Alcohol Problems Among Lesbians - Frequency

There has been little research in Britain regarding lesbians and alcohol, although some is being conducted (Creith, Middlesex Polytechnic).

Lesbian Information Service began a survey into the needs of young lesbians in 1990; the research is on-going and is underpinned by seven years experience of working with lesbians throughout Britain. To date we have interviewed 20 lesbians (three aged over 25, the rest aged 25 and below). Our questionnaire was extensive: in-depth interviews lasted from two to eight hours. All but three of the participants used alcohol, ten (50%) having serious alcohol problems (i.e. heavy drinking, 'black' outs, hospitalisation, suicide attempts whilst under the influence of alcohol).

Fifty percent
is very high. I am not suggesting that this will be the level of alcohol misuse among all lesbians in Britain. Our research is unusual for several reasons: 1. It was conducted primarily with young lesbians who were trying to come to terms with their sexuality. 2. Many - 15 - grew up in areas where there was no support for them, i.e. not even a helpline, in parts of Cumbria, Lancashire, and Yorkshire. 3. A high proportion of the participants are multi-oppressed (thirteen are working class; three are black; and four are disabled). Neisen and Sandall (1990) have noted the links between sexual abuse and alcohol misuse; half - ten - of the participants had been sexually abused or raped. Saghir et al (1970), Rofes (1983) and Gibson (1989), have linked suicide attempts with alcohol misuse; there was also a high level of attempted suicide among the participants: 14 had attempted suicide, four had serious thoughts of suicide and only two said they had never thought about suicide. All of the participants had experienced periods of depression. Furthermore, ten of the participants had been homeless and ten were unemployed. Four are mothers (all having attempted suicide). We are, therefore, focussing upon some of the most isolated and oppressed lesbians, lesbians who usually slip through the research net.

Of course, not all lesbians have drink problems. Some lesbians, for cultural reasons, will not drink at all. At the same time, there will be some women who would not show up on surveys because, as the experience of one of the participants in our survey shows, they are suppressing their lesbianism:

"I'd just come out of hospital. I started drinking heavily. I packed my job in and stayed on the booze. I tried to kill myself (four times), with booze and pills. I either woke up the next morning or someone found me. I used to drink three bottles of vodka a day. I collapsed about five years ago and ended up in a coma. When I came round two days later I was told that everything had given up; my nervous system. I'd had a heart attack. I was told that if I carried on drinking I would be dead within six months. I have always drunk, but not to the excesses that I did when [my mother forced me to end] my first [lesbian] relationship ... and I got married [to please her]." (Julie, white, working class, aged 34 years).

U.S. research, Saghir et al (1970); Weathers (1974); Fifield, DeCrenzo & Latham (1975); Lewis, Saghir & Robins (1982), suggest that between 27-35% of lesbians have alcohol problems. Lewis et al (1982) found that 33% of the lesbian participants were heavy drinkers or 'alcoholics' compared with only 7% of the heterosexual controls; and that 28% of the lesbians were 'alcoholics' compared with only 5% of the heterosexual controls. An earlier survey (Saghir et al, 1970) found that 35% of the lesbian participants, compared with 30% of the gay male participants, were alcohol dependent. Gillow & Davis (1987), in their research on coping methods used by lesbians to deal with stress, discovered that 59% of their participants had previously used alcohol to cope. Barbeler (1992) found, in her Australian study of young lesbians, that 100% of the participants drank weekly compared with an earlier study which found that 41.4% of women in the same age group drank at all.

Further, wider, research is needed in this country, but it is clear that alcohol misuse among lesbians is a very serious problem, given that about 10% or more of the population are lesbian (Kinsey, 1953, Hite, 1988).

Why are Lesbians Vulnerable to Alcohol Problems?

We are all brought up in a society whose institutions such as religions, the media, education, laws and the family are heterosexist. Institutional heterosexism - wherein heterosexism is built into the structures of institutions - and individual heterosexism is discrimination against homosexuals based on the belief that heterosexuality is superior to homosexuality. The result of this conditioning is that everyone is taught to be homophobic. Slater (1988) defines homophobia as the recognised or unrecognised fear or hatred of homosexuals or homosexuality which is present in both heterosexuals and homosexuals.

In other words,

1. Heterosexuals -

a. experience internalised superiority to homosexuals;

b. are more likely to achieve positions of power;

c. are therefore able to discriminate against homosexuals; and

2. Homosexuals -

a. experience internalised inferiority to heterosexuals;

b. are less likely to achieve positions of power if they are open about their sexuality and, if closet, will experience constant stress about having to keep secret an essential part of their being and consistently fear being discovered and dismissed or rejected;

c. are discriminated against.

Institutional heterosexism teaches us that homosexuality is a mental disorder, a sickness, an illness; that homosexuality isn't normal, it's not natural, it's a deviancy, it's a perversion, it's a crime against nature; that homosexuality is a sin, it's immoral; that homosexuals are promiscuous, only interested in sex, obsessed with sex, carry disease, have all got AIDS; that homosexuals are not to be trusted, they lead young people astray, they are child molesters, they are dangerous, they are sex abusers; that male homosexuals are all sissies, effeminate, limp-wristed, want to be women, dress like women; that all female homosexuals are butch, masculine, ugly, want to be men, dress like men, do not have children, hate children; that homosexuality is a white disease, it's a capitalist disease, it's a western disease, it isn't found in the country only in cities; ad nauseum.

It is hardly surprising, therefore, that we are all homophobic or that we remain homophobic unless and until we come across accurate information which contradicts the lies we have been conditioned to believe. The system works in a similar way against all oppressed groups so understanding how it works, for example in relation to homosexuals, means that we are more likely to understand how it works against black people, women, working class people, disabled people, Irish people, Jewish people, etc., and vice versa. One major difference, however, is that the families of oppressed groups often defend their children against oppression and teach them how to cope with it; the families of lesbians and gays are more likely to be one of the main sources of oppression and often reject their children when they most need their support and understanding.

As well as being homosexual, lesbians are also female, which means that we experience two lots of discrimination and internalise two lots of negative messages. Those lesbians who reject femininity, i.e. tomboys/butches, are particularly vulnerable to discrimination and internalised self hatred because they do not conform to the stereotyped image of femaleness and are more easily recognisd as lesbian. Wilsnack (1976) suggested that sex-role conflict may be one cause of alcohol problems among women.

Lesbians, therefore, feel inferior because they are homosexuals and because they are female. Those lesbians who are multi-oppressed, i.e. those who are black, working class, minority ethnic, disabled, etc., experience further discrimination and inferiority. The more oppressed groups we belong to, the more likely we will have low self-esteem, low confidence, poor self identity and are more vulnerable to depression, alcohol and drug problems, and other self-destructive behaviours or coping methods. Fig 1 , Some Common Effects of Discrimination: Visibility, and Fig 2 , Some Common Effects of Discrimination: Privileges , suggest some of the effects which positive and negative visibility and privileges or lack of privileges have on people. The powerful and powerless groups are given as examples others might include, for instance, old people, adolescents, non-Christians, and so on. Clearly, the more groups one belongs to on the minus side - less visible and less privilege - the more vulnerable one would be due to the compounded effects of multi-oppression, and vice versa.

Discussing the rising number of African-American women who attempt suicide, Aldridge (1980) noted: "The costs of having several negatively evaluated statuses are particularly high and lead to social bankruptcy when people simply cannot muster the resources to pay them." Toni, one of the participants in the L.I.S. survey, is a 21-year-old, black (mixed race) lesbian who was brought up by a white middle-class family. She experienced dreadful racism in both her junior and secondary schools where, for a time, she was the only black child. Toni has also been raped. Before she contacted L.I.S. Toni had had a couple of relationships with women who considered themselves to be heterosexual. Her last lover, a married woman, had just finished with her. Toni had tried to kill herself several times. I asked her how she felt. She said, "Now I feel hurt, a bit angry, I feel used. I still care about her. I still love her even though she shits on me. But I've got more pride than that. I'll take some time off work, get my head together, stay out of her way, try and find another job, another woman, a dyke (this time) - if they're willing to take me on." I asked her why they shouldn't be, she answered, "Because I'm black," and continued, "Someone the same age as me, who I can go out with and get pissed with." I asked her why she wanted to get drunk. She said "It's something I've always done, to get clear of what's in my head, until the next morning when it's all back again. Then [I] get pissed again or stoned. Getting stoned is better." I asked Toni how often she used alcohol. She said she used to go out "Twice a week and get slaughtered. Now it's once every few months but I still get pissed. If I go out I get pissed. I don't go out for a drink and not get pissed. It makes me feel good."

Different cultures may alter or mitigate against some of the effects of
oppression. For example, another participant in the L.I.S. study, Su, an 18-year-old, working class, Asian, Muslim, lesbian never used alcohol or other drugs. When we discussed suicide she told me "In our religion it's a sin to kill yourself but many Asian people do kill themselves, but I wouldn't consider it, it wouldn't really solve anything." But there would still be over-riding conflict with the dominant culture in Britain and one of the compounded effects of multi-oppression is that those who belong to several oppressed groups will be more isolated.

Scientists, LeVay (1991), Bailey & Pillard (1992), and Hamer (1993), are increasingly coming up with evidence that some people are pre-disposed to homosexuality. In any case, many agree that same-sex preference is present as early as five years with recognition by adolescence: Bell, Weinberg & Hammersmith, (1981); Berzon (1979); Borhek (1983); Cass (1985); Jay & Young (1979); Minton & McDonald (1985); Morin & Schultz (1978); Woodman (1979). Many young lesbians and gays say that they began to notice they were 'different,' i.e. they were falling for members of the same sex, at around the age of eleven (some earlier, some later). Even before they have become aware of their 'difference' they have already internalised the negative messages they have heard about homosexuality. Gibson (1989) notes: "The age of onset for substance abuse among all youth has become lower in recent years and in 1985 is estimated to be 11.9 years for boys and 12.7 years for girls. This coincides with the age that many youth are becoming aware of a gay or lesbian orientation."

It is during adolescence when serious damage is done. Adolescence is a time when there is tremendous pressure for girls to conform to femininity, to be dating and, more and more, to be having sex (Sears, 1991; Fazal, 1994). Most important, this is happening round about the same time that many lesbians are becoming painfully aware that they are different; a time when they are extremely vulnerable. All this is within the context of a wider culture which promotes alcohol consumption and a youth culture which promotes both alcohol and drug use.

It is hard for heterosexuals to understand what it is like being lesbian and growing up with that knowledge in a society which hates and fears homosexuals. Everywhere you turn you hear something negative about homosexuality - on the television, in newspapers, from your friends, from parents, grandparents and siblings, from other kids at school, from teachers! Because of pending legislation there is currently a lot of discussion around the Age of Consent for male homosexuals. Turn on the television and you are likely to hear famous and 'respectable' politicians coming out with blatantly homophobic remarks. On Monday, 10th January 1994, BBC News at mid-day, Lady Olga Maitland, M.P., suggested that older homosexuals would pressurise young men into homosexuality and that this would "deprive them of future personal happiness, of family life and really, in a sense, being on the fringe of society." She continued, "If a girl of 16 has sexual intercourse she is carrying out, in a sense, a natural heterosexual function. But if a boy is forced into that mode he then could be forced into a sexuality for the rest of his life which would make him very troubled and very disturbed and very unhappy." On the BBC early evening news of the same day, Valerie Riches, Family & Youth Concern, said: "Heterosexual activity, even amongst 16-year-olds, is at least a normal activity. Homosexual activity is not normal, it is unnatural." Again on the same day, on BBC television, Lord Hailsham said "I think it [homosexuality] is a corrupt and corrupting vice."

We, Lesbian Information Service, are currently supporting a thirteen-year-old lesbian. Paula knew about her sexuality when she was eleven but it was two years before she spoke to anyone about it. She desperately needed support and told her school teacher whose response was to say that she was too young to make such a serious decision; the teacher now seems to avoid Paula. She told her best friend who, initially, said it was okay but has since become distant and constantly asks Paula, "When are you going to have a boyfriend?" Most recently, a boy in her class asked Paula out. When she refused he taunted her with: "Are you a lesbian, then?" Paula wanted to say, "Yes, I am, so what?" instead she told him to "Get lost."

Paula is one of the few younger lesbians who has contacted us after learning about our helpline in a magazine. We seem to be getting more and more calls from younger lesbians. Remafedi (1990) says:

"The youngest adolescents who are grappling with the possibility of homosexuality appear to be especially vulnerable to stigma and isolation because of emotional and physical immaturity, inexperience, the need to belong to a peer group, and dependence on families, schools, and communities for help during the transition to adulthood."

When Paula telephones she is often upset and cries when she tells us about the latest anti-homosexual joke or incident she has witnessed at school. She is desperate for support nearer home and, whilst it seems her parents may be supportive - one of their relatives is lesbian and her parents have gay friends - Paula is terrified to tell them. She fears they will not believe her.

We are able to give Paula limited support over the telephone and, more recently, she has felt able to receive information from us in the form of a booklet called "i think i might be a lesbian ... now what do i do?" Paula lives in a city where there is a Young Lesbian Group, which is quite rare. However, the Group meets a few miles away, in the evening, and the lower age limit is 16 years. It will be some time before Paula is able to meet other young lesbians of her own age.

To some degree Paula is fortunate to have come across our telephone number and to have had the confidence to call us; she can at least share her anger and sadness. But she is still without access to other young lesbians for friendship and without the support of those most dear to her, her parents.

Of the 20 lesbians we have interviewed, most knew they were 'different' at an early age and most had no-one to talk to for years. Without anyone to talk to young lesbians bottle up their feelings; many use drugs and alcohol to cope with their isolation.

Young lesbians do not need to become alcohol/drug dependent, depressed or suicidal, although because of isolation most are depressed during the very vulnerable early stages of coming out. Hetrick and Martin (1987) note:

"In a non-threatening supportive environment that provides accurate information and appropriate peer and adult role models, many of the concerns [of lesbian and gay youth] are alleviated and internalized negative attitudes are either modified or prevented from developing."

But Young Lesbian Groups are few and far between, often only exist in large cities and are rarely adequately staffed with specially trained workers who know how to deal with the issues (most groups are run on a part time basis). Young lesbians hold onto years of pain, anger, fear, guilt, shame, and sadness inside them. When their emotions do come out this often takes the form of self-harm. I knew I was different when I was eleven but talked to no-one for years and did not come out until I was 23 years old. At my 18th birthday party I got drunk and, because the girl I was in love with was hitting it off with a chap and I couldn't tell her about my feelings, I tried to walk under a moving car. That wasn't the first time I'd been drunk nor felt suicidal.

For many young lesbians, who eventually make contact with other lesbians, the only visible place to meet lesbians is in the local gay bar. All too often, however, the only role models available there are negative, as one of the participants in our study told us:

"Between the ages of 18 and 20 I was drinking with the town mob (lesbian prostitutes). I felt the people at work didn't want to know me. I hated myself. I had an uproar with the family and lost a lot of mates. I felt unusual at the maintenance job, they asked me lots of questions about my sexuality because I was out.

I was lonely and isolated ... it was when I was drinking. It got bad, I really hated myself. The only gay people I knew were a bad crowd. They were always fighting. They were a tight knit, rough, group who would go out with men or women, anybody. It was a rough life. I realised now I hated myself because of that. My home was a real tip, I didn't look after my child properly."
Karen, white, working class, age 24.

We discussed the use of alcohol in one of the Young Lesbian Groups run by Lesbian Information Service. We talked about why we drink, and get drunk, and came up with the following reasons:

* To get out of everyday situations.

* Depression - to drown my sorrows.

* Not being able to express myself.

* Fear.

* Loneliness.

* Not having any social contact with lesbians.

* Not having any lesbian lovers.

* To build up my confidence.

* To help me say things.

* To help me do things.

* I can sort things out better.

* Because I've been rejected.

* To be able to say I'm attracted to another lesbian.

* I can cope with things better. If I've got to see someone who I've got to talk to having a drink helps. For example, seeing a solicitor.

* Not being able to drink in moderation.

* The more we drink the more we need to get drunk.

* It's important to have someone on the same wave length as you to be able to talk to them.

Gibson (1989), notes:

"Substance use often begins in early adolescence when youth first experience conflicts around their sexual orientation. It initially serves the functional purposes of (1) reducing the pain and anxiety of external conflicts and (2) reducing the internal inhibitions of homosexual feelings and behavior. Prolonged substance abuse, however, only contributes to the youth's problems and magnifies suicidal feelings."

Having got into the habit of using alcohol or drugs to cope during adolescence, those lesbians who are out continue to use it to deal with the pain and effects of everyday discrimination whilst those who are in the closet at work, or with their families or friends, use alcohol or drugs to deal with the mental stress this causes. After pretending to be heterosexual at work all day, many lesbians drink to help them relax when they get home.

Because of homophobia and isolation, many lesbians try to suppress their homosexuality with heterosexual sex, having children, and getting married. Of the requests for help we receive from lesbians two-thirds are from young lesbians and the remainder from older women coming out, the majority of whom knew about their sexuality when they were young and tried to suppress it. Alcohol, and often prescribed drugs, is then used to deal with the depression and conflict which ensues from trying to maintain the pretence of heterosexuality. When these women come out later in life (some never do) they will go through a similar, stressful, process which young lesbians experience in adolescence; this makes them particularly vulnerable to alcohol dependency.

Two recent articles have emphasised the connection between the development, and/or suppression, of lesbian identity and alcohol misuse. Deevey and Wall (1992) state:

" present, at least, we know of no lesbian women who use alcohol who seem fully self-accepting. We see alcohol use as one of several strategies for coping with the self-hate of simultaneously accepting and rejecting shaming messages. Alcohol use in combination with accepting shaming messages leads either to active suicide or to indirect suicide as a result of the progression of alcoholism."

Whilst Hall (1992) notes the similarities between lesbians and African-American and Latina women who experience alcohol problems:

"...[Lesbians] often described being unable to accept fully the idea of being lesbian in a positive way before they stopped drinking and using drugs...Likewise, some of the African-American and Latina women interviewed described recovery as a process of accepting their racial and ethnic heritages and confronting painful racial conflicts that they had buried through their substance use."

In summary, because of internal and external oppression lesbians, especially those who are multi-oppressed, are likely to be vulnerable to depression, alcohol or drug misuse. The origins of this vulnerability lie in the negative messages lesbians internalise, especially when they are young and during adolescence when many become aware of their stigmatised identity. The coming out period, for lesbians of all ages, is a particularly vulnerable time.

While there may be other 'presenting' problems, such as relationship breakdown, bereavement, etc., these experiences will exacerbate the under-lying vulnerability. In no way should the presenting problem be minimalised but it is likely that the suppressed pain and anger of years of homophobia - if not dealt with - may be projected onto other problems. Whatever the presenting problem is it must be viewed within the general context of homophobia which will make the situation more complex. Take relationship breakdown as an example. Isolated lesbians are often not out to anyone but their partners, and maybe a few close friends; they are often totally dependent on their partners for support against discrimination. Relationship breakdown can be suffered in complete isolation, it often brings up again the whole question of sexual identity and some lesbians may decide to re-suppress it whilst others may have to take a further step in the coming out process.

What Difficulties do Lesbians experience trying to achieve Sobriety?

Some of the difficulties lesbians experience in trying to achieve sobriety will be similar to those experienced by other people with alcohol problems who belong to oppressed groups. For example, the major reasons for their vulnerability to alcohol/drug problems, are 1) internalised negative images (internalised oppression) and 2) daily discrimination and powerlessness (external oppression). It is possible to challenge internalised oppression and develop self esteem which will help to develop healthier methods of dealing with external oppression. It is important for members of oppressed groups, and for those trying to help, to understand the processes many people go through in moving from a negative to a positive identity.

Several U.S. academics, Cass (1979), Coleman (1982), Sophie (1983), and Troiden (1989), have produced identity stage models for homosexuals; Chan (1989), Loiacano (1989), and Morales (1989), have produced models for people who are homosexual and who belong to other minorities; whilst others have produced models to cover the identity development of all minority groups: Barret (1990), Atkinson, Morton & Sue (1983), and Sue (1981).

Utilising previous work, the following model has been developed to assist our understanding. It should be noted that, without help, only a few will arrive at the final stage - isolation and multi-oppression make progression more complex.

Stage 1: Whilst we have internalised the negative messages about our minority status, at this early stage we are not aware that we are different.

Stage 2: We begin to realise we are different from the 'majority' and, because of internalised negative messages, are ashamed of who we are. If possible we try and hide our difference. We want to be like the majority and try to conform to something we are not. This creates depression and conflict and makes us vulnerable to drug or alcohol misuse. Use of alcohol or drugs as a means of coping, and isolation from accurate information and other members of our minority group who challenge the stereotyped images, means that we can get stuck in this stage.

Stage 3: If/when we have access to other members of our minority group (some people, for example homosexuals, disabled people, black children adopted by white families, etc., have no, or limited, access to members of the same minority group and are denied their support and understanding) we realise that we share similar experiences. We begin to meet people and read information which challenges the negative images perpetuated by society. However, we are still greatly influenced by the dominant culture which means we experience conflict and confusion about our beliefs and values.

Those who can 'pass' - i.e. some homosexuals, some people with hidden disabilities, black people with light coloured skin, educated working class people - can get stuck in this stage, never deal with their internalised oppression and never fully develop their self-esteem. They will remain vulnerable to depression and suicide, alcohol and drug misuse.

Stage 4: We reject the dominant view of society and culture and positively identify with our minority status. Through access to accurate information, positive role models and support, we realise that it is society which is wrong, not us. This stage is extremely important in helping to eliminate internalised negative images and beliefs, making us complete persons, and developing our self-esteem.

There is also a danger of getting stuck in this stage, however, when we become arrogant and argue that we are the 'most oppressed.' We ignore or minimalise other oppressions. In consequence we are, in turn, guilty of oppressing not only other minority groups but also members of our own minority group who are multi-oppressed. If we are multi-oppressed we continue to oppress ourselves by not dealing with all of our internalised oppressions. We often project the effects of other oppressions onto the one we consider the 'worst.' For example, many feminist lesbians consider their oppression as women to be 'worse' and deal only with that, ignoring or minimalising lesbian oppression and projecting the effects of heterosexism and homophobia onto sexism and mysogyny.

Stage 5: We realise that there are often many aspects to our identity and, by accepting and dealing with all of our internalised oppressions, we are on the road to recovery, developing our self-esteem and confidence, and becoming complete human beings. This plays a crucial role in helping us to cope with everyday discrimination.

We realise that being separate from the rest of society means we are limited in what we can do, what we can achieve, that we must engage in society to fulfill all of our needs and to challenge the system. We become aware that oppression follows a similar pattern for all minority groups. We make links between oppressions and want to eliminate all forms of oppression.

Most services, including alcohol treatment agencies, are geared towards serving a white, heterosexual, male, clientel. Unless great effort has been put into awareness training, developing knowledge about the experiences and circumstances of minority groups, and the establishment of programmes to deal with the special needs of different groups of oppressed people, services will simply perpetuate institutional discrimination. U.S. researchers Lohrenz et al (1978) found that 37% of homosexuals experienced discrimination from alcohol agency staff while Fifield, De Crescenzo & Latham (1975) discovered that 75% of homosexuals who are recovering from a drink problem believe that mainstream agencies are not geared to treating homosexuals and do not provide an accepting and supportive environment.

There are unique difficulties which homosexuals face - and lesbians in particular - in trying to achieve sobriety in the same way that there will be unique difficulties for other oppressed groups.

One major difference between homosexuals and other oppressed groups is that we have to come out. Coming out is a process which is never ending. (Some people - especially lesbians - never come out). It begins with admitting, and accepting, to ourselves that we are homosexual, telling others - especially our families and friends, work colleagues and, ultimately, telling the world (i.e. being in the media). Each time we tell someone we face rejection and discrimination. The early stage of the coming out process is a vulnerable period for all homosexuals at whatever age but especially youth; it is a time when many lesbians and gays turn to alcohol or drugs for support.

Being able to 'pass' as heterosexual is sometimes seen as an advantage by other oppressed groups. However, passing creates deep psychological problems and means we are more vulnerable to depression, alcohol and drug misuse: we are less likely to develop positive identities and self-esteem; we face the constant threat of being discovered and are open to extortion; we are unlikely to get appropriate support; and, in any case, many homosexuals cannot pass! Whilst those who can pass benefit by escaping external oppression, the toll on internal oppression is likely to be great.

Because of discrimination homosexuals are less likely to attend alcohol dependency treatment centres unless, that is, they are 'passing.' In this case, if the worker does not bring up the subject, one of the major causes of their problems will be ignored. Pauline, one of the participants in our research who is white, middle class and aged 21 years, told us:

"I've had alcohol problems since I was 18. I was getting help, from the Community Alcohol Team, but not now. It did nothing for me. As soon as he'd been I'd go out to the pub. I never talked to him about my sexuality, it was never mentioned. I didn't talk about the situation about why I'd got into drinking, to blot everything out that was happening around me, all the troubles. I never mentioned anything about Ellen. We talked about general problems, about the mortgage. He knew I'd split up in a relationship but he didn't know what sex. I saw him for six months, he never raised sexuality."

Pauline was desperate to talk to someone who would be accepting and understanding. Rofes (1989) says:

"By ignoring the special problems that a lesbian alcoholic, for example, presents, programs will be doing a service to no one. Their treatment of the individual will be less than adequate and may tend to intensify the woman's feelings of isolation and 'difference.' Only by bringing the issue into the open and addressing the woman's lesbianism as an aspect of her life which she needs to feel positively about, will the program be truly effective."

We visited the co-ordinator of the Community Alcohol Team. He said it was not up to the counsellor to raise sexuality. At the same time, he admitted, "sexuality was the most hidden issue." He said that he would not refer a client onto a Young Lesbian Group because lesbianism might be a phase his client was going through and she might feel ashamed and later regret having labelled herself lesbian. Shernoff & Finnegan (1991) discuss the case of a lesbian who is hiding her sexuality, then stress:

"It is the responsibility of each counselor to take the lead in this area the same way counselors routinely question early family history, dynamics of shame, denial and spirituality. By omitting questions about sexual orientation, or the more subtle questions about sexual or affectional feelings or fantasies for a person of the same sex, the counselor is not obtaining information about all the possible contributing factors for achieving and maintaining sobriety."

While Hellman et al (1989) note:

"Therapists may fear causing offense by asking patients about sexual orientation because of discomfort with the subject. However, this questioning can be essential in helping to overcome the secrecy and denial that are hall marks of the struggle with both alcoholism and homosexuality."

Of course, if a worker is ignorant about homosexuality s/he is likely to make the situation worse: American surveys, referred to by Hellman et al (1989), reveal a list of complaints about mainstream provision ranging from heterosexual bias in treatment and evaluation (including either focussing primarily on sexual orientation when inappropriate or ignoring important factors linked with sexuality); ignorance about lesbian/gay issues and discomfort at approaching matters of sexuality; to ignorance about the inter-relation of homosexuality and alcohol misuse. Lesbians and gays felt discomfort in the mainly heterosexual environment of agencies and were fearful of being viewed as pathological or stereotyped. Neisen & Sandall (1990) work at a programme designed to offer treatment to chemically dependent lesbians and gays. They list their clients' experiences of non-gay provision, which include: difficulty in being open about their sexual orientation due to fear of staff/client harassment; staff telling them it wasn't acceptable to discuss sexual orientation; some were forced to disclose their sexual orientation; as soon as their sexuality was known, some were discharged; some said that after disclosure the treatment they received was different due to an atmosphere of condemnation; some feared that if their sexual orientation was known about this would receive more emphasis than their chemical dependency; and some were not happy having their partner attend a family rogramme.

Inclusion of families in treatment programmes is becoming an acceptable way of supporting those coming off alcohol dependency (Nardi, 1982; Shernoff & Finnegan, 1991). This would be problematic for the homosexual client, partly because many will have been rejected by their families and those families who do not reject their offspring rarely want to discuss anything connected with homosexuality. Yet it is the ignorance and unacceptance of families which is one of the main reasons why homosexuals are vulnerable to alcohol and drug misuse. When discussing coming out to parents in our survey, Pauline said:

"My parents know. My mum suggested I should seek help for my sexuality. She said it was a phase I was going through. She suggested I saw a psychiatrist but I didn't go. She thought it was a big joke and went to the corner shop and said 'My daughter is going out with a woman.' My proper dad flipped. (My parents split up ten years ago). I blamed my (step) mum for what happened to me with the alcohol and drugs. My dad threw me out of my granmas (where I was when I told him). I was friendly with him before but since coming out I haven't spoken to him. His wife (my step-mother) said they knew I was [lesbian] years ago, she said she'd never liked me."

Lesbians and gays often replace their family of origin with an extended family of lesbian and gay friends, many of whom will also have alcohol/drug problems. Rofes (1989) points out: "The inability of the traditional networks which people use to support their recovery from alcoholism - family, church, school, employers - are closed to many gay people."

Alcoholics Anonymous (AA) is one of the main support agencies which helps people with alcohol problems. However, because AA is Christian based and Christianity - along with other religions - is particularly responsible for society's homophobia, it will be inappropriate for many lesbians and gays. Hawkins (1976) notes that closet homosexuals will attend heterosexual-oriented AA groups and that "It can easily be seen that this would produce some detrimental effects, considering the fact that the acknowledged key to sobriety is an open and honest relationship with one's peers." At the same time, lesbians and gays in the U.S.A. founded Alcoholics Together (AT), a lesbian and gay version of AA, in 1970 and since then there have been 100's of groups formed across the States. Clearly this is fulfilling a desperate need but some people have reservations about the relevance of AA to lesbians and gays (Bittle, 1982; O'Halleran Glaus, 1989; Tallen, 1990; Hall, 1992).

Culture plays a major role in developing both group and individual esteem and identity. Culture can be oppressive to minority groups, for example, in Britain the major culture is white, male, middle-class, heterosexual and Christian. But culture can also help minority groups - in particular minority ethnic groups - to combat the effects of discrimination. Many things go towards making up culture: mainly religion but also mores, community, family, customs, as well as music, art, literature, language, history, etc. Culture can enable minority groups and individuals to develop pride in who they are, despite living in a society which discriminates against them. It can, therefore, act as a barrier against the effects of oppression.

However, those who are multi-oppressed, for example black lesbians, will not only be oppressed as a black person, a woman and a homosexual by the dominant culture but they will also be oppressed, because of their sexual orientation and gender, by their minority ethnic culture. This then leaves them without the support the minority culture affords against racism, unless, that is, they are passing, the effects of which have already been referred to. In the same way other cultures are homophobic, gay culture is also racist, classist, ableist, ageist and sexist. Thus a multi-oppressed homosexual would find little respite from oppression even within gay culture which is, in any case, oppressive to all homosexuals.

Alcohol and drugs are very much part of gay culture (Diamond & Wilsnack, 1978; Nardi, 1982; Zehner & Lewis, 1984). Gay pubs and clubs (the 'scene') serve many purposes. As Blume (1985) says: "The gay bar has historically been the protected place where homosexual persons could meet, socialize, be the dominant culture, make sexual contacts, start relationships, hold hands, dance, belong - all the things that nongays can integrate into the totality of their lives and therefore take for granted." However, as Zehner & Lewis (1985) note: "It is in many ways unfortunate that the bar has become the most recognized institution in the gay/lesbian culture because along with it comes the tradition of using alcohol while socializing and as the main psychic relief." Whilst Nardi (1982) notes: "For many who are just 'coming out,' bars aid in the development of a gay identity. However, some do get swept up in the pleasure-reinforcing dimensions of a drinking-oriented sub-culture, viewing alcohol and drug consumption as a necessary component for a gay identity." The lack of institutional support, in the form of lesbian and gay youth groups for example, means that lesbian and gay youth coming out are automatically thrown into an adult environment where they are out of place. Schneider (1989) says: "Their abrupt introduction to an alcohol-focussed and sexually loaded environment bypasses the gradual and safe ways in which most heterosexual youngsters learn to deal with alcohol and sexual intimacy..."

Because of discrimination gay culture is primarily hedonistic and escapist and, as Nardi (1982) notes, not only is there a strong denial of alcohol problems (or any problems for that matter) among the lesbian and gay community but drinking is an accepted way of coping with oppression and many homosexuals directly and indirectly encourage heavy drinking.

Whilst the above is applicable to both male and female homosexuals, because we are doubly oppressed the situation facing lesbians will be more complex, and even more complicated for those who are multi-oppressed. The same will be true for female members of other oppressed groups. Because we are female homosexuals we are less visible and more isolated; lesbians are more likely to be in the closet and some will not even be aware of their true sexual identity. Lesbians are more likely to try and suppress their sexuality; we have fewer positive role models. Many lesbians, like heterosexual women, have been subjected to sexual abuse which has further implications for alcohol misuse (Neisen & Sandall, 1990; Deevey & Wall, 1992; Copeland & Hall, 1992a). At the same time, our problems are least likely to be acknowledged or understood and we are least likely to acquire the support we need. It is not, therefore, surprising that lesbians are more depressed, suicidal and dependent on alcohol than heterosexual women, heterosexual men or homosexual men (Bell & Weinberg, 1978; Saghir & Robins, 1974; Saghir et al, 1970; Lewis et al, 1982; Schilit et al, 1990; Brandsma & Pattison, 1982; Blume, 1985; Diamond & Wilsnack, 1978; McKirnan & Peterson, 1989; Anderson & Henderson, 1985).

We, in Britain, are probably at the stage where, in the U.S.A. O'Donnell et al could say in 1978:

"One in every three gay persons abuses alcohol and is either an alcoholic or is rapidly heading towards that destination. This is more than three times the estimate of problem drinkers in the general population. Does this surprise you? Alcoholism isn't talked about very much in the lesbian community. Some of us think we don't know anyone who drinks heavily. But most of us do know women who drink heavily - we just don't recognize the extent of the problem."

However, as Hall (1992) notes, lesbian communities in the U.S.A. have been discussing alcohol use and recovery for several decades, to the extent where now there are many lesbian and lesbian and gay AA groups and 'clean & sober' social events which provide some of the social functions previously provided by the lesbian bar subculture.

What are Alcohol Services in Britain Doing?

In late 1992 we contacted several Alcohol Agencies in the North West with regard to the need for a booklet about Lesbians and Alcohol. One manager told me: "In principle it [the booklet] is probably needed" but, she added, "... [they] had no evidence of the need as few lesbians were 'presenting' themselves." A worker at another Centre said it was an "excellent idea" and that "other Centres usually shy away from the subject. Some are not even aware of the need!" The Alcohol Counselling and Prevention Services in Brixton said, "There is an incredible demand for support for lesbians with drinking problems; we run a lesbians and alcohol group."

In the 1991/92 Alcohol Services Directory thirteen agencies say they welcome, or provide services for, lesbians and gays. Of these, six are in London. Only one was in the North West. I telephoned them to see what they provided and was told that there had been a mistake, there was no special provision for lesbians and gays.

DAWN (Drugs, Alcohol, Women, Network) have recently conducted a survey (Webb, 1993) and found that only 9% of the agencies which responded offered something for lesbians; these were all in London.

Whilst there are women and alcohol groups, (35% of the agencies who responded in the DAWN survey said they provided women's groups), and Copeland & Hall (1992b) found that such programmes are more likely to attract lesbians, these groups usually do not address the specific needs of lesbians. We were supporting a young lesbian in the Midlands who attended a women and alcohol group; half of the group were lesbian; none were out. Schilit et al (1988) suggest that the nine most usual activities in self-help groups are "empathy, mutual affirmation, explanation, sharing, morale building, self-disclosure, positive reinforcement, personal goal setting, and catharsis." It is unlikely that a lesbian in a women's group - whether open about her sexuality or not - will experience these activities. Indeed, it is worth noting that whilst papers at the 1986 Conference: Women's Problems with Alcohol and Other Drugs concerned other minority group women, there were none on lesbians (Waterson et al, 1986). Similarly, had Lesbian Information Service not given a workshop at the North West Conference on Women and Alcohol, 1993, it is unlikely that lesbians would have been mentioned, in the main plenary at least. Certainly, lesbians were not included in the key note speech, but then neither were working class women and black women only received a cursory comment.

Survey of Alcohol Services in the North West of England


Having identified that lesbians are a high risk group for alcohol misuse and that many alcohol agencies were not picking up on the issues, we decided to conduct a survey of alcohol services in the North West of England. A 31-item questionnaire was designed based on the Hellman et al (1989) New York Survey.

The Alcohol Services Directory, Owen Wells, Alcohol Concern, 1991/92, was used to contact Alcohol Agencies. We telephoned 38 agencies to obtain staff numbers and a named person to send a covering letter, questionnaires and stamped, addressed, envelopes to. Of these Agencies two returned the questionnaires: English Churches Housing, who said "...we are unable to assist as our service only works with men at present" and Merseyside, Lancashire and Cheshire Council on Alcoholism, who said the Executive Director did not feel it appropriate to distribute the questionnaires but instead sent a letter stating general responses to the questions; these have been incorporated below.

Altogether, 326 questionnaires were distributed (this includes ten extra ones which were photocopied by someone). Sixty questionnaires were returned blank (17 - English Churches; 39 - Merseyside; plus 1 returned in an envelope and three sent back from an agency because their staff had been reduced). One-hundred-and-twenty-one questionnaires were returned completed. This is a return rate of 37%, which is slightly higher than average.

The questionnaire was divided into four sections: Personal; Training, Clinical Knowledge and Practice related to Lesbian Clients; Alcohol Treatment Provider's Opinions and Attitudes about Alcohol Problems in Lesbian Individuals; and Alcohol Treatment Provider's Perceptions of their Facility's Services for Lesbian Clients.

Several issues came up during organisation of the information: Some respondents ticked more than one answer, e.g. in education, vocational qualification, and primary responsibility. This caused slight problems during analysis, especially in relation to education. Some respondents added the category 'don't know' to several questions. Where relevant these have been included. If someone left a question blank or wrote a comment instead, this has been counted as no response. Many of the comments have been included. Where 'other' was an optional answer we asked respondents to be specific. Many of these responses have been included. I have included many of the comments because I believe they help to paint a clearer picture of the attitudes of the participants.

Occasionally I will compare the results of this survey with that of the original, Hellman et al (1989), New York study. Both surveys are similar in size, the New York one being sent to 36 government sponsored agencies and eliciting 164 responses, a response rate of 41%. To enable readers to make further comparisons I have included the New York findings in Tables 2, 3 and 4 as a plus or minus percentage figure in brackets.


Section I: Personal

The personal details shown in Table 1 reveal that provision in the North West seems to be comprised of white (96%), heterosexual (91%), females (68%), and workers who are aged primarily between 25 and 44 years (76%). This has implications not
only for lesbians and gay men but also for black and minority ethnic people. It has specific implications for lesbians because Goodyear, Abadie & Barquest (1981) suggest that homophobia is stronger from people of the same sex, i.e. heterosexual women are more homophobic towards lesbian women; heterosexual men are more homophobic towards gay men. In comparison, less than half of the workers in the New York study were white (47%) but, interestingly, almost the same number were heterosexual (90%).

Fifty-two percent of the participants were educated up to polytechnic or university level whilst 25% left school at 16 years and a further 25% attended 6th form college. The level of academic qualifications are clearly higher in the alcohol field in the U.S.A. as only 11% did not have a degree compared to 46% in our study.

People working in the alcohol field in the North West come from a variety of vocational backgrounds, including nursing, alcohol treatment, psychiatry, social work and psychology. 'Other' vocational qualifications included: counselling, probation, teaching, youth and community work, and management. Whilst 7% of the participants indicated they had no vocational qualifications, many of these were administration workers or other support staff. Only 3% of the respondents who had no vocational qualifications were involved in providing a clinical service. It is interesting to note that the U.S. study consisted of 12% fewer psychiatrists, 15% more social workers and 15% fewer nurses.
Section II: Training, Clinical Knowledge, and Practice Related to Lesbian Clients.

Responses ( Table 2 ) show that there is little training, supervision or knowledge in relation to lesbians and alcohol misuse in agencies in the North West of England and that a substantial number of workers would welcome training on the same: Four percent felt that the quality of training in relation to supporting lesbian clients was excellent; 8% thought it was good; 15% fair; whilst 20% said that it was poor and 53% said they had no training. One participant commented: "Pre-qualification was fair but in-service training non-existent." Another noted: "In my role as an administrator I have limited contact with clients. I treat all individuals in an even-handed way and do not differentiate between lesbians and the 'rest of the world!!"

Only 13% of the respondents said that they had experienced clinical supervision in relation to supporting lesbian clients while 87% had had no supervision. It is worth noting that 67% of the respondents said they would like more training. By comparison, the New York survey found that staff received more training and supervision, are more knowledgeable and are more interested in training. Two of the participants noted: "Would seek if it became necessary." "If there is a specific need."

Only 4% said that they were very knowledgeable about lesbians and alcohol misuse; 54% said they were somewhat knowledgeable whilst 42% admitted that they were not knowledgeable.

The question 'How familiar are you with health and social resources in relation to lesbians?' elicited the following response: 2% said they were very familiar, 7% familiar, 44% somewhat familiar but the majority, 47%, said they were unfamiliar. In the New York survey 23% more of the workers said they were either very familiar or familiar.

Only 9% of the participants were aware of specialised alcohol treatment programmes for lesbians. Comments included: "No. Why should there be?? What's so special about lesbians? If they have a drink problem, it's the same for single mothers, seemingly happily married women, so what's the bloody fuss about lesbians!" "AA seems appropriate for most people who have become totally dependent on alcohol." "I know of an alcohol group for lesbians called Moonshine and have given women leaflets re this. I wouldn't consider this a specialised alcohol treatment programme."

Eight percent of the participants thought that none of their clients were lesbian; 45% thought that between 1 and 25% were lesbian; 3% that between 26 and 50% were lesbian and 44% admitted that they did not know. It is not surprising that many respondents did not know the sexuality of their clients considering the number of workers who asked clients about sexual orientation: 4% said they always asked; 9% that they asked most of the time; 30% some of the time; 20% almost never and 36% never. In contrast, workers in the New York study were more aware of the sexuality of their clients because many more asked about sexual orientation. Comments regarding this question included: "Usually ask a lot of other things first." "If problems related to sexual orientation are apparent clients are facilitated into discussing same." "Nothing to do with an alcohol problem." "Only if it is suspected to be an issue in counselling." "Don't actually ask clients unless it appears to be a problem to them but I do facilitate a response with regards to their sexual orientation." "I let them tell me." "Never - we leave it to client to reveal what they wish, when they wish to do so."

The results are interesting and somewhat contradict answers to the previous question, i.e. 56% of the respondents indicated they almost never or never ask clients their sexual orientation and a further 30% responded 'some of the time.' Yet 45% claim that between 1 and 25% of their clients were lesbian. Clearly some respondents are guessing at this answer whilst others are maybe working on assumptions (i.e. a client 'looks' lesbian).

The vast majority of respondents, 95%, said that they felt no discomfort treating any clients whilst 5% said they were uncomfortable working with lesbians who hide their sexuality. Most of the respondents (84%) - and this is despite the low levels of training, supervision and knowledge about lesbians and alcohol misuse - would treat lesbian clients whereas the remainder would either refer or consult with other counsellors (2%) or refer to another agency (8%). Comments included: "If I am assessing a female client I ask her if she would prefer a female counsellor." "Refer to other agency if appropriate." "Treat client, if this unit is appropriate to their needs." "Work in consultation with outside agency in order to ensure anti discriminatory practice." "Knowingly never had to deal with lesbian client." "Will consult with client if they want contact, support from lesbian group." "Treat client re individual as a whole with all problems." "As with any other client." "Possibly a combination of treatments after discussion with client." "May refer to another agency in addition to seeing me. Would give information on lesbian services." "Offer all alternatives."

Comparisons with the U.S. survey reveal - quite strongly - the greater levels of training, and the effects of training on the understanding of workers knowledge and practice, about lesbians and alcohol misuse.

Section III: Alcohol Treatment Provider's Opinions and Attitudes about Alcohol Problems in Lesbian Individuals.

Table 3 shows that 22% of the respondents agreed that lesbians with alcohol problems have unique treatment needs whilst 34% disagreed and a further 44% said they did not know. In contrast, in the New York study, 55% more said they agreed, only 6% disagreed and 17% fewer said they didn't know. Comments included: "All problem drinkers have 'unique' needs, but many of their needs are very much the same! The lesbians I have treated have not expressed unique needs." "No, unless their lesbianism is a root cause of their drinking." "Some may be having problems with alcohol abuse aggravated by other factors, i.e. death/bereavement, anxiety, etc, sexuality may not always be primary problem." "Not in my experiences with lesbian clients." "In group or residential setting - yes." The Merseyside Lancashire & Cheshire Council on Alcoholism responded by saying: " [we] recognise that women have some unique treatment needs and that this will include the safety and security to explore issues relating to sexuality. Women have the choice of seeing a female or a male counsellor within our Service and our Women's Outreach Service
guarantees that a woman will be seen by a female counsellor who is there to
encourage and support her on any issues she may bring to treatment. In the event
of there not being a counsellor available to meet specific needs then we would refer
some clients to a more appropriate agency whilst we continued to offer our support
for alcohol related issues."

Seventy-seven percent of the participants felt that it was either very important (15%) or important (21%) or somewhat important (41%) to assess sexual orientation whilst 20% felt that it was not important and 3% said they did not know. This is a fascinating response when we consider that 56% of the respondents never or almost never asked clients about their sexual orientation and 30% said they asked some of the time. By comparison, in the American study, 25% more said it was very important to ask clients about their sexuality, 11% more that it was important, 21% fewer that it was somewhat important and only 7% said it was not important. Comments included: "If it's important to the person, then it's important. It is the client's choice whether they talk about sexual orientation." "Not important to assess directly. However I feel it is very important to be aware of different sexual orientations and to promote a service where people can feel able to talk freely about themselves. Only then can real levels of trust be built up. Assessment of sexual orientation is important in relation to arguing for specialised services/choice of service." "If it is suspected to be a relevant issue." "It's not important for me as a
worker but it can be very important for a client to assess their sexual orientation."

Thirty-three percent of the respondents said that it was less likely that lesbians would seek help compared with heterosexuals; 19% said there was no difference and 48% that they didn't know.

In the Hellman et al (1989) survey, seventeen percent more said it was less likely that homosexuals would seek help compared with heterosexuals (22% fewer said they didn't know).

The majority of the respondents (69%) felt that the best treatment approach for lesbians was the same as other clients; 25% said that they would either refer to a therapist with specialist training (10%) or to an agency with specialist provision (15%); only 6% said they did not know. In contrast, thirty-six percent fewer in the U.S. study said they would treat homosexuals the same as other clients and 44% more that they would refer to a therapist with specialised training. Comments included: "According to the latest research some lesbians need special groups but not all do." "Each person has their own needs." "Refer to agency with specialised programmes sometimes, depending on needs." "Surely it depends on the individual clients needs and choice." "Again the term 'best treatment' seems to indicate a generalisation. Some lesbians/gay men will benefit from specialised programmes. Other's won't. The choice should be there." "Perhaps this is too general?"

Just over half (51%) were unaware whether it would be helpful to have openly lesbian staff; 20% felt that it would not be helpful whilst the remainder (29%) agreed that it would be helpful. Twenty-one percent more in the U.S. survey said it was helpful to have openly homosexual staff. Comments included: "Maybe helpful for some individuals." "Irrelevant." "Perhaps in a Alcohol service specifically for Lesbians." "Not necessarily."

Section III, more than any other, reveals large differences between this study and the New York survey. This strongly suggests that there are much greater levels of awareness of the specific treatment needs of lesbians with alcohol problems and a greater understanding of the importance of assessing the sexual orientation of clients among U.S. alcohol workers than amongst staff in the North West of England.

Section IV: Alcohol Treatment Provider's Perceptions of their Facility's Services for Lesbian Clients.

Table 4 shows that 59% of the respondents did not know whether their administrators were knowledgeable about alcohol problems in lesbians while 33% said they were not and only 8% that they were. One respondent said: "Don't understand the question. Who are our administrators? If you mean managers I would say no." Some administrative staff said they thought the survey was not relevant to them. Use of the term 'administrators' obviously caused some confusion.

Twenty-six percent of the respondents said all or most of their co-workers were knowledgeable about alcohol problems in lesbian individuals, 51% said that a few or
I do not know whether respondents came from all of the agencies in the North West but it would seem, from the responses (100%), that there are no specialised programmes for lesbians in alcohol treatment agencies in the North West. Yet 7% of the respondents rated the quality of special programmes at their facility as excellent, 18% good, 12% fair, 10% poor and 51% said there were no special programmes. Only 2% said they did not know. Comments included: "For drinking problems/for homosexual clients?" "We like to think our programme is special!" "No lesbian programme, but treatment generally is good." "In relation to lesbian/gay issues? None to my knowledge." "No programmes - depends on the individual counsellor (as with most other issues)." "They are all special to the individual." "Don't understand this." "Programmes/counselling are developed to individuals needs." "Tend to work on an individual basis with client and not provide specialised programme." "Special alcohol group for females."

Twenty percent said that their colleagues were in favour of specialised programmes, 14% said they were not and 66% said they did not know. Comments included: "I rather doubt it." "We respond according to needs and wishes of residents." "Don't understand."

Fourteen percent said that their project gave the highest priority to develop and improve their programmes, 26% high, 15% medium, 16% low, 27% no priority and 2% said they did not know. Comments included: "Depends on the district centre." "(High) i.e. generally speaking as opposed to specifically for lesbians which I suppose is low." "Ongoing review of what we do via staff meetings, staff development, etc." "I don't know what you mean by these questions." "Low - at the moment. This may well change." "Low - due to lack of demand (I think)." "Weekly revue (sic.) on our service provision." "To ensure equal access of services." "What are programmes? Programmes for who? Having difficulty keeping current service going. Lack of resources for development."

Comparison with the New York study suggests that there are fewer specialised programmes there and that workers are more critical of the quality of those special programmes which exist. It would also seem that their administrators were more knowledgeable about alcohol problems in homosexuals.

Nine respondents said there were openly lesbian staff at their facility. Of course, they could all be referring to the same person. Only two participants said they were lesbian. Comments included: "We have previously had openly gay male staff." "In some centres." "I don't know all the staff." "Among staff, not among residents." "Don't talk about it." The Merseyside Lancashire & Cheshire Council on Alcoholism said: "none of our staff are openly Lesbian nor do I believe there is any kind of professional risk to them being so if they choose."

With regard to professional risk to openly lesbian staff, 3% said there was definitely a risk, 11% probably, 25% not sure, 33% probably not and 28% definitely not. Comments included: "Not sure what is meant by 'professional risk' if it means 'would an open lesbian woman be discriminated against in terms of appointment or promotion' then the answer is definitely not." "In some instances."


The results of the survey show that, apart from a few enlightened individuals (maybe 12% of the respondents), the majority of alcohol workers and administrative staff of alcohol services in the North West of England are lacking in knowledge and understanding about the specific needs of lesbians with alcohol problems, and of the inter-relation of lesbianism and alcohol misuse. There is little training or supervision in this area, limited knowledge about lesbian community resources, an inability to identify lesbian clients, hardly any openly lesbian staff, and no/little priority to create special provision for lesbians.

I would suggest that putting an emphasis on the 'individual' is often a euphemism for ignoring the special circumstances and needs of minority groups. I would speculate that similar results would come up if a survey were conducted regarding other minority groups. At the same time, if work in the North West is based on the assumption that the needs of all those with alcohol problems are the same and there is no/little priority for special programmes, it is fair to assume that the needs of minority groups are not being met.

There is clearly less homophobia, more awareness, training and specialist counsellors in government funded mainstream provision in New York than there is in the North West of England. This is, no doubt, a reflection of the almost total lack of research on this topic in Britain compared to a wealth of information from research conducted over twenty years in the U.S.A., much of which is available in this country through the Library Service. There are also many more alternative support groups provided by the lesbian/gay community in the U.S.

We have a lot to learn in this country but the results also show that a substantial number of workers do want training. We do not have to re-invent the wheel. Much of the U.S. research will be applicable in Britain, the possible difference being that we are where they were twenty-odd years ago!


The context for any recommendations are:-

* There are high levels of alcohol problems among lesbians, lesbians are vulnerable to alcohol misuse and they face special problems in achieving sobriety.

* Because of the double oppression of heterosexism/homophobia and sexism/mysogyny, many women are unaware of their true sexual identity, many are aware but are suppressing it, many are in the closet, and some are open about it. Many lesbians are multi-oppressed.

* There is little knowledge about the needs of lesbians with alcohol problems in this country - at least in the North West of England. Many workers are homophobic and most agencies are heterosexist.

* There is no special provision within the mainstream for lesbians with alcohol problems in the North West and only a few workers seem to have some idea of what some of the issues are.

With this in mind, the following recommendations are made:-

1. Alcohol Treatment Agencies should:

a. Examine how their structures and policies are discriminatory and introduce anti-discriminatory practice. (See, for example, Equal Opportunities for Lesbians and Gay Men: Guidelines to good practice in employment, 1993, Lesbian & Gay Employment Rights; Less Equal Than Others: A Survey of Lesbians and Gay Men at Work, Anya Palmer, 1993, Stonewall).

b. Introduce procedures to deal with incidents of discrimination - ensuring that the person discriminated against receives ample support.

c. Introduce strict interviewing procedures to eliminate potential workers who hold discriminatory views.

d. Introduce compulsory awareness training for all staff, including administrators and managers, with policies to ensure that all staff should be aware and challenge their own and other peoples' oppressive behaviour - if not, they should not be employed. We have all been taught to be homophobic, racist, sexist, classist and ableist and will continue to hold these beliefs until challenged. Slater (1988), says:

"The professional's first step is to make one's own internalized homophobia conscious so that confused or concerned youths are not further burdened with projections onto them. This is essential regardless of whether one is counselling these youths, referring them outside of the schools or agencies, or serving as a role model of objectivity. It is clear that if psychologists are victims of homophobia, little help can be provided to adolescents struggling with self-worth and self-identity."

e. Ensure that staff are more reflective of society, including lesbians and gays who are out. It is important that there are lesbian/gay members of staff who are out, for various reasons:

         * Morales and Graves (1983) found that 60% of the homosexuals they consulted preferred a counsellor of the same sexual orientation.

         * Lesbian and gay clients are more likely to feel welcome and at ease (and present) if they are aware there are openly lesbian/gay staff; this information should be included in publicity.

* A person who is out is more likely to have dealt with their own internalised homophobia. Rofes (1989) says, " Many adult gay men and women have not come to terms with their own youth and have not faced the pain of those years of repression, stigma, and harassment. Working with young people would force them to confront difficult, unresolved feelings." This is applicable to alcohol workers.

* An out lesbian or gay man could act as a positive role model for clients. Vergara (1984), notes:

"In recruiting foster parent applicants, Eromin [a lesbian and gay youth service programme] gives priority to gay adults. Gay youth have too few positive role models with which to identify; our foster parents fulfill this need if they are comfortable with their own sexual minority status in their communities, their workplace, and their family and friend networks. An assessment of their comfort level with their own sexual minority status is made in the initial screening process."

        Again the same is applicable to alcohol workers. (See McNally & Finnegan, 1982, for a discussion about the establishment of the National Association of Gay Alcoholism Professionals).

f. Ensure that the premises are friendly and safe for all possible clients. For example, are posters discriminatory? Is it wheelchair accessible? How can you show to homosexuals, and other minorities, that they are welcome and will not be discriminated against?

g. Policies should be well publicised - to other agencies, staff and clients.

2. Treatment

a. All counsellors should receive training to make them aware of the special risk factors for alcohol misuse, including, for example, external and internal oppression, sexual abuse, etc.

b. All counsellors should receive clinical supervision to ensure they are not discriminatory and know how to treat members of oppressed groups.

c. A questionnaire should be designed, perhaps the one used at the Pride Institute, 14400 Martin Drive, Eden Prairie, MN 55344, USA (Neisen & Sandall, 1990) could be adapted? It includes questions on, for example, alcohol/drug use, sexual history, sexual and emotional abuse, and family history. Clients are expected to complete this extensive evaluation which is then discussed, over a 3-5 day period, with a member of staff. Clearly workers would need training in the use of the questionnaire.

Because of the connection between internalised oppression (and sex abuse) and alcohol misuse, it is imperative to include questions on those issues which may be hidden, otherwise they are likely to be overlooked (Rofes, 1989; Hellman et al, 1989; Neisen & Sandall, 1990; Shernoff & Finnegan, 1991). It would be pointless, and potentially dangerous , however, to ask clients about their sexual orientation or any other hidden issue if the worker has not (i) had awareness training, or (ii) special training to deal with such clients/issues, or (iii) is not willing, whenever possible, to refer client to a specialised worker or programme - if this is acceptable to the client.

A lesbian could still deny her sexual orientation, in which case it is unlikely that the underlying cause - internalised homophobia - will be dealt with. If an agency is open and up front about its support of all people, including lesbians and gays, and has homosexual staff who are out, this is likely to give lesbian clients the confidence to be open about their own sexual orientation. Zigrang (1982) notes: "Patients tend to model staff behavior, and if the staff cannot deal openly with and accept a fellow staff member's homosexuality, patients can hardly be expected to do so." Tokenistic policies and programmes would make the situation worse by encouraging lesbians to be out in situations which are oppressive.

d. Information about resources for lesbians with alcohol problems should be easily available. General information about the local lesbian/gay community should be known and, where there are no support groups, the nearest lesbian/gay telephone helpline numbers and a comprehensive library of books and videos about lesbian issues. (See, for example, i think i might be a lesbian ... now what do i do? 1993, Lesbian Information Service).

e. There should be a member of staff, preferrably an out lesbian or gay man, who has been specially trained in understanding the connections between homophobia and alcohol misuse. (For treatment methods see, for example, Diamond & Wilsnack, 1978; Mongeon & Ziebold, 1982; Whitney, 1982; Zigrang, 1982; Zehner & Lewis, 1984; Anderson & Henderson, 1985; Blume, 1985; Nicoloff & Stiglitz, 1987; O'Halleran Glaus, 1989; Neisen & Sandall, 1990; Shernoff & Finnegan, 1991; and Deeevey & Wall, 1992). Because many lesbians who are coming off alcohol will be dealing with the pain and emotions suppressed during adolescence, workers would find knowledge of the problems lesbian and gay youth face useful. (See, for example, Martin, 1982; Lewis, 1984; Vergara, 1984; Sullivan & Schneider, 1987; Hetrick & Martin, 1987; Sophie, 1987; Slater, 1988; Berg-Cross, 1988; Borhek, 1988; Martin & Hetrick, 1988; Gibson, 1989; Morales, 1989; Mercier & Berger, 1989; Hanley-Hackenbruck, 1989; Sandford, 1989; Strommen, 1989; Bernstein, 1990; and D'Augelli, 1992).

f. Special projects should be established where possible. (See, for example, Neisen & Sandall, 1990). O'Donnell et al (1978) stress:

"Alcoholism is a major unmet healthcare problem in the lesbian community and we need many more alcohol recovery centers that are staffed by lesbians and that specifically reach out to our community. (Many lesbians don't feel comfortable in groups with men, even gay mixed groups.) But women who are alcoholic now cannot wait until there are better services - they need to get help now, wherever they can, however they can."

Not all lesbians, especially those who may be unaware of their sexual orientation or those who are suppressing or hiding it, would attend a lesbian project/group and special projects are likely to be available only in cities. It is important, therefore, that all alcohol agencies ensure their services are accessible, and relevant, to lesbians. Helping a lesbian client to develop enough confidence to see a specialist counsellor or attend a special programme is a good way of measuring success.

3. Lesbians

a. We have to begin to admit that there are serious alcohol problems among lesbians.

b. We must develop a culture which does not revolve around pubs/clubs/alcohol/drugs; a culture which includes an understanding and historical perspective of our oppression; we must create alcohol and drug free spaces, support groups, social events.

c. We have a responsibility to deal with our internalised homophobia and other oppressions, to come out and be positive role models for other lesbians, especially lesbian youth. An advantage in being out is that we can develop our own self esteem in the process.

d. We must challenge our own oppressive beliefs and behaviours and ensure that we build communities which are relevant and accessible to all lesbians; we must acknowledge and deal with the effects of multi-oppression.

e. We must take responsibility for supporting lesbians who are coming out, especially young lesbians.

f. We must set up 'lesbians-coming-off-alcohol' groups and develop healthier ways of coping with oppression such as support groups, assertiveness training, etc. (See, for example, Mongeon & Ziebold, 1982).

4. Prevention

a. Statutory and voluntary agencies, for example, the health service, counselling services, youth and community services, social services, etc., should be anti-discriminatory and accessible to everyone. They should also work with, and alongside, minority groups to make special provision available to help deal with the effects of internal and external oppression and develop healthier ways of coping. Help for lesbians and gays, for example, should be available especially during the early stages of coming out.

b. Genuine multi-cultural education and equal opportunities in education should be introduced. This would include, for example, acknowledging when people in history, literature, art, music, etc., are lesbian or gay; encouraging coming out stories in creative writing; including the history of oppressed peoples in history; including homosexuality and relationship skills in sex education; including development of self-esteem; dealing with examples of discrimination in the classroom; awareness training, etc. (See, for example, Krysiak, 1987; Powell, 1987; Hunter & Schaecher, 1987; Rofes, 1989; Chesler & Zuniga, 1991; and Uribe & Harbeck, 1992). Of course, this should begin by including homophobia and heterosexism awareness courses at teacher-training and in-service training levels, as well as special courses and research to enable teachers to include homosexuality in the curricula. It is worth noting that the State of Massachusetts have recently passed a bill to end discrimination against lesbians and gays in public schools.

c. Repealing anti-homosexual laws and introducing anti-discrimination laws, to include the media.

d. The media: television, newspapers, magazines, radio, etc., should be responsible for not perpetuating negative images, for ensuring minority/oppressed groups are fully represented and for educating and challenging the public about oppression and oppressive attitudes.

e. Religious leaders need to accept and acknowledge the role religions play in oppressing homosexuals, and other groups, and take a leading role in denouncing oppression.

Jan Bridget, co-founder and joint co-ordinator of Lesbian Information Service, P.O. Box 8, Todmorden, Lancashire, OL14 5TZ. I am a 46-year-old, white, working class lesbian who was aware of her 'difference' from the age of 11 but grew up in complete isolation. I used to have a drink problem.


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