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Coming-out Issues for LGBTs: Connections to Substance Use and Treatment

April 07, 2014

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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

Coming-out is a joyful and liberating experience or it can be one of the most devastating events LGBTs go through.  Negative responses to coming-out experiences can influence LGBTs to cover up emotional pain through the use of drugs or alcohol.  Consequences of coming-out in loss of familial support or peer relationships can further damage the psyche and contribute to a downward spiral of depression or substance use. 

Coming-out and self-disclosure

Counselors need to understand the coming out process, stages of sexual identity development (Cass, 1979) and how to incorporate these tools in the treatment setting.  Levels on which someone can “come out”include personal, interpersonal, social and public (James, 2012).  Self-disclosure can be one of the greatest challenges facing counselors who work with LGBTs. 

Many LGBTs have faced discrimination and outright rejection and as a result, are reluctant to disclose their sexual orientation in treatment. Some clients have experienced this discrimination and disapproval within the very service institutions that they have turned to for assistance: shelters, social service agencies and substance abuse treatment centers.  These negative experiences can have a lasting impact, making subsequent disclosures less likely and difficult to attain.  A client’s hesitancy to “come out” should be understood as the protective mechanism that it is for the client’s psychological and, in some cases, physical well-being.

Internalized Homophobia

Cheng (2003) highlights internalized homophobia as an explanation for the high rates of substance use and abuse among gays and lesbians, stating “many LGBT people…feel self-hatred”.  The use of mood-altering substances temporarily relieves but then reinforces this self-loathing in the drug withdrawal period…leading to a worsening of self-esteem” (Cabaj, 1996).  It is vital that LGBT clients have access to counselors who accept their sexual orientation.  It is equally important that these clients have treatment that considers and is sensitive to their unique situation as sexual minorities. 

Stages of Coming Out

The personal stage of coming-out is when the person admits to themselves that they are, or might be gay, lesbian, bisexual or transgender.  They may or may not choose to tell another person, and may also keep this information to themselves.  There is no prescribed time limit on this, or other stages.  It can happen across the lifespan and the decision to come out is contingent on a myriad of factors.

In the interpersonal stage, the person tells other people that they are/might be lesbian, gay, bisexual or transgender.  There are no rules on who a person decides to tell.  It is usually someone they feel will not betray their confidence.  In the event the experience is negative, they may go back “into the closet,” choose to not tell other people, or they may continue to seek support.  Supporting and connecting individuals who are coming-out to others is critical to personal acceptance of a healthy sexual identity development.

Social coming-out pertains to the process of the LGBT person developing a group of friends, typically in loose, social settings such as the bar scene.  Online forums can be a mechanism to meet other LGBTs and develop a social network.  Online forums can be particularly helpful for people who live rurally, where coming-out and meeting others could be dangerous.

Coming-out on a public level typically happens when LGBTs do advocacy work. When a person “outs” themselves in any public forum, they are taking a risk as well as advocating for those who have no voice.  Public discussion of sexual and gender orientation can be viewed as a positive way to educate others, normalize identity issues and dispel harmful myths about what it is like to be LGBT.

Recognition of the poignancy of the Coming-Out event/process

Counselors should operate with the knowledge that the coming-out process is pivotal in the lives of their LGBT clients.  The initial realization of same-sex attraction can be a source of internal turmoil for some clients – an event with which they may still be grappling.  For others, this personal acknowledgement was a positive, relief-inducing moment.  In either case, counselors should not overlook or ignore the coming-out process as significant for our LGBT clients, and should reflect genuine interest in discussion and exploration of the subject in treatment.

Since coming-out is an ongoing process that is reinitiated every time a client is in a new situation or meets new people, counselors should be aware that clients are never “done” with coming-out.  As practitioners in the substance abuse field become more cognizant of the importance of multiculturalism in the application of our practice, we cannot overlook the LGBT substance abuser and their individualized needs.  This, therefore, requires a commitment of education, introspection and training on the part of counselors to insure that the best care is being imparted in a manner that does not re-traumatize clients.

Many treatment facilities have no LGBT-identified staff members.  There is a high probability that LGBT clients will experience substance abuse counseling with counselors who have had no training on providing LGBT-specific substance abuse treatment.  Some studies have revealed that 50% of substance abuse counselors have received no training at all about LGBT issues in substance abuse counseling (Eliason, 2000). 

LGBT clients face unique challenges in recovery.  As a result, treatment plans should reflect a cognizance of this and be tailored to meet the multiple needs of this segment of the substance abusing population.  Coming-out is a complex and ongoing process that must be respected by substance abuse counselors in order to provide a safe, affirming atmosphere conducive to reparative change for LGBT clients.

Author Bio:

Dr. Raven James is an Assistant Professor of Addictions Studies and Behavioral Health at Governors State University in Illinois and has worked in the substance abuse field since 1994 providing counselor training to addiction professionals at the state and national level.  Her work has centered on women, HIV prevention, working with LGBT issues, and improving sexual self-esteem and sexual health as an integral component of the recovery process.  Dr. James is conducting women’s research in the Chicago area and has several publications to date, including her latest book “Sexuality and Addiction: Making Connections, Enhancing Recovery”.  She is an active member of the Society for the Scientific Study of Sexuality (SSSS), and serves on the board for the International Coalition of Addiction Studies Education (INCASE) and the National Association of LGBT Addictions Professionals (NALGAP).  Dr. James will be pilot testing a sexual health intervention for women in substance abuse treatment in 2014 and is currently writing and editing a 3 volume encyclopedia set on “Sex and Sexuality” for publication with ABC-CLIO in 2016. 


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Cabaj, R. P. (1996). Substance abuse in gay men, lesbians, and bisexuals. In R. P. Cabaj & T. S. Stein (Eds.), Textbook of homosexuality and mental health (pp. 783–799). Washington, DC: American Psychiatric Press, Inc.

Cass, V. (1979).  Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4, 219-235.

Cheng, Z. (2003). Issues and standards in counseling lesbians and gay men with substance abuse concerns. Journal of Mental Health Counseling, 25, 323–336.

Eliason, M. J. (2000). Substance abuse counselor’s attitudes regarding lesbian, gay, bisexual, and transgendered clients. Journal of Substance Abuse, 12(4), 311-328.

James, R. (2012).  Sexuality and addiction: Making connections, enhancing recovery. CA: Praeger.

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