ADDICTIVE BEHAVIORS AND THE LGBT CLIENT David Fawcett

ADDICTIVE BEHAVIORS AND THE LGBT CLIENT David Fawcett

ADDICTIVE BEHAVIORS AND THE LGBT CLIENT David Fawcett PhD, LCSW Agenda Welcome/Overview Epidemiology LGBT identity Substances and behaviors Syndemics: mental health and HIV

Case study Treatment and recovery Role of the professional Summary Copyright David Fawcett, PhD, LCSW Terminology Sex Gender

Self concept not always derived from anatomy Not always binary..two spirit Sexual orientation Concept of femininity/masculinity Gender role: behaviors/desire to act Gender identity

Anatomy Most dont see as preference Queer Along the spectrum Copyright David Fawcett, PhD, LCSW Epidemiology Epidemiology How are LGBT addicts different than straight addicts?

1970s 1980s Rates as high as 30% Homosexual drinking 19% Heterosexual drinking 11% (San Francisco) Gay men more likely than heterosexual men to use and abuse recreational drugs: 1/3 gay men use drugs 1x/week

What drugs? 2/3 used in past 6 months Copyright David Fawcett, PhD, LCSW Epidemiology Data Sources National Household Survey on Drug Abuse &Monitoring the Future Study Studies of alcohol and other drug use in the LGBT community focused primarily on lesbians and gay men

does not include sexual orientation or gender identity as demographic variables Few have been designed specifically to include bisexual or transgender persons. www.gaydata.org Copyright David Fawcett, PhD, LCSW Epidemiology Alcoholism and drug abuse affect LGBT persons at 2-3 times the rate of the general population

Copyright David Fawcett, PhD, LCSW Epidemiology - Youth Age at first alcohol or drug use is younger in gays and lesbians Among gay male adolescents: 68% reported alcohol use (with 26% using alcohol once or more per week) 44% reported drug use (with 8% considering themselves drug-dependent) Copyright David Fawcett, PhD, LCSW

Epidemiology - Youth Those who identify as LGBT; had same-sex experiences; or who are perceived by their peers to be LGBT have significantly higher prevalence use CDC Youth Risk Behavior Survey LGBT youth were more likely to be victimized, threatened, and engage in a variety of risk behaviors, including suicidal ideation and attempts as well as high-risk sexual behavior Copyright David Fawcett, PhD, LCSW

Epidemiology Gay Men (April 2000 Millennium March in Washington, D.C.) How often are party drugs used in your close circle of friends? 13.4% used party drugs one or more times a week 26.3% used party drugs once a month

21.9% used one or two times a year 38.4% never used in their circle of friends (Illicit drug use not just party: 26% of gen pop SAMHSA) Copyright David Fawcett, PhD, LCSW Epidemiology- Lesbians (K-Y Community Health Survey (307 self-identified lesbians) How often are party drugs used in your close circle of friends? 5.9% used party drugs one or more times a week

11.4% used party drugs once a month 20.8% used party drugs one or two times a year. 61.9% never used party drugs Growing evidence of party drug use among lesbians Copyright David Fawcett, PhD, LCSW Epidemiology - Lesbians (Curtin University, Australia 2010) 33% use tobacco (16% general pop) 49% used illicit drugs in prior year

36% marijuana 18% ecstasy 16% amphetamines 35% had anti-gay harassment in prior year 20% had domestic violence with partner Copyright David Fawcett, PhD, LCSW Epidemiology - Transgender Women (209 transgender women)

Past month use: 37% used alcohol (heavy drinking 6% gen pop) 13% used marijuana 11% used methamphetamine 11% used crack 7% used powdered cocaine 2% used heroin Copyright David Fawcett, PhD, LCSW Epidemiology suicide risk

Self harm and suicide Gay men 7x more likely to have attempted suicide Gay youth comprise 30% of completed suicides annually Gay and bisexual men have higher rates of deliberate self-harm [John Grant, MD, PhD, U Minn.] Copyright David Fawcett, PhD, LCSW LGBT IDENTITY SOCIAL CONTEXT OF ADDICTION Historical Perspectives

1940s through 1960s 1957 Same-sex sexual attraction and behavior was a mental disorder Dr. Evelyn Hookers landmark study finds gays and lesbians normal 1973

The American Psychiatric Association removes homosexuality as psychopathology from the DSM Copyright David Fawcett, PhD, LCSW Developmental Models Linear Non-linear DAugelli

Medical Cass WPATH (Harry Benjamin) Feminist, Post-modern, Queer Narrative, Solution Focused, etc. Copyright David Fawcett, PhD, LCSW Two sides of stigma Felt stigma

Real or imagined fear of societal attitudes and potential discrimination Shame Survival strategy Enacted stigma Actual experience of discrimination Copyright David Fawcett, PhD, LCSW Stigma is Dynamic

Addict, gay, HIV, disabled, sex worker, homeless Social context extremely important poverty, racism, sexism Overlapping and reinforcing stigmatized conditions. Double stigma, layers of stigma, synergistic stigma Copyright David Fawcett, PhD, LCSW

False Self Child hides/dissociates from differences Difficulty accepting aspects of self that are different from the majority Contributes to denial and dissociation from true feelings and needs Substance use allows expression of suppressed desires and needs Facilitates denial and dissociation

Internalized Homophobia Devalue other LGBT persons Hide self /monitor behaviors Assume marginalized group identity Disassociate (e.g. during sex play) Overachieve Discomfort with ones homosexuality

Lust/love Excessive fear and anxiety re discovery Negative emotional reactions about people who are open Prejudice and opposition to aspects of LGBT relationships (parenting, public displays) Rigid conformity to traditional gender roles Will this experience differ by generation? Cultural Homophobia

Cultural norms and institutional policies Discriminate against LGBT (e.g. marriage, adoption, tax laws, military service, glass ceiling in professional settings) Gender socialization stress Men: shaming and punishment of other gay males for failing to achieve masculine ideals Women: more fluid in gender expression/orientation Copyright David Fawcett, PhD, LCSW

Changes in Masculinity Ideals 1964: 12.5 biceps 1994: 26 biceps Copyright David Fawcett, PhD, LCSW Shame The Velvet Rage: Overcoming the Pain of Growing Up Gay in a Straight Man's World Alan Downs, PhD Copyright David Fawcett, PhD, LCSW

Stage 1: "Overwhelmed by Shame" Begins in childhood. Feeling unloved and flawed Learns to fake being straight Receives false rather than authentic validation Can be sensitive to slightest invalidation Pushes people away, along with validation so desperately craved.

Can be linked to Trauma/trauma Copyright David Fawcett, PhD, LCSW Stage 2: Compensation of shame Longest stage of development Usually, but not always, out (does not necessarily mean identity crisis solved) Compensates by becoming the very best and through acquisitions (material, physical, sexual, cultural)

Not satisfied because this validation is still inauthentic. Eventually results in emptiness and vicious cycle Copyright David Fawcett, PhD, LCSW Stage 3: "Discovering Authenticity" Usually later in life Search for real meaning, purpose, and integrity. Least visible stage - likely to withdraw from the clubs and social scene because they arent needed for fulfillment.

Copyright David Fawcett, PhD, LCSW Developing a relationship with self Inner child Finding ones inner strong adult Changing old core beliefs Pivotal moments/ trauma/ shock What conclusions were drawn from that event? What decisions about behavior were made?

Copyright David Fawcett, PhD, LCSW Risk factors Sense of self as worthless or bad. Lack of connectedness to supportive adults and peers. Lack of alternative ways to view differentness Lack of access to role models.

Lack of opportunities to socialize with other gays/lesbians except bars. The risk of contracting HIV and other STIs Copyright David Fawcett, PhD, LCSW Gratuitous cute puppy photo Drugs of Abuse Alcohol

Gay bar is primary source of social contact Refuge from judgment and heteronegativity Remains a significant social center for LGBT youth More so in rural areas Copyright David Fawcett, PhD, LCSW Tobacco http://lgbttobacco.org More likely to smoke than general

population Specific targeting by tobacco industry American Lung Association 2009: Gay men 1.1 to 2.4 odds of smoking Lesbians 1.2 to 2.0 odds Bisexuals 1.3 and up Transgender no data Copyright David Fawcett, PhD, LCSW Opiates Prescription Medication

Rx opiate deaths surpass cocaine and heroin combined Heroin Many rx med users go to heroin due to availability and/or cost Copyright David Fawcett, PhD, LCSW Marijuana High rates of use in LGBT community Medical marijuana (HIV)

Marinol/THC Smoke toxins Higher rates testicular cancer Copyright David Fawcett, PhD, LCSW Amphetamines Powdered cocaine Crack cocaine Methamphetamine

Highly addictive Highly sexual Increased HIV risk Bath salts MPVD/mephedrone 4x stronger than ritalyn Club Drugs X Ecstasy MDMA

G Gamma Hydroxybutirate Anesthetic K Ketamine Veterinary anesthetic Circuit parties Copyright David Fawcett, PhD, LCSW Others

Poppers Amyl nitrate, butyl nitrate Dangerous with antihypertensives, PDE-5 inhibitors Steroids Copyright David Fawcett, PhD, LCSW Process Addictions

Sex addiction Gambling Video games Shopping Internet Work Exercise DSM 5 Behavioral Addictions? (only gambling) Copyright David Fawcett, PhD, LCSW Co-Occurring or Concurrent Addictions

Anne Wilson Schaef - Addictions rarely, if ever, exist in isolation Pat Carnes - It may be one of the greatest, unacknowledged contributions to recidivism in alcoholism is the failure of treatment programs to treat multiple addictions. Copyright David Fawcett, PhD, LCSW Syndemics 2 or more epidemics interacting simultaneously and synergistically (having a greater effect than would be expected by adding the effects of each.

http://www.cdc.gov/syndemics/overviewprinciples.htm Copyright David Fawcett, PhD, LCSW Case Study Part 1 Break Focus on Methamphetamine Remember when we only had black & white tv? Then came color tv-- its the same with methamphetamine and sex

Natural Rewards Elevate Dopamine Levels 200 200 DA Concentration Concentration (% (% Baseline) Baseline) DA FOOD 200 200 150 150 150 150

100 100 100 100 50 50 00 Empty Empty Box Box Feeding Feeding 15 15

10 10 55 00 00 60 60 120 120 Time Time (min) (min) Source: Source: Di Di Chiara

Chiara et et al. al. 180 180 Frequency Copulation Frequency Copulation % of of Basal Basal DA DA Output Output % NAc NAc shell

shell SEX Scr Scr ScrScr Scr Scr Scr Scr Female 1 Present Female Bas Female 22 Present Present BasFemale 1 Present Sample 99 10

Sample 11 22 33 44 55 66 77 88 10 11 11 12 1213 13 14 14 15 15 16 1617 17 Number Number Mounts Mounts Intromissions Intromissions Ejaculations Ejaculations Source: Source: Fiorino

Fiorino and and Phillips Phillips Effects of Drugs on Dopamine Levels % of of Basal Basal Release Release % 200 200 Accumbens Accumbens Caudate Caudate 150

150 100 100 00 1100 1100 1000 1000 900 900 800 800 700 700 600 600 500 500

400 400 300 300 200 200 100 100 00 400 400 Accumbens Accumbens COCAINE COCAINE Accumbens

Accumbens DA DA DOPAC DOPAC HVA HVA 300 300 200 200 100 100 00 11 22 33 hr

hr Time Time After After Nicotine Nicotine % of of Basal Basal Release Release % 00 % of of Basal Basal Release Release %

NICOTINE NICOTINE 250 250 00 11 22 33 44 Time Time After After Cocaine Cocaine AMPHETAMINE AMPHETAMINE

DA DA DOPAC DOPAC HVA HVA 00 11 22 33 44 Source: Di Chiara and Imperato Source: Di Chiara and Imperato Time

Amphetamine Time After After Amphetamine 55 hr hr 55 hr hr Meth Slang names Tina, ice, crystal, fire, speed

Ingestion Snort, smoke, booty bump, slam Copyright David Fawcett, PhD, LCSW History of Meth 1940s Japanese soldiers use meth Nazi soldiers use meth

Pervitin Hitler a meth addict Allied soldiers use meth 5 meth tablets in each soldiers kit Copyright David Fawcett, PhD, LCSW Meth Americas love

affair with speed Copyright David Fawcett, PhD, LCSW Meth & Sex Mansergh (2004) Meth users were twice as likely as nonusers to engage in unprotected receptive anal intercourse Sildenafil users were 6.5 times more likely to report having had unprotected insertive anal intercourse.

Gay party pack Meth, Viagra, Truvada Copyright David Fawcett, PhD, LCSW Meth + STDs Studies from San Francisco and New York show that MSMs who use crystal vs. non users are: 2-3X more likely to have HIV 6x more likely to have syphilis 2X more likely to have gonorrhea Copyright David Fawcett, PhD, LCSW

Causal Link between Meth and HIV Long term MACS (Multicenter AIDS Cohort Study) MSM using meth had 46% greater risk of becoming infected with HIV MSM using poppers (93%) and meth had 3x risk Plankey MW, Ostrow et.al. The relationship between methamphetamine and popper use with HIV seroconversion in the Multicenter AIDS Cohort Study. J.Acquir Immune Defic Syndr. (published online ahead of print (March 29, 2007) Copyright David Fawcett, PhD, LCSW Meth and the internet

Sexual networking sites PNP Location-based Utilized by law enforcement Copyright David Fawcett, PhD, LCSW Meth & HIV The effect of methamphetamine [is] two

or three times greater for individuals on combination therapy, especially combinations including ritonavir (Norvir) CYP2D6 Halkitis, Parsons, and Stirrat (2001) Meth & HIV Meds an acceptable compromise Unplanned nonadherence Planned nonadherence

meth-related disruptions in eating and sleeping recognition that a rigorous medication schedule would not be maintained while using methamphetamine concerns about mixing methamphetamine and medications. Reback, Larkins, Shoptaw (2003) Copyright David Fawcett, PhD, LCSW Fusion of Meth and Sex Neurons that fire together wire together

Focused attention Reinforced through fantasy New cognitive maps increase at expense of old ones (vanilla sex replaced by darker sex) Increased desire vs ED (crystal dick) Copyright David Fawcett, PhD, LCSW Sex without Meth Fusion of Behavior and Sex Since I've quit using I've been practically impotent. Sadly I dont know [how sex could be better without crystal].

Copyright David Fawcett, PhD, LCSW Treatment Treatment Similar physical protocols Need safe treatment environment Overt/covert messaging by staff

Recognize drug-specific differences/ needs Opiates versus amphetamines Meth for example, CBT lite Copyright David PhD, LCSW process Ease of transfer forFawcett, example, How is the LGBT recovery process different? Issues for >6 months recovery

Physical recovery and co-occurring disorders Shame and stigma Sex and intimacy concerns Rebuilding identity Copyright David Fawcett, PhD, LCSW Physical Recovery and Co-Occurring Disorders PAWS (Post Acute Withdrawal Syndrome)

Trouble thinking clearly/ concentrating Mood swings; emotional overreaction or numbness Memory problems Sleep disturbances Physical coordination problems Difficulty managing stress Rigid, repetitive thinking Copyright David Fawcett, PhD, LCSW Physical Recovery and Co-Occurring Disorders

PAWS Results from: GABA-agonist (benzos, barbs, ethanol, GHB) Opioid dependence Amphetamine dependence (dopamine transporter system repair) Duration 1 year to indefinite Copyright David Fawcett, PhD, LCSW

Physical Recovery and Co-Occurring Disorders Layers of stigma - syndemics HIV/AIDS Hepatitis Physical concerns Prescribed medications

Treatment complications Encephalopathy Mental Health Concerns Increased risk Copyright David Fawcett, PhD, LCSW Treatment and Supports 12 step programs SMART Recovery

www.smartrecovery.org Harm Reduction AA, NA, CMA www.harmreduction.org Various levels of treatment Copyright David Fawcett, PhD, LCSW Tool kit

Stages of Change Precontemplation Contemplation Preparation Action Maintenance Motivational Interviewing Copyright David Fawcett, PhD, LCSW Psychosocial Co-Factors

Social Disinhibition Cope with negative social meanings of gay Overcome inhibition Second coming out Particularly sexual Conflicting social norms

Social activities involving substances Copyright David Fawcett, PhD, LCSW Psychosocial Co-Factors Identity Slammers Clubkids Tribe Barebackers Obtain self esteem through sex

Boredom Copyright David Fawcett, PhD, LCSW Psychosocial Co-Factors Shame Long term Internalized Homophobia Relationship with self

No fats, no fems No fakes, no flakes, no fruity-cakes Str8 acting UB2 d/d free Copyright David Fawcett, PhD, LCSW Psychosocial Co-Factors Dealing with feelings Cognitive Escapism and Social Leveling Loneliness

Attractiveness Ageism Copyright David Fawcett, PhD, LCSW Sex What is healthy sex? Copyright David Fawcett, PhD, LCSW

Psychosocial Co-Factors Intimacy LUSTLOVE LUST Romance is not intimacy Limerance Oxytocin, vasopressin Copyright David Fawcett, PhD, LCSW LOVE Beliefs about intimacy

1. 2. 3. 4. 5. Tell me who you want me to be If you really knew me youd go away I dont know how I can only say no or I can ever say yes Relationships are made in heaven Copyright David Fawcett, PhD, LCSW Rebuilding Identity

Build Connections Friendships and Community Need non-commercial connections NSBF (no sex best friend) Good and bad of the internet Recreation Copyright David Fawcett, PhD, LCSW Move Beyond Labels

Copyright David Fawcett, PhD, LCSW Noodlesandbeef.com Build Interpersonal Strengths Social Bonding Sense of Community Practice Dating/Sex/Intimacy/Relationships Healthy Sense of Being LGBTQI Spirituality

Copyright David Fawcett, PhD, LCSW Case Study Part 2 The Role of the Professional The Professional Professional characteristics to treat LGBT addiction: Which are helpful? Which are necessary?

Copyright David Fawcett, PhD, LCSW Reframe from deficits-based to strengths-based From victim to empowered Deficits-based approaches Raise condom use skills Raise condom negotiation skills

(gay men dont know how to use condoms) (gay men dont know how to negotiate sex) Change peer norms (gay men have unhealthy peer norms, esp. around sex) Raise skills to face homophobia (gay men have few skills to face homophobia) Copyright David Fawcett, PhD, LCSW Strengths-based approaches (resilience)

Gay men quit smoking at high rates. LGBTs report low levels of problematic drug use given exposure rates. LGBTs can resolve heavy substance use over time. Large proportions of gay men stay seronegative for decades on end, even while enjoying a very active sexual life Copyright David Fawcett, PhD, LCSW

Surveys of LGBT Substance Abuse Clients Copyright David Fawcett, PhD, LCSW LGBT opinions about treatment Address substance abuse and sexual orientation directly, rather than wait for clients to bring it up Be knowledgeable about addiction and sexual orientation and how these two interact. Provide gay/lesbian specific meetings and groups, which provide opportunities

for sober role models (connection, identification, and safety) Copyright David Fawcett, PhD, LCSW Opinions about treatment Most effective treatment helped clients move through shame to self acceptance Shame of addiction and also homosexuality An atmosphere of acceptance was felt to be particularly healing. Be sensitive to client struggling whether or not they can safely come out to staff

and peers One cannot work an honest program if he/she is not real about who they are. Copyright David Fawcett, PhD, LCSW Opinions about Treatment Know the social context of alcohol and drugs within the gay community. Be aware of the high risk of suicide in the gay community One man hospitalized himself for suicidal depression and the facility addressed

neither his addiction nor his sexual orientation. Copyright David Fawcett, PhD, LCSW Opinions about Treatment Be aware of ones own internalized homophobia Be cognizant of verbal and non-verbal cues of acceptance or rejection. Recognize the importance of family, however it is defined

Questionnaires were typically reflective of families of origin or heterosexual unions. Copyright David Fawcett, PhD, LCSW Thank you! David Fawcett PhD, LCSW 2655 East Oakland Park Blvd, Suite 2 Fort Lauderdale, Florida 33306 954.776.3639 [email protected] www.david-fawcett.com

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