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Department of Psychological Sciences, University of Missouri, Columbia, USA
Received July 17, 2012; Accepted July 18, 2012; Published July 20, 2012
Citation: Talley AE (2012) Establishing Effective Interventions for Sexual Minority Substance Users. J Addict Res Ther 3:e110.doi: 10.4172/2155-6105.1000e110
Copyright: © 2012 Talley AE. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Certain subgroups of sexual minority individuals have higher prevalence rates of alcohol, nicotine, and illicit drug use disorders, compared to their heterosexual counterparts. Moreover, previous findings indicate that sexual minority individuals are more likely than heterosexual individuals to enter treatment with more severe substance use problems. Work that examines explanations for these disparities highlights the potential for findings to inform targeted intervention efforts. Unfortunately, relatively few LGB-tailored interventions have been conducted, and those that do not have support that these tailored interventions are more efficacious than generalized interventions. Nevertheless, substance use interventions that target LGB individuals may be beneficial in generating initial interest in enrollment and reducing concerns that typically hinder sexual minority individuals from seeking treatment.
Certain subgroups of sexual minority individuals have higher prevalence rates of alcohol, nicotine, and illicit drug use disorders, compared to their heterosexual counterparts [1-4]. Moreover, previous findings indicate that sexual minority individuals are more likely than heterosexual individuals to enter treatment with more severe substance use problems . Work that examines explanations for these disparities highlights the potential for findings to inform targeted intervention efforts [6-8]. Unfortunately, relatively few LGB-tailored interventions have been conducted [9-12], and those that do not have support that these tailored interventions are more efficacious than generalized interventions . Nevertheless, substance use interventions that target LGB individuals may be beneficial in generating initial interest in enrollment and reducing concerns that typically hinder sexual minority individuals from seeking treatment .
Five published studies of four-independent samples have administered a pharmacological or behavioral intervention to reduce alcohol use in gay/bisexual men [13-17]. Each of the four randomized controlled studies [13-15,17] showed significant reductions in drinking outcomes at follow up (e.g., 12-weeks, 1-year) compared to control conditions. A variety of outcomes were examined across studies (e.g., average number of drinks per day/week; number of days of alcohol consumption; heaviest level of alcohol consumption per episode; number of heavy drinking days per week). Importantly, none of the five treatment studies included LGB-tailored treatment protocols (although a subset of participants in Morgenstern et al.’s  study received an individual counseling component that addressed internalized homonegativity), and thus, findings only provide support for the effectiveness of generalized treatments (e.g., motivational interviewing [MI]; modified cognitive behavioral therapy [CBT] techniques) to reduce drinking in gay/bisexual men. It remains unclear whether targeted interventions that include LGB-tailored protocols would be more beneficial than generalized interventions that are known to be effective for alcohol use disorders.
Three smoking cessation studies [12,18,19] have been conducted with samples of LGB individuals. The primary outcome is the percentage of participants who reported being abstinent by the end of treatment and at follow-up, confirmed with expelled carbon monoxide readings. Despite that Schwappach  found that gay male smokers endorsed strong preferences for cessation programs provided by GLBT healthservice organizations and those which included only gay male attendees, Covey et al.  found nearly identical abstinence rates for heterosexual (57%) and gay/bisexual (59%) men enrolled in a generalized 8-week smoking cessation program (total n = 297). Although Harding, Bensley, & Corrigan  did not include a heterosexual comparison group, 76% (n = 44) of gay men who specified a quit date were confirmed to quit by the end of a generalized seven-week smoking cessation intervention. More recently, Walls and Wisneski  administered an LGBT-tailored smoking cessation course to a community sample of gay/lesbian, bisexual, and transgendered persons. Despite a small overall sample size (n = 44), at the end of the seven-class course, 73% of participants who had attended at least one class session had quit smoking. Given that the two studies with higher quit rates did not include comparison groups, it is difficult to determine, for example, whether heterosexual men enrolled in similar programs would have comparable abstinence rates  or whether a non-tailored intervention would have resulted in similar success rates for LGB smokers .
A variety of studies containing samples of gay/bisexual-identified men or men who have sex with men (MSM) have sought to decrease or cease problematic substance use, targeting a specific class of drugs, such as club drugs  or methamphetamines and other stimulants [9,10,22,23], as well as multiple substances [11,16]. Typical outcomes are percentage/sum of days/weeks abstinent (confirmed with urinalysis; [9-11,16,21-25]), longest period of consecutive negative urine samples , total number of drugs used , self-reported frequency of use  and scores on the Addiction Severity Index [9,24]. Most often, follow-up periods subsequent to active treatment occurred, at six months and one year [10,11,16,21], with some studies including more frequent assessments. Among non-treatment-seeking men, results show that contingency management (CM; [22,26]) and motivational interviewing (MI; ) interventions were not generally effective in reducing methamphetamine and club drug use, respectively, compared to those in control conditions. In two studies [9,10] examining one sample of treatment-seeking men, generalized cognitive behavioral therapy [CBT], CM, and combined CBT + CM all showed positive outcomes for gay and bisexual males who exhibited methamphetamine dependence . Gay-specific CBT, which combines gay/bisexualrelevant cultural aspects of methamphetamine use with CBT , has been examined in samples of treatment-seeking gay/bisexual male poly drug users  and dependent methamphetamine users [9,10]. Evidence for its efficacy has been shown to be comparable to other generalized interventions [9,10] as well as social support therapy attended exclusively by gay/bisexual male participants . Finally, a study examining client outcomes at an outpatient substance abuse treatment agency specifically intended for treatment-seeking gay/ bisexual men found reductions in self-reported drug use (with the exception of methamphetamine use) that were maintained at one-year follow-up .
Despite the potential for improved outcomes among LGB individuals who use substances, there are a number of methodological issues in the extant literature that must be addressed to provide appropriate support for the efficacy of LGB-tailored interventions. First, it is difficult to determine the benefit of an intervention for a specific population if there is not a comparison group (e.g., heterosexual men) included in the study design [16,22]. Whenever possible, future studies should include heterosexual participants to compare whether treatment outcomes are similar across sexual orientation groups for specific interventions. Second, if researchers seek to establish that LGB-tailored interventions produce superior results for LGB substance users, it is imperative that study designs include conditions that can provide evidence that tailored interventions provide benefits superior to generalized interventions administered by a culturally sensitive provider that are already known to be effective in treating substance use disorders. Moreover, intervention studies should include assessments of both general and LGBspecific mediators and moderators (e.g., internalized homophobia; ) to speak to the importance of specific hypothesized determinants of treatment success, especially among LGB-tailored interventions. Third, when given a choice, a large majority of alcohol-using LGB clients [13-15] report treatment goals based on controlled/moderated drinking , as opposed to abstinence. Consistent with this, an examination of the substance use studies included in the current review reveals that treatment outcomes appear more promising for individuals actively seeking treatment. If client goals are in line with available treatment goals, this may increase readiness to change and improve treatment outcomes in LGB substance users. Fourth, treatment samples have, thus far, overwhelmingly included only gay/bisexual-identified men or MSM [13,14,17], which may limit the generalizability of findings. Given that substance use behaviors and predictors of use are likely to be distinct for subgroups of sexual minority men and women, it is important that interventions studies investigate whether certain interventions and associated components may work better or worse for the diversity of sexual minority subgroups. Finally, if studies continue to use limited sexual orientation identity categories (e.g., gay, straight, bisexual) to recruit targeted samples, other sexual minority subgroups (e.g., mostly straight, those on the “down low”) could miss out on opportunities for substance treatment services.
GLBT-tailored interventions may provide a built-in sense of group cohesion and social support and thus, increase participation in and success of substance use interventions . Although GLBT individuals seeking treatment for substance may report a preference for like-minded people in group therapies [20,26], this may not be feasible in geographical areas with fewer GLBT substance users. Importantly, many generalized substance use treatment strategies are recommended to be individually adapted  and thus, a provider who is culturally aware and sensitive to the unique stressors of sexual minority clients may prove to be as equally effective as a LGB-tailored intervention protocol. Additional, rigorous randomized controlled trials are needed to further explore the utility and effectiveness of tailored interventions. In the service of this goal, it is important that researchers are able to disseminate and share research findings among researchers with similar goals in open-access, peer-reviewed journals.
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