Introduction
It is important to point out at the outset that we do not know a lot about alcohol dependence and misuse among older people who are lesbian or gay, in part because we don’t know that much about the problem in the younger people. There are a lot of myths, stereotypes and misconceptions in this area.

It is generally stated that the prevalence of substance abuse and dependence among people who are lesbian, gay, bisexual or transsexual is substantially higher than in the general population (1, 2, 3). Some early studies said the misuse rate was 30% and higher, but these samples probably over-sampled heavy users.

More recent research points out that younger lesbian women (particularly those aged 20-34) report using alcohol more frequently. They also drank in greater quantities than heterosexuals. That pattern of drinking in turn conceivably places some of them at greater risk for alcohol-related problems (4, 5). The women were also more likely to smoke, with the potential for tobacco-related health problems in later life. (6)

In a recent large scale study of urban gay and bisexual men, both recreational drug (52%) and alcohol use (85%) were very common, as was multiple drug use (18 %). Twelve per cent of the men reported experiencing three or more alcohol-related problems, 19 % reported frequent drug use and 8% reported heavy-frequent alcohol use (7). On the other hand, there is some suggestion that prevalence of substance abuse and dependence among lesbians has been overestimated because samples were unrepresentative (e.g. drawing from lesbian bars) (8).

It has been suggested that problem drinking in the gay population may be decreasing, possibly because of an increased acceptance of homosexuality, awareness of the problem, HIV education, or due to the availability of more social outlets for gays and lesbians (9).

There are lots of explanations for why alcohol problems may be (or have been) more common among gays and lesbians.

As people were growing up in the 1930s through to the 1980s and even to today, society clearly said gay and lesbian people should not exist. If people were gay or lesbian, they were not supposed to act on their feelings. Many people who were lesbian, gay or transgender internalized these societal feelings throughout the decades, leading to psychological conflict and psychological stress.

Many older gay and lesbian people had their first sexual experiences under the influence of alcohol. Others would only have sex when they were drinking. It was a way to overcome the internal fear, denial, and anxiety about gay sex when they were young adults. Many older gay and lesbian people had to stay “in the closet” almost all of their adult life. Some married and had children. Many may not have disclosed their sexual orientation to their immediate family or other relatives. Among younger people, self-acceptance of homosexuality may be important in the treatment of men who have problems with alcohol. One study found that self-acceptance was a key variable in the substance use recovery of gay men (10).

Societal factors are the reason most gay/lesbian people give for the increased prevalence of substance problems in the gay/lesbian population. There have been many legal prohibitions on homosexual behavior throughout the lives of older gays and lesbians. Gays and lesbians, of all ages have often faced discrimination and hate crimes. Sexuality and expression of anyone’s sexual “difference” was treated with secrecy, shame and was highly stigmatized.

People could only “safely” express their sexuality in a few places. Gay bars were one of those. Gay bars in most Canadian cities only became evident in the early 1970s. The gay bars have been described as a combination of bar, country club and community centre for many gays.

Alcohol and Substance Use Treatment Issues
We know that few gay and lesbian clients enter treatment centers, and most treatment centers do not address the special needs of the gay and lesbian populations. In some cases, people coming to treatment are gay but are not identifying themselves in that manner. While many older gay people are open about their sexuality, a large number has been in the closet for many years. They often keep their sexual orientation secret, because they feel vulnerable and fear discrimination, abuse, or social condemnation.

In the past, gay men and lesbians occasionally encountered problems when seeking treatment at some treatment agencies. In many cases, counselors were not fully sympathetic to, or even knowledgeable about, being gay. Some would even go so far as attempting to "cure" a client's homosexuality, falsely believing that their gayness was the root of their excessive use of alcohol.

Until gays started establishing self help groups specifically for their members or before gay friendly meetings became available in some communities, those who tried to attend the mainstream groups were made to feel out of place, and they were openly threatened in some situations. The treatment options available through most of the lives of older gays and lesbians have often had a strong moral or religious aura to them. While some components of AA approaches such as the 4th step (taking a moral inventory) could be a positive way to come to terms with one’s sexuality, it was more likely to be perceived and treated as a way as castigating gays for their sexual orientation.

Mainstream addiction treatment continues tend to overlook gays and lesbians. For example, although the Canadian publication “Best Practices: Treatment and Rehabilitation for Women with Substance Use Problems” has a section on women with "special needs", it ignores both lesbian women and older women (11). Similarly the 1997 Society of Obstetricians and Gynecologists Canada (SOGC) Clinical Practice Guidelines, “Lesbian Health Guidelines”, covered mental health issues, the adolescent lesbian, lesbian women as parents, assault and sexual abuse, but ignored older lesbian woman (12).

It has been suggested that gays and lesbians have different developmental paths. Both groups face homophobia, but lesbians more likely to have faced sexism, violence, or rape earlier in life. These issues also surface in substance use treatment. There are many special stressors for gays and lesbians, including experiencing grief and loss resulting from deaths of partners and friends to HIV/AIDS, or by violence by others.

Aging Issues
In addition to the many special issues they can face in relation to the substance dependence, older gay and lesbian also face special age related issues. It has been noted that the gay and the mainstream culture is so consumed by the worship of youth that often society fails to see anything else. Older lesbians and gays can face anti-gay discrimination in situations that are unique to or particularly difficult for older people. This includes discrimination in housing, public accommodations, and medical treatment. They are often dealing with physical, psychological, and emotional anti-gay abuse. They struggle with silence that often leaves older gay people invisible both within and outside the gay community. 

Like other older people, the social support networks that older gay and lesbian people have affects whether they feel lonely as well as influences their physical and mental health. (13) When giving care to chronically ill same sex partners, they encounter many of the same experiences as other caregivers (including physical and emotional strains, and loneliness and depression following the loss of the caregiving role). But there are unique aspects as well in their interactions with formal and informal support persons and services and their long-term planning and decision-making processes because of the nature of their relationship. (14) In post-caregiving, many also faced the challenge of re-engaging in the gay community and establishing new romantic relationships. These are the same problems of their heterosexual peers, but at the same time, the impact is very different too.

References
(1) Stall R. &, Wiley J (1988). A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco men’s health study. Drug & Alcohol Dependence 22:63-73.

(2) Skinner, W.F (1994). The prevalence and demographic predictors of illicit and licit drug use among lesbians and gay men. Am J Public Health 84:1307-1310.

(3) Skinner W.F. & Otis M.D. (1996). Drug and alcohol use among lesbian and gay people in a Southern US sample. J Homosex 30:59-91

(4) Parks, C.A. (1999). Lesbian social drinking: The role of alcohol in growing up and living as a lesbian. Contemporary Drug Problems, 26(1):75-129.

(5) Also Cochran, S.D. Keenan, C., Schober, C. et al. (2000). Estimates of alcohol use and clinical treatment needs among homosexually active men and women in the U.S. population. Journal of Consulting and Clinical Psychology, 68(6):1062-1071

(6)Gruskin, E.P.; Hart, S.; Gordon, N.; Ackerson, L. Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organization. American Journal of Public Health, 91(6):976-979, 2001

(7) Stall, R., Paul, J.P., Greenwood, G. et al. (2001). Alcohol use, drug use and alcohol-related problems among men who have sex with men: The urban men's health study. Addiction, 96(11):1589-1601.

(8) Hughes, T.L. (2003) Lesbians’ drinking patterns: Beyond the data. Substance Use and Misuse, 38(11-13):1739-1758.

(9) Crosby, M.G., Stall, R.D., Paul, J.P. et al (1998). Drug and alcohol and drug use have declined between generations of younger gay-bisexual men in San Francisco. Alcohol Dependence 52:177-182

(10) Kus, R.J. (1988). Alcoholism and non acceptance of gay self: the critical link. The Haworth Press: 25-41.

(11) “Best Practices: Treatment and Rehabilitation for Women with Substance Use Problems” has a section on women with special needs, it does not cover lesbian women, nor older women for that matter. See:

www.hc-sc.gc.ca/ahc-asc/alt_formats/hecs-sesc/pdf/pubs/drugs-drogues/bp_women-mp_femmes/women-e.pdf

(12) Society of Obstetricians and Gynecologists Canada (SOGC). SOGC Clinical Practice Guidelines, “Lesbian Health Guidelines”. Online at:www.sogc.org/guidelines/pdf/ps87.pdf. J Soc Obstet Gynaecol Can 2000; 22(3),202-5.

(13) Grossman, A.H., D'Augelli, A.R. & Hershberger, S.L. (2000) Social support networks of lesbian, gay, and bisexual adults 60 years of age and older. Journal of Gerontology: Psychological Sciences, 55B (3), P171-P179.

(14) Kristina Hash, K. (2001). Caregiving and Post-caregiving Experiences of Midlife and Older Gay Men and Lesbians. Doctoral Dissertation. School of Social Work. Virginia Commonwealth University http://kmhash.tripod.com/disspage.htm