Substance abuse and dependence
within the gay/lesbian community
California State University, Long Beach
This paper examines the prevalence and risk factors of chemical abuse and dependence within the gay and lesbian community. From an extensive review of published literature concerning the gay and lesbian community of the different stressors that may lead to substance abuse as well as the related risks of HIV transmission and infection, this paper concludes that further research and better education are necessary. They are necessary in order to acknowledge the unique experiences, stressors, and confusion that homosexual men and women suffer from as they go through life. These experiences of growing up gay in a homophobic society build a unique history and influence one’s interpretation of the world; better education may lead to improved treatment and prevention.
Substance abuse and dependence
within the gay/lesbian community
Throughout history substance abuse and dependence have been and continue to be an important area of extensive research because they affect the psychological and physiological health of individuals who engage in these behaviors as well as the people surrounding them. Substance abuse and dependence continue to be highly related to car accidents, and they are associated with violent deaths like homicide and suicide (Rivera, Mueller, Somes, Mendoza, Rushforth & Kellerman, 1997). Furthermore, there is a distinct connection between substance abuse and expression of violence. People who consume more alcohol are more likely to become violent (Chermack, Dingell, Walton, Fuller, & Blow, 2001). Also, substance abuse is related to inappropriate and dangerous behavior that may lead to harsh consequences such as risky sexual behavior and suicide (Stephen, Chermack, Walton, Fuller & Blow, 2001).
Due to the negative outcomes of substance abuse, it is important to look at the different subgroups that exist within the United States. A closer look within these subgroups may help understand the unique historical and cultural background that may place an individual at greater risk for substance abuse and dependence. By acknowledging these differences, clinicians will be able to provide better therapy, treatment, and intervention methods. Accordingly, it is very important to look within the gay and lesbian community when it comes to substance abuse and dependence because individuals in this specific population experience stress, anxiety, and depression which is directly related to their sexual orientation, and these factors may lead to the problem of substance abuse and dependence (Rotheram-Borus & Rosario, 1994). Further, substance abuse in this population is highly correlated with risky sexual behaviors and HIV/AIDS infection and transmission (Hauer et al., 1984; as cited by Israelstam &Lambert, 1986). This paper will examine the prevalence and risk factors of substance abuse and dependence within the gay and lesbian community.
According to the DSM-IV (APA, 1994), substance abuse is defined as the use of substances in a manner that impairs and harms either the individual and/or the people around him/her. The individual may have problems with the law and continue to abuse in spite of recurring legal problems. The individual may also continue to use in spite of having social problems, such as losing touch with friends and even physical fights. Individuals may continue to use the substance even when it becomes dangerous to do so. For example, they may drive under the influence. The criteria to diagnose substance abuse includes a maladaptive pattern that causes impairment or distress for a minimum of 12 months and may be demonstrated by one or more of four maladaptive behavioral patterns. The maladaptive behavioral patterns include: inability to perform important tasks, continuing to use when it becomes dangerous, encountering problems with the law, and having social deficiencies (Morrison, 2001). See table 1 for a complete listing of DSM-IV (APA, 1994) criteria for substance abuse.
The main difference between substance abuse and dependence is that unlike substance abuse, dependence includes building tolerance, experiencing withdrawal, and inability to stop using the substance. Substance dependence is defined as the maladaptive and repetitive use of substances that causes significant distress or impairment. The behavior needs to be clinically important, which means that it was brought to the attention of professionals because the use is interfering with the individual’s life. The criteria to diagnose individuals with substance dependence includes a maladaptive behavioral pattern that brings about clinically important distress for a period of at least 12 months. (Morrison, 2001). See table 2 for a complete listing of the DSM-IV (APA, 1994) criteria for substance dependence.
It is important to study the prevalence of substance abuse and chemical dependence within the gay and lesbian community. This way clinicians will be able to assess the problem more accurately and examine whether or not growing up as gay or lesbian is actually related to higher rates of substance abuse and dependence. Reports show that over 16.6 million people, both homosexual and heterosexual, age 12 and older in the United States have substance abuse and dependence problems (Cheng, 2003). In a national household survey, higher rates of substance abuse were found among gay and bisexual men compared to heterosexual men (National Institute on Drug Abuse, NIDA, 1992). Previous research has found drinking problems in up to two thirds of lesbians and one third of gay men (Bux, 1996). McKirnan &Peterson (1989; as cited by Anderson, 1996) found a higher prevalence rate of substance use among the gay and lesbian population compared to heterosexuals and the general population. They showed that only 14% of gay and lesbian individuals abstained from alcohol compared to 29% of the general population. Gay men and lesbians showed higher rates of moderate consumption of alcohol (71%), and heavy consumption of alcohol (15%), as compared to the heterosexual population for whom the prevalence rates for moderate drinking was 57% and heavy drinking was 14%. McKirnan &Peterson (1989; as cited by Anderson, 1996) also showed higher rates of marijuana use (56%) for gay and lesbians compared with 20% for the heterosexual population, and higher rates of cocaine use (23%) for the gay and lesbian population compared with 8.5% among the general population.
Accordingly, Cochran, Keenan, Schober and Mays (2000) examined the patterns of alcohol abuse and treatment among adults who were interviewed through a 1996 National Household Survey regarding drug abuse. Respondents were divided into two groups. One group consisted of people who were sexually active with a partner of the same sex, and the second group consisted of people who were sexually active with a partner of the opposite sex. The two groups were compared. The survey found that homosexual women consumed alcohol more frequently and in larger amounts compared to heterosexual women. According to Skinner (1994; as cited in Cochran, Keenan, Schober & Mays 2000), the likelihood of consuming alcohol regularly is higher for gay men and lesbian women compared with other heterosexual Americans. However, a study by Stall and Wiley (1988) examined unmarried men ages 25-54 who live in San Francisco. They found that homosexual men were at no higher risk of engaging in heavy drinking than heterosexual men (as cited by Cochran, Keenan, Schober & Mays, 2000).
Sandfort, de Graaf, Bijl & Schnabel (2001) studied the relationship between homosexuality and psychiatric morbidity. Seven thousand and seventy six subjects of the Dutch population, ages 18-64, were interviewed face-to-face using to the Composite International Diagnostic Interview. Results of the study showed that homosexual men and women was at greater risk for psychiatric disorders. They also found that substance abuse among homosexual women were higher compared to heterosexuals. In addition to that, Skinner (1994; as cited by Anderson, 1996) found that the prevalence of drug use was higher for homosexual men and women compared with the general population.
Possible causes for substance abuse and dependency
Stress and depression.
Stress can be defined as external or internal events that are too difficult for an individual to endure, and it may cause psychological or physical problems (Meyer, 2003). Gay men and lesbian women may experience increased stress due to society’s negative attitudes regarding their sexual orientation. That stress may then be related to drug abuse and alcohol consumption within the gay and lesbian community (Rotheram-Borus & Rosario, 1994). Homosexual men and women are very susceptible to stress and are vulnerable to negative experiences in association with their sexual orientation (Rotheram-Borus, Rosario & Koopman, 1991; as cited by Rotheram-Borus & Rosario, 1994).
Research also shows that homosexual men and women have a higher risk of suffering from depression and anxiety compared to their heterosexual counterparts (Hughes &Ellison, 2002). Lewis, Derlega, Griffin & Krowinski (2003), examined the relationship between life stressors that are related to depression. They looked specifically within the gay and lesbian community. Two hundred and four men and women who identified themselves as either gay, lesbian, or bisexual completed a variety of self-report measures. The self-report measures included a Measure of Gay-Related Stressors, a Life Event Scale, an Internalized Homophobia Scale ( Lewis et al., 2002; as cited by Griffin & Krowinski, 2003), A Stigma Consciousness Questionnaire (SCO; Piner, 1999; as cited by Griffin & Krowinski, 2003), a Measure of Openness (Frank & Leary, 1991; as cited by Griffin & Krowinski, 2003), the Center for Epidemiological Studies- Depression questionnaire (CES-D; Radloff; 1977, as cited by Griffin & Krowinski, 2003). The results of the study showed that homosexual individuals go through stressful life events that are positively correlated with their sexual orientation. These stressful life events were related to depression. Individuals who experienced more gay related stress were found to be more depressed.
Accordingly, a study by Lock & Steiner (1999) examined the susceptibility of gay, lesbian and bisexual youth to poor mental and physical health. By using a self-report survey, they assessed the mental, social and behavioral health of 1,769 high school students. They found that gay and lesbian youth were at increased risk of mental health problems. Lock & Steiner (1999) also argued that gay, lesbian, and bisexual youth are in danger of becoming depressed, homeless, suicidal and chemically dependent. Also, gay men and women may go through a substantial amount of stress that is connected to their work place. These stressors arise from having to hide one’s sexual orientation and keep a “fake” heterosexual-self in front of co-workers and friends, and may even go as far as having to listen to gay jokes told by those co-workers (Hughes &Ellison, 2002).
As a result, according to Lazarus and Folkman (1982; as cited by Savin-Williams, 1994), gay and lesbian individuals may use substances in order to self medicate and to suppress their stress and depression. They may use substances in order to justify homosexual behavior in order to avoid the embarrassment they may feel about their sexuality.
Drug use and alcohol consumption may also provide an opportunity to be accepted by others, and being high or drunk can provide an acceptable explanation for their homosexual behavior by claiming that they were under the influence when the behaviors took place. The fact that the individual was high or drunk and not in full control of his/her behavior can provide a rational explanation for that individual’s behavior which he/she feels will be viewed as unacceptable by the general population. (Rotheram-Borus et al., 1995, & Savin-Williams, 1994; as cited by Jordan, 2000). The meaning homosexual individuals may attach to substance abuse may be different from the meaning heterosexuals attach to the same behavior. Since we live in a society that is predominantly heterosexual and that is un-accepting of homosexuality, gay and lesbian individuals may use substances in order to make it easier for them to handle the embarrassment of being gay (Nicoloff &Stigilitz, 1987; as cited by Anderson, 1996). According to Mckirrnan & Peterson (1989), participants claimed that during the periods when they were heavily consuming alcohol, they had not yet accepted their sexual orientation and were living as heterosexual individuals. They even reported that they used the alcohol as a way to avoid the issue of sexual orientation (as cited by Bux, 1996).
According to Fielde (1975; as cited by Saulnier & Miller, 1997), the social isolation that many individuals from the gay and lesbian community experience contributes to their increased problem with substance abuse. Many homosexual individuals have experienced so much homophobia and heterosexism that it has become impossible for them to participate in homosexual sexual behavior without being under the influence of either alcohol or illegal drugs; this way, they do not have to confront their sexuality (Anderson, 1995). According to Feinstein & Looney (1982; as cited by Coolay 1998), gay and lesbian youth receive positive reinforcement for acting like heterosexuals, and so they attempt to hide their sexual orientation and live their lives as heterosexual individuals. The fact that they are deceiving their peers creates stress in any relationship they are trying to form and often results in a great sense of isolation. Homosexual individuals may feel isolated and rejected by family, friends, religious and educational institutions, and they may feel like they need to hide in order to avoid verbal and physical abuse from the heterosexual society (Martin & Hetrick, 1988; as cited by Savin-Williams, 1994). Hiding one’s sexual orientation increases feelings of loneliness and isolation (Martin & Hetrick, 1988; as cited by Savin-Williams, 1994). Homosexual individuals experience feelings of isolation due to the rejection of their sexuality by the mainstream society (Roesler &Deisher, 1972; as cited by Savin-Williams, 1994). Using drugs and consuming alcohol may provide gay men and lesbian women with special opportunities for human contact and social interaction, which may positively reinforce the substance use and increase its frequency of use (Fielde, 1975; as cited by Saulnier & Miller, 1997).
Verbal and Physical Abuse.
In addition to the social isolation that homosexual men and women go through, they also may suffer from the fear of being verbally and physically abused due to their sexual orientation (Savin-Williams, 1994). Savin-Williams (1994) reviewed the physical and verbal abuse that gay and lesbians suffer from, and how it relates to problematic behaviors like substance abuse, prostitution, and suicide. He found that chronic stress is associated with verbal and physical abuse, especially when the abuse comes from friends or family members. According to the Center of Population Options (1992; as cited by Savin-Williams, 1994), it is very challenging to grow up as gay or lesbian in a society that is largely anti-homosexual. Gay and lesbian individuals have to deal with rejection, isolation, harassment and violence, and so, the risk of developing some kind of problematic behavior increases. All of these stressors that gay and lesbians individuals may endure create a unique history, which may influence the way they interpret the world. As a consequence homosexual men and women as a group may have a frame of reference that is different than that of heterosexuals due to their qualitatively different histories. Since everything we see, hear, or feel is filtered through our frame of reference, homosexuals and heterosexuals may attach different meanings to the same experiences.
Another major factor that exists in the gay and lesbian community that may contribute to substance abuse and dependence is what is referred to as the “bar scene”. The homosexual lifestyle is largely oriented around gay bars as places for social interaction (Bux, 1961). According to Zhankun (2003), bars in the gay community function as places where individuals can socialize in a stigma-free environment, creating a community where drinking is not only accepted, it is welcomed. Since the gay and lesbian community does not provide enough organizations and activities for gay people where they would be able to socialize, they are left with gay bars and clubs (Zhankun, 2003). Homosexuals are many times turned away from community organizations like churches and even school clubs, so they turn to the clubs and the bars where they feel accepted (Zhankun, 2003). Gay bars have been described as the gay social center (Cory ,1951; as cited by Israelstam &Lambert, 1986). They are places that are free from heterosexual judgment and hatred (Benshoff & Janikowski, 2000; as cited by Cheng, 2003).
Warwick, Douglas, Agletton &Boyce (2003) studied the benefits of HIV/AIDS education at four different gay bars in London. Thirty-nine participants were interviewed regarding issues concerning HIV and their experience at the gay bars for a period of 15-30 minutes. Participants were also observed. The study found that gay individuals enjoy the gay bar because it provided them with a safe environment, with similar people and, without physical or emotional threat, which they may experience around heterosexual individuals. Perceiving the gay bar as a safe and accepting place contributes a lot to its popularity among gay and lesbian individuals. This perception of the gay bar as safe and accepting, as well as its popularity may contribute to the acceptance and popularity of substance use among gay and lesbian individuals.
Homophobia and internalized homophobia
Homophobia is a term that needs to be defined when talking about the different and unique stressors that gay and lesbian individuals experience. Homophobia refers to anti-homosexual attitudes and fears that are expressed by the general society. Internalized homophobia refers to anti-homosexual feelings beliefs and attitudes that are held by homosexual individuals because they have been incorporated into the self after growing up in a homophobic society (Cabaj, 2000). This fear and dislike accompany the life of homosexual men and women and may significantly affect their mental and psychological health (Cabaj, 2000). Both of these terms are related to feelings of depression, confusion and anxiety, which in turn may lead to heightened susceptibility and rates of substance abuse. Cabaj (2000) reviewed the different factors that contribute to internalized homophobia from the psychodynamic perspective and how that internalization relates to substance abuse. He argued that homophobia is an enormous negative influence that homosexuals endure, and that growing up in this homophobic environment causes homosexuals to internalize these homophobic attitudes. These attitudes result in feelings of shame, anxiety, depression, isolation and helplessness. Substance abuse offers a relief from these unpleasant feelings.
In addition to that, Rowan, Malcolm & Psychol (2002), examined the relationship between internalized homophobia and different stages of homosexual identity formation. In this study, 96 homosexual men answered a questionnaire. The questionnaire included six different sections. The first section included demographic information. The second section of the questionnaire identified where each participant was in terms of his or her homosexual identity formation. The third section measured self-concept and self-esteem, using the Self-Description Questionnaire III (SDQ III, Marsh, 1991). The forth section used the Mosher Sex Guilt Inventory (Mosher, 1979) to measure feelings of guilt regarding one’s sexuality. The fifth section included an Internalized Homophobia Scale (Ross & Rosser, 1996) in order to measure the degree to which the participants suffered from internalized homophobia, and the sixth section included the Perception of Repression Environment Scale (Rowan, Malcolm & Psychol, 2002). Results of the study showed a negative relationship between internalized homophobia and homosexual identity formation. Individuals who reported higher levels of internalized homophobia were shown to also reported a less developed homosexual identity, lower self-esteem and self-concept, and higher levels of guilt regarding their sexuality.
When it comes to substance abuse within the gay and lesbian community, there is extensive research specifically concerning the differences between lesbian women and heterosexual men and women. Jaffe, Clance, Nicholas & Emshoff (2000) examined the relationship between alcoholism among lesbians and feelings of alienation. Eighty-seven lesbians and 89 heterosexual women answered questionnaires. The researchers found that alcoholism was more prevalent among lesbians. Interestingly, the two groups did not differ in terms of alienation, which suggests that feelings of alienation among lesbians cannot explain the higher rates of alcoholism. One explanation for the finding might be that the alienation felt by lesbians is qualitatively different than the alienation that was measured by the Dean Alienation Scale (Dean 1961), which measures helplessness and powerlessness that is also felt by heterosexual women. Lesbians might experience alienation in terms of internalized homophobia, prejudice, and discrimination, which in turn may explain the higher rates of alcoholism in that community. Saulnier & Miller (1997) studied the differences between heterosexual women, lesbians and bisexuals, in overall substance abuse. They used a clinical sample of 572 women ages 18 through 45. Participants were questioned about the quantity and frequency of their alcohol consumption and/or drug use. They found that there was no significant difference in alcohol consumption between lesbian/ bisexual women and heterosexual women; however, lesbians and bisexual women reported using marijuana more frequently than heterosexual women. A study by Skinner and Otis’ also found that lesbians are more likely to abuse marijuana and cocaine (36.1% of lesbians as compared to 8.2% heterosexuals), (1990; as cited by Soulnier & Miller, 1997). Fifield (1975), Saghir & Robins (1963) and Weathers (1976) reported that lesbians engage in heavier consumption of alcohol as compared to heterosexual women, and that up to one in three lesbians suffered from alcoholism and needed some intervention to recover from it (as cited by Soulnier & Miller, 1997). Bux (1996) and MacKirnan and Peterson (1989) found that homosexual women and heterosexual men share similar patterns of alcohol consumption including increased likelihood of alcohol dependence and treatment for alcohol related problems (Cochran, et al. 2000). This information strengthens the belief that individuals within the lesbian community are more susceptible to substance abuse disorders.
Health implications specific to the gay community
Sexual behavior and substance use.
Since research shows that substance use and abuse is prevalent within the gay and lesbian community, it is important to examine whether there is a relationship between the use of drugs and alcohol and sexual behavior. A study by Rotheram-Borus, Rosario, Mayer-Bahlburg, Dopkins & Davies (1994), examined the sexual and substance abuse behaviors of 131, 14-19 year old, gay and bisexual adolescents. Participants answered a questionnaire that assesses the participants’ past and current sexual behavior. They also answered a survey, which examined past and current substance use. The researchers found that compared to the heterosexual adolescents, gay and bisexual adolescents had higher rates of alcohol and drug use. Moreover, substance use was related to risky sexual behavior, including exchanging sexual favors for drugs and reduced use of condoms.
Myers et al. (2002) studied the relationship between sexual behavior and substance use. Twenty-seven Canadian men were interviewed. Interviews included open-ended questions in a semi-structured format and lasted up to 90 minutes. Results of the study showed that the use of substances in order to enhance, prolong, facilitate and increase sexual encounters and performance is common within the gay and lesbian community. Participants claimed that sex is better when it is combined with drugs and/or alcohol. According to this study, substance abuse was related to sexual behavior. It allowed individuals to feel more self-confidence in themselves and behave more sexually towards others, and it made it easier to participate in and initiate sexual contact.
Research about chemical dependency and substance abuse among the gay and lesbian community has important public health implications. There is a relationship between drug abuse and dependence within the gay and lesbian community and the transmission of the HIV virus, which is the leading cause of death in the gay community (Hauer et al., 1984; as cited by Israelstam &Lambert, 1986; Anderson, 1996). Also, alcohol use may cause a decrease in white blood cells, which negatively affects the immune system and may make the abusers more susceptible to the transmission of diseases (Hauer et al., 1984; as cited by Israelstam & Lambert, 1986; Anderson, 1996). To examine the relationship between sexual behavior and substance abuse among homosexual and bisexual men, Rotheram-Borus and Rosario (1994) recruited 138 males ages14 to 19. Participants were asked to respond to sexual items. They found that drug use and alcohol consumption were related to a greater number of sexual partners as well as participation in oral or anal sex. Substance abuse was also related to the non-frequent use of condoms. According to Stall, Wiley, McKusick, Coates and Ostrow (1986; as cited by Rotheram-Borus & Rosario, 1994), information from focus groups and discussions with homosexual adolescent men showed that drugs and alcohol use is related to a loss of inhibition sexually and to increased HIV transmission. Moreover, heavy alcohol consumption is related to more risky sexual behavior and other behaviors associated with HIV transmission. (Stall, McKusick, Wiley, Coates & Ostrow, 1986; as cited by Keenan, Schober & Mays, 2000).
Another study by Kalichman, Tannenbaum & Nachimson (1998) examined the relationship between substance abuse, sexual activity, and sensation seeking. Two hundred and eighty nine men, who attended a gay pride parade, completed a survey concerning HIV/AIDS, sexual behavior, and substance abuse. The study found that gay and bisexual men abuse drugs and alcohol frequently in the context of sex and that risky sexual behavior is related to sensation seeking. Therefore, one could conclude that substance abuse and high-risk sexual activity are closely related.
In contrast, Ryan, Huggins and Beatty (1999) studied the association between substance abuse and the risk of HIV infection. They asked 187 gay men who had previously been tested for HIV to answer a questionnaire assessing their drug use, sexual behavior, and demographic information. The participants also went through individual interviews. They found that there was not enough evidence to support the idea that increased risk of HIV infection can be caused solely by abusing alcohol. An elevated risk of HIV infection was related only to those subjects who could be diagnosed with both alcohol and other substance dependencies. However, Kelly et al., (1991, as cited by Ryan, Huggins & Beatty, 1999) argued that heavy drinking among gay men was related to participation in unsafe sex, which may lead to the transmission of the virus. Also, the use of stimulants and the incidence of unprotected, anal sex were highly related (Klee, 1992, as cited by Halkitis, Parsons, and Stirratt, 2001).
When it comes to treatment of substance use and abuse within the gay and lesbian community, there is still a lot to learn and modify. Both assessment and treatment is plagued with heterosexual prejudice due to limited knowledge by therapists, and by the fact that in most cases, gay and lesbian individuals will not discuss their sexual orientation in the context of therapy (Rbin, Keefe, & Burton, 1986; as cited by Anderson, 1996). By avoiding the issue of sexuality, therapists may be missing some important factors that would help lead the client into sobriety (Shernoff & Finnegan, 1991). Prior to 1973, when homosexuality was not yet removed from the DSM and was regarded as a disorder, therapists attempted to “fix” the homosexuals’ sexual orientation by converting them into becoming heterosexuals before attempting to deal with their addiction problems (Cheng, 2002; as cited by Cheng 2003). Some mental health therapists today still subscribe to this old opinion (Cabaj, 1996; Committee on Lesbian and Gay Concerns, 1990; as cited by Cheng, 2003). Hellman, Stanton, Lee, Tytun, &Vachon (1989; as cited by Anderson, 1996) described therapists’ training regarding gay and lesbian issues as non- existing, and De Crescenzo (1984; as cited by Anderson, 1996) added that homophobia exists within the mental health professionals. The homophobia and heterosexism that exists among mental health professionals may create fear among gay and lesbian individuals when it comes to seeking treatment; these individuals may have already experienced prejudice, mistreatment and lack of understanding in therapy (Bux, 1996).
When working with an individual in therapy, it is very important to examine that individual’s living environment and family system. It is impossible to separate the individual from his/her environment. Homosexual clients may come from a family with predominantly heterosexual beliefs and values, which causes the growing up process to be dysfunctional because it pushes the individual to form a “false self” (Shernoff & Finnegan, 1991). Therapists should be ready and willing to confront these issues of sexuality and not avoid them. They should assess what stage of the coming out process their client is in. Is the client in denial about his/her sexual orientation or is he/she comfortable with it and has accepted it? (Anderson, 1995).
As mentioned above, substance abuse and chemical dependency is one of the leading causes of violent deaths and suicide (Rivara et al., 1997). Therefore, it is important to keep on searching for effective methods of treatment and prevention. In order to provide the best therapy possible, we need to explore the different subgroups that exist in the United States. Only then we will be able to understand the different factors that may lead to substance abuse and addiction. Further research concerning the gay and lesbian community is very important because members of that community go through a substantial amount of unique stressors throughout their life that are directly associated with their sexual orientation (Rotheram-Borus & Rosario, 1994). Homosexual men and women are more likely to suffer verbal and physical abuse from strangers, peers, and family members compared with the general public (Martin & Hetrick, 1988; as cited by Savin-Williams, 1994). They may also suffer from social isolation, alienation, and depression. Substance abuse may be a way of self-medicating. Homosexual individuals may also internalize society’s homophobic attitudes; therefore, they may use these substances in order to justify their homosexual behaviors. These stressors may contribute to substance abuse and risky sexual behavior which is highly correlated with the transmission and infection of the HIV virus. There is still a lot to learn and change when it comes to treatment of substance abuse within the gay and lesbian society. Clinicians who wish to provide an effective and appropriate treatment for gay and lesbian indeviduals who suffer from substance abuse problems should seek further education in order to learn more about gay and lesbian issues.
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The patient’s maladaptive substance use pattern causes clinically important distress or impairment, as shown in a single 12-month period by one or more of the following:
- Because of repeated use, the patient fails to carry out major obligations at work, home
- The patient repeatedly uses substances even when it is physically dangerous to do so.
- The patient repeatedly has legal problems resulting from the substance use.
- Despite of knowing that it has caused or worsened social or interpersonal problems, the patient continues to use the substance.
- The patient has never fulfilled the criteria for substance dependence.
DSM-IV (APA1994, pp. 68-69) Diagnostic criteria for substance dependency.
The patient’s maladaptive pattern of substance use leads to clinically important distress or impairment, as shown in a single 12-month period by three or more of the following:
- Tolerance, shown by either of these:
*Markedly increased intake of the substance is needed to achieve the same effect.
*With continued use, the same amount of the substance has markedly less effect.
- Withdrawal, shown by either of these:
* The substance’s characteristics withdrawal symptom is experienced
* The substance (or one closely related) is used to avoid or relieve withdrawal symptoms
- The amount or duration of use is often greater than intended.
- The patient repeatedly tries without success to control or reduce substance use.
- The patient spends much time using the substance, recovering from its effects, or trying to obtain it.
- The patient reduces or abandons important work, social, or leisure activities because of substance use.
- The patient continues to use the substance, despite knowing that it has probably caused ongoing physical or psychological problems.