Clinical Issues With Gay Male Clients

Many factors may contribute to the prominent role of substance use and abuse in gay men. At one point, American psychoanalysts even postulated that homosexuality itself caused alcoholism. We know now, of course, that homosexuality, repressed or not, does not “cause” alcoholism, because alcoholism and substance abuse are the result of the complex interactions of genetic, biological, familial, and other psychosocial factors.

However, the psychological effects of heterosexism, antigay bias, and internalized homophobia may make gay men more prone to using alcohol and other substances, and that use, in turn, may lead to substance abuse or dependency and may trigger the genetic expression of alcoholism and drug abuse. Higher rates of alcoholism have been documented in societies or cultures in turmoil or undergoing social change—a description that can be said to apply in the case of lesbian, gay, bisexual, and transgender (LGBT) individuals (Cassel, 1976). For most of the 20th century, societal pressures forced most gay people to remain “in the closet,” hiding their sexual orientation or not acting on their feelings. Legal prohibitions against homosexual behavior, overt discrimination, and the failure of society to accept or even acknowledge gay people have limited the types of social outlets available to gay men to bars, private homes, or clubs where alcohol and drugs often played a prominent role. The role models for many young gay people just coming out are often gay people using alcohol and drugs at bars or parties.

Some gay men, in fact, cannot imagine socializing without alcohol or other mood altering substances. Brought up in a society that says they should not act on their sexual feelings, gay men are very likely to internalize this homophobia. Often their first homosexual sexual experience was while drinking or being drunk to overcome fear, denial, anxiety, or even revulsion about gay sex. For many gay men, this linking of substance use and sexual expression persists and may become part of the coming out and social and personal identity development processes. Even after coming out, many gay men will use mood-altering substances to temporarily relieve persistent self-loathing, which is then reinforced in the drug withdrawal period.

Given the lack of widespread acceptance of homosexuality and bisexuality in our society at this time, the stages of developing a gay identity may be intimately involved with substance use. Swiss psychoanalyst Alice Miller (1981) sheds light on the link between the psychodynamic forces in developing a gay identity and the use of substances in her work on the emotional lives of children who are talented or otherwise different. Her description of how parents influence the emotional development of these children has strong parallels with the development of a gay identity. Parental reactions shape and validate expressions of children’s needs and longings. Parents reward what is familiar and acceptable to them and discourage or deemphasize behavior or needs they do not value or understand. To get rewards, children eventually learn to behave the way parents expect and to hide or deny the longings or needs that are not rewarded.

Many gay men fit Miller’s description of being aware of being different early in life. They recognize that their loving and sexual needs and longings make them different from others around them. Some male children who will grow up to be gay may desire a closer, more intimate relationship with their father, but this desire often is not encouraged or even understood. The “prehomosexual” child learnsto hide such needs and longings, creating a “false self.” Real needs and desires often are repressed or rejected as wrong, bad, or sinful. Dissociation and denial become major defenses to cope with this conflict.

The psychology of being different, and of learning to live in a society that does not accept difference readily, shapes sexual identity development as a boy emerges from childhood and the latency period. Accustomed to the rewards of the false self, the child suppresses his more natural feelings. He usually has no clear role models to show him how to be gay.

In latency, boys who will become gay, especially boys who may be effeminate, may fear other children and become more isolated. In adolescence, gay sexual feelings can emerge with great urgency but with little or no permission for expression. Conformity is certainly encouraged, which may support further denial and suppression of gay feelings. Adolescents often reject and isolate those who are “different,” so the gay adolescent further develops a disconnection between his feelings and his external behavior.

These same factors may also help explain the many problems facing gay youth—such as depression, suicidal thoughts (or attempts), and running away from home, as well as drug use—even if they have accepted their sexual orientation (Savin-Williams, 1994). Gay youth are subject to sexual abuse and violence and sometimes are introduced to sex via hustling or prostitution. They may be otherwise “used” or exploited sexually by others. The extreme difficulty many gay men have in coming out and integrating sexuality and personal identity makes sense from this perspective.

Substance use serves as an easy relief, can provide acceptance, and, most important, simulates the comforting dissociation or disconnection developed in childhood where feelings become separated from behavior. Alcohol and drugs cause a dissociation of feelings, anxiety, and behavior and may, in a sense, mimic the emotional state many gay men develop in childhood to survive. The “symptom-relieving” aspects help fight the effects of homophobia, allow “forbidden” behavior, provide social comfort in bars (or other unfamiliar social settings), and alleviate somewhat the familiar experiences of disconnection and isolation.

The easy availability of alcohol and drugs at gay bars or parties and the limited social options other than at bars and parties encourage the use of substances early in the coming out and gay socialization process. For gay men especially, sex and intimacy are often split. Substance use allows them to act on feelings long suppressed or denied but also adds a new disconnection and makes it harder to integrate intimacy and love. As some longings and needs find easy relief with sex and/or substance use, the much more challenging needs for love and intimacy may be ignored.

Substances help many gay men brace themselves for the rejection that they expect from others. They allow for denial and even “blackouts” about sexual behavior, including risky sexual behavior. They certainly can make living in the closet with its built-in need for denial and dissociation possible or even easier (the “I-was-so-drunk-I-didn’t-know-what-I-didlast- night” scenario often used in high school and college).

The state that accompanies internalized homophobia and the one that occurs with substance abuse are very similar—the “dual oppression” of homophobia and abuse described by Finnegan and McNally (1987). The following traits are seen in both: denial; fear, anxiety, and paranoia; anger and rage; guilt; self-pity; depression, with helplessness, hopelessness, and powerlessness; self-deception and development of a false self; passivity and the feeling of being a victim; inferiority and low selfesteem; self-loathing; isolation, alienation, and feeling alone, misunderstood, or unique; and fragmentation and confusion. These close similarities make it very difficult for gay men who cannot accept their sexual orientation to recognize or successfully treat their substance abuse. Providers need to know that self-acceptance of one’s sexual orientation may be crucial to recovery from substance abuse.