Out On The Couch
“Grant me the serenity to accept the things I cannot change, the courage to change the things that I can, and the wisdom to know the difference.”
In 12-step treatment settings, the Serenity Prayer often makes an appearance at the beginning or end of a group session. Drawn from the Christian tradition, reciting this prayer is intended to unite group members, reminding them to make the small choices every day that will help them maintain their sobriety from substance use. Some things, like developing healthy coping skills, are within the client’s control. With access to resources, a supportive sober community, and for many, clinical treatment, recovery from substance abuse can and does happen.
But what about those things that are outside of our clients’ control? For many LGBTQIA+ people, factors like homophobia, transphobia, family rejection, and discrimination complicate the recovery process. These systemic forces weigh on our clients along with the pressures of finding a support network, managing basic needs like shelter and food, and learning new coping skills for cravings and mental health symptoms. While recent years have seen an increase in resources allocated for people in recovery, navigating this system can be challenging. It can also be isolating as an LGBTQIA+ person to successfully start treatment for substance abuse, only to arrive on day one and be the only queer and/or trans person in the room. How can a client find sober support when they feel singled out? And how can they mitigate the overtly Christian themes of 12-step and other sober communities as a queer and/or trans person?
As treatment providers, it is important for us to practice cultural humility and establish competence in LGBTQIA+-affirming therapy in our substance use treatment. The 2018 National Survey on Drug Use and Health revealed that in sexual minority adults–those who described themselves as lesbian, gay, or bisexual–37.6% reported marijuana use in the past year, compared with 16.2% in the general population (Drugabuse.gov). This suggests that it is likely that many of your clients identify as part of the LGBTQIA+ community, and will be looking to you to cultivate an environment that is both affirming of their identities and informed about how substance abuse may impact their community differently. While this process of learning and unlearning is a lifelong commitment to growing your clinical practice, starting to research and reflect is a great place to start.
Using a barriers model to accessing treatment, there are several elements that may deter LGBTQIA+ clients from seeking services. First, to reiterate, substance abuse treatment is often heavily rooted in Christianity. While many in recovery find comfort in finding a higher power and drawing strength from their faith community, for others, the church has historically been a place of harm and rejection. The idea alone of going to an Alcoholics Anonymous meeting in the basement of a church might feel like walking into the lion’s den. AA and other 12-step groups also often use literature like the Big Book and daily devotionals that have been criticized for their gendered language and heteronormative themes. This may lead LGBTQIA+ clients to feel as though they do not fit into the recovery community.
Similarly, many treatment programs themselves are gendered. From settings such as sober housing to residential treatment, as well as within intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs), many groups are gender segregated. Veteran treatment providers may remember the original logic for this decision as preventing group members from starting romantic relationships while in treatment, or perhaps to give clients a “safe place away from the opposite sex.” We know now that this line of thinking is flawed: it erases the existence of same-sex relationships.
While many treatment programs do recommend that clients refrain from starting new relationships while they are in the vulnerable period of early recovery, it is naive to think that two members of a women’s discussion group could not start dating. Additionally, that “safe place” we are trying to establish for our clients must also take into account gender-expansive identities. How can we properly serve our transgender and non-binary clients if we only offer women’s and men’s treatment programs? If you are at the level of executive leadership in your agency, asking these questions is a good place to start in establishing accessible and equitable treatment provision.
It is also important for clinicians to understand how substance abuse can impact different populations within the LGBTQIA+ community. Since the 1970s, for example, the vasodilator inhalant “poppers” has been a club drug popular among gay men, as it can produce a euphoric effect and relax smooth muscle in the body, making sex more pleasurable (Hall et al., 2014). Other club drugs, like methamphetamines and cocaine, have been commonly used among gay and bisexual men as well (Hazelden Betty Ford, 2016). Similarly, when considering substance use in social settings, research indicates that lesbians and gay men are less likely to abstain from alcohol use than their straight counterparts, with lesbian and bisexual women reporting more frequent heavy drinking (Green & Feinstein, 2013).
Further, it is worth noting that for LGBTQIA+ clients, seeking substance abuse services is an issue of access to healthcare. According to Faces and Voices of Recovery, a 2017 survey by the National Institute on Drug Abuse (NIDA) found that 77% of respondents identifying as gay, lesbian, or bisexual, and only 57% of those identifying as transgender, have access to affordable healthcare (Pennelle, 2019). While many substance abuse treatment agencies are funded by state programs like Medicaid, and do not require that clients have health insurance, others do require coverage. Still more are private-pay only, and can get quite expensive. For someone who is contemplating starting treatment, finding out that they are not able to afford it or that a state-funded program has a long wait list can be enough to push them back to a state of precontemplation.
As we know that substance abuse affects the LGBTQIA+ community at higher rates, and that it can impact various LGBTQIA+ populations differently, service provision may seem like a daunting task. Whether your role is as a case manager, a therapist, or a program director, there are a number of resources that you can offer to your clients as they start their recovery journey. While the best place to start is by making changes within your own agency, you may also want to review community resources. One place to start is calling 211, a nationwide service provided by the United Way. Whether you call or go online for information, a trained resource navigator can help you to identify LGBTQIA+ specific resources like sober support group meetings, sober housing, and more. Keeping in mind that many queer clients may not feel comfortable going to traditional 12-step meetings, an alternative to consider is SMART Recovery. This program uses a non-denominational approach to promote sobriety using science- and evidence-based interventions, and may appeal to clients seeking a peer support group without religious overtones. Another option may be looking into support groups or other resources through your local LGBTQIA+ center, or services on campus at your local college or university.
Revisiting the idea of the Serenity Prayer, we as clinicians do not have to accept the things we cannot change in the substance abuse treatment community. There are real, tangible actions we can take to make services more equitable and accessible for our LGBTQIA+ clients. Whether you are part of executive leadership or a newly hired clinical staff member, you can and should educate yourself about how substance abuse impacts your queer clients. Remember: recovery can and does happen. It is up to us to help identify and remove institutional barriers, and help our clients get what they need to do it.
Butler Center for Research. (2016, January 1). Substance Abuse Factors Among LGBTQ Individuals. Retrieved October 11, 2020, from https://www.hazeldenbettyford.org/education/bcr/addiction-research/lgbtq-substance-abuse-ru-116.
Green, K. E., & Feinstein, B. A. (2012). Substance use in lesbian, gay, and bisexual populations: an update on empirical research and implications for treatment. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors, 26(2), 265–278. https://doi.org/10.1037/a0025424.
Hall, T. M., Shoptaw, S., & Reback, C. J. (2015). Sometimes Poppers Are Not Poppers: Huffing as an Emergent Health Concern Among MSM Substance Users. Journal of Gay & Lesbian Mental Health,19(1), 118-121. doi:10.1080/19359705.2014.973180
National Institute on Drug Abuse. (2020, August 25). Substance Use and SUDs in LGBTQ* Populations. Retrieved October 11, 2020, from https://www.drugabuse.gov/drug-topics/substance-use-suds-in-lgbtq-populations.
Pennelle, O. (2019, August 16). LGBTQ+ Recovery Resources. Retrieved October 11, 2020, from https://facesandvoicesofrecovery.org/blog/2019/08/16/lgbtq-recovery-resources/.
Rapp, R. C., Xu, J., Carr, C. A., Lane, D. T., Wang, J., & Carlson, R. (2006). Treatment barriers identified by substance abusers assessed at a centralized intake unit. Journal of substance abuse treatment, 30(3), 227–235. https://doi.org/10.1016/j.jsat.2006.01.002