• According to a 1990 finding by the Division of Mental Health, Substance Abuse and Forensic Services, the prevalence of substance abuse is 30% in the lesbian and gay community as opposed to 10% in the general population
• A 1994 study of the gay and lesbian communities in two metropolitan areas of a southern state likewise found alcohol, drug, and tobacco usage to occur at consistently higher rates than in the general population
• The same study found that frequency of alcohol use increased among gay men who were affluent and resided in urban areas
• In a 1991 substance abuse needs assessment of the San Francisco lesbian, gay, and bisexual community, 30% of female respondents and 40% of male respondents used drugs other than alcohol
• Roughly 33% of women and 42% of men were found to be using alcohol or drugs at "risky" levels
• 1 in 3 men and 1 in 5 women were found to be using alcohol or drugs in the highest risk category, defined as "likely to lead to chemical dependency or addiction"
• Overall, lesbian and bisexual women were found to use alcohol and drugs more frequently, in greater amounts, and in combination more often than women in the general population
• A 1990 study estimates that 1 in 3 lesbian women abuses alcohol
• A 1995 JRI survey of lesbian, gay, and bisexual young adults, 84.3% of respondents reported alcohol use; 13% of respondents reported "problem drinking"
• The JRI survey found a significantly higher usage of drugs other than marijuana among men than among women
• San Francisco area lesbians, gay men, and bisexual men and women participating in the substance abuse needs assessment reported that, after recreation, their primary reasons for using alcohol and drugs were:
• to avoid emotional pain
• to fit in with other drinkers
• to reduce social discomfort
• to avoid problems
• to feel less shy

Tobacco Use

• Although no large scale study of the prevalence of GLBT tobacco use has been conducted, the San Francisco substance abuse needs assessment for the lesbian, gay, and bisexual community found that respondents smoked at a 61% higher rate (combined) than members of the general population
• The JRI survey of lesbian, gay, and bisexual young adults, 38.7% of respondents reported smoking; 50% of respondents who smoked were under 21
• 67.9% of the sample had tried to quit and had been unsuccessful
• Of respondents to the 1985 National Lesbian Health Care Survey:
• 30% smoke daily
• 11% smoke occasionally
• 26% were worried about their tobacco usage
• According to the 1988 National Lesbian Survey, the rate of smoking among lesbians increases with age, whereas rates of smoking among women in the general population decline with age

        As tobacco sales fell 35% between 1973 and 1991, the current decade has seen the tobacco industry hurriedly looking for new markets in which to invest. Following the lead of Absolut Vodka, one of the first advertisers in the gay media, Philip Morris launched the first targeted marketing of tobacco to the gay community in Genre in 1992, followed by an Out campaign in May of 1994 (CLASH, 1994), and the soon to be introduced cigarette designed "just for gay men." The recent rise in tobacco advertising makes the lesbian and gay community the third community for the tobacco industry to target after African Americans and women.
        As a spokesperson for CLASH comments: "Philip Morris makes thousands of products that don't cause cancer, but doesn't advertise any of them in Genre or any other lesbian or gay publication. Why is tobacco the only product that Philip Morris wants us to buy?" (10/92)
        The effects of tobacco use on HIV/AIDS are ambiguous and still disputed. Some findings:

• In the 1984 San Francisco Men's Health Study, the highest rate of heavy smoking (9.4%) was among HIV positive men
• The Men's Health Study further found that smoking may activate an immune response, and thus HIV positive smokers initially had significantly higher T-cell counts than HIV positive non-smokers; the difference in counts, however, was markedly reduced two years post-seroconversion
• A 1992 study from the 8th International Conference on AIDS found that HIV positive smokers are more than three times as likely to develop Pneumocystis carinii pneumonia than HIV positive non-smokers
• A 1993 study of 84 seropositive persons found that median time for HIV positive smokers to develop AIDS was significantly less for non-smokers

        In an effort to reduce the prevalence of tobacco use in the GLBT community, CLASH recommends the designation of smoke-free spaces at community events, the development of cessation services, mobilization of the GLBT community's political muscle, advocacy for GLBT oriented research (such as the effect of tobacco use on the immune system), and coverage on the marketing strategies of the tobacco industry in the gay press (which may prove challenging if the tobacco industry is a significant paying advertiser).

Substance Abuse and Violence (see also Violence)

• According to the 1991 San Francisco substance abuse needs assessment of lesbians, gay men, and bisexuals:
• A fifth of gay and bisexual men had experienced violence while drunk or high
• 14% of lesbian and bisexual women had experienced violence while drunk or high
• Of respondents to a 1990 study of the relationship between violence and substance abuse in lesbian relationships, 39% of respondents reported involvement in a past or present abusive relationship
• The FBI reports that alcohol and drugs are factors in 75% of all domestic violence cases

Substance Abuse and Risk Behavior

• According to the San Francisco needs assessment, high rates of amyl nitrate, cocaine, and amphetamine use for gay men were linked to unsafe sexual practices
• A third of gay men said they had unprotected sex while drunk or high in the past year
• 28% of men in the highest risk level had engaged in unprotected sex while drunk or high in the past year
• Of respondents to a forthcoming survey of young adult lesbians, gay men, and bisexuals, 58.1% had engaged in sex while drunk or high in the past two years; 50% reported engaging in unprotected sex under those conditions

Underserved Populations
         Lesbians and gay men of color, non-urban lesbians and gay men, low income gay men and lesbians, and bisexuals and transgendered individuals also face additional substance abuse concerns and barriers to treatment.:

• According to the 1991 San Francisco substance abuse needs assessment, in the response to GLBT substance abuse concerns, bisexuals "appear to be invisible"
• The lack of services for bisexuals is especially distressing since bisexual women reported alcohol and drug use at substantially higher rates than lesbians
• According to the 1994 Lesbian and Gay Substance Abuse Workshop report Recommendations on Access to Substance Abuse Services for the Lesbian and Gay Community, rural lesbians and gay men are more likely to be closeted and less likely to have access to lesbian and gay specific treatment services; Kus (1988) notes that gay Alcoholics Anonymous meetings are restricted primarily to urban areas
• Hall (1992) comments that substance abuse treatment for gay men and lesbians of color must acknowledge their double or triple minority status; lesbians of color interviewed characterized their recovery as a process of accepting both their lesbianism and their racial/ethnic identity

Availability of Services
         There are relatively few treatment centers that specifically address issues of homophobia and comfort with sexual orientation that may be contributing to the lesbian or gay client's substance abuse concerns. As substance abuse treatment services are not mandated to collect statistics on sexual orientation, it is likewise difficult to assess the number of gay and lesbian clients receiving treatment in mainstream programs. In San Francisco, as of 1991, there were few services specifically for gay men with substance abuse needs and none for lesbians; one residential treatment program for gay men was in operation, and none existed for lesbians (EMT Associates, 1991). Of the "straight" programs that did report lesbian and gay clients participating in their programs, only half provided sensitivity training to their staff, a third had specific policies against homophobic actions among staff and clients, and a third offered welcoming cues (such as gay/lesbian specific posters or information) within the treatment center atmosphere.
        Lesbians evidently face added barriers beyond gay men in finding treatment for substance abuse concerns. The stigmatization of alcoholism is compounded by a lesbian's gender and sexual orientation, which may make it more difficult for her to identify the substance abuse problem, to feel safe in the treatment environment, and to maintain a positive self-image during recovery (Hall, 1992). Furthermore, substance abuse treatment may be more available to gay men since it is often linked to HIV prevention, treatment, and support; substance abuse treatment targeting women, however, often focuses on the perinatal affects of substance abuse, which may be irrelevant to lesbians, especially younger ones (EMT Associates, 1992). In the San Francisco substance abuse needs assessment, although 25% of respondents reported participating in twelve step programs, and 16% reported seeing professional counselors for substance abuse concerns, twice as many men as women reported receiving treatment from an alcohol or drug out or inpatient facility: this suggests a lack of services available to lesbian and bisexual women, rather than a low demand.

Lesbian- and Gay-Specific Issues in Recovery and Services
        Beyond dealing with substance abuse issues, the lesbian or gay man in recovery who is not yet "out," or who has used alcohol or drugs as a way of coping with either anxiety over sexual orientation or as a reaction to internalized and/or external homophobia, faces the added challenges of recognizing and reconciling his or her sexual orientation, or, if out, confronting the effect of homophobia on his or her substance abuse. In 1988 ethnographic interviews with twenty gay men who were recovering alcoholics, 100% of informants reported that they had been unable to accept their sexual orientation while drinking, and that alcohol had served to relieve their guilt and allow them to engage in and enjoy sexual activity. Furthermore, rather than supporting the thesis that reconciliation of sexual identity would lead to a decrease in alcohol abuse, all the men found that they were able to accept their sexual orientation only after reaching sobriety. As the National Task Force on AIDS Prevention observed (cited in CSAT), identification is a key function of safety, suggesting that only in a treatment atmosphere where the lesbian or gay client feels secure will sexual orientation issues be resolved: a treatment program focusing solely on a client's substance abuse without addressing sexual orientation issues may ultimately treat the symptom of the problem, not the cause.
        For the men in the ethnographic interviews, gay Alcoholics Anonymous (AA) meetings provided that function of safety, with the 4th step of "moral inventory" especially allowing them to acknowledge their resentment and anger, and accept their powerlessness over their sexual orientation and alcoholism (Kus, 1988). For lesbians, however the "powerlessness" model of Alcoholics Anonymous may become problematic (Hall, 1992). A 1992 ethnographic study of 35 lesbians in recovery found women objected to a model which tells those who have felt powerless most of their lives to "surrender their wills" (Hall, 1992). Furthermore, the AA program mirrors a conversion process which would require lesbians to abandon many of the valuable coping and survival skills that they have developed in the past. An alternative approach is found in the informants' perception of substance abuse as the product of an addictive, racist, patriarchal society, the recovery from which represents individual and collective empowerment. (Hall, 1992). The prevalence of such a sentiment in the lesbian community may explain what is generally considered to be the current trend away from substance abuse and towards "sober" social activities in lesbian social life (Hall, 1992)
        Despite this alternate model, one aspect considered most beneficial of the gay Alcoholics Anonymous setting is the opportunity for gay men and lesbians to feel a part of a community of recovering lesbian and gay alcoholics, and to explore the personal and social consequences of sexual orientation in a sensitive environment. The Lesbian and Gay Substance Abuse Workgroup notes that many mainstream treatment centers tend to be hostile and homophobic to lesbian and gay concerns, perhaps accounting for the success of the growing number of lesbian- and gay-specific residential treatment centers such as Minnesota's Pride Institute. A follow-up study of 102 patients admitted to the Pride Institute between September 1988 and February 1991, 50% of whom had been in treatment before, indicates the following:

• 14 months after treatment, 60% of Pride consumers reported abstinence from alcohol or drugs; prior to admission, the average period of sobriety for consumers had ranged from six to nine months
• Although Pride Institute consumers entered treatment programs with two times more severe alcohol and drug addiction problems (as measured by the Addiction Severity Index) than entrants to traditional programs, their levels of improvement mirrored and even exceeded levels of improvement by consumers from a compilation of traditional programs
• Upon admittance, Pride Institute consumers reported chronic problems with relatives and partners (50%), extreme levels of serious depression (66%) and suicide attempts (32%)
• Upon follow up, HIV negative consumers showed overall improvement in alcohol and drug use, employment issues, family problems, psychiatric concerns, and medical condition; of the 19 HIV positive consumers, improvement was shown in all areas except psychiatric and medical condition, in which there was a general decline
• Attesting to reasonable recognition and inclusion of lesbians, similar outcomes of improvement were demonstrated across gender