Lesbian clients face multiple challenges

It is extremely important that the lesbian, gay, bisexual and transgender (LGBT) community continue to band together on both behavioral health and political levels so that we can help one another maintain the fight for equal rights, acceptance by the heterosexual community, and effective treatment in addiction and mental health. On the other hand, it is also important that appropriate attention be given to the different psychologies of each orientation and gender identity within this united group. This will ensure that generalized healing practices are not directed to each subgroup when it would not be helpful to do so.

This article focuses on the lesbian population’s unique psychological and cultural concerns from a lesbian-affirmative perspective. It highlights how addiction and mental health professionals can better understand the specific issues lesbians face as they grow up in a heterosexist, homophobic and sexist world. At the same time, it will not only look at the similarities lesbians share with one another, but also pay attention to the many differences that exist within each lesbian’s life experiences and psychological makeup.

Important concepts affecting lesbians

Heterosexism. Herek defined this idea best when he referred to heterosexism as “an ideological system that denies, denigrates, and stigmatizes any non-heterosexual form of behavior, identity, relationship, or community.”1

Heteronormativity. This is similar to heterosexism, but needs its own explanation because it is a belief system that teaches, overtly and covertly, that heterosexuality and traditional family systems (man, woman, children) are the most valued lifestyle and the only lifestyle that is considered normal, given attention and celebrated by society as a whole.

Lesbianphobia. This is a concept I developed years ago to distinguish between male-focused homophobia and the kind of discrimination lesbians face in being both same-sex oriented and women. This is the irrational fear and/or hatred of same-sex emotional, romantic and erotic love between women—combined with the varying degrees of misogyny that exist in a patriarchal and heteronormative culture.2

Sexism/misogyny. Still alive and well in our current culture, this ideology continues to have a negative impact on all women. Developing authentic feelings of self–love is difficult when the world keeps saying that men are more valuable than women.

Genderphobia. This is the irrational fear and/or hatred of anyone whose gender expression is different from the prescribed gender roles placed upon people by the heteronormative society (e.g., women should be feminine in nature and men should be masculine). Lesbians whose natural style of personal and gender expression falls into the more “masculine” expression and roles can face greater discrimination than lesbians who fit more “acceptable” gender expressive roles. On the other hand, lesbians who are more feminine in their expression may be able to “pass” as heterosexual (which can give them certain types of privilege), putting them in the position of having to “come out” frequently because everyone assumes they are heterosexual. Both of these situations carry varying degrees of emotional distress and life stressors.

Internalized lesbianphobia. This occurs when societal lesbianphobia is internalized into the psyche and stored in the unconscious. This can cause chronic and misunderstood feelings of self-hatred, low self-esteem, and low self-worth as a lesbian, a woman, and a human being. These core issues, because they reside outside of conscious awareness, can disrupt and/or hinder the development of a stable sense of self, thus creating symptoms such as depression, anxiety, the inability to self-regulate intense or distressing emotions, substance abuse, eating disorders, sex and love addictions, and so on.2 Because these institutionalized oppressions are internalized into the psyche, a greater threat of addictive and mental health disorders surfaces.

Multiple oppressions. These are experienced by LGBT people who have more than one minority status. People of color and women fall into this category. For example, an African-American lesbian experiences triple oppressions, being that she is black, lesbian, and a woman. She has to deal with racism and lesbianphobia. These oppressions are then internalized, and again addiction and psychological issues can occur.

Lesbian visibility and invisibility. Although media visibility for lesbians is increasing in the U.S. in breathtaking ways through television programs such as “Orange Is the New Black,” “The Real L Word” series, “The Fosters,” “The L Word,” and the breakthrough show “Ellen,” lesbians still experience an invisibility in pop culture that affects self-esteem and self-efficacy. Though not as obvious as overt lesbianphobia, areas such as marketing campaigns (TV commercials, billboards, magazine ads), and mainstream articles that are chronically heteronormative represent ways in which lesbians experience invisibility on a daily basis. These examples affect a lesbian’s self-esteem because of their lifelong pervasiveness and subtle nature. Because lesbians rarely see themselves represented in everyday life, feeling important and valuable can be a struggle. It is difficult for a lesbian to develop authentic feelings of self-love when she knows in her heart of hearts that her family, community, and culture either hates her or at the very least does not find her existence valuable.

Coming out as a lesbian

Coming out, for all LGBT people, is a big deal. For some lesbians, it can be a wonderful experience. Unfortunately for others, it can be traumatizing, depending on how the news is received by family members, peers and community.

Stages of coming out and identity development are differ for every lesbian. Some know at a very early age and stay out once they announce it to themselves and others. Some lesbians know early on, but having had lesbianphobic experiences with parents, siblings and/or their community, they try to be straight in order to hide in the safety of the dominant culture. This way, they avoid experiencing discrimination and/or hatred at least until they deal with their feelings toward other women.

Some lesbians of color might have to choose between their lesbian self and their ethnic origin because of how same-sex love is perceived in their community. Other lesbians might not know until well into a heterosexual marriage that includes children. Each of these scenarios carries a different set of circumstances, stressors and good or bad experiences.

Understanding Cass’s model of identity development is helpful to counselors unfamiliar with the coming out process of LGBT people, but it is also important to know that for many lesbians, the process of coming out is not as linear as this model depicts. Difficulties or challenges in developing a lesbian identity, when they do exist, are different for every lesbian. Unfortunately for some, the stress of coming out can reinforce shame and internalized lesbianphobia, which will influence substance abuse and dependence. In addiction treatment centers, it is not uncommon to see lesbians in the earlier stages of the coming out process having used substances to mask the pain and fear caused by this process. It is imperative that behavioral health professionals know how to use subtle labeling strategies during this phase while simultaneously holding the concepts of lesbianphobia and internalized lesbianphobia as possible reasons for difficulties in identity development.

Sexual assault and childhood sexual abuse

Studies also show that 21% of lesbians were sexually abused as children and 15% were sexually assaulted as adults.3 This does not mean that childhood sexual abuse or adult sexual assault causes lesbianism, contrary to dangerous myths and stereotyping. It is common, however, for these kinds of traumas to cause substance abuse and other addictive and harmful behaviors. Unfortunately, most girls who experienced sexual abuse and most women who were sexually assaulted do not get the help they need when the problem is happening or even after it happens.

As a matter of fact, many women don’t even report rape or childhood sexual abuse because of shame, self-blame and fear of retaliation from their attacker. More often than not, girls and women blame themselves for the incidents. With no safe person or place to take this information, traumatic events go untreated, sometimes for decades.4 Instead, substances often are used, unconsciously, to push away the pain.

Growing up lesbian in a heterosexist world

All that is described above constitutes varying degrees of trauma. Much of it can create multiple symptoms of post-traumatic stress disorder (PTSD) and difficulty forming a stable sense of self, which can influence a lesbian’s ability to regulate painful emotions. Substances and other addictive techniques are used to medicate the emotional pain these traumas cause. For some lesbians, this can last for an entire lifetime, but others might find themselves in treatment trying to get sober. To avoid any experiences that can add to the trauma, it is imperative that a lesbian seeking help for her addictions find a treatment center that is affirmative in nature.

Not surprisingly, studies reveal that lesbians have higher rates of substance abuse and other addictive disorders than their heterosexual counterparts.5 Higher rates of substance abuse are also linked to internalized phobias. Research has shown that the uses of substances is correlated with the desire to mask feelings of self-hatred.6,7

Look out for your own biases

No one is immune to the influences of our heteronormative, heterosexist, lesbianphobic and racist society. We are all negatively affected and influenced by it. Most of us know from our educational background the importance of being culturally competent, yet most of us don’t get the education necessary to understand the myriad of issues facing lesbians. The fact remains that most LPC, MFT, LCSW, PsyD, and PhD programs have little to no studies on LGBT-affirmative psychotherapy, let alone training on the lesbian psyche, lesbian sexuality, lesbian culture and multiple oppressions. The trauma and addictive disorders that occur behind these issues are therefore little understood.

The good news is that for those of you interested in articles on LGBT issues, you already are showing the kind of awareness needed to become the best provider you can be. The next piece, of course, is what part of these oppressions resides outside of your own awareness? Being aware of how multiple oppressions affect even those behavioral health workers who are naturally empathic and highly educated is a vital component to providing the best care for lesbians seeking treatment. I suggest that all clinicians question their own internalized oppressions and lives of privilege and how they could affect their work with lesbian clients.

Stay tuned for future articles that will provide more lesbian-affirmative treatment techniques to help providers working with lesbians who have addictions.

Lauren Costine, PhD, is a licensed psychologist, educator, writer, activist and founding member of the LGBT specialization in clinical psychology at Antioch University in Los Angeles, where she teaches. She is Clinical Director of the LGBT-affirmative track at BLVD Treatment Centers, a new intensive outpatient and partial hospitalization program in Hollywood, and she maintains a private practice in Beverly Hills.

References

1. Herek GM. Psychological heterosexism in the United States. In Lesbian, Gay, and Bisexual Identities Over the Lifespan. New York City: Oxford University Press; 1995. Retrieved from www.oxfordscholarship.com/view/10.1093/acprof:oso/9780195082319.001.0001/acprof-9780195082319-chapter-13.

2. Costine L. Lesbianphobia. Lecture taken from Lesbian Liberation workshop. The LGBT Specialization in the MAP program at Antioch University.

3. Bradford J, Ryan C, Rothblum ED. National Lesbian Health Care Survey: implications for mental health care. J Consult Clin Psychol 1994;62:228-42.

4. Clum GA, Nishith P, Calhoun KS. A preliminary investigation of alcohol use during trauma and teritraumatic reactions in female sexual assault victims. J Trauma Stress 2002;15:321-8.

5. Hughes T. Wilsnack S. Use of alcohol among lesbians: research and clinical implications. Am J Orthopsychiatry 1997;66:20-36.

6. Cheng Z. Issues and standards in counseling lesbians and gay men with substance abuse concerns. J Mental Health Couns 2003;25:323.

7. Cabaj RP. Sexual orientation and the addictions. J Gay Lesbian Psychother 1995;2:97-117.