Substance Abuse Treatment
for Lesbian, Gay, Bisexual,
Transgender Individuals
Substance Abuse Treatment
Substance Abuse Treatment
for Lesbian, Gay, Bisexual,
for Lesbian, Gay, Bisexual,
Transgender Individuals
Transgender Individuals
Jon E. Grant, JD, MD, MPH
University of Minnesota
School of Medicine
Medical Director, The Pride Institute
Jon E. Grant
Jon E. Grant, JD, MD, MPH
, JD, MD, MPH
University of Minnesota
University of Minnesota
School of Medicine
School of Medicine
Medical Director, The Pride Institute
Medical Director, The Pride Institute
Disclosure Information
Disclosure Information
I have the following financial relationships to
I have the following financial relationships to
disclose:
disclose:
•
•Grant/Research support from: Forest Grant/Research support from: Forest Pharmaceuticals, GlaxoSmithKline Pharmaceuticals, GlaxoSmithKline
I will discuss the following off
I will discuss the following off
-
-
label use and/or
label use and/or
investigational use in my presentation:
investigational use in my presentation:
•
•All medications used to treat non-All medications used to treat non-substance substance addictions are off
addictions are off--label and include label and include --SSRIs, lithium, SSRIs, lithium, antiepileptics
antiepileptics, , opioidopioidantagonists, stimulants, antagonists, stimulants, antipsychotics
antipsychotics, calcium channel blockers, muscle , calcium channel blockers, muscle relaxants,
relaxants, antiemeticsantiemetics
Substance and Non
Substance and Non
-
-
Substance
Substance
Addictions
Addictions
Methamphetamine
Methamphetamine
Cocaine
Cocaine
Alcohol
Alcohol
GHB, Ecstasy
GHB, Ecstasy
Compulsive sexual behavior
Compulsive sexual behavior
Pathological gambling
Pathological gambling
Compulsive Internet use
Compulsive Internet use
Compulsive spending
Compulsive spending
Gays, Lesbians, and Addiction
Gays, Lesbians, and Addiction
National Health and Social Life
National Health and Social Life
Survey (NHSLS) found that
Survey (NHSLS) found that
approximately 3% of men in a
approximately 3% of men in a
community sample identified as gay
community sample identified as gay
or bisexual
or bisexual
Gay and bisexual men appear to
Gay and bisexual men appear to
suffer from substance use disorders
suffer from substance use disorders
at two to three times the rate found
at two to three times the rate found
in the general population
in the general population
Epidemiology
Epidemiology
•
•Gay men more likely than heterosexual Gay men more likely than heterosexual men to use recreational drugs; 1/3 gay
men to use recreational drugs; 1/3 gay
men use drugs 1x/week; 2/3 used in
men use drugs 1x/week; 2/3 used in
past 6 months
past 6 months
•
•Lesbians at greatest riskLesbians at greatest risk •
•Substance abuse 1.47 times greater in Substance abuse 1.47 times greater in gay men compared to heterosexual men
gay men compared to heterosexual men
•
•Age at first alcohol or drug use younger Age at first alcohol or drug use younger in gays and lesbians
in gays and lesbians
Co
Co-
-Occurring Disorders
Occurring Disorders
Gay men twice as likely to have a
Gay men twice as likely to have a
mental disorder in their lives
mental disorder in their lives
More likely to have mood, anxiety or
More likely to have mood, anxiety or
substance use disorder
substance use disorder
Bisexual men more likely to have
Bisexual men more likely to have
psychiatric disorder compared to gay
psychiatric disorder compared to gay
men
men
Psychiatric disorders even greater in
Psychiatric disorders even greater in
African
Research and Data
Research and Data
In a recent (1999, 2000) San Francisco study by In a recent (1999, 2000) San Francisco study by Dr. Kristin Clements at the San Francisco Dr. Kristin Clements at the San Francisco Department of
Department of PublicHealthPublicHealthAIDS Office:AIDS Office:
HIV prevalenceHIV prevalenceamong MTF persons was among MTF persons was 35% 35% and 65%
and 65%among African-among African-American American MTFsMTFs..
Injection drug use was 34%Injection drug use was 34%among MTF among MTF
transgender individuals and
transgender individuals and18%18%among FTM among FTM transgender individuals.
transgender individuals.
55%55%of MTF individuals reported they had been of MTF individuals reported they had been
in alcohol or drug treatment sometime during in alcohol or drug treatment sometime during their lifetimes.
their lifetimes. Power Point Slide # 10-5, n40
Research
Research
A study from Hollywood, California, (
A study from Hollywood, California, (RebackRebackand and Lombardi1999) reported that the
Lombardi1999) reported that the drugs most drugs most commonly used by MTF transgender individuals commonly used by MTF transgender individuals were alcohol, cocaine/crack, and
were alcohol, cocaine/crack, and methamphetamine
methamphetamine
Other recent studies of transgender health risks Other recent studies of transgender health risks in urban areas around the country , including in urban areas around the country , including Boston, New York City, Washington D.C., Boston, New York City, Washington D.C., Chicago, Los Angeles and Houston, show Chicago, Los Angeles and Houston, show similar similar results with higher rates of substance abuse in results with higher rates of substance abuse in general and higher rates of substance abuse with general and higher rates of substance abuse with HIV prevalence, particularly among transgender HIV prevalence, particularly among transgender sex workers.
sex workers.
. .
Power Point Slide # 10-6, n41
HIV infection rates
HIV infection rates
have dropped
have dropped
among young gay
among young gay
white men and new
white men and new
infections are lower
infections are lower
among all gay men
among all gay men
than among their
than among their
heterosexual heterosexual counterparts counterparts FALSE FALSE
7 % infection rates7 % infection rates among 3,000 15
among 3,000 15--to 22to 22-
-year
year--old old young gay menyoung gay men sampled in a rigorous new
sampled in a rigorous new
CDC study (
CDC study (VilleoyVilleoy2000). 2000).
Fully one half of all new Fully one half of all new
infections
infectionsoccur among occur among
people
people younger than 25. younger than 25.
Young gay white menYoung gay white men form the largest group in
form the largest group in
this age bracket,
this age bracket, followed followed
closely by young gay
closely by young gay
black men.
black men.
Power Point Slide # 11-2, n2
There is
There is
overwhelming
overwhelming
evidence that verbal
evidence that verbal
and physical and physical violence against violence against LGBT youth of all LGBT youth of all backgrounds can backgrounds can lead to high
lead to high--risk risk
behaviors that
behaviors that
increase their risk
increase their risk
for substance abuse
for substance abuse
and HIV/AIDS
and HIV/AIDS
TRUE
TRUE
Youth who were victims of
Youth who were victims of
bias related harassment
bias related harassment
and/or violence are:
and/or violence are:
Twice as likely to report Twice as likely to report
bingeing on alcohol bingeing on alcohol(5(5- -plus drinks at one time) at
plus drinks at one time) at
least once in the past
least once in the past
month
month
Twice as likely to report Twice as likely to report
using marijuana using marijuanain the in the
past month
past month
Three to ten times as likely Three to ten times as likely
to report having tried to report having tried cocaine
cocaine
Two to three times as Two to three times as
likely to report having ever likely to report having ever tried hallucinogens, tried hallucinogens, depressants or stimulants depressants or stimulants Report of the Anti
Report of the Anti--Violence Documentation Violence Documentation Project from the Safe Schools Coalition Project from the Safe Schools Coalition of Washington (1997).
of Washington (1997).
Power Point Slide # 11-3, n3
Dynamics of Multiple Addictions
Dynamics of Multiple Addictions
Switching: Replacing on addiction
Switching
: Replacing on addiction
with another
with another
Alternating: Cycling from one
Alternating
: Cycling from one
addiction to another in a
addiction to another in a
patterned, systematic way
patterned, systematic way
Masking: Using denial around one
Masking
: Using denial around one
addiction to cover up for another
addiction to cover up for another
Ritualizing: one addiction is part
Ritualizing
: one addiction is part
of the ritualizing for another
of the ritualizing for another
Dynamics of Multiple
Dynamics of Multiple
Addictions
Addictions
Intensifying
Intensifying: Using addictive
: Using addictive
patterns simultaneously to
patterns simultaneously to
intensify the overall experience
intensify the overall experience
Numbing
Numbing: using addiction to
: using addiction to
medicate shame and pain due to
medicate shame and pain due to
another addiction
another addiction
Disinhibiting
Disinhibiting: Using one addiction
: Using one addiction
to lower inhibitions for other
to lower inhibitions for other
addictive acting out
Methamphetamine
Methamphetamine
Methamphetamine
Methamphetamine
Prevalence of people who have used Prevalence of people who have used
within the past 12 months is 0.6%
within the past 12 months is 0.6%
Prevalence rates for methamphetamine Prevalence rates for methamphetamine
use in the previous 6 months among MSM
use in the previous 6 months among MSM
in San Francisco range between 11%
in San Francisco range between 11%–– 17%
17%
Associated with high rates of HIVAssociated with high rates of HIV
1313--25% experience psychosis; 11x the 25% experience psychosis; 11x the
population
population
90% of gay men using 90% of gay men using methmethalso use also use
other drugs
other drugs
In New York City, rates of syphilis In New York City, rates of syphilis
increased 400% in the past 5 years. Gay
increased 400% in the past 5 years. Gay
men account for virtually the entire rise.
men account for virtually the entire rise.
Between 1998 and 2000, 15% of syphilis Between 1998 and 2000, 15% of syphilis
cases in Chicago were attributed to gay
cases in Chicago were attributed to gay
men. Since 2001, that number has grown
men. Since 2001, that number has grown
to 60%.
to 60%.
25% of men who reported 25% of men who reported methmethuse in the use in the
previous month were H.I.V+. The drug
previous month were H.I.V+. The drug
appears to double the risk of infection
appears to double the risk of infection
The number of men who say they use The number of men who say they use
condoms regularly is below 50%
condoms regularly is below 50%
The number of new H.I.V. diagnoses The number of new H.I.V. diagnoses
among gay men increased every year
among gay men increased every year
between 2000 and 2003. between 2000 and 2003.
Compulsive Sexual
Compulsive Sexual
Behavior
Behavior
Compulsive Sexual Behavior
Compulsive Sexual Behavior
Sexual thoughts, urges and
Sexual thoughts, urges and
behaviors that are normative
behaviors that are normative
Engaged in with a frequency or
Engaged in with a frequency or
intensity that leads to distress or
intensity that leads to distress or
impairment
impairment
CSB Behaviors
CSB Behaviors
Compulsive masturbation
Compulsive masturbation
85%
85%
Phone sex dependence
Phone sex dependence
31%
31%
Pornography dependence
Pornography dependence
73%
73%
Ego
Ego
-
-
dystonic
dystonic
promiscuity
promiscuity
50%
50%
Sexual chat room dependence
Sexual chat room dependence
40%
Characteristics
Characteristics
Begins in late adolescence
Begins in late adolescence
Peaks between ages 20 and 30
Peaks between ages 20 and 30
Ratio of males to females is 3:1
Ratio of males to females is 3:1
Minimum TSO of 7/week for at least
Minimum TSO of 7/week for at least
6 months
6 months
Health Concerns
Health Concerns
HIV and AIDSHIV and AIDS
HepatitisHepatitis SyphilisSyphilis STDsSTDs
Self-Self-EsteemEsteem
Nicotine dependenceNicotine dependence
Body Image, Sex, and
Body Image, Sex, and
Crystal
Crystal Meth
Meth
Eating Disorders
Eating Disorders
Gay men 3x more likely than
Gay men 3x more likely than
heterosexual men to have an
heterosexual men to have an
eating disorder
eating disorder
Often takes the form of
Often takes the form of
compulsive exercise
compulsive exercise
Steroid abuse
Steroid abuse
Problem Gambling and
Problem Gambling and
Compulsive Sexual Behavior:
Compulsive Sexual Behavior:
Unrecognized Co
Unrecognized Co-
-Occurring
Occurring
Disorders
Gay Men, Sex, Gambling
Gay Men, Sex, Gambling
105 men with pathological gambling
105 men with pathological gambling
Twenty
Twenty
-
-
two (21.0%) subjects
two (21.0%) subjects
identified themselves as gay or
identified themselves as gay or
bisexual
bisexual
Gay/bisexual men were more likely
Gay/bisexual men were more likely
than heterosexual men to report a
than heterosexual men to report a
lifetime or current behavioral
lifetime or current behavioral
addiction
addiction
15 (68.2) 37 (44.6) 29 (34.9)† 18 (81.8)†
Any MIDI diagnosis, n (%)
10 (12.0) 8 (9.6) 2 (2.4) 2 (2.4) 0 (0) 12 (14.5) 14 (16.9) 3 (3.6) 2 (2.4) 1 (1.2) 4 (18.2) 11 (50.0)‡ 0 (0) 0 (0) 0 (0) 5 (22.7) 13 (59.1)‡ 1 (4.5) 0 (0) 0 (0) Compulsive buying, n (%) Compulsive sexual behavior, n (%) Kleptomania, n (%) Trichotillomania, n (%) Pyromania, n (%) Current Lifetime Current Lifetime Heterosexual (n = 83) Gay/Bisexual (n = 22) MIDI Diagnosis
Addiction and Depression
Addiction and Depression
Self
Self-
-Harm and Suicide
Harm and Suicide
Gay men 7x more likely to have
Gay men 7x more likely to have
attempted suicide
attempted suicide
Gay youth comprise 30% of
Gay youth comprise 30% of
completed suicides annually
completed suicides annually
Gay and bisexual men have
Gay and bisexual men have
higher rates of deliberate self
higher rates of deliberate self
-
-harm
harm
Nicotine Dependence
Nicotine Dependence
Nicotine
Nicotine
20
20
-
-
24% of men and women smoke
24% of men and women smoke
Approximately 50% of adult gay men
Approximately 50% of adult gay men
and women smoke
and women smoke
Fewer gay men and women have
Fewer gay men and women have
made attempts to quit
made attempts to quit
Smoking associated with faster
Smoking associated with faster
progression to AIDS from HIV
progression to AIDS from HIV
Higher numbers of male partners
Higher numbers of male partners
correlate with higher rates of tobacco
correlate with higher rates of tobacco
use
use
Lung Cancer in PLWHA
Lung Cancer in PLWHA
Elevated incidence of lung cancer
As people with HIV live longer and
age, clinicians should be alert to the
possible diagnosis of lung cancer in
HIV-infected patients
Need to develop effective
interventions to assist individuals in
their attempts to quit smoking
Women: Cigarette Smoking and
Women: Cigarette Smoking and
HIV Prognosis in the HAART Era
HIV Prognosis in the HAART Era
(
(
highly active antiretrovirals
highly active
antiretrovirals)
)
Feldman JG, Minkoff H et al. The association of cigarette smoking with HIV prognosis among women in the HAART era—A report from the Women’s Interagency HIV Study. Am J Public Health 2006;96(6):1-6
Oral Health
Oral Health
HIV+ smokers are more likely to
HIV+ smokers are more likely to
develop
develop
•
•Oral candidiasisOral candidiasis
•
•PeriodontitisPeriodontitis
•
•Oral hairy leukoplakiaOral hairy leukoplakia
• •CancersCancers
Assessment and
Assessment and
Intervention
Intervention
Ask about interpersonal violence in privateAsk about interpersonal violence in private
Ensure confidentialityEnsure confidentiality
Ask questions in an affirming and culturally Ask questions in an affirming and culturally
sensitive manner sensitive manner
Empathize with clientEmpathize with client’’s feelingss feelings
Look for indicators of interpersonal violenceLook for indicators of interpersonal violence
Use thirdUse third--person examples to screen possible person examples to screen possible
batterers batterers
If a client is identified as either a victim or If a client is identified as either a victim or
batterer, refer him or her to an LGBT support batterer, refer him or her to an LGBT support group, to an LGBT affirmative batterers group, to an LGBT affirmative batterers’’ intervention program, and for ongoing intervention program, and for ongoing consultation with an LGBT domestic violence consultation with an LGBT domestic violence treatment expert
treatment expert
Treatment for Lesbian, Gay,
Treatment for Lesbian, Gay,
Bisexual, Transgender
Bisexual, Transgender
Individuals
Individuals
Curriculum for GLBT Substance
Curriculum for GLBT Substance
Abuse Treatment
Abuse Treatment
Prepared by
Prepared by
Prairielands
Prairielands
Addiction
Addiction
Technology Transfer Center (ATTC)
Technology Transfer Center (ATTC)
Anne Helene
Anne Helene
Skinstad
Skinstad
, PhD
, PhD
Jennifer
Jennifer
Kardos
Kardos
, MA
, MA
Candance
Candance
Peters, MA, CADC
Peters, MA, CADC
Barbara Warren
Barbara Warren
PsyD
PsyD
22 classroom hours
22 classroom hours
Overview
Overview
4 Modules: Overview, Cultural
4 Modules: Overview, Cultural
Issues, Legal Issues, and Treatment
Issues, Legal Issues, and Treatment
Approaches
Approaches
Clinician
Clinician
’
’
s Guide
s Guide
Administrative Guide
Administrative Guide
Neisen's
Neisen's
3
3-
-Phase Model
Phase Model
for Recovery From Shame
for Recovery From Shame –
–
Phase
Phase
I
I
Breaking the Silence
Breaking the Silenceparallels the process of parallels the process of coming out. It is important for LGBT individuals coming out. It is important for LGBT individuals to tell their stories and to address the pain of to tell their stories and to address the pain of being different in a heterosexist society being different in a heterosexist society..
Counselor Tasks:
Counselor Tasks:
1.
1. Facilitate client discussion of hiding LGBT Facilitate client discussion of hiding LGBT feelings from others
feelings from others
2.
2. Explore emotional costs of hiding/denying one's Explore emotional costs of hiding/denying one's sexuality
sexuality
3.
3. Discuss how the client has tried to fit in and at Discuss how the client has tried to fit in and at what cost
what cost
4.
4. Examine negative feelings of selfExamine negative feelings of self--blame, feeling blame, feeling bad or sick, and the effect of shaming messages bad or sick, and the effect of shaming messages on client
on client
5.
5. Foster client's ability to be out Foster client's ability to be out
Power Point Slide # 5-11
Phase Two: Establishing Phase Two: Establishing Perpetrator Responsibility Perpetrator Responsibility
Allows clients to understand their struggle in Allows clients to understand their struggle in the context of societal discrimination and the context of societal discrimination and prejudice.
prejudice.
Counselor Tasks
Counselor Tasks: :
1.
1. Facilitate focusing and, managing anger Facilitate focusing and, managing anger constructively, not destructively constructively, not destructively
2.
2. Help client understand and accept negative self-Help client understand and accept negative self -image as socio cultural, not personal
image as socio cultural, not personal
3.
3. Counteract client's experience of heterosexism Counteract client's experience of heterosexism and homophobia by role
and homophobia by role--modeling and by modeling and by providing a treatment environment that is providing a treatment environment that is empowering for LGBT persons, not empowering for LGBT persons, not stigmatizing.
stigmatizing. Power Point Slide # 5-12
Phase Three:
Phase Three:
Reclaiming Personal Power
Reclaiming Personal Power
Involves improving self
Involves improving self--concept, selfconcept, self--esteem, esteem, and self
and self--confidenceconfidence
Counselor Tasks
Counselor Tasks::
1.
1. Facilitate client's self-Facilitate client's self-concept and selfconcept and self--efficacyefficacy
2.
2. Identify and change negative messages to Identify and change negative messages to affirmations
affirmations
3.
3. Recognize and release residual shame Recognize and release residual shame
4.
4. Develop a positive affirming spiritualityDevelop a positive affirming spirituality
5.
5. Integrate public and private identitiesIntegrate public and private identities
6.
6. Build a support network, connect to communityBuild a support network, connect to community
Special Issues for Lesbians
Special Issues for Lesbians
1.
1.
Multiple stigmas and stressors
Multiple stigmas and stressors
related to sexism, lesbian
related to sexism, lesbian
identity, and substance use
identity, and substance use
2.
2.
Relationships as a major
Relationships as a major
treatment focus for all lesbians
treatment focus for all lesbians
3.
3.
Relapse
Relapse
to protect themselves
to protect themselves
from painful feelings
from painful feelings
surrounding their sexuality
surrounding their sexuality
Power Point Slide # 7-8, n21Special Issues for Gay Men
Special Issues for Gay Men
1.
1.
Linking of substance abuse and
Linking of substance abuse and
sexual expression
sexual expression
2.
2.
Internalized homophobia
Internalized homophobia
3.
3.
The role of sexual abuse and
The role of sexual abuse and
violence
violence
4.
4.
Limited social outlets
Limited social outlets
Power Point Slide # 8-6, n27
Clinical Issues and
Clinical Issues and
Implications for Treatment
Implications for Treatment
1.
1. Issues about Issues about
appearance, appearance, "passing" and "passing" and body image body image 2.
2. History of hiding History of hiding
or suppressing
or suppressing
gender identity
gender identity 3.
3. Lack of family and Lack of family and
social support
social support 4.
4. Isolation and lack Isolation and lack
of connection to of connection to positive, proactive positive, proactive transgender transgender community community resources resources 5.
5. Hormone therapy Hormone therapy
and use or
and use or
injection history
injection history 6.
6. Stigma and Stigma and
discrimination discrimination 7. 7. Employment Employment problems problems 8. 8. Relationship/child Relationship/child custody issues custody issues
Power Point Slide # 10-7, n42
Summary
Summary
Conclusions
Conclusions
Addictions appear to be common in the
Addictions appear to be common in the
GLBT
GLBT commuity
commuity
Frequently co
Frequently co-
-occur with other disorders and
occur with other disorders and
health issues
health issues
Treatment interventions should to target
Treatment interventions should to target
issues within the community and
issues within the community and
comorbidities