Sexual Orientation and Substance Abuse among Women

1. Sexual Orientation and Substance Abuse among Women Laurie Drabble, Ph.D. 1 Karen Trocki, Ph.D. 2 Lorraine T Midanik, Ph.D. 3 Discussant: Michele Eliason4 • Affiliate Associate Scientist, Alcohol Research Group; Associate Professor, San Jose State University School of Social Work • Senior Research Scientist, Alcohol Research Group • Senior Research Scientist, Alcohol Research Group; Professor, UC Berkeley School of Social Welfare • Assistant Professor, San Francisco State University

2. Why consider sexual orientation? • Importance of understanding health disparities among different populations, including sexual minorities • Recognition that differences in risk and resiliency factors are important to consider in prevention and treatment

3. Research Issues The “hidden” nature of the homosexual population has made it difficult to obtain data on anything that comes close to a representative sample of gay men and lesbians S. Israelstam & S. Lambert Source : The International Journal of Addiction, 1986, 21, 509-537.

4. Relational issues (e.g., partnership or parenting status, family of origin) Sexuality (e.g., coming out) Minority stress (e.g., homophobia/heterosexism) Community/social support (e.g., connection to school, social norms) Risk/Protective Factors that May Differ

5. Early studies on alcohol consumption in LGB communities • Early studies, based on convenience samples such as bar patrons, found extremely high rates of heavier and problem drinking (approximately 30%) • Purposive samples with less biased samples have found less abstention among lesbian and gay populations and mixed findings related to alcohol dependence and alcohol problems

6. Recent population based studies • Higher odds for drinking, heavier drinking, alcohol dependence, among women reporting female sex partners(Cochran et al., 2000; Cochran & Mays, 2000; Scheer et al., 2003; Valanis et al., 2000) • However some studies showed elevated but not significantly greater DSM alcohol abuse and dependence among women(Gilman et al., 2001; Sandfort et al., 2001). • Another regional study found no difference in heavier drinking among women but found that lesbians were more likely to report being in recovery(Bloomfield, 1993)

7. How is sexual orientation defined? Definitions include: • Behavior • Self Identity • Desire, Attraction

8. Background • Dearth of population-based studies on sexual orientation and alcohol use • Few of the population-based studies to date: • measure both sexual orientation identity and behavior • include full range of alcohol use indicators and alcohol-related problems • Use national samples

9. Purpose: To Examine… • Abstinence, drinking, heavier drinking & other drug use • Alcohol related problems and dependence • Drinking in specific contexts (e.g., bars)

10. METHODS • 2000 National Alcohol Survey (NAS 10) • Telephone (CATI) Survey • RDD N=7,612, 18 and over • Sexual orientation defined by two questions: sexual orientation identity and sexual behavior (past 5 years)

11. Women, full sample (N=6924) • 96% heterosexual, exclusively opposite sex partners • 1.8% heterosexual, reporting same sex partners • 1.3% bisexual • 0.9% lesbian

12. Distribution of Drinking, Women

13. 2 + Social Consequences Alcohol Dependence Past Treatment Sexual Orientation Heterosexual (and same sex partners) .77 2.2 2.2 Bisexual 8.1** 6.4* 4.3* Lesbian 10.9** 7.1 8.1** Odds for Alcohol-Related Problems Among Women, Current Drinkers Ref group: Exclusively heterosexual women. (Adjusted for age, relationship status, race/ethnicity, employment, education and income) *p<.01, **p<.001

14. Odds for Tobacco and Marijuana Use Ref group: Exclusively heterosexual women. (Adjusted for age, relationship status, race/ethnicity, employment, & education) *p<.05, **p<.01, ***p<.001

15. Theories about difference • Experiences of marginalization • Greater willingness to report use • Barriers to obtaining sensitive treatment • Bars and other drinking contexts as “safe place” to gather • Environmental risk factors (such as target marketing from alcohol and tobacco industries)

16. Exploration of two theories • Bar-going/drinking contexts • Treatment satisfaction

17. Odds for Bar-going and for Drinking 4+ in Bar Contexts Ref group: Exclusively heterosexual women. (Adjusted for age, relationship status, race/ethnicity, employment, education) *p<.01

18. Very or Mostly Satisfied with Treatment

19. In progress… • Exploration of correlates of heavier drinking & alcohol-related problems (e.g., mental health measures, sense of coherence, early childhood trauma) with combined 2000 and 2005 data. • Tobacco and marijuana use, relationship with sensation seeking and other variables.

20. SUMMARY • Lesbians, bisexuals, and heterosexually identified women with same sex partners have lower alcohol abstention rates. • Lesbian and bisexual women have greater odds for reporting past year alcohol-related problems and dependence symptoms and as well as lifetime help-seeking for alcohol related problems. • The relationship between bar-going and drinking in bar contexts varies by sexual orientation, but is more complex than originally assumed.

21. Discussion • 3 levels of practice and policy implications: • Institutional • Program Design and Agency • Clients and their Communities

22. Discussion: Client level • Bisexual women and lesbians, may have unique risk and protective factors related to drinking. However, same-sex behavior may have somewhat different risk and protective factors. • More research is needed to understand the dynamics of women (and men) who identify as heterosexual but have significant same-sex activity.

23. Why the difference in consequences? • Lesbian and bi women were more likely to report negative consequences from drinking than hetero and hetero with same-sex activity. Why? • Minority stress? • Greater likelihood to disclose problems once “out?”

24. Client level • Consider the roles of bars and other drinking contexts in relation to both risk and connection to community. • Drinking and relationships (friends, significant others) • Consider other environmental and individual differences in risk & resiliency

25. Client Level: Treatment satisfaction • Why the differences in satisfaction? • Treatment settings are a microcosm of society—all sorts of prejudices exist in some staff members and other clients, the agency is organized around the “norm” and policies and procedures may not consider sexual minority issues. • Focus on honesty in treatment, yet many counselors tell LGBT clients that their sexuality/gender is irrelevant. • The mix of clients may not feel safe to some women, particularly those with PTSD.

26. Client Level: Principles of Lesbian-Sensitive Service Delivery • Create safety • Eliminate overt and covert bias • Consider the cultural and community context of women’s lives • Recognize the importance of relationships and sexuality in women’s lives • Facilitate formal and informal social support • Use of client-centered interventions

27. Agency level Policies and procedures… • Help ensure that delivery of equitable services are institutionalized • Set an inclusive tone for all agency activities • Provide a “compass” for Board members, managers and staff.

28. Administrative Policies/Procedures • Create/confirm agency policies regarding: • freedom from discrimination for both clients and staff members • procedures for filing and resolving violations of these policies • Train and ensure enforcement on all levels of the agency.

29. Outreach and Community Relations • Inclusive language & images in promotional materials • Conduct outreach through LGBT media and organizations • Co-sponsor alcohol-free LGBT specific or inclusive activities

30. Agency Personnel • Openly recruit lesbian and bisexual board members, staff, volunteers, and consultants • Establish an advisory board to help with program design, services and outreach • Provide comprehensive staff training

31. Program Design • Examine program from beginning to end for • Inclusive language • Inclusive images • Inclusive assessment tools • Welcoming and safe programming • Programming that addresses critical issues • Aftercare planning that takes into account the environment the client goes home to

32. Critical Program Issue: • Assessment and ongoing individual work with all clients must address sexuality: • Sexual identity • Sexual behavior • Other issues related to sexuality

33. Program Design cont’ • Emphasize and enforce confidentiality of all treatment services • Ensure opportunities to participate in meetings, workshops, and community activities appropriate to clients of diverse cultural backgrounds • Ensure relapse prevention and aftercare planning helps clients prepare for high risk situations & identify support resources specific to them

34. ATOD Prevention • Support development and funding of LGBT specific ATOD prevention • Organize existing coalitions/efforts to be inclusive of LGBT communities • Facilitate/provide technical assistance and training for LGBT organizations to counter target marketing and advance other environmental prevention

35. Institutional Level • Explore opportunities to include sexual orientation as a demographic variable in state and local data collection, using questions about both identity and behavior. • Continue and extent funded efforts (e.g., TA/ Training) that help to reduce stigma associated with sexual minority identification and behavior, gender, race/ethnicity, substance abuse, etc. • Access to health care benefits; policies that promote equity and prohibit discrimination (e.g., changes in laws/policies about marriage, and other legal recognitions ofrelationships)