Journal of Homosexuality, 62:433–462, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2014.983375

Self-Identified Heterosexual Clients in Substance Abuse Treatment With a History of Same-Gender Sexual Contact EVAN SENREICH, PhD Department of Social Work, Lehman College, City University of New York, Bronx, New York, USA

There is virtually no literature concerning the experiences of self-identified heterosexual clients in substance abuse treatment who have a history of same-gender sexual contact (HSGS). In a U.S. urban inpatient program in 2009–2010, 99 HSGS clients were compared to 681 other heterosexual and 86 lesbian, gay, and bisexual clients regarding background factors, program completion rates, and feelings about treatment. Male HSGS participants had lower completion rates than other male heterosexual participants. Qualitative data indicated that most male HSGS participants experienced difficult emotions regarding same-gender sexual encounters, particularly those involving trading sex for money or drugs. Implications for treatment are discussed. KEYWORDS heterosexual, homosexual, substance abuse treatment, MSM, WSW, prostitution, gay, lesbian, bisexual, same-gender sex

Numerous books have addressed the clinical issues of self-identified lesbian, gay, and bisexual (LGB) clients in substance abuse treatment (e.g., Anderson, 2009; Cabaj, 2005, 2008; Crisp & DiNitto, 2012; Finnegan & McNally, 2002; SAMHSA, 2001; Senreich & Vairo, 2014; van Wormer & Davis, 2008). Furthermore, a limited number of empirical studies have focused either on the perceptions of LGB clients regarding their substance abuse treatment or on comparing the perceptions and outcomes of LGB clients in Address correspondence to Evan Senreich, Department of Social Work, Lehman College, City University of New York, Carman Hall B-18, 250 Bedford Park Boulevard West, Bronx, NY 10468, USA. E-mail: [email protected] 433

434

E. Senreich

chemical dependency treatment with those of heterosexual clients (Chaikin, 1995; Cochran, 2004; Copeland & Hall, 1992; Cullen, 2004; Greenwood, Woods, Guydish, & Bein, 2001; MacEwan, 1994; Matthews & Selvidge, 2005; Senreich, 2009). A majority of these studies have identified at least some difficulties experienced by the LGB population in substance abuse treatment settings due to their sexual orientation or have found that the perceptions or outcomes of the LGB clients were not as favorable as those of heterosexual clients (Chaikin, 1995; Cullen, 2004; MacEwan, 1994; Matthews & Selvidge, 2005; Senreich, 2009). In contrast, there do not appear to be any published studies that have focused on the specific issues and treatment experiences of self-identified heterosexual clients in substance abuse programs who have had samegender sexual contact as an adult (HSGS). In addition, the treatment needs of this population have been virtually ignored in the clinical literature, including books and articles that discuss the issues of LGB clients. No studies have indicated the percentage of HSGS clients in substance abuse treatment. Only one of the numerous U.S. national random sample studies over the past 15 years whose purpose was to compare the prevalence of substance use by sexual orientation groups included HSGS individuals as a separate cohort (Drabble, Midanik, & Trocki, 2005). This study, which focused only on alcohol use, found that HSGS women consumed over twice the number of drinks each year than other self-identified heterosexual women, a difference that was statistically significant. There was no significant difference in number of drinks consumed between HSGS and lesbian women. Although HSGS men in the Drabble et al. study consumed 26% more drinks per year than the other heterosexual men and 25% more drinks per year than the gay men, these differences were not statistically significant. Over the last two decades, the inclusive terms men who have sex with men (MSM) and women who have sex with women (WSW) have been widely used in the research literature, particularly in regard to studies exploring high-risk behaviors for HIV, including substance use. Few of these studies clearly differentiated between participants who identified as LGB and those who considered themselves heterosexual or a different sexual orientation identity. Young and Meyer (2005) cautioned against the utilization of the labels MSM and WSW without identification of the participants’ specific self-identified sexual orientation. They emphasized that there is cultural importance in taking participants’ sexual orientation identity into account, and that not doing so could distort the results of research studies. In this regard, Munoz-Laboy and Dodge (2007) found that, among men, bisexual behavior but not bisexual identity was predictive of greater sexual risks in regard to HIV. Young and Meyer’s (2005) comments have particular relevance to substance abuse treatment, where the experiences and needs of LGB clients are most likely very different from those of HSGS clients. The LGB clients’

Heterosexual Clients With Same-Gender Sex

435

same-gender sexual behavior is consonant with their stated identity, whereas this is not the case in regard to HSGS clients. As will be discussed below, many substance-abusing HSGS individuals may not primarily experience same-gender sexual attraction but have engaged in same-gender sex in the context of (a) prostitution to support their drug use; (b) incarceration; and (c) sexual situations that were induced by the disinhibiting characteristics of substances. Other HSGS individuals may use substances as a way to quell shameful feelings about same-gender sexual attraction that they cannot accept. All of these situations have the potential to induce feelings of selfloathing and self-alienation, which may result in secrecy in treatment and emotional barriers to recovery (Senreich & Vairo, 2014). Yet the treatment needs of the HSGS population are ignored in nearly every comprehensive substance treatment textbook, as well as in literature focusing on the treatment of LGB chemically dependent clients. There have been a small number of articles regarding HIV transmission and prevention that have focused separately on the HSGS population, each one coming to the conclusion that their issues are very different from those of the self-identified LGB population, with different interventions required (Doll et al., 1992; Martinez & Hosek, 2005). Goldbaum, Perdue, and Higgins (1996) performed a qualitative study that included interviews with 39 HSGS men, in which the participants were placed in six categories: (1) “hustlers”; (2) “closeted”; (3) “New Age men or experimenters”; (4) “incarcerated or formerly incarcerated”; (5) “people of color or cultural groups”; and (6) “heterosexually identified bisexual men” (pp. 37–38). Their conclusion was that HSGS men, in comparison to self-identified gay and bisexual men, pose far greater challenges for the development of effective HIV prevention strategies. Currently, there are no studies performing a similar comparison for substance abuse treatment issues. In regard to the prevalence of prostitution among clients in chemical dependency treatment, Burnette et al. (2008) performed a secondary analysis of a study that took place in 78 substance abuse treatment facilities in the United States and found that 18.5% of the men and 50.8% of the women had traded sex for money or drugs in their lifetime, a majority doing so in the past year. Unfortunately, this study included neither the sexual orientation of the participants nor the gender of the respondents’ prostitution sex partners as variables. For both men and women, prostitution was associated with increased likelihood of psychiatric symptoms, including suicide attempts, as well as blood-borne viral infections and sexually transmitted diseases. In seven studies of men who sold sex to other men, the percentage of those identifying as heterosexual varied widely, ranging from 8% to 83% (Boles & Elifson, 1994; Earls & David, 1989; McCabe et al., 2011; Miller, Klotz, & Eckholdt, 1998; Morse, Simon, Baus, Balson, & Osofsky, 1992; Newman, Rhodes, & Weiss, 2004; Timpson, Ross, Williams, & Atkinson, 2007). All of these studies except the one by Miller et al. inquired about substance use,

436

E. Senreich

and each found that the vast majority of male prostitutes used illegal drugs. In the McCabe et al. study, it was found that the vast majority of male prostitutes (83% self-identifying as heterosexual) became involved in sex work as a way to support their drug habits, and that all were currently using drugs. Three quarters of the respondents scored either in the moderate or severe range of depression on the Beck Depression Index, and one half reported suicidal ideation. Studies regarding women trading sex for money or drugs with other women are scarce. Bell, Ompad, and Sherman (2006) surveyed a sample of 251 substance-abusing women ages 15 to 30 in Baltimore, MD, and found that only 10 reported having been paid by a female sex-trade partner in their lifetime, in comparison to 62 who reported having been paid for sex in the previous 6 months by a man. A study by Friedman et al. (2003) found that drug-injecting WSW (ages 18 to 30) in five U.S. cities were more likely to engage in prostitution than were women who had sex with men only (WSMO), but the genders of the for-pay sex partners were not specified. In both the Bell et al. and Friedman et al. studies, the self-identified sexual orientations of the respondents were not reported. Ompad et al. (2011) found that 55% of WSW substance users in New York City traded sex for money in the prior 2 months in comparison to 38% of WSMO, a statistically significant difference. The genders of the for-pay sex partners were not reported. The study included self-identified heterosexual, bisexual, and lesbian participants, with only 10 of the 256 heterosexual women (3.9%) reporting that they had sex with a woman in any context in the prior 2 months. In a qualitative study of 62 African American women in the Atlanta, GA, area who were currently using crack cocaine and who reported a history of same-gender sexual contact, Sterk and Elifson (2006) found that 42 (68%) of the participants had exchanged sex for crack or had engaged in sexual performances for which they were paid with crack. While many of these encounters were with men, a number reported such experiences were with women, which they found to be less abusive. No statistics were provided regarding how many of the sex-for-drugs situations were with other women. In this study, 32 of the 62 women (53%) self-identified as heterosexual and stated that they preferred a man as their primary sex partner but sometimes had sex with women. In substance abuse treatment, many clients have a history of incarceration. Studies have indicated that many inmates who self-identify as heterosexual participate in same-gender sex while in prison (Garland, Morgan, & Beer, 2005; Hensley, Tewksbury, & Wright, 2001). Furthermore, Beck and Johnson (2012) reviewed data from the U.S. Department of Justice and found that 9.6% of former state prisoners in 2008 reported at least one incident of sexual victimization during their most recent episode of incarceration. Same-gender sexual encounters in prisons, particularly when coerced through either violence or persuasion, may result in subsequent emotional

Heterosexual Clients With Same-Gender Sex

437

turmoil (Dumond, 2000; Long, 1993; Morash, Jeong, Bohmert, & Bush, 2012). This could certainly impact these clients’ efforts to ameliorate their substance abuse problems. In regard to self-identified heterosexual individuals having same-gender sex while under the influence of substances, studies have indicated that alcohol, cocaine, methamphetamine, methylphenidate, and GHB are associated with increased sexual desire and disinhibition (Fromme, D’Amico, & Katz, 1999; George & Norris, 1991; George, Stoner, Norris, Lopez, & Lehman, 2000; Kopetz, Reynolds, Hart, Kruglanski, & Lejuez, 2010; Lee & Levounis, 2008; Leigh, 1990; Volkow et al., 2007). However, it is not clear how much if this is a function of the psychopharmacological properties of the substances, the expectancies of the user, or the social contexts involved in their use. In a study by Rawson, Washton, Domier, and Reiber (2002) of clients in substance abuse treatment, 50% of methamphetamine users, 41% of cocaine users, and 16% of alcohol users agreed with the statement: “I have become involved in sex acts that are unusual for me when I am under the influence of my primary substance of abuse.” This may possibly result in situations where self-identified heterosexual individuals engage in same-gender sexual experiences while using certain substances. Apart from issues related to substance abuse, studies have indicated that far more people engage in same-gender sexual contact than self-identify as LGB. For example, in the National Health and Social Life Survey, only 46% of men and 37% of women (ages 18 to 59) in the United States who had engaged in same-gender sexual contact since age 18 self-identified as LGB (Laumann, Gagnon, Michael, & Michaels, 1994). There are several reasons for this. First, some self-identified heterosexual individuals who are attracted primarily to the opposite gender may experiment with homosexual contact. Second, some people who are attracted to the same sex and engage in samegender sexual contact feel shame about their homosexuality and therefore do not identify as gay, lesbian, or bisexual. Writers have suggested that this shame, referred to as internalized homophobia or internalized sexism, may induce these individuals to quell their painful emotions with substances, and it can serve as a barrier to recovery for such individuals in substance abuse treatment (Cabaj, 2005; Finnegan & McNally, 2002). These authors further state that these individuals’ acceptance of their homosexual feelings is a necessary goal of treatment. Third, members of diverse ethnicities and cultures define sexual orientation differently. For example, among some Latino American groups, men who maintain the dominant role during same-gender sexual contact may not be seen as gay according to their cultural reference group (Greene, 1994). One study demonstrated that among men who became HIV-positive through same-gender sexual contact, African Americans were four times more likely than European Americans to self-identify as heterosexual than as gay or bisexual (Villarosa, 2001).

438

E. Senreich

One of the few studies that at least in some way examined the experiences of HSGS substance abusers was performed by Harawa et al. (2008). In this qualitative study of 46 African American MSM who either identified as heterosexual or bisexual, the researchers found that many exchanged sex for drugs and used substances as a way to cope with shame regarding homosexual desires and behaviors. One of the conclusions of this study was that substance abuse treatment programs need to be sensitive to the issues of non-gay-identified MSM for treatment to be successful. This current study, which took place in a short-term inpatient substanceabuse program, had several purposes. First, demographic and psychosocial background factors of the HSGS, other heterosexual, and LGB clients were compared to determine if there were differences between these groups before they began treatment. Second, program completion rates were compared for the three groups to learn if any of them were less likely to finish treatment. Third, scales measuring client satisfaction, therapeutic alliance with counselors, social affiliation with peers, and connection to the treatment program were utilized to learn if there were differences in perceptions of treatment between the cohorts. Last, in a qualitative portion of this study, the HSGS clients were asked how their history of homosexual encounters had affected their recovery in order to obtain a subjective account of their experiences. It was hoped that this study could begin to shed light on the specific substance-abuse treatment needs of a population which has received scant attention in the literature.

METHODS Participants This study took place in a large city in the northeast of the United States from October 2009 until November 2010 at a short-term inpatient substanceabuse rehabilitation program that did not have any specialized services for LGB clients. Soon after they entered treatment, 866 clients completed Part 1 of a written survey inquiring about their demographic and background information. It included items regarding the participants’ self-identified sexual orientation and whether they ever had sexual contact with the same gender since age 18. At a later date, while they were still in the program, 611 of the 866 respondents completed Part 2 of the survey, which inquired about their treatment experiences. Part 2 included scales measuring client satisfaction, therapeutic alliance with counselors, social affiliation with other clients, and connection to the treatment program. It also included an openended question for the HSGS participants regarding how same-gender sexual experiences affected their recovery from substance abuse. The age of the 866 participants ranged from 19 to 75, with a mean of 43.8 (SD = 9.6). Fifty-five percent identified as Black, 26% as Hispanic, 12%

Heterosexual Clients With Same-Gender Sex

439

as White, and 7% as either mixed race or another race/ethnicity. Nineteen percent of the participants were female. In regard to sexual orientation, 9.9% of the respondents self-identified as LGB (5.9% of the men and 27.1% of the women). A total of 99 (11.4%) of the 866 participants who completed Part 1 of the survey reported being HSGS. The mean age of the HSGS participants was 44.0 (SD = 7.5), with 55% identifying as Black, 25% as Hispanic, 16% as White, and 4% as mixed/other, which was similar to the entire sample. The HSBS respondents also represented 71 (11.6%) of the 611 participants who completed Part 2 of the survey. There were no statistically significant differences in age and race/ethnicity between the HSGS participants who completed Part 2 of the survey and those who completed only Part 1.

Procedures Permission was obtained from the director of the inpatient substance-abuse rehabilitation program to perform data collection 1 day a week for a period of 13 months at the facility. The program had a maximum capacity of 53 clients (44 men and 9 women). According to the program’s annual report, approximately 1,400 clients were admitted to the facility during the 13 months of the study. Because many clients left treatment within several days of admission or were not available on the day of the week of data collection, only 905 (65%) clients were asked if they wished to participate in the study. Of those, 866 (96%) agreed to participate and completed Part 1 of the survey regarding their background/demographic information, including information about the gender of their sexual partners since age 18. Although the program was officially 28 days in length, many clients’ insurance plans only covered a far shorter treatment episode, and many clients either dropped out or were prematurely discharged due to treatment noncompliance. Therefore, the clients’ length of stay was quite variable. According to the facility’s 2010 annual report, only 35% of clients were in treatment for over 21 days. As Part 2 of the survey concerned the participants’ feelings regarding their treatment experiences, they were not permitted to complete it without having been in the program for at least 7 days. Due to the variation in length of stay, participants completed Part 2 anywhere from 7 to 28 days, with a mean of 15.7 (SD = 4.5) days. As described below, a multivariate analysis was therefore performed to make sure that differences in the number of days into treatment when participants completed Part 2 of the survey did not confound the results. As numerous participants left treatment early, only 611 (71%) of the 866 participants who completed Part 1 also completed Part 2. Respondents received a $4.50 Metrocard or $5.00 gift card from a fast food restaurant for having participated in the study. The institutional review board of the researcher’s university approved the procedures of this study in 2009.

440

E. Senreich

Measures CHARACTERISTICS

OF THE

SAMPLE

Part 1 of the survey included the following items regarding the demographic/background information of each participant: ● ●

●

●

●

●

●

●

●

●

●

●

Age: An item asked respondents to fill in their age. Race/ethnicity: A multiple-choice item with an additional “other” fill-in response asked respondents how they identified their race/ethnicity. Number of previous treatment episodes: A multiple-choice item asked respondents if they had been in treatment zero, once, twice, three times, or four or more times before the current treatment episode. In analysis, this was collapsed into three categories. Substances used regularly before treatment: Respondents were instructed to circle which substances they were using regularly before treatment from a list that included alcohol and many different drugs. Frequency of substance use: A multiple-choice item was included with six possible responses for participants to report how often they used substances in the 30 days before treatment. The responses ranged from not at all to every day. In analysis, this was collapse into three categories. Number of years of substance use: A fill-in item asked participants how long they were regularly using substances, not including periods of abstinence. General health: A multiple-choice item with six possible responses asked participants to rate their general health (from excellent to very poor). In analysis, this was collapsed into three categories. Presence of medical conditions: A multiple-choice item with five possible responses asked participants how concerned they were about medical conditions (from Yes, a great deal to No, not at all). In analysis, this was collapsed into three categories. Use of psychiatric medication: Respondents were asked a yes/no question inquiring whether they were prescribed psychotropic medication in the previous 10 years. Psychiatric hospitalization: Participants were asked a yes/no question inquiring whether they were ever hospitalized for psychiatric reasons. History of felonies and misdemeanors: Multiple-choice items asked participants about the number of felonies and misdemeanors on their records, with possible responses of none, 1, 2, 3 or more. For the analysis, these were collapsed into dichotomous yes/no categories regarding having had at least one felony or misdemeanor. Homelessness: A multiple-choice question asked participants about their living situation before beginning treatment, with five possible responses and a fill-in “other” response. In analysis, this was collapsed into a dichotomous yes/no category regarding being homeless prior to treatment.

Heterosexual Clients With Same-Gender Sex ●

●

●

●

●

●

441

Presence of significant other: A yes/no item asked participants whether they had a spouse, partner, or significant other in their lives. A fill-in “other” response was also provided for the participant. Education: A multiple-choice item with eight possible responses inquired about the participants’ completion of different levels of education from “I did not complete high school” to “I completed a graduate school program.” For analysis, this was collapsed into four categories. Recent employment: Respondents were asked to fill in the number of months that they were employed either full-time or part-time in the prior 2 years. Gender: A multiple-choice item asked respondents to indicate if they were male, female, or transgender. Self-identified sexual orientation: A multiple-choice item asked participants to indicate their sexual orientation. The choices included “I am uncertain about my sexual orientation” and “other (please specify)” with a space to write in a response. Same-gender sexual contact since age 18: Respondents were asked “Since age 18, have you ever had sexual contact with a member of your own sex for any reason whatsoever? (This could include for drugs, for money, being in prison, etc.).” Participants who responded that they were heterosexual in the aforementioned item regarding self-identified sexual orientation and also answered that they had sexual contact with a member of their own sex were categorized as heterosexual with a history of same-gender sex (HSGS). The item did not ask respondents the exact type(s) of sexual contact in which they participated (oral insertive, oral receptive, anal insertive, anal receptive, manual, etc.), nor did it differentiate between the various contexts of the sexual experiences.

COMPLETION RATES The completion rates of the 866 participants who completed Part 1 of the survey were determined from the unit records. Non-completing respondents were those who either dropped out of treatment prematurely or who were discharged by staff for breaking rules or treatment noncompliance. The 18 participants who were discharged for medical reasons, transferred to another facility, or lost their insurance coverage before 7 days of treatment were excluded from the analysis of completion rates. PARTICIPANTS’ TREATMENT EXPERIENCES In Part 2 of the survey, the following quantitative instruments were utilized to measure the participants’ satisfaction with treatment, therapeutic alliance

442

E. Senreich

with counselors, social affiliation with other clients, and connection to the treatment program: Client Satisfaction Questionnaire-8 (CSQ-8). This is a commonly used scale with eight questions used to measure consumer satisfaction with health and human services (Attkisson & Zwick, 1982; Attkisson & Greenfield, 2004). As each question has four possible Likert responses, the scoring range is 8 to 32. The internal consistency reliability of the responses in this study as measured by the Cronbach’s alpha was .90. Treatment Perception Questionnaire (TPQ). This scale was developed to measure client satisfaction in substance abuse treatment programs (Marsden et al., 2000). Respondents indicate their level of agreement with each of 10 statements by choosing one of five Likert responses. The scoring range is 10 to 50. The Cronbach’s alpha for the responses in this study was .79. Revised Helping Alliance Questionnaire (HAq-II). To determine participants’ therapeutic alliance with the treatment counselors, the 19-item client version of this scale was utilized (Luborsky et al., 1996). This scale was designed to measure therapeutic alliance between a client and therapist in psychotherapy. As this substance abuse program utilized a group-oriented model of treatment with clients exposed to numerous counselors, permission was obtained to change the word therapist to counselors in each item of the instrument. Respondents indicated their level of agreement with each of 19 statements regarding their relationship with the counselors in the program by selecting one of six Likert responses. The scoring range is 19 to 114. The Cronbach’s alpha for the responses in this study was .91. Social Affiliation Scale. An instrument designed to measure clients’ social cohesion with peers in different types of settings was utilized (Dermatis, Salke, Galanter, & Bunt, 2001; Galanter, Egelko, & Edwards, 1993). Permission was obtained to adapt the wording of the items for use in a short-term residential treatment program. Participants indicated their level of agreement with eight statements regarding their relationship with other clients by selecting one of five Likert responses. The scoring range for the scale is 8 to 40. The Cronbach’s alpha value for the responses in this study was .75. Connection Scale. As there is a lack of scales designed to measure clients’ feelings of connection to substance abuse treatment programs as a whole, a 4-item scale was created for this study. It included the following items: “How connected do you feel to this rehab program?”; “How much do you feel you are a part of this program?”; “How much of a sense of belonging do you have to this rehab program”; and “How much do you feel like this is your program?” Each question has four possible Likert responses, and the scale’s scoring range is 4 to 16. These four items loaded together in a factor analysis, and the Cronbach’s alpha value for the responses in this study was .86.

Heterosexual Clients With Same-Gender Sex

443

Experiences of Heterosexual Participants with a History of Same-Gender Sex. In Part 2 of the survey, participants who indicated that they were HSGS were directed to answer the following open-ended question: “If you are heterosexual or ‘straight,’ but since age 18 you have ever had any sexual contact with a member of your own sex for any reason whatsoever, how has this affected your recovery from substance abuse (if at all)?” This item was included in Part 2 as opposed to Part 1, as it was felt that the question might be too intimidating for participants to answer during their first encounter with the researcher. It was therefore posed to respondents after they had met the researcher for a second time and had completed questions regarding their treatment experiences. After completing Part 2 of the survey, the researcher met with each HSGS participant and inquired whether there was anything they wished to say regarding their same-gender sexual experiences, whether or not they completed this in writing. The researcher asked follow-up questions to clarify the meaning of the participants’ responses. The researcher wrote down these responses as the participant spoke. Due to the sensitive nature of the material, it was decided not to use recording equipment to capture participants’ responses regarding this subject.

Analysis CHARACTERISTICS

OF

SAMPLE

Differences in the characteristics of the sample between the HSGS participants, the other heterosexual participants (without same gender sexual experiences), and the LGB participants were determined utilizing chi-square analyses. This included gender; race; number of previous treatment episodes; frequency of substance use before treatment; history of use of psychiatric medications and psychiatric hospitalizations; history of felony and misdemeanor convictions; homelessness; presence of a significant other; education; health and medical concerns; and types of substances used regularly before treatment. ANOVA analyses were used to compare age, number of substances used regularly before treatment, number of years of substance use, and number of months of employment in the prior 2 years.

COMPLETION RATES Differences in program completion rates between the HSGS participants, other heterosexual participants, and LGB participants were determined using chi-square with Bonferroni corrections. This was performed for the entire sample, and separately by gender.

444

E. Senreich

TREATMENT EXPERIENCES Differences between the three aforementioned cohorts for the results of the CSQ-8, the TPQ, the HAq2, the Social Affiliation Scale, and the Connection Scale were determined by using ANOVA with Tukey post hoc analyses. This was performed for the entire sample, and separately by gender. As participants completed these scales in Part 2 of the survey, which was administered at different lengths of time into their treatment episode, an ANCOVA analysis was also performed with “number of days in treatment” as a covariate. This was done to make sure that these differences did not confound the results.

QUALITATIVE DATA A phenomenological perspective was utilized to analyze the responses to the open-ended question in the written survey and to the follow-up interview by the researcher. As the primary purpose of this portion of the study was to gain an understanding of the heterosexual participants’ reactions to the experience of same-gender sexual contact, a phenomenological approach appeared to be appropriate for the qualitative analysis of the data. Creswell (2007) stated that a phenomenological approach’s primary focus is an understanding of the essence of the participants’ experiences. Utilizing Hycner’s (1985) guidelines for performing phenomenological qualitative studies, a line-by-line analysis of the data was performed by the researcher of this study, delineating units of meaning. These units were clustered into central themes by the researcher, which are reported and illustrated with direct quotes from the participants.

RESULTS Characteristics of Sample There were a number of statistically significant differences in characteristics between the HSGS participants, the other heterosexual participants, and the LGB participants (see Table 1). Whereas only 13% of the heterosexual participants without same-gender experiences were female, 30% of the HSGS participants and 52% of the LGB participants were women. Upon further analysis, approximately one tenth (10.4%) of the self-identified heterosexual men in comparison to one quarter (25.6%) of the self-identified heterosexual women reported same-gender sexual experiences (χ 2 = 20.83, df = 1, p = .001). The HSGS respondents were more likely to have had three or more prior treatment episodes than the other cohorts. However, this result was statistically significant for the men but not for the women. As many as 73% of the HSGS men, in comparison to 56% of the LGB and 48% of the other

445

Heterosexual Clients With Same-Gender Sex TABLE 1 Selected Characteristics of Sample (N = 866) HSGS Other Hetero LGB (N =99) (N =681) (N =86) % % % Gender: Female Race/Ethnicity: Black Hispanic White Mixed/Other Previous Tx.: Never Once or Twice Three or More Frequency of Use Less than 1× weekly 1× to Several × weekly Almost Daily/Daily Psych Meds Psych Hospital Felonies Health (self-rated): Very Good/Excellent Good Fair/Poor Medical Concerns: Yes—A Great Deal Yes—Somewhat/A Little Not Much/Not at All Substances Used Alcohol Cocaine Marijuana Heroin Painkillers Tranquilizers Hallucinogens Amphetamines Inhalants Age Number of Substances Used Number of Years Using Mo. Employed—Last 2 Yrs.

Total (N =866) %

χ2

(df )

p

30

13

52

19

88.43

(2)

.001∗∗∗

55 25 16 4

55 26 12 7

56 27 9 8

55 26 12 7

3.20

(6)

.78

7 25 68

13 38 48

4 34 52

13 36 51

13.57

(4)

.009∗∗

9 27 64 79 42 56

14 30 55 54 32 55

9 28 62 73 45 39

13 30 57 59 34 54

4.56 30.43 9.49 8.36

(4) (2) (2) (2)

.34 .001∗∗∗ .009∗∗ .02∗

29 29 41

34 35 31

42 26 33

34 33 32

7.47

(4)

.11

29 53 18

22 44 34

30 41 29

24 45 32

12.51

(4)

.01∗∗

68 64 69 65 1.06 (2) 72 59 78 62 15.60 (2) 28 31 49 32 12.42 (2) 38 28 19 28 9.11 (2) 16 9 11 10 4.51 (2) 13 9 12 10 2.51 (2) 5 4 5 4 .56 (2) 1 1 6 1 13.69 (2) 2 1 4 1 7.28 (2) Mean (SD) Mean (SD) Mean (SD) Mean (SD) F (df ) 44.0 (7.5) 44.1 (9.9) 41.2 (9.0) 43.8 (9.6) 3.48 (2,853) 2.4 (1.3) 2.0 (1.1) 2.5 (1.3) 2.1 (1.1) 9.50 (2,861) 20.6 (9.6) 19.4 (10.8) 17.2 (10.1) 19.3 (10.6) 2.43 (2,853) 4.1 (6.5) 5.6 (7.6) 5.1 (8.2) 5.4 (7.5) 1.76 (2,829)

.59 .001∗∗∗ .002∗∗ .01∗∗ .11 .29 .76 .001∗∗∗ .03∗ p .03∗ .001∗∗∗ .09 .17

∗ p ≤ .05. ∗∗ p ≤ .01. ∗∗∗ p ≤ .001. Note. Percentages do not include unanswered items in the surveys.

heterosexual male clients, reported being previously in treatment three or more times (χ 2 = 15.37, df = 4, p = .004). Furthermore, compared to the other heterosexual participants, HSGS respondents reported greater levels of medical concerns. Once again, this was statistically significant for the men but not for the women.

446

E. Senreich

HSGS respondents reported similar characteristics with the LGB participants in several areas. Both of these cohorts, in comparison to heterosexual participants with no history of same-gender sex, were more likely to report being prescribed psychiatric medications in the previous 10 years, psychiatric hospitalizations in their lifetime, regular use of cocaine before treatment, and regular usage of a greater number of different substances before treatment. The LGB respondents differed from both heterosexual cohorts in reporting fewer felony convictions and younger age, as well as more likely regular usage of marijuana, amphetamines, and inhalants before treatment. LGB participants also reported the lowest rates of heroin usage before treatment among the three cohorts, with HSGS respondents reporting the highest rates. The rate of regular usage of heroin among male members of the latter cohort was as high as 42% in comparison to 28% of the other male heterosexual participants and only 15% of the gay and bisexual men (χ 2 = 10.30, df = 2, p = .006). Male HSGS respondents also reported a statistically significant higher rate of painkiller usage before treatment (20%) than the gay and bisexual male respondents (10%) and the other male heterosexual participants (9%; χ 2 = 8.42, df = 2, p = .02).

Completion Rates Table 2 indicates that there were differences in the results according to the gender of the participants. In comparing the completion rates of HSGS, other heterosexual, and gay/bisexual male participants, HSGS men were less likely to complete treatment than were the other heterosexual men at levels that were statistically significant. Only 37 (54%) of the 69 male HSGS respondents completed treatment in comparison to 401 (70%) of the 581 other heterosexual male respondents. Virtually no differences were found between the rates of completion of gay/bisexual male participants (68%) and the heterosexual male participants with no history of same-gender sexual contact (70%). Among the women, there were no statistically significant differences in completion rates between HSGS, other heterosexual, and lesbian/bisexual participants. When all men with a history of same-gender sex (including selfidentified gay, bisexual, and heterosexual participants) were compared to men with no history of same-gender sex, the former group had lower completion rates (59% vs. 70%; χ 2 = 5.44, df = 1, p = .02). However, when self-identified gay/bisexual men were compared with self-identified heterosexual men (regardless of sexual history), there were no statistically significant differences between the groups (68% vs. 68%; χ 2 = .01, df = 1, p = .92). There were no statistically significant differences in completion rates for these same comparisons among the women.

447

37 (54%)

407 (70%)

Other Hetero (n=581) 27 (68%)

LGB (n=40) 7.69

χ2 (2)

(df)

HSGS (n=29) 21 (72%)

pb .02∗

65 (76%)

Other Hetero (n=86)

27 (63%)

LGB (n=43)

Female

2.32

χ2

(2)

(df)

.31

p

a The

≤ .05. 18 participants who were discharged due to medical problems, transferred to the rehab’s other facility, or lost their insurance coverage before seven days of treatment were not included in the analysis. b Pair-wise comparisons with Bonferroni corrections indicate significant differences (p ≤ .05) between HSGS and Other Hetero, but not between the other cohorts.

∗p

Completed

HSGS (n=69)

Male

TABLE 2 Differences in Program Completion Rates Between Heterosexuals With a History of Same-Gender Sex (HSGS), Other Heterosexuals, and LGB Respondents (by Gender; N = 848)a

448

E. Senreich

Treatment Experiences The bivariate analyses revealed that there were no statistically significant differences in the results of the CSQ-8, the TPQ, the HAq-II, the Social Affiliation Scale, and the Connection Scale between the HSGS respondents, the other heterosexual respondents, and the LGBT participants (see Table 3). This was true as well when analyzing the results separately by gender. Including the number of days into treatment that participants completed these scales in Part 2 of the survey as a covariate in ANCOVA analyses did not influence the findings.

Qualitative Results Of the HSGS respondents who completed Part 2 of the survey, all 23 of the women and 44 out of 48 of the men responded to the open-ended question, either on the written questionnaire or verbally to the researcher. Four of the men declined to write anything about these experiences or discuss it with the researcher. The analysis of the data indicated major differences between the responses of the male and female participants. Approximately 30 (67%) of the men but only four of the women (17%) reported difficult emotional reactions when recalling their same-gender sexual experiences. Due to this major difference, the themes present in the responses of the men and women will be discussed separately, with verbatim examples from each. The vast majority of the 30 men who expressed very negative feelings about their homosexual experiences reported that it was in the context of trading sex for money or drugs. However, the two men in the sample who reported engaging in sex with men in prison also expressed very disturbing feelings about it. Experiencing shame and/or guilt was expressed by many of these respondents:

TABLE 3 Differences in Satisfaction (CSQ-8; TPQ), Therapeutic Alliance (HAQ-II), Social Affiliation (SA), and Connection (C) Between Heterosexuals With a History of Same Gender Sex (HSGS), Other Heterosexual, and LGB Respondents (Mean Scores; N = 611)

CSQ-8 TPQ HAq-II SA C

HSGS (n=71)

Other Hetero (n=465)

LGB (n=75)

F

(df )

p

24.86 35.78 88.39 30.25 13.16

25.52 35.53 87.63 30.23 12.74

25.76 36.16 91.82 31.03 13.13

.78 .29 2.25 .68 1.09

(2,608) (2,591) (2,578) (2,586) (2,601)

.46 .75 .11 .51 .34

Heterosexual Clients With Same-Gender Sex

449

I worked in a gay bar. A customer offered me $700 for sex. This became a regular thing. He became my “sugar mommy,” and I moved in with him. He found me other people for sex. I did this until about six months ago. It was an easy way to make money without moving my ass, with less risk of arrest. I feel used, shame, and guilt . . . like a prostitute. I feel like a piece of shit, like a rag doll. I was raised in a Christian family, and this makes me feel like shit to go to that extreme to get money. I would do anything for drugs. I did this for money and drugs . . . . It’s embarrassing and shameful, not a masculine thing to do. I do see it would be beneficial to my recovery and my life if I could resolve such issues that has plagued me since a young age and still does ’til my current age today. Being handsome sucks (no pun intended, nor is any vanity there) . . . It sometimes plagues me. I did this for money and a place to sleep. I have a great deal of shame about it. I’m straight . . . . I have to be intoxicated to do it, but I think maybe I’ll still do it for money, clothes, and gifts. I can’t resort to this. It will bring about a relapse. In the gay community, substance abuse is all over the place. Personally, although I have had contact with another man in my past, for money to buy drugs, I think that it’s really wrong, and that it’s an abuse of self . . . There are times in my life when I struggled with this and it ate me up. When you are on drugs, you do not know how far you may go. I just have to move on.

Secrecy was a very common theme expressed by the men, with several respondents stating they had never divulged their participation in samegender sexual contact before to anyone. This was particularly the case in regard to trading same-gender sex for money or drugs: It affected me mentally. It’s something I have to hide from friends and family for the rest of my life . . . I never really tried to talk about it. This is the first time revealing such a thing. It has affected me in ways of not becoming totally honest with myself because of the shame and guilt I’ve carried for years . . . . I have twin boys. God forbid they should find out. These stupid ignorant fucks will judge me, and then I will end up being discharged or leaving. The fact that I am reluctant to reveal this to my peers is an issue, being your disease is only as dark as your secrets . . . I don’t want people to perceive me as homosexual. I feel both shame and guilt about it.

450

E. Senreich

It’s hard. I don’t want to speak about it because of the way people are going to look at me . . . . I don’t think I can talk about this with counselors. They’ll look at me different. People speak about this in group, and then others talk about them after group. You’re the first person I’ve talked to about this. It stays in me, but it’s hard for me to speak about. It bothers me, the things I did for drugs. This shit is crazy.

Attempting not to think about the sexual experiences was a theme expressed by a number of the men: I did some things in my addiction with the same sex that I’m not proud of. I try not to think about it. It’s a nightmare. These experiences, being bottled up, really mess with me, because I’d never had thoughts of being with a man . . . But I was very actively using alcohol and drugs, and many times want to forget these experiences.

A number of participants expressed feeling exploited in regard to these experiences: When I’m on drugs, I’m vulnerable. You get baited in for drugs, then you gotta do more . . . . I have an ego to protect. It makes you feel “less than.” I feel like I was suckered. People will give me this much drugs, then say, “Do this for more.” For the most part I exchanged drugs or sex for money in the past and that would really confuse me in recovery as well. I felt degraded and taken advantage of. It’s too painful to talk about. I don’t want to talk about it. Drugs and sex go hand in hand.

For some of the participants, the feelings of shame or guilt around these experiences encouraged use of substances: I was in prison for 12 years and I had sex with men. My wife found out about it. It was part of the reason she left me. I never talk about it. Because of the feelings of shame, I sometimes drink over it. I’ll take this with me to my grave. It could get me to relapse to numb the pain. I don’t want to speak to a counselor about it. I would say since I am not gay, guilt and shame, and a sense of feeling dirty kept me using so as not to feel these feelings. It’s not a big thing now, but it still bothers me. I did it against my will. No one was forcing me, but drugs were forcing me.

Heterosexual Clients With Same-Gender Sex

451

On the other hand, others stated that the memories of their same-gender sexual experiences encouraged abstinence: It helps to keep me in recovery, because I don’t want it to happen again. That’s why I need to stay clean. It encouraged it [my recovery], as I’d rather avoid those situations going forward. It was directly related to use of mind-altering substances. I’ve had experiences I don’t care to repeat. It helps me not to use. Getting fucked in the ass while using crack is not an experience I care to repeat.

Among the men who stated that they did not feel disturbed by their having participated in same-gender sex, several stated that they participated in these experiences, either while sober or while using substances, as sexual experimentation: I am straight, but have experimented a little. This is a secret and has not affected my recovery or really any other part of my life. I’ve had some wild sex, and feel fine about it. I have had sex with same sex, but it is not affecting my recovery. I was with the same women for seven years. She enjoyed just watching . . . I feel okay about it. It was different.

A number of men who stated that they engaged in same-gender sex for money or drugs expressed not being disturbed by these experiences, accepting it as part of their addiction: I have had sex with men for drugs. I wasn’t in control. If I was, it would bother me. But I wasn’t. I have no flashbacks about it. I wouldn’t do it again as long as I’m getting help. I don’t think about it. I’m not ashamed of it. I know it was my disease doing it. It has not affected me at all. I talk about my sexual experiences and why I did it for drugs. While on crack, I would exchange sex for drugs. It doesn’t kick up feelings. I had no choice. I was homeless and on drugs.

A number of other men who did not express feeling disturbed about samegender sex made it a point to indicate that they knew they were heterosexual: It doesn’t bother me . . . . I understand that it’s not my preference, and it was done out of desperation to get my drug of choice.

452

E. Senreich

I know and am very comfortable with my sexuality and rarely think of the few occasions it happened, and when I do, I know it was only because I was under the influence of drugs and/or alcohol. I know I’m straight, so it doesn’t affect me.

Only four of the women expressed very negative feelings about having participated in same-gender sex, and for each one it was in the context of trading sex for money or drugs. Like the men who reported disturbing feelings about these incidents, there was a sense of shame and/or guilt, but also feelings of disgust: I feel bad about it. It’s not the way God raised me to be . . . It was disgusting. I should feel shame about it. It happened a few times. I really don’t want to talk about it. It was for drugs. It was “yukky,” that’s all I can say about it . . . that it was “yukky.”

Nineteen out of the 23 women expressed that they were not particularly disturbed about their homosexual experiences. The two women who reported same-gender sex in prison did not express negative feelings at all about it. A number of women who participated in same-gender sex for money or drugs, like most of the men who did not express distress about these incidents, accepted it as part of their addiction and made it a point to indicate that they knew they were heterosexual. Far more women than men, however, expressed that a sense of curiosity and experimentation was involved in these sexual interactions, even when it was part of drug use and/or prostitution. I had sex with a woman in prison out of curiosity. When I grew up, I would look at women. I feel okay about it. I was curious about women before I was married and tried it with a friend. It wasn’t for me. I don’t have any shame about it. I’m straight. Not at all that it affected my recovery. I did it for drugs and because I was curious. But after the fact I knew who I was and that I didn’t like women in that way at all, even though the other woman made me feel great for what she did to me.

Several women stated that they were not particularly bothered by the samegender sexual contact, because the sex was performed on them. This was not a theme expressed by the men.

Heterosexual Clients With Same-Gender Sex

453

I am a heterosexual, but I been with my same sex, and it doesn’t affect me for no means. I did it for drugs . . . I didn’t do the work, she did. It will not have no effect on my recovery, because I never touch girls. They touch me, only when getting high.

A number of the women also reported that they participated in homosexual encounters as part of multiple partner sex with a man present. (Only one male participant reported homosexual encounters in conjunction with a female partner.) I did have a sexual experience with my boyfriend and a menage a trois or whatever for my boyfriend’s benefit and curiosity, but it has nothing to do with my recovery. I had sexual contact with my own sex for money. I’ve accepted my sexuality and I am comfortable with it. The man paid to have sex with two women. Sometimes I can go both ways. This is always for money. I have experimented with it and I have good feelings during it. When my husband was using drugs, he would hire escorts. I was there while he had an escort there. One time I participated in the sex with her. I have no bad feelings about it.

DISCUSSION The results of this study suggest that many self-identified heterosexual individuals with a history of same-gender sexual contact since age 18 have unique treatment needs in substance abuse programs. This seems to be particularly true for men. In comparison to male heterosexual participants without a history of same-gender sexual contact, HSGS men were more likely to have been in treatment three or more times previously, to have concerns about their physical health, and to have regularly used heroin and/or painkillers before treatment. Particularly concerning is that the male HSGS respondents were less likely to complete treatment than were the other male heterosexual clients at levels that were statistically significant, a result that was not found for the women. However, when the results for the men and women were analyzed together, the HSGS respondents in comparison to the other heterosexual clients were more likely to have had a history of being prescribed psychiatric medication and of having been psychiatrically hospitalized. Furthermore, the HSGS participants were more likely to have reported regular use of cocaine and usage of a greater number of different substances before treatment.

454

E. Senreich

The results of the qualitative portion of this study indicated that many of the male HSGS respondents were emotionally troubled by their homosexual experiences. Many of the same-gender sexual contacts were in the context of trading sex for money and/or drugs, and this was disturbing for most of these men. Feelings of shame and guilt were prominent, with secrecy about these sexual encounters a recurring theme. A number of the men expressed attempts to mentally dissociate from these experiences, and several men angrily expressed feeling exploited by others in regard to these encounters. When discussing these experiences, many of the men appeared embarrassed, although some appeared relieved to discuss an issue that they usually, if not always, kept hidden. This was in contrast to the women with a history of same-gender sexual contact, who, for the most part, talked about these incidents in a matter-of-fact way, some appearing amused by the discussion. The vast majority of the women did not express very negative feelings about these encounters. However, it must be noted that four of the women who traded sex for money or drugs with other women did express difficult feelings about their homosexual encounters in ways similar to most of the men. The men and women who did not express much emotional disturbance about their prostitution experiences generally held a practical view regarding these incidents. They stated that they knew they were heterosexual, but that this was something they did because they were dependent on substances. In general, the self-identified heterosexual men and women who discussed having engaged in same-gender sexual contacts in the context of curiosity and experimentation appeared not to be disturbed by these incidents, particularly when these encounters were not related to their substance use. Two men and two women discussed participating in same-gender sex while incarcerated, and it was interesting that both men expressed painful feelings about this, whereas the women discussed the relationships they had in prison in a positive light. In the qualitative portion of this study, the HSGS participants were specifically asked how their history of same-gender sex had affected their recovery from substance abuse (if at all). A number of respondents directly answered this question in different ways—for example, by either stating that the difficult emotions elicited by these experiences were relapse triggers or by conversely stating that the painful memories of these sexual incidents reminded them of the necessity of remaining abstinent. Some participants expressed that these incidents did not bother them and therefore had no impact on their recovery. Many of the respondents, however, did not directly answer the research question relating the impact of same-gender sex on their recovery but instead expressed their specific reactions to same-gender sexual contact. In regard to phenomenological qualitative analysis, Hycner (1985) cautioned researchers not to dismiss content that might seem tangential to the subject, as it may indeed be relevant to the issue being researched. This is probably true in this study, because for many of the participants,

Heterosexual Clients With Same-Gender Sex

455

same-gender sexual contact has been a behavior associated with their addiction that they may not have had an opportunity to discuss in an environment that felt safe for them. Whereas many of the HSGS respondents in the qualitative part of this study discussed the context of their same-gender sexual contact, only a few discussed the exact type of sexual acts in which they were engaged. Furthermore, there was no item in the quantitative portion of this study that specifically clarified this. Therefore, it is not possible to determine from this study whether specific types of sexual contact were associated with different emotional reactions among the participants. The findings of this study did not indicate any differences between the HSGS, other heterosexual, and LGB participants in regard to client satisfaction, therapeutic alliance with counselors, social affiliation with peers, or feelings of connection to the treatment program. This was true for each gender separately and for both genders combined. Despite the findings that the male HSGS participants had lower program completion rates and that many were not discussing sexual issues that deeply disturbed them, their ratings of their treatment experiences were similar to the other respondents. Although this study took place in only one urban treatment program, this study appears to indicate that HSGS clients may be a sizeable group in substance abuse programs. One quarter of the self-identified heterosexual women and 10% of the self-identified heterosexual men reported such contact. There were far more heterosexual men reporting same-gender sexual contact than there were self-identified gay and bisexual male respondents. More specifically, 3.6% of the entire male sample self-identified as gay, 2.3% as bisexual, and 9.8% as HSGS. Most likely, the number of HSGS men was even greater but was underreported due to issues of stigma, shame, and fear of having homosexual behaviors discovered by other clients and staff members. Among the women, 20.4% of respondents self-identified as bisexual, 18.5% as HSGS, and 7.4% as lesbian. It is interesting to note that nearly one half (46.3%) of the female sample, in comparison to 17.7% of the male sample, reported being either LGB or HSGS. Another noteworthy finding of this study was that a significant number of women reported trading sex for drugs and money with other women. In the literature that discusses prostitution among female substance users, there seems to be an underlying assumption that these encounters are heterosexual. The results of this study corroborate the findings of Sterk and Elifson (2006), who found that same-sex prostitution among women dependent on crack cocaine was not uncommon.

Implications for Treatment The results of this study indicate that there are many HSGS clients in substance abuse treatment, and that it is common for these clients, particularly

456

E. Senreich

the men, to have difficult emotional reactions in regard to their homosexual experiences. Furthermore, the male clients in this group had lower treatment completion rates than the other male clients without a history of same-gender sexual contact. However, the substance abuse treatment literature barely recognizes this population, and it is virtually devoid of discussion regarding how to help them. The following recommendations are suggested:

1. Clinical staff members in substance abuse programs need to ask clients in a sensitive but detailed way about their sexual history, normalizing the issue of same-gender sexual behavior. It may be advisable not to perform this assessment of sexual issues during formal intake sessions, but to wait until there has been an engagement process between the clients and their primary counselors. Having counselors administer a comprehensive questionnaire to their clients regarding many aspects of their sexual behavior would probably be an appropriate venue to include questions about homosexual behavior. This should include individual questions regarding different contexts of same-gender sexual contact such as self-identifying as LGB, trading sex for money or drugs, sex during incarceration (both consensual and forced), sex while under the influence of substances, experimentation, sexual coercion, and so forth. 2. Clinicians need to include issues related to self-identified heterosexual clients’ history of same-gender sex in their treatment and relapse prevention plans, if relevant to the clients’ recovery. It is important for clinicians to enhance their expertise in assessing the impact of same-gender sex on the lives of their clients and to develop comfort in exploring this with them. Some of the male participants expressed that their memories of same-gender sexual contact were a relapse trigger, while others expressed that these recollections encouraged abstinence. In either case, the clients’ thoughts and feelings regarding these encounters should be incorporated into relapse prevention strategies. 3. Substance abuse programs need to include discussion of same-gender sex in their group modalities, particularly from an educational perspective. Although many self-identified heterosexual clients will not feel comfortable revealing their history of same-gender sexual encounters in a group setting, it is important for this issue to be normalized and not ignored. Such group discussion might increase the possibility that clients will then discuss this issue in individual sessions, particularly if the clinician subsequently broaches the subject. In regard to same-gender sex while in prison, clients may be more apt to reveal such experiences in a specialized group for clients with a history of lengthy incarceration. 4. Substance abuse programs should have specific rules forbidding homophobic comments and actions. Studies have indicated that LGB clients are often exposed to such encounters while in chemical dependency

Heterosexual Clients With Same-Gender Sex

457

treatment (Cullen, 2004; Senreich, 2009). The presence of homophobic reactions in the treatment environment creates a formidable barrier in regard to HSGS clients discussing their same-gender sexual histories. Strictly enforcing regulations regarding the unacceptability of homophobic comments and actions in the therapeutic milieu could possibly result in the reduction of such incidents and may increase the willingness of HSGS clients to disclose their history of same-gender sex. 5. Whereas substance abuse program staff members may have received at least some training and supervision regarding working with LGB clients in an affirming way, this is rarely the case in regard to working with HSGS clients. The issues of working with HSGS clients should be included in substance abuse treatment textbooks and discussed in the classroom where substance abuse professionals receive their education and training. As this study indicates that there may be a larger percentage of HSGS clients in substance abuse treatment than there are self-identified LGB clients, this is a population that certainly needs more attention in the clinical literature and in educational settings.

Limitations of Study The purpose of the qualitative portion of this article was to focus on the experiences of HSGS clients in substance abuse treatment, as this population has been virtually ignored in the literature. Although it would have been helpful to have also asked the LGB participants how their history of samegender contact affected their recovery, this was not done. Direct comparisons of the qualitative data between the HSGS and LGB respondents most likely would have added to the depth of the data analysis. There are other limitations of this research project. First, this study took place in only one substance abuse program in a large urban area in the northeastern United States. The vast majority of the clients self-identified as Black or Hispanic. Therefore, the results may not be generalizable to programs in other geographic areas and to programs where the majority of clients are from other racial/ethnic groups. Second, although there were a range of situations in which self-identified heterosexual clients engaged in same-gender sexual contact, the written survey did not inquire about each of the contexts separately. It would have been a helpful addition to the study to have collected this information. Third, as discussed previously, there was probably underreporting of a history of same-gender sexual contact among the self-identified heterosexual clients, particularly the men, due to issues of shame and fear of exposure. Fourth, only a single researcher analyzed the qualitative data. Therefore, the formulation of themes was not verified by multiple coders. Last, there was considerable variation in the number of days in treatment when respondents completed Part 2 of the survey. For

458

E. Senreich

the quantitative data, however, this variation was controlled for by use of multivariate analyses.

CONCLUSION This study found that in an urban inpatient substance-abuse program, 10% of the male and 25% of the female self-identified heterosexual respondents reported that they engaged in same-gender sexual contact since age 18. There were no differences in satisfaction with treatment, therapeutic alliance, social affiliation, and connection to the treatment program between HSGS and other participants. However, the HSGS respondents reported a history of more psychiatric involvement, use of a greater number of substances before treatment, and a greater likelihood of cocaine use before treatment than the other heterosexual participants. Furthermore, the male HSGS participants were less likely to complete treatment, had more previous treatment episodes, and reported more health concerns and a greater likelihood of heroin and painkiller use before treatment than the other male self-identified heterosexual participants. In addition, most of the men and several of the women in this cohort expressed very negative feelings about their history of homosexual contact, particularly when it involved trading sex for money or drugs. The results indicate that more attention needs to be paid to the specific issues of HSGS clients both in the literature and in clinical practice in substance abuse treatment settings.

ACKNOWLEDGMENTS The researcher would like to thank Susan Thomas, CASAC, Clinical Director of Rehab Services, Cornerstone of Medical Arts Center, for her help in facilitating this research project.

FUNDING This research project received funding from the PSC-CUNY Research Award Program of the City University of New York.

REFERENCES Anderson, S. (2009). Substance use disorders in lesbian, gay, bisexual, and transgender clients. New York, NY: Columbia University Press.

Heterosexual Clients With Same-Gender Sex

459

Attkisson, C. C., & Greenfield, T. K. (2004). The UCSF client satisfaction scales: I. The Client Satisfaction Questionnaire-8. In M.E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment, Vol. 3 (3rd ed.; pp. 799–811). Mahwah, NJ: Erlbaum. Atkisson, C. C., & Zwick, R. (1982). The Client Satisfaction Questionnaire: Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning, 5, 233–237. Beck, A. J., & Johnson, C. (2012). Sexual victimization reported by former state prisoners, 2008. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice. Retrieved from http://bjs.ojp.usdoj.gov/index.cfm?ty=tp&tid=20 Bell, A. V., Ompad, D., & Sherman, S. G. (2006). Sexual and drug risk behaviors among women who have sex with women. American Journal of Public Health, 96, 1066–1072. doi:10.2105/AJPH.2004.061077 Boles, J., & Elifson, K. W. (1994). Sexual identity and HIV: The male prostitute. Journal of Sex Research, 31, 39–46. Burnette, M. L., Lucas, E., Ilgen, M., Frayne, S. M., Mayo, J., & Weitlauf, J. C. (2008). Prevalence and health care correlates of prostitution among patients entering treatment for substance use disorders. Archives of General Psychiatry, 65, 337–344. doi:10.1001/archpsyc.65.3.337 Cabaj, R. P. (2005). Gays, lesbians, and bisexuals. In J. H. Lowinson, P. Ruiz, R. B. Millman, & J. G. Langrod (Eds.), Substance abuse: A comprehensive textbook (4th ed.; pp. 1129–1141). Philadelphia, PA: Lippincott, Williams, & Wilkins. Cabaj, R. P. (2008). Gay men and lesbians. In M. Galanter & H. D. Kleber (Eds.), Textbook of substance abuse treatment (4th ed.; pp. 623–638). Arlington, VA: American Psychiatric Publishing. Chaiken, S. B. (1995). Cultural factors and outcome in neurobehavioral outpatient cocaine treatment. (Doctoral dissertation, California School of Professional Psychology, 1994) Dissertation Abstracts International (UMI No. AAT 9510852) Cochran, B. N. (2004). Sexual minorities in substance abuse treatment: The impact of provider biases and treatment outcomes. (Doctoral dissertation, University of Washington, 2003) Dissertation Abstracts International (UMI No. AAT 3102639) Copeland, J., & Hall, W. (1992). A comparison of predictors of treatment drop-out of women seeking drug and alcohol treatment in a specialist women’s and two traditional mixed-sex treatment services. British Journal of Addiction, 87, 883–890. Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: SAGE. Crisp, C. L., & DiNitto, D. M. (2012). Substance abuse treatment with sexual minorities. In C. A. McNeece & D. M. DiNitto (Eds.), Chemical dependency: A systems approach (4th ed.; pp. 336–353). Boston, MA: Pearson. Cullen, J. (2004). Understanding the experiences of gay men in addiction treatment: A phenomenological study. (Doctoral dissertation, University of Toronto, 2004). Dissertation Abstracts International (UMI No. AAT NQ91649) Dermatis, H., Salke, M, Galanter, M., & Bunt, G. (2001). The role of social cohesion among residents in a therapeutic community. Journal of Substance Abuse Treatment, 21, 105–110. doi:10.1016/S0740-5472(01)00183-0

460

E. Senreich

Doll, L. S., Peterson, L. R., White, C. R., Johnson, E. S., Ward, J. W., & The Blood Donor Study Group. (1992). Homosexually and nonhomosexually identified men who have sex with men: A behavioral comparison. Journal of Sex Research, 29, 1–14. Drabble, L., Midanik, L. T., & Trocki, K. (2005). Reports of alcohol consumption and alcohol related problems among homosexual, bisexual, and heterosexual respondents: Results from the 2000 National Alcohol Survey. Journal of Studies on Alcohol, 66, 111–120. Dumond, R. W. (2000). Inmate sexual assault: The plague that persists. Prison Journal, 80, 407–414. doi:10.1177/0032885500080004006 Earls, M. E., & David, H. (1989). A psychosocial study of male prostitution. Archives of Sexual Behavior, 18, 401–419. Finnegan, D. G., & McNally, E. B. (2002). Counseling lesbian, gay, bisexual, and transgender substance abusers: Dual identities. New York, NY: Haworth. Friedman, S. R., Ompad, D. C., Maslow, C., Young, R., Case, P., Hudson, S. M., . . . Garfein, R. S. (2003). HIV prevalence, risk behaviors, and high-risk sexual and injection networks among young women injectors who have sex with women. American Journal of Public Health, 93, 902–906. Fromme, K., D’Amico, E. J., & Katz, E. C. (1999). Intoxicated sexual risk taking: An expectancy or cognitive impairment explanation? Journal of Studies on Alcohol, 60, 54–63. Galanter, M., Egelko, S., & Edwards, H. (1993). Rational recovery: Alternative to AA for addiction? American Journal of Drug and Alcohol Abuse, 19, 499–510. Garland, J. T., Morgan, R. D., & Beer, A. M. (2005). Impact of time in prison and security level on inmates’ sexual attitude, behavior, and identity. Psychological Services, 2, 151–162. doi:10.1037/1541-1559.2.2.151 George, W. H., & Norris, J. (1991). Alcohol, disinhibition, sexual arousal, and deviant sexual behavior. Alcohol Health and Research World, 15, 133–138. George, W. H., Stoner, S. A., Norris, J., Lopez, P. A., & Lehman, G. L. (2000). Alcohol expectancies and sexuality: A self-fulfilling prophecy analysis of dyadic perceptions and behavior. Journal of Studies on Alcohol, 61, 168–176. Goldbaum, G., Perdue, T., & Higgins, D. (1996). Non-gay-identifying men who have sex with men: Formative research results from Seattle, Washington. Public Health Reports, 111, 36–40. Greene, B. (1994). Ethnic-minority lesbian and gay men: Mental health and treatment issues. Journal of Counseling and Clinical Psychology, 62, 243–251. Greenwood, G. L., Woods, W. J., Guydish, J., & Bein, E. (2001). Relapse outcomes in a randomized trial of residential and day drug abuse treatment. Journal of Substance Abuse Treatment, 20, 15–23. doi:10.1016/S0740-5472(00)00147-1 Harawa, N. T., Williams, J. K., Ramamurthi, H. C., Manago, C., Avina, S., & Jones, M. (2008). Sexual behavior, sexual identity, and substance abuse among lowincome bisexual and non-gay-identifying African American men who have sex with men. Archives of Sexual Behavior, 37, 748–762. Hensley, C., Tewksbury, R., & Wright, J. (2001). Exploring the dynamics of masturbation and consensual same-sex activity within a male maximum security prison. Journal of Men’s Studies, 10, 59–71. Hycner, R.H. (1985). Some guidelines for the phenomenological analysis of interview data. Human Studies, 8, 279–303.

Heterosexual Clients With Same-Gender Sex

461

Kopetz, C. E., Reynolds, E. K., Hart, C. L., Kruglanski, A. W., & Lejuez, C. W. (2010). Social context and perceived effects of drugs on sexual behavior among individuals who use both heroin and cocaine. Experimental and Clinical Psychopharmacology, 18, 214–220. doi:10.1037/a0019635 Laumann, E. O., Gagnon, J. H., Michael R. T., & Michaels, S. (1994). The social organization of sexuality: Sexual practices in the United States. Chicago, IL: University of Chicago Press. Lee, S. J., & Levounis, P. (2008). Gamma hydroxybutyrate: An ethnographic study of recreational use and abuse. Journal of Psychoactive Drugs, 40, 245–253. Leigh, B. C. (1990). The relationship of sex-related alcohol expectancies to alcohol consumption and sexual behavior. British Journal of Addiction, 85, 919–928. Long, G. T. (1993). Homosexual relationships in a unique setting: The male prison. In L. Diamant (Ed.), Homosexual issues in the workplace (pp. 143–170). Washington, DC: Taylor & Francis. Luborsky, L., Barber, J. P., Siqueland, L., Johnson, S., Najavits, L. M., Frank, A., & Daley, D. (1996). The Revised Helping Alliance Questionnaire (HAq-II): Psychometric properties. Journal of Psychotherapy Practice and Research, 5, 260–271. MacEwan, I. (1994). Differences in assessment and treatment approaches for homosexual clients. Drug and Alcohol Review, 13, 57–62. Marsden, J., Stewart, D., Gossop, M., Rolfe, A., Bacchus, L., Griffiths, P., Clarke, K., & Strang, J. (2000). Assessing client satisfaction with treatment for substance use problems and the development of the Treatment Perceptions Questionnaire (TPQ). Addiction Research, 8, 455–470. Martinez, J., & Hosek, S. G. (2005). An exploration of the down-low identity: Nongay identified young African American men who have sex with men. Journal of the National Medical Association, 97, 1103–1112. Matthews, C. R., & Selvidge, M. M. D. (2005). Lesbian, gay, and bisexual clients’ experiences in treatment for addiction. Journal of Lesbian Studies, 9, 79–90. doi:10.1300/J155v09n03_08 McCabe, I., Acree, M., O’Mahoney, F., McCabe, J., Kenny, J., Twyford, J., Quigley, K., & McGlanaghy, E. (2011). Male prostitution in Dublin: A psychological analysis. Journal of Homosexuality, 58, 998–1021. doi:10.1080/00918369.2011.598394 Miller, R. L., Klotz, D., & Eckholdt, H. M. (1998). HIV prevention with male prostitutes and patrons of hustler bars: Replication of an HIV preventive intervention. American Journal of Community Psychology, 26, 97–131. Morash, M., Jeong, S., Bohmert, M. N., & Bush, D. R. (2012). Men’s vulnerability to prisoner-on prisoner sexual violence: A state correctional system case study. Prison Journal, 92, 290–311. doi:10.1177/0032885512439185 Morse, E. V., Simon, P. M., Baus, S. A., Balson, P. M., & Osofsky, H. J. (1992). Cofactors of substance use among male street prostitutes. Journal of Drug Issues, 22, 977–994. Munoz,-Laboy, M. A., & Dodge, B. (2007). Bisexual Latino men an HIV and sexually transmitted infections risk: An exploratory analysis. American Journal of Public Health, 97, 1102–1106. doi:10.2105/AJPH.2005.078345 Newman, P. A., Rhodes, F., & Weiss, R. E. (2004). Correlates of sex trading among drug-using men who have sex with men. American Journal of Public Health, 94, 1998–2003.

462

E. Senreich

Ompad, D. C., Friedman, S. R., Hwahng, S. J., Nandi, V., Fuller, C. M., & Vlahov, D. (2011). HIV risk behaviors among drug using women who have sex with women (WSWs) in New York City. Substance Use and Misuse, 46, 274–284. doi:10.3109/10826084.2011.523284 Rawson, R. A., Washton, A., Domier, C. P., & Reiber, C. (2002). Drugs and sexual effects: Role of drug type and gender. Journal of Substance Abuse Treatment, 22, 103–108. doi:org/10.1016/S0740-5472(01)00215-X SAMHSA (Substance Abuse and Mental Health Services Administration). (2001). A provider’s guide to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. Rockville, MD: U.S. Department of Health and Human Services. Senreich, E. (2009). A comparison of perceptions, reported abstinence, and completion rates of gay, lesbian, bisexual, and heterosexual clients in substance abuse treatment. Journal of Gay & Lesbian Mental Health, 13, 145–169. doi:10.1080/19359700902870072 Senreich, E., & Vairo, E. (2014). Assessment and treatment of lesbian, gay, and bisexual clients with substance use disorders. In S. L. A. Straussner (Ed.), Clinical work with substance-abusing clients (3rd ed.; pp. 466–494). New York, NY: Guilford Press. Sterk, C. W., & Elifson, K. W. (2006). Exploring sexual behaviors and sexual orientation: An ethnographic study of African American female crack cocaine users. In A. M. Omoto & H. S. Kurtzman (Eds.), Sexual orientation and mental health: Examining identity and development in lesbian, gay, and bisexual people (pp. 269–280). Washington, DC: American Psychological Association. Timpson, S. C., Ross, M. W., Williams, M. L., & Atkinson, J. (2007). Characteristics, drug use, and sex partners of a sample of male sex workers. American Journal of Drug and Alcohol Abuse, 33, 63–69. doi:10.1080/00952990601082670 van Wormer, K., & Davis, D. R. (2008). Addiction treatment: A strengths perspective (2nd ed.). Belmont, CA: Thomson-Brooks/Cole. Villarosa, L. (2001, April 3). AIDS education is aimed “down low.” New York Times, p. F5. Volkow, N. D., Wang, G. J., Fowler, J. S., Telang, F., Jayne, M., & Wong, C. (2007). Stimulant-induced enhanced sexual desire as a potential contributing factor in HIV transmission. American Journal of Psychiatry, 164, 157–160. Young, R. M., & Meyer, I. H. (2005). The trouble with “MSM” and “WSW”: Erasure of the sexual-minority person in public health discourse. American Journal of Public Health, 95, 1144–1149. doi:10.2105/AJPH.2004.046714

Copyright of Journal of Homosexuality is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.