Full length articleSexual orientation, treatment utilization, and barriers for alcohol related problems: Findings from a nationally representative sample
Introduction
Alcohol-related problems are associated with various medical, psychiatric, and drug comorbidity issues (Hasin et al., 2007, Kopelman et al., 2009, Rehm et al., 2009). Therefore, research on individuals who utilize alcohol-related treatment programs have examined co-occurring mental health problems (Glass et al., 2010), alcohol consumption severity (Booth et al., 1991, Kaskutas et al., 1997), perceived alcohol-related stigma (Glass et al., 2013), larger social networks (Mowbray, 2014, Mowbray et al., 2014) and various other socio-demographic factors related to education, age, marital status, and income (Cohen et al., 2007, Ilgen et al., 2011). As such, the economic costs of alcohol-related problems in the United States totaled $223.5 billion in 2010, which included adverse medical consequences, lost worker productivity, crime, accidents, and treatment/prevention costs (Bouchery et al., 2011). While there have been many treatments for alcohol related problems that have been shown to reduce the costs associated with excessive alcohol use (Holder et al., 2000, Zarkin et al., 2010), and shown to increase the likelihood of recovery from alcohol use disorders (Moos and Moos, 2006; Mowbray et al., 2015; Moyer et al., 2002), there is still a substantial incentive to provide treatment to individuals with alcohol related problems among GLB individuals.
Sexual minority groups, specifically gay, lesbian and bisexual individuals (GLB), are one of many understudied groups associated with alcohol related treatment utilization. This is unfortunate and regrettable as past research has shown that GLB individuals were more likely to engage in alcohol use, and to experience alcohol use disorders, when compared to heterosexual individuals (Amadio, 2006, Hughes, 2005, Hughes and Eliason, 2002, Nawyn et al., 2000). In fact, there is compelling research that GLB individuals engaged in alcohol use and treatment utilization differently. For example, bisexual individuals reported higher prevalence of alcohol use disorders when compared to individuals who identify as gay, lesbian, or heterosexual (Hughes and Eliason, 2002, McCabe et al., 2013, Ziyadeh et al., 2007), with bisexual women having a higher rate of binge drinking when compared to heterosexual women (Eisenberg and Wechsler, 2003, Nawyn et al., 2000). Lastly, research findings indicated that lesbian women reported higher levels of alcohol consumption compared to gay men (Heffernan, 1998, Lea et al., 2013), had more negative consequences associated with increased alcohol consumption (Heffernan, 1998, Nawyn et al., 2000), and had a higher likelihood of any substance use disorder when compared to heterosexual women (McCabe et al., 2013).
Given these observations of increased alcohol use severity among GLB individuals, previous research using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) demonstrated that GLB individuals utilized treatment for alcohol related problems at higher rates (McCabe et al., 2013). This previous finding could be extended though a systematic examination that works to identify gaps where service utilization differences may emerge between gay/lesbian, bisexual and heterosexual individuals with alcohol use disorders. Similarly, future research is needed to examine whether or not there would be any existing differences in barriers associated with treatment utilization for alcohol-related problems between gay/lesbian, bisexual and heterosexual individuals. Given the range of options currently available for treating alcohol-related problems, paired with the relatively low levels of service utilization among the GLB population with alcohol use disorders, a more expansive examination of treatment utilization across various treatment service utilizations in order to identify the barriers that disproportionately impact GLB individuals.
Epidemiologic research of American adults, independent of sexual orientation, examining treatment utilization for alcohol related problems suggested that those who did not seek treatment often reported they felt strong enough to handle it on their own, thought the problem would get better on its own, or they stopped drinking on their own (Cohen et al., 2007). However, GLB individuals may have additional reasons for not utilizing treatment for alcohol related problems, including sexual identity development milestones, and sexual orientation-based discrimination (Hughes, 2011), and service providers being trained largely to use heteronormative treatment practices (Anhalt et al., 2003, Röndahl, 2011), which may be perceived as insensitive, hostile, phobic, and discriminatory to GLB individuals (Dibble et al., 2008, Eliason, 2000, Eliason and Hughes, 2004, Kreiss and Patterson, 1997, Lombardi and van Servellen, 2000, Schilder et al., 2001). Such inadequate exposure and training to providers may cause many GLB individuals to feel they were perceived as an inherently high-risk population prone to additional medical illness, and as a consequence, are provided with differential treatment (e.g., assumption of engagement in high risk sexual activity and unknown sexual health/HIV status; Cochran, 2001, Kreiss and Patterson, 1997, Röndahl, 2011, Schilder et al., 2001). These barriers may present larger obstacles for gay and lesbian individuals, as it could be assumed that bisexual individuals may be more likely to capitalize on sexual fluidity and be a presumed member of a heterosexual group in specific contexts (Lingel, 2009).
Thus, despite the observed increase in treatment utilization for alcohol related problems among GLB individuals, overall utilization rates have remained low (20–32%; McCabe et al., 2013). Therefore, it is likely that many GLB individuals continued to experience barriers to treatment, and that these barriers may be very different than heterosexual individuals seeking treatment for alcohol related problems.
Regrettably, many of the barriers associated with GLB individuals receiving effective treatment has been studied using small, community-based survey data, and lack a nationally representative sample necessary to generalize research to the development of effective interventions to address the common barriers GLB individuals experience. Also, with the goal to move services research beyond binary measurement of treatment utilization (Mowbray et al., 2015), the goal of this study was to examine what differences in treatment utilization and barriers, if any, may exist for GLB and heterosexual individuals, from a large and nationally representative sample, across multiple treatment sectors for alcohol related problems.
Section snippets
Sample
Combined Wave 1 (2001–2002) and Wave 2 (2004–2005) National Epidemiologic Survey on Alcohol Related Conditions (NESARC) was used for this study. NESARC is a population-representative survey of United States adults with ages 18 or older living in non-institutionalized settings, who were compensated 80$ per wave of the NESARC (Grant et al., 2007, Grant et al., 2003, Stinson and Hasin, 2007). Both waves of the NESARC were administered through computer assisted personal interviews (CAPI) in
Sample characteristics
Socio-demographic and clinical associations with sexual orientation are presented in Table 1. Weighted prevalence estimates showed that gay/lesbian (24.1%) or bisexual (29.3%) individuals were significantly more likely to have reported lifetime treatment utilization for alcohol related problems, compared to heterosexual individuals (13.9%). Among the individuals with a lifetime alcohol use disorder, 10,874 (97.2%) identified as heterosexual, 182 (1.6%) identified as gay or lesbian, and 126
Discussion
The purpose of this study was to examine whether differences in treatment utilization and barriers existed between GLB and heterosexual individuals, from a large and nationally representative sample, across multiple treatment services for alcohol related problems. Results from across multiple treatment sectors indicated that GLB individuals showed higher rates of treatment utilization, and reported more barriers to treatment utilization than their heterosexual counterparts.
Conclusion
Ideally, treatment for alcohol related problems should be provided in a culturally informed, integrated and holistic approach that minimizes the barriers persons with alcohol use disorders experience in accessing these services. While substantial improvements have been made to accessing treatments for alcohol related problems, many barriers still exist, especially for bisexual individuals. While mental health researchers and providers have begun to address how sexuality fits within the broader
Role of funding
Nothing declared.
Contributors
Junior Lloyd Allen developed the initial research hypotheses and primary author in manuscript preparation. Orion Mowbray carried out the statistical analyses and contributed to manuscript preparation.
Conflict of interest
No conflict declared.
Acknowledgements
None
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