Affirming one’s self-identity can be powerful and empowering. So, when an individual seeking help with their addiction is questioning their gender identification or sexual orientation, or if they are very clear about either one, they need to have a supportive encounter. The message given needs to be one of sensitivity, respect, and validation. If you are unfamiliar with terminology and definitions as they pertain to the lesbian, gay, bisexual, transgender, queer, intersex, asexual or ally, and other identities (LGBTQIA+) communities, you can find a comprehensive list online.1 Note that definitions may vary with location, era, and culture.
In March of 2023, during an interview with Yahoo Life, Shannon Minter, legal director of the National Center for Lesbian Rights and a transgender man, stated that “You can get into very complicated terminologies, but it’s about people. It’s mostly important to focus on humanity as opposed to terminology and to be patient and believe people when they say how they identify, and not use such discussions to make political points. Language is important, but what’s most important is just understanding and acceptance and inclusion and support”.2
During the last decade, we have seen a proliferation of substance use disorder (SUD) that has led to death and destruction, such as never witnessed historically. Costs of SUD to the United States (U.S.) economy are profound, estimated at $193 billion annually related to lost work productivity, healthcare, early mortality, and crime, from the abuse of illicit substances; when including alcohol-related costs these totals exceed $220 billion.3 LGBTQIA+ individuals have higher rates of alcohol use than cisgender people.4,5 Surveys among lesbian, gay and bisexual adults have found that sexual minorities have higher rates of substance misuse and SUDs than people who identify as heterosexual. Still in its nascency, it is not yet possible to establish long-term trends about substance use and SUD prevalence in LGBTQ populations.6 Similarly, research is currently limited on rates of SUD treatment episodes among transgender populations, although extant research shows that transgender individuals are more likely to seek SUD treatment than the non-transgender population.5 Research on minorities has shown significant disparities in excess usage in lesbian, gay, bisexual (LGB) women and in greater magnitude for Black and Hispanic LGB women compared with White LGB women, which may reflect their unique experiences of discrimination at the intersection of multiple minority identities.7 In this commentary, discussion is on how LGBTQIA+ individuals are able to cope with and maintain their identities and yet avoid inherent and/or hidden stigmas associated with unfortunate added barriers to their recovery and their involvement in twelve-step programs.
The first twelve-step program, Alcoholics Anonymous® (AA), was developed and founded in the 1930s by Bill Wilson and Bob Smith and aided its membership to overcome alcoholism.8 Alcoholics Anonymous® was the first program of its kind and has been the blueprint for 12-step programs ever since. Over the last 85-years, demographic preferences related to the users’ drug of choice have led to the creation of specialized twelve-step groups with a focus on specific issues. Some of these include Cocaine Anonymous, Crystal Meth Anonymous, and Marijuana Anonymous. Behavioral issues such as compulsions towards or addiction to gambling, food, sex, and other similar issues, led to the formation of further specialized twelve-step groups addressing issues such as crime, gambling, dietary issues, sexual activities, etc. Potential downsides of these types of programs are that they draw on outdated methods and theories originating in the 1930s and there is limited research into their effectiveness. They’ve ignored many scientific advancements in research of addiction and have been offering solutions which are not grounded in modern psychology. Recent scientific studies on addiction have led to the development of a number of medications for pharmacological interventions, along with other non-pharmacotherapies including behavioral, cognitive, and social interventions.9 The spiritual component of these programs can be negative for some, thus dissuading individuals who are in need of treatment from pursuing it. For many people, when they hear the phrase “spiritual awakening”, which is throughout AA literature and is in the Twelfth Step, it feels like a requirement to have a religious awakening, which is often not an appealing idea to non-religious individuals and especially for those who may feel ostracized by religions that reject the LBGTQIA+ communities. For these reasons and more, non-twelve-step addiction treatment may be a good alternative for many recovering individuals.
When the AA twelve-step program was initially formed, it was assumed that alcohol addiction was a moral defect that could be cured alone with willpower. As outlined in the AA book “Twelve Steps and twelve traditions”, it was positioned that meetings led by others in recovery would provide moral support and accountability, thus encouraging abstinence, and participants are to place faith in a higher power and accept that they are powerless.10
We now know much more about the science of addiction and have a greater understanding of biopsychology and the way addiction fundamentally alters the structure of a person’s brain. Based upon this knowledge, non-twelve-step programs can provide science-based treatments such as cognitive behavioral therapy and provide customized treatment plans built around an individual’s needs rather than a one-size-fits-all approach. Options may include individual and group counseling sessions, pharmacological therapies, motivational interviewing, and psychodynamic (supportive–expressive) therapies.11 Many programs incorporate some form of group meeting which provides a safe space for discussion and moral support, but these meetings will make up just one part of holistic and integrative therapy.
Belief in a higher power can provide comfort and assurance for some people throughout the difficult recovery process. A lot of science-based programs still encourage individuals to embrace spirituality. But by removing it as a requirement for recovery, these programs can reach people who would otherwise reject the teachings of a faith-based plan.
One individual, King, a male-to-female transgender, spoke to us (March 2023) about what she considered a turnoff to twelve-step treatment, that is the “powerlessness” that twelvestep treatment invoked. She and her partner felt they needed to be empowered, rather than made to feel helpless. By empowering themselves and others they could better meet the challenges of active addiction.
However, many recovering alcoholic members of the LGBTQIA+ community reported feeling quite comfortable in twelvestep groups and found, for identification purposes, additional support at “special interest” Alcoholics Anonymous® groups for the LQBTQIA+ community.12 Michael Radkowsky, PsyD, a licensed psychologist who specializes in LGBTQIA+ individual therapy and couples counseling in Washington, DC, wrote in a column for the Washington Blade, America’s LGBTQ News Source, that the best way to learn if twelve-step programs are a good fit for an individual, is to actually attend several twelve-step meetings, including LGBTQIA+ meetings.13 LGBTQIA+ individuals who have shared their positive experiences can be found in the Alcoholics Anonymous® publication “LGBTQ Alcoholics in AA”.14
Ultimately, each individual’s experience with twelve-step groups and recovery is as unique as they are, and more research and discussion need to be done. Prior studies have demonstrated that transgender people with substance use disorders are the least studied of all, and the least catered to in treatment.15 More than ten years ago, Grant et al16 stated that “Rates of human immunodeficiency virus (HIV) infection, attempted suicide, drug and alcohol abuse, and smoking among transgender and gender non-conforming people were just some of the identifiers to the overwhelming need for…transgender-sensitive recovery programs”. These issues have compounded with the addition of even deadlier substances and greater availability, further exacerbating already precariously deadly rates.10A study on how non-binary people who use drugs are an underserved group at high risk of harm, concluded that clinicians should be trained in trans-affirmative language and practice, that development and implementation of specialist substance use disorder interventions for trans and/or non-binary people are needed, and a greater effort to include trans people in sexualized drug use research is needed as well.17 Findings from an additional study illustrated the need for gender-based, anti-stigma policies and programs to be established within existing addiction treatment programs, and as recommended by the participants in the study, it is vital to establish transgender and/ or LGBTQIA+ specific treatment programs.15 Examining these phenomena will hopefully provide a more profound understanding of the issues these individuals encounter. The hope is to further discussions about what has been witnessed, document various experiences, and what others throughout the world may contribute towards this dialogue for future commentaries.
Social Behavior Research and Practice
Open journal
ISSN 2474-8927
Are the LGBTQIA+ Communities able to Maintain their Identity within Twelve-Step Programs: A Brief Narrative
Nelson J. Tiburcio*, Kristin S. Kimmell and Scarlett L. Baker
Nelson J. Tiburcio, PhD
Chief Executive Officer, The SASSI Institute, 201 Camelot Lane, Springville, IN 47462, USA; Tel. 800-726-0526; Fax: 800-546-7995; E-mail: research@sassi.com
Affirming one’s self-identity can be powerful and empowering. So, when an individual seeking help with their addiction is questioning their gender identification or sexual orientation, or if they are very clear about either one, they need to have a supportive encounter. The message given needs to be one of sensitivity, respect, and validation. If you are unfamiliar with terminology and definitions as they pertain to the lesbian, gay, bisexual, transgender, queer, intersex, asexual or ally, and other identities (LGBTQIA+) communities, you can find a comprehensive list online.1 Note that definitions may vary with location, era, and culture.
In March of 2023, during an interview with Yahoo Life, Shannon Minter, legal director of the National Center for Lesbian Rights and a transgender man, stated that “You can get into very complicated terminologies, but it’s about people. It’s mostly important to focus on humanity as opposed to terminology and to be patient and believe people when they say how they identify, and not use such discussions to make political points. Language is important, but what’s most important is just understanding and acceptance and inclusion and support”.2
During the last decade, we have seen a proliferation of substance use disorder (SUD) that has led to death and destruction, such as never witnessed historically. Costs of SUD to the United States (U.S.) economy are profound, estimated at $193 billion annually related to lost work productivity, healthcare, early mortality, and crime, from the abuse of illicit substances; when including alcohol-related costs these totals exceed $220 billion.3 LGBTQIA+ individuals have higher rates of alcohol use than cisgender people.4,5 Surveys among lesbian, gay and bisexual adults have found that sexual minorities have higher rates of substance misuse and SUDs than people who identify as heterosexual. Still in its nascency, it is not yet possible to establish long-term trends about substance use and SUD prevalence in LGBTQ populations.6 Similarly, research is currently limited on rates of SUD treatment episodes among transgender populations, although extant research shows that transgender individuals are more likely to seek SUD treatment than the non-transgender population.5 Research on minorities has shown significant disparities in excess usage in lesbian, gay, bisexual (LGB) women and in greater magnitude for Black and Hispanic LGB women compared with White LGB women, which may reflect their unique experiences of discrimination at the intersection of multiple minority identities.7 In this commentary, discussion is on how LGBTQIA+ individuals are able to cope with and maintain their identities and yet avoid inherent and/or hidden stigmas associated with unfortunate added barriers to their recovery and their involvement in twelve-step programs.
The first twelve-step program, Alcoholics Anonymous® (AA), was developed and founded in the 1930s by Bill Wilson and Bob Smith and aided its membership to overcome alcoholism.8 Alcoholics Anonymous® was the first program of its kind and has been the blueprint for 12-step programs ever since. Over the last 85-years, demographic preferences related to the users’ drug of choice have led to the creation of specialized twelve-step groups with a focus on specific issues. Some of these include Cocaine Anonymous, Crystal Meth Anonymous, and Marijuana Anonymous. Behavioral issues such as compulsions towards or addiction to gambling, food, sex, and other similar issues, led to the formation of further specialized twelve-step groups addressing issues such as crime, gambling, dietary issues, sexual activities, etc. Potential downsides of these types of programs are that they draw on outdated methods and theories originating in the 1930s and there is limited research into their effectiveness. They’ve ignored many scientific advancements in research of addiction and have been offering solutions which are not grounded in modern psychology. Recent scientific studies on addiction have led to the development of a number of medications for pharmacological interventions, along with other non-pharmacotherapies including behavioral, cognitive, and social interventions.9 The spiritual component of these programs can be negative for some, thus dissuading individuals who are in need of treatment from pursuing it. For many people, when they hear the phrase “spiritual awakening”, which is throughout AA literature and is in the Twelfth Step, it feels like a requirement to have a religious awakening, which is often not an appealing idea to non-religious individuals and especially for those who may feel ostracized by religions that reject the LBGTQIA+ communities. For these reasons and more, non-twelve-step addiction treatment may be a good alternative for many recovering individuals.
When the AA twelve-step program was initially formed, it was assumed that alcohol addiction was a moral defect that could be cured alone with willpower. As outlined in the AA book “Twelve Steps and twelve traditions”, it was positioned that meetings led by others in recovery would provide moral support and accountability, thus encouraging abstinence, and participants are to place faith in a higher power and accept that they are powerless.10
We now know much more about the science of addiction and have a greater understanding of biopsychology and the way addiction fundamentally alters the structure of a person’s brain. Based upon this knowledge, non-twelve-step programs can provide science-based treatments such as cognitive behavioral therapy and provide customized treatment plans built around an individual’s needs rather than a one-size-fits-all approach. Options may include individual and group counseling sessions, pharmacological therapies, motivational interviewing, and psychodynamic (supportive–expressive) therapies.11 Many programs incorporate some form of group meeting which provides a safe space for discussion and moral support, but these meetings will make up just one part of holistic and integrative therapy.
Belief in a higher power can provide comfort and assurance for some people throughout the difficult recovery process. A lot of science-based programs still encourage individuals to embrace spirituality. But by removing it as a requirement for recovery, these programs can reach people who would otherwise reject the teachings of a faith-based plan.
One individual, King, a male-to-female transgender, spoke to us (March 2023) about what she considered a turnoff to twelve-step treatment, that is the “powerlessness” that twelvestep treatment invoked. She and her partner felt they needed to be empowered, rather than made to feel helpless. By empowering themselves and others they could better meet the challenges of active addiction.
However, many recovering alcoholic members of the LGBTQIA+ community reported feeling quite comfortable in twelvestep groups and found, for identification purposes, additional support at “special interest” Alcoholics Anonymous® groups for the LQBTQIA+ community.12 Michael Radkowsky, PsyD, a licensed psychologist who specializes in LGBTQIA+ individual therapy and couples counseling in Washington, DC, wrote in a column for the Washington Blade, America’s LGBTQ News Source, that the best way to learn if twelve-step programs are a good fit for an individual, is to actually attend several twelve-step meetings, including LGBTQIA+ meetings.13 LGBTQIA+ individuals who have shared their positive experiences can be found in the Alcoholics Anonymous® publication “LGBTQ Alcoholics in AA”.14
Ultimately, each individual’s experience with twelve-step groups and recovery is as unique as they are, and more research and discussion need to be done. Prior studies have demonstrated that transgender people with substance use disorders are the least studied of all, and the least catered to in treatment.15 More than ten years ago, Grant et al16 stated that “Rates of human immunodeficiency virus (HIV) infection, attempted suicide, drug and alcohol abuse, and smoking among transgender and gender non-conforming people were just some of the identifiers to the overwhelming need for…transgender-sensitive recovery programs”. These issues have compounded with the addition of even deadlier substances and greater availability, further exacerbating already precariously deadly rates.10A study on how non-binary people who use drugs are an underserved group at high risk of harm, concluded that clinicians should be trained in trans-affirmative language and practice, that development and implementation of specialist substance use disorder interventions for trans and/or non-binary people are needed, and a greater effort to include trans people in sexualized drug use research is needed as well.17 Findings from an additional study illustrated the need for gender-based, anti-stigma policies and programs to be established within existing addiction treatment programs, and as recommended by the participants in the study, it is vital to establish transgender and/ or LGBTQIA+ specific treatment programs.15 Examining these phenomena will hopefully provide a more profound understanding of the issues these individuals encounter. The hope is to further discussions about what has been witnessed, document various experiences, and what others throughout the world may contribute towards this dialogue for future commentaries.
1. Bloomington Pride. Glossary of Terms. Website. https:// bloomingtonpride.org/glossary. Accessed March 20, 2023.
2. Artavia D. Sex vs. gender: What’s the difference? Yahoo Life. Website. https://news.yahoo.com/sex-gender-biology-science-lgbtq-gay-queer-trans-230343934.html. Accessed March 20, 2023.
3. National Institute on Drug Abuse. Trends & Statistics. 2015. Website. https://nida.nih.gov/research-topics/trends-statistics. Accessed March 21, 2023.
4. Santos GM, Rapues J, Wilson EC, et al. Alcohol and substance use among transgender women in San Francisco: Prevalence and association with human immunodeficiency virus infection. Drug Alcohol Rev. 2014; 33(3): 287-295. doi: 10.1111/dar.12116
5. Keuroghlian AS, Reisner SL, White JM, Weiss RD. Substance use and treatment of substance use disorders in a community sample of transgender adults. Drug and Alcohol Dependency. 2015; 152: 139- 146. doi: 10.1016/j.drugalcdep.2015.04.008
6. Substance Abuse and Mental Health Services Administration (SAMHSA). 2020 National Survey on Drug Use and Health: Lesbian, Gay, and Bisexual (LGB) Adults. Website. https://www.samhsa.gov/data/report/2020-nsduh-lesbian-gay-bisexual-lgb-adults. Published July 27, 2022. Accessed April 18, 2023.
7. Schuler MS, Prince DM, Breslau J, Collins RL. Substance use disparities at the intersection of sexual identity and race/ethnicity: Results from the 2015–2018 National Survey on Drug Use and Health. LGBT Health. 2020; 7(6): 283-291. doi: 10.1089/ lgbt.2019.0352
8. VandenBos GR. APA Dictionary of Psychology. 1st ed. Washington, DC, USA: American Psychological Association; 2007.
9. Xu B, Labar KS. Advances in understanding addiction treatment and recovery. Sci Adv. 2019; 5(10): eaaz6596. doi: 10.1126/sciadv. aaz6596
10. Alcoholics Anonymous®. Twelve Steps and Twelve Traditions. New York, NY, USA: Alcoholics Anonymous World Services, Inc. 1989.
11. McGovern MP, Carroll KM. Evidence-based practices for substance use disorders. Psychiatr Clin North Am. 2003; 26(4): 991-1010. doi: 10.1016/s0193-953x(03)00073-x
12. Alcoholics Anonymous®. General Service Office of Alcoholics Anonymous. 2022. Website. https://www.aa.org/sites/default/ files/literature/Final%20LGBTQ%20Press%20Release%20-%20 EN_0.pdf. Accessed March 22, 2023.
13. Radkowsky M. Are 12-steps right for me? How to recognize if you have an addiction problem. 2014. Website. https://www.washingtonblade.com/2014/09/10/advice-alcoholics-anonymous-are12-steps-right-for-me/. Published September 10, 2014. Accessed March 23, 2023.
14. General Service Office of Alcoholics Anonymous®. LGBTQ Alcoholics in AA. 2018. Alcoholics Anonymous. Website. https:// www.aa.org/sites/default/files/literature/assets/p-32_LGBTQalcoholicsinAA.pdf. Accessed March 24, 2023.
15. Lyons T, Shannon K, Pierre L, Small W, Krüsi A, Kerr T. A qualitative study of transgender individuals’ experiences in residential addiction treatment settings: Stigma and inclusivity. Subst Abuse Treat Prev Policy. 2015; 17: 10. doi: 10.1186/s13011-015-0015-4
16. Grant JE, Potenza MN, Weinstein DA. Introduction to behavioral addictions. Am J Drug Alcohol Abuse. 2010; 36(5): 233-241. doi: 10.3109/00952990.2010.491884
17. Bracke S. Non-binary people who use drugs are an underserved group at high risk of harm. 2021. Website. https://blogs.bmj. com/bmjsrh/2021/07/19/non-binary-people-who-use-drugsare-an-underserved-group-at-high-risk-of-harm/. Posted July 19, 2021. Accessed March 28, 2023.
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