian" or "gay" refers to a woman or a man whose primary sexual and emotional attachments are to persons of the same gender.
- "Bisexual" refers to individuals who have sexual or emotional attachments to both men and women, although typically they are not simultaneously involved with both.
- "Transgender" is a more encompassing term that includes people who do not fit societal expectations for sex (male/female) or gender (masculine/feminine) role. This might include people who are cross-dressers or drag performers, or those who live full time as members of the opposite sex. Transgendered individuals may identify as heterosexual, lesbian, gay, or bisexual, because gender identity and sexual orientation are separate, distinct constructs (Hughes & Eliason, 2002).
Research focused on substance abuse within the LGBT population has been severely limited in both quantity and comparability across studies. Stigmatization of non-heterosexual identity and behavior, resulting from societal homophobia and heterosexism, provokes reluctance on the part of funding agents and researchers to study sexual orientation, out of fear of the impact it will have on professional and political careers. That same fear of stigmatization and rejection leads many LGBT individuals to avoid participation in the research that is conducted. Due to a lack of standard definition of sexual orientation and of efforts to develop reliable estimates or random samples, the reported numbers of LGBT persons within the general population are confounded. Consequently, representation is uneven and reported research findings probably do not fully reflect the experience of most LGBT individuals.
Those individuals who are willing to participate in research are probably very different from those unwilling to identify openly as LGBT. Most research participants have been drawn from convenience samples of individuals who are members of gay identified groups, attendees at gay events, or patrons of gay bars. As a result, most samples have included a disproportionate number of white, well-educated, middle class lesbians and gay men who are open about their identity and perhaps more likely to be heavy drinkers (among bar samples). Little is yet known about other racial/ethnic groups, those of lower educational or socioeconomic backgrounds, adolescents. and older adults, persons who are "closeted" or identify as bisexual or transgendered, or those who do not frequent bars or clubs.
Early Research: Use and Abuse of Alcohol Among Gay and Lesbian Individuals
Lesbian & Gay Respondents
Heterosexual Respondents LESBIANS GAY MEN FEMALES MALES Saghir & Robins, 1973 (N = 57)
35% excessive or dependent
(N = 89)
30% excessive or dependent
(N = 43)
5% excessive or dependent
(N = 35)
20% excessive or dependent
Fifield, et al., 1977 N = 200 bar users, 98 bartenders, 53 recovering alcoholics, 132 users of G/L service center. Lifetime prevalence rate of 31.4% problem drinkers and alcoholics among both lesvians and gay men. No comparison group provided Lohrenz et al., 1978
(N = 29)
(N = 145)
29% alcoholic (MAST)
No comparison group provided
Table 1 illustrates studies conducted during the 1970s and early 1980s that reported rates of alcohol use and abuse among lesbian and gay persons up to three and a half times higher than rates among heterosexuals (Saghir & Robins, 1973; Fifield, Latham, & Phillips, 1977; Lohrenz, Connelly, Coyne, & Spare, 1978). However, these studies were plagued by various methodological limitations, raising serious questions about the validity of reported findings.
More recent investigations (see Table 2), employing more rigorous research methods, have identified substantially lower rates of heavy drinking among lesbian and gay respondents (Bloomfield, 1993; Bradford & Ryan, 1988; Crosby, Stall, Paul, & Barrett, 1998; Hughes, Haas, Razzano, Cassidy, & Matthews, 2000; McKirnan & Peterson, 1989a; Skinner, 1994; Stall & Wiley, 1988). These rates reflect patterns of use and related problems that are more similar to, yet still somewhat higher, than those of heterosexual men and women. Separate analyses for bisexual and transgendered individuals were not conducted in any of the cited studies.
Table 2 - Current Findings: Gay and Lesbian Alcohol Use
Study Lesbian & Gay Respondents Heterosexual Respondents LESBIANS GAY MEN FEMALES MALES
Bradford, Ryan &Rothblum, 1987
(N = 1852)
83% drank occasionally, 25 %> once a week, 6% drank daily, 14% worried about use
Stall & Wiley, 1988
(N = 748)
19% freq. heavy use past 12 mos, 6% abstained pat 12 mos.
(N = 286)
11% freq. heavy use past 12 mos, 3% abstained pat 12 mos.
McKiman & Perterson 1989
(N = 748)
15% abstained, 76% moderate users, 9% heavy users, 23% report problems.
(N = 2652)
13% abstained, 70% moderate users, 17% heavy users, 23% report problems.
34% abstained, 59% moderate users, 7% heavy users, 8% report problems.
23% abstained, 54% moderate users, 21% heavy users, 16% report problems.
Skinner & Otis 1992
(N = 500)
*7.5% reported freq heavy use, *31% abstained pat month.
(N = 567)
13.2% reported freq heavy use, *21% abstained pat month.
2.5% reported freq. heavy use, 58% abstained pat month.
11.52% reported freq heavy use, 40% abstained pat month.
(N = 550)
(N = 397)
Hughes, Haas, Razzano, Cassidy & Matthews, 2000
(N = 550)
24% abstinent 12 mos, 73% light drinkers, 3% heavy drinkers, 21% problems last year, 14% received AOD help past year
(N = 279)
17% abstinent 12 mos, 82% light drinkers, 1% heavy drinkers, 21% problems last year, 6% received AOD help past year
Based on the available research, several conclusions can be drawn. Fewer lesbians than heterosexual women abstain from alcohol. However, at comparable levels of drinking, lesbians report more alcohol-related problems than do heterosexual women. Lesbian drinking does not decline with age as it does among heterosexuals, but use among lesbians appears to be declining as changes in drinking norms have occurred in some gay and lesbian communities. Thus, the detected changes in drinking behavior are more reflective of cohort shifts than of developmental phenomena.
Gay men are less likely to abstain or to drink heavily than are heterosexual men, yet gay men also report more alcohol-related problems than heterosexual men at lower levels of use. Finally, use norms among gay men appear to be declining, like the pattern seen among lesbians.
Risk & Protective Factors Affecting Alcohol Problems Among LGBT Persons
Numerous explanations have been suggested to account for the differences in patterns of alcohol use and related problems experienced by heterosexuals and LGBT persons. Conflicts related to LGBT identity and internalized homophobia, stressors inherent in the LGBT lifestyle (heterosexism), incongruities in gender roles and expectancies, and the centrality of the gay bar as a source of socialization and support are variables most frequently cited. Research has not confirmed any single etiological explanation, but gay/lesbian individuals identify societal factors, including heterosexism and discrimination, as having the greatest impact.
Other demographic, psychosocial, and interpersonal variables have been identified through general population research as risk or protective factors for substance abuse problems. These, in conjunction with certain LGBT "lifestyle" variables, provide the best available information in projecting risk and protective factors for LGBT substance abuse problems. It must be noted, however, that the predictive value of these factors for LGBT people has not yet been adequately evaluated and further research is needed in this area. Following is a brief discussion of several of these risk/protective factors.
First, it is important to operationalize the terms "risk factors" and "protective factors."
Risk factors are defined as:
(1) the variables positively associated with alcohol problems (empirically observed or hypothesized), such that the variable and the substance abuse increase or decrease together
(2) variables suggested by previous research or theory to have etiological significance in the development of alcohol and other substance abuse or dependence
Protective factors are defined as:
variables negatively associated with alcohol problems (empirically observed or hypothesized), such that the variable and substance abuse increase and decrease inversely to each other
variables suggested by previous research or theory have significance in the prevention of alcohol and other substance abuse or dependence
Lifestyle variable: homophobia and heterosexism
The expression of homophobia and heterosexism is a pervasive force in the lives of many LGBT individuals, ranging from personal rejection by family and friends, to the absence of institutional recognition given to committed LGBT partnerships, to victimization by hate crimes and overt acts of discrimination in housing and employment. The majority of Americans continue to view homosexuality as "morally wrong" (Dean, Meyer, Robinson, Sell, et al., 2000) although a growing number believe LGBT persons should receive equal treatment in housing, employment and other civil rights. The term "homophobia," originally coined by Weinberg (1972), was an all-encompassing term, referring to psychological, social, and political oppression and marginalization (Saulnier, personal communication, February, 2001). The term has since become refined in its usage (Herek, 1992). Homophobia is now used to refer to psychological distress, as is the case with other phobias. Heterosexism is the preferred term for referring to social and political constraints. It is used similarly to other "ism" terms, such as sexism, racism, ageism, or classism (Appleby & Anastas, 1998).
Lifestyle variable: gay bar
The gay bar is frequently identified as a primary source of social contact and, therefore, a major determinant of heavy drinking among gay men and lesbians (Hughes & Wilsnack, 1994; McKirnan & Peterson, 1989a; Saghir & Robins, 1973). Historically, the gay bar has functioned as a social center, and as a refuge from the discrimination and homonegativity present in mainstream society. While the role and function of the gay bar have changed over time, both within LGBT communities and among individuals, it remains central to the social life of many LGBT persons, particularly young adults. Because access to LGBT services and other social activities tends to be greater in urban areas, there may be a heavier reliance upon gay bars in non-urban locales
Lifestyle variable: coming out and identity formation
The process by which LGBT individuals self-identify and, subsequently, disclose to others their sexual preference or gender identity is referred to as "coming out." Growing up in a society that denigrates LGBT identity, individuals have few role models or safe havens to which they can turn for understanding of their feelings and experiences. Negotiating the internal process of selfdefinition, and the social process of disclosure or remaining "closeted" can engender immense stress, conflict and confusion.
Demographic variable: age
General population studies indicate that the quantity and frequency of alcohol use declines with age. Among LGBT individuals, the decline is less dramatic. One study found that daily drinking among lesbians increased with age (Bradford & Ryan, 1988).
Risk or protective factors:
- Homophobia, heterosexism
- Gay bars
- Coming out, identity formation
- Social roles/responsibilities
- Childhood sexual abuse
- Intimate partner/domestic violence
- Peer and partner drinking
Demographic variable: gender
General population studies indicate that being female is somewhat protective against alcohol abuse. Among LGBT individuals, there are smaller differences between men and women in the quantities of alcohol consumed and the consequent problems experienced.
Demographic variable: race/ethnicity
By and large, general population studies indicate that white men and women are more likely to use alcohol than are their nonwhite counterparts. Very limited data suggests that LGBT persons of color are more like other LGBT persons than they are like their racial/ethnic heterosexual counterparts.
Demographic variable: social roles/responsibilities
General population studies associate unemployment and unwanted employment status with increased drinking; the combination of employment, marriage, and parenting is believed to be protective against drinking problems. Many LGBT persons are underemployed, they cannot legally marry, and relatively few have children. Stressors associated with the lack of access to, or support for, these roles diminish the protective capacity among LGBT individuals, and may increase risk. The future effect of new civil union legislation is uncertain. Despite an apparent increase in the frequency of parenting, especially among lesbians (often referred to as the "lesbian baby boom"), fewer LGBT people have children as compared to the general population (Parks, 1998; Patterson, 1992; Gartrell, Banks, Hamilton, Reed, Bishop, & Rodas, 1999).
Psychosocial factors: depression/stress
General population studies document the relationship between negative life events and depression, and between depression and drinking, particularly among women. LGBT studies indicate no differences in psychological adjustment of gay men and lesbians from heterosexuals, although LGBT persons may be at greater risk for depression and stress. However, evidence is mixed regarding the use of alcohol in response to stress or depression among LGBT individuals. The high rate at which LGBT persons use mental health services may provide a buffering or protective effect on the relationship between stress, depression and alcohol abuse.
Interpersonal factors: childhood sexual abuse (CSA)
General population studies suggest a relationship between CSA and alcoholism among both men and women. Limited research suggests that the rate of CSA among lesbians and gay men may be higher than that among heterosexuals, indicating a potentially high risk factor for substance abuse. Findings regarding the association between CSA and sexual orientation are inconsistent, with some researchers finding an association (Cameron & Cameron, 1995; Saewyc, Bearinger, Blum, & Resnick, 1999) and others not finding a significant relationship (Bernhard, 2000; Saulnier & Miller, unpublished).
Interpersonal factors: intimate partner/domestic violence
A significant proportion of persons involved either as victims or perpetrators in intimate partner/domestic violence report use of alcohol or other drugs during or prior to the incidents of battering. The few studies that included LGBT participants indicate that gay men and lesbians are equally likely as heterosexuals to experience violence in their intimate partner relationships. The isolation and stigma associated with intimate partner/domestic violence is compounded for LGBT persons, thus heightening the risk potential of this factor for substance abuse.
Interpersonal factors: peer and partner drinking
Women have a tendency to engage in drinking patterns that parallel those of their significant others, and this serves as a significant risk factor for problem drinking among heterosexual women. Because fewer lesbians abstain from alcohol, they are more likely to couple with a drinking partner, potentially increasing this risk factor among lesbians. Evidence also suggests that drinking practices of both partners and peers influence the drinking patterns of gay men.
The above is not intended as an exhaustive listing of risk and protective factors that may affect LGBT alcohol use and abuse. It is a sampling of those factors that have received at least some limited research attention. Other important areas of protection and risk related to LGBT community characteristics and societal awareness have been suggested and require further research investigation to evaluate. These include the effects of community changes in drinking norms (Hall, 1993) and increased target marketing (Drabble, 2000).
Prevention and Treatment: Barriers and Suggested Strategies
Stigma, intolerance, and overt discrimination are the most substantial barriers to both prevention and treatment of alcohol use among LGBT persons. As a result of these factors, LGBT youth and adults lack access to healthy role models who can help foster positive identity formation and self-esteem. Availability and access to supportive and affirming social service resources and substance free social/recreational outlets is also limited. This contributes to greater marginalization and feelings of isolation among LGBT individuals, and increases their consequent vulnerability to substance use.
Stigma, intolerance, and overt discrimination are the most substantial barriers to prevention and treatment of alcohol use disorders among LGBT persons.
Social work (and other helping) professionals are inadequately trained in the special needs and concerns of LGBT individuals and may personally harbor the same homophobic and prejudicial attitudes expressed by a majority of the general population (Schwanberg, 1993; Stevens, 1992). Past experience with service providers who attempted to address their sexual orientation, rather than focus on the presenting problem, has caused many LGBT persons to be distrustful and guarded about seeking help (Bradford, Ryan, & Rothblum, 1994; Saulnier, 1999; Saulnier & Wheeler, 2000). Lack of LGBT specific or culturally sensitive screening and assessment instruments, use of treatment modalities that involve group disclosure, and lack of adequate insurance coverage are additional barriers to LGBT individuals receiving care. If group treatment interventions involve mixed populations (rather than LGBT-specific composition), social workers need to guard against marginalization or scapegoating of LGBT participants (Saulnier, personal communication, February, 2001) and against the emergence of heterosexism.
Education, visibility, inclusion, and further research are perhaps the strongest antidotes to each of these barriers. Prevention efforts must focus heavily on youth, including information about substance abuse and sexual orientation in outreach and educational activities in the schools and with community caregivers. Professional training for professionals and the creation of environments in service agencies that affirm LGBT staff and clients will enhance visibility of positive rolemodels and improve accessibility of services. LGBT individuals and their family members (whether biological or defined as family by LGBT individuals) should be appropriately included in prevention programming and treatment activities. "Extended family" may not be related biologically or as family of origin; friends, ex-partners and others from the LGBT community may be significant in an individual's recovery. Appropriate inclusion varies by situation and circumstances. For example, given the seriousness of preliminary evidence about the danger in LGBT youth coming out to their families (D'Augelli, Hershberger, & Pilkington, 1998), social workers should carefully avoid routinely encouraging adolescents to come out to their families and should help them to explore safe strategies. Existing networks of LGBT groups and organizations should likewise be consulted and engaged as resources in prevention, outreach and aftercare services. Finally, further research with a broader representation of LGBT individuals needs to be conducted. All of these efforts will help to improve services and outcomes in the prevention and treatment of alcohol abuse among LGBT individuals.
- See the article: Neisen, J. (1997). An inpatient psychoeducational group model for gay men and lesbians with alcohol and drug abuse problems. Journal of Chemical Dependency Treatment, 7, 37-52.
Consider the agency in which you currently work, or have worked in the past. Would an LGBT individual find the setting, program, and staff to be supportive, knowledgeable and affirming of LGBT issues? What antigay/heterosexist elements would you need to address? What gay affirming programming and service elements exist? Draft a report to your supervisor that describes and discusses these points.
- Review at least three screening/assessment/diagnosis instruments for their applicability to LGBT individuals. What additional information should be included? How can you respond to the factors that enhance motivation in this population? Devise a 10-15 item instrument and a plan for testing it with this population (sampling and reliability/validity issues likely to arise in validating your instrument).
- Visit a minimum of four of the websites listed in this module. Report to your classmates about what you found at each site.
- What organizations and services are available to LGBT clients served by your agency? Is information about those organizations or services posted in public locations throughout your agency? How can you act to insure that LGBT individuals within your agency or practice receive the message that it is safe to disclose that identity? Is it safe? Is sexual orientation written in the client's record? Who makes that decision?
- What are the pros and cons associated with intervention groups that are specifically for LGBT members versus those that mix populations? What issues and concerns are important for the LGBT social worker to address with each of these types of groups? What issues and concerns are important for the non-LBGT social worker?
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Stevens, P. E. (1992). Lesbian health care research: a review of the literature from 1970 to 1990. Health Care for Women International, 13, 91-120.
Stevens, P. E. (1994). Protective strategies of lesbian clients in health care environments. Research in Nursing & Health, 17, 217-229.
Weinberg, G. (1972). Society and the healthy homosexual. New York: St. Martin's.
Weinberg, T. S. (1994). Gay Men, Drinking, and Alcoholism. Carbondale, IL: Southern Illinois University Press.
White, J. C., & Dull, V. T. (1997). Health risk factors and health-seeking behavior in lesbians. Journal of Women's Health, 6, 103-112.
Agency and Organizational Resources for LGBT Persons
Additional BibliographiesAlcohol and Drug Abuse Institute, University of Washington
ADAI Bibliography # SP 020 Gay, Lesbian and Bisexual Substance Abusers
Indiana Prevention Resource Center at Indiana University.
The National Clearinghouse for Alcohol and Drug Information
A service of SAMHSA
Social Work and Chemical Dependence
Indexed Bibliography of Articles Published in Professional Social Work Journals.
American Psychological Association
Lesbian, Gay and Bisexual Concerns
CSAP's RADAR Network Specialty Center
Project Connect, Lesbian & Gay Community Services Center
208 West 13th Street New York, NY 10011
National Association of Lesbian & Gay Addiction Professionals (NALGAP)
1911 North Fort Myer Drive, Suite 900, Arlington, VA 22209
Al-Anon Family Groups
1600 Corporate Landing Parkway
Virginia Beach, VA 23454-5617
International Advisory Council for Homosexual
Men and Women in Alcoholics Anonymous (IAC)
P.O. Box 18212
Washington, DC 20036-8212
Gay and Lesbian Medical Association (GLMA)
459 Fulton Street, Suite 107
San Francisco, CA 94102
National Youth Advocacy Coalition
1638 R Street, NW
Washington, DC 20009
Parents, Families, and Friends of Lesbians and Gays (PFLAG)
1726 M Street, NW, Suite 400
Washington, DC 20036
The Audre Lorde Project
Since 1996, the Audre Lorde Project has served Lesbian, Gay, Bisexual, Two Spirit, and Transgender African Americans, Hispanics, Asian and Pacific Islander Americans, Native Americans, and Arab Americans.
85 South Oxford Street
Brooklyn, NY 11217
Treatment and Health ResourcesOnline Directory of Treatment Resources
Health Care Information ResourcesUpdated: March 2005
Compiled and maintained by Tom Flemming
McMaster University Health Sciences Library
1200 Main Street West, Hamilton, ON Canada L8N 3Z5