LGBTQIA: Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersex, Asexual or Allied

Abstract

Knowledge of the cultures and communities of patients helps mental health and addiction treatment practitioners provide optimal care. Part of understanding and treating LGBTQIA people (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual or LGBT for short) effectively is recognizing the higher rates of substance use in this group. Substance use among LGBT people may be a way to avoid symptoms or ameliorate psychiatric conditions such as generalized anxiety disorder, major depressive disorder, eating disorders, and other disorders that occur in the context of widespread stigmatization. Not only are LGBT adults more likely to use illicit substances, but also they use those substances more frequently than their heteronormative counterparts. Many well-meaning and otherwise supportive healthcare providers feel uncomfortable when meeting an LGBT patient for the first time due to a general lack of knowledge about the community and the terminology used to discuss and describe its members. Common mistakes, such as incorrect language usage or neglecting to ask about sexual orientation and gender at all, may inadvertently alienate patients and compromise their care. A current of warmth, curiosity, and acceptance flowing through the encounter will help avoid these pitfalls. Taking a sexual history as it relates to addiction is often overlooked when establishing care with an LGBT patient. Taking a sexual history in a respectful manner is of the utmost importance.

Review Questions

• 1. Alex, a 29-year-old male with a self-reported history of anxiety and depression, comes to you, a physician, for help. As the initial interview progresses, Alex asks you to use the pronouns “she” and “her” when referring to her. Later, she tells you that her partner, Pat, a woman, occasionally encourages her to use methamphetamine during sex. A little embarrassed, you realize you have been referring to Pat as “he.” Alex is now somewhat upset. You’ve made an erroneous assumption about

  • A. Gender identity

  • B. Gender expression

  • C. Biological sex

  • D. Attraction

  • E. Affectation

  Correct answer: D. Attraction

  Gender identity, gender expression, and biological sex are the three dimensions of gender. Gender identity refers to how one conceives of themselves with regard to “man-ness” or “woman-ness.” Gender expression refers to how one displays femininity or masculinity to the outside world. Biological sex refers to the sex that someone is assigned at birth. Sexual orientation is independent of the previous three factors and refers to the type(s) of person(s) that one relates to sexually. Identity, behavior, and attraction are the three elements that describe sexual orientation.

  In the vignette, the physician assumed heteronormativity, thinking that a patient whose gender identity leans toward “woman-ness” must be attracted to men. Furthermore, you may have thought to yourself, perhaps unconsciously, that transgender women (Alex, for example) must be heterosexual or would have been happy staying with their gender assigned at birth (male for Alex). This is not true.

• 2. Bob, a 24-year-old man, comes to you for help. He identifies as “straight” but reluctantly admits having sexual experiences with other men “once in a blue moon.” Last night, he was at a club, used a “party drug,” saying “sorry, doc, all I could think of was that this guy looked just like Dwayne Johnson—how could I possibly remember the name of the drug?” and is now worried about any lasting effects that the mystery drug may have. He says, “The drug was already mixed into my Cosmo when the Rock look-alike—swear to god, doc, he looked just like the dude in the movies—handed it to me; he told me it would be fun.” Bob answers your question that last night’s drink did not taste any differently than the usual Cosmos he has at home with Barbara, and afterward he felt “incredibly relaxed, sexed up, and sexy.” Which of the following substances the patient most likely ingested?

  • A. Methylene-dioxy-methamphetamine (MDMA or “ecstasy”)

  • B. Gamma-hydroxy-methamphetamine (GHB)

  • C. Lysergic acid diethylamide (LSD)

  • D. Ketamine

  • E. Delta-9-tetra-hydro-cannabinol (THC)

  Correct answer: B. GHB

  GHB may be referred to as “liquid X” or “liquid ecstasy” and is a central nervous system depressant that leads to euphoria, increased sex drive, and tranquility. It is available as an odorless, colorless drug that is frequently combined with alcohol. Similarly, ketamine or “special K” may come in a powdered or liquid form and may be consumed in drinks, snorted, or injected. However, ketamine has a more pungent taste and smell that some users describe as “salty.” Both could lead to the effects described by the patient, but only GHB is odorless. GHB is far more likely than ketamine to result in LSD overdose and death.

  LSD would have had more potent hallucinogenic effects. Ecstasy is a sensual rather than sexual drug and is most commonly taken as a pill. Cannabinoids such as THC and cannabidiol (CBD) are typically smoked or consumed with food.

• 3. Helen, a 23-year-old woman, comes to you for help. When taking a sexual history, she tells you that she is a lesbian and has only had intercourse with other women. She says that it is difficult to meet other women in her rural town. “Traveling long distances to the state capital is the only way I can find other people like me.” She later admits to using various substances to help her relax and meet people. Since high school, she has sporadically used cannabis, GHB, ketamine. She currently drinks about three beers a day. Which one of the following substances disproportionately affect women having sex with women (WSW) but not men having sex with men (MSM)?

  • A. Cannabis

  • B. GHB

  • C. Alcohol

  • D. Ketamine

  • E. Hallucinogen

  Correct answer: C. Alcohol

  Whereas certain studies show that alcohol use disorder is less common in the MSM population compared with heterosexual men, alcoholism may be as much as three times more prevalent in lesbians and bisexual women as compared with heterosexual women. Cannabis, GHB, and ketamine use is higher in both lesbian and gay populations (but some studies show that they are relatively less prevalent in the lesbian population). While alcohol use disproportionately affects lesbians, it has also been shown that lesbian and bisexual women who enter treatment have higher rates of abstinence and fewer relapses compared with men.