High Risk Sex Behavior and Meth Use in the GLBT Community: DrugSex Fusion and Methamphetamine Abuse - PowerPoint PPT Presentation

Loading...

PPT – High Risk Sex Behavior and Meth Use in the GLBT Community: DrugSex Fusion and Methamphetamine Abuse PowerPoint presentation | free to download - id: 1d124-NzA5O



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

High Risk Sex Behavior and Meth Use in the GLBT Community: DrugSex Fusion and Methamphetamine Abuse

Description:

Of those, how many are 'out' to you as lesbian, gay, bisexual, or transgender? ... 2.8% of women Identify selves as bisexual ... Bisexuals are in denial about ... – PowerPoint PPT presentation

Number of Views:647
Avg rating:3.0/5.0
Slides: 86
Provided by: afo6
Learn more at: http://www.uclaisap.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: High Risk Sex Behavior and Meth Use in the GLBT Community: DrugSex Fusion and Methamphetamine Abuse


1
High Risk Sex Behavior and Meth Use in the GLBT
Community Drug-Sex Fusion and Methamphetamine
Abuse Treatment Implications
  • Thomas Freese, Ph.D., Sherry Larkins, Ph.D.,
  • Cathy Reback, Ph.D., Steven Shoptaw, Ph.D.,
  • and Josh Riley, M.S.
  • 7th Annual Co-Occurring Disorders Conference
  • Long Beach, CA
  • March 31, 2009

2
Goals of Presentation
  • Provide overview of disease and biopsychosocial
    models of addiction.
  • Discuss methamphetamine abuse treatment options
    including harm reduction, individual therapy,
    support groups, intensive outpatient programming,
    and residential treatment.
  • Provide HOPE and ENCOURAGEMENT!!!

3
Addiction Disease Model
  • Substance use disorders are chronic, progressive,
    relapsing conditions that require comprehensive
    treatment.
  • Disease label helps to reduce shame, guilt, and
    stigma associated with diagnosis.

4
Biopsychosocial ModelBiology of Addiction
  • Brain Chemistry (Neurotransmitters)
  • Dopamine, Serotonin, Norepinephrine
  • Brain Structures
  • Amygdala/hippocamus (memory)
  • Limbic System (pleasure)
  • Prefrontal Cortex (reasoning and judgement)

5
Prefrontal Cortex
Limbic System
Amygdala/hippocampus
6
Natural Rewards Elevate Dopamine Levels
7
(No Transcript)
8
Dopamine Surge Pleasant Effects
  • Profound euphoria
  • Enhanced mood
  • Extreme pleasure
  • Increased energy and productivity
  • Focus on pleasurable activities like SEX!!!!
  • Uninhibited sexual fantasies
  • Increased confidence
  • Sense of Invulnerability

9
Dopamine Depletion Withdrawal
  • What Goes Up Must Come Down
  • Depression
  • Lack of interest
  • Lack of motivation
  • Isolation
  • Increased Risk for Suicidality

10
Treatment Issues for LGBT Clients
  • How many are there?

11
How many LGBT clients are in your treatment
facility ?
  • How many clients does your facility/agency/
    organization see/treat on a monthly or annual
    basis?
  • Of those, how many are "out" to you as lesbian,
    gay, bisexual, or transgender?
  • How many are out as LGBT to everyone in the
    treatment setting?

12
Limitations
  • Lack of reliable data on how many lesbians, gay
    men, bisexuals, and transgender people in the
    general population
  • Reluctance to disclose sexual orientation, gender
    identity, and drug use
  • Use of convenience samples which may bias
    results
  • collecting data
  • in gay bars
  • from LGBT events like Pride Parades
  • at HIV services organizations

13
Historical Prospectives on Homosexuality
Bisexuality
  • 1940s through 1960s- Same-sex sexual attraction
    and behavior was a mental disorder.
  • 1957- Dr. Evelyn Hookers landmark study finds
    gays and lesbians normal.
  • 1973- The American Psychiatric Association
    removes homosexuality as psychopathology from the
    DSM.

14
The Kinsey Scale
  • 0 Exclusively heterosexual
  • 1 Predominantly heterosexual, incidentally
    homosexual
  • 2 Predominantly heterosexual but more than
  • incidentally homosexual
  • 3 Equal heterosexual and homosexual
  • 4 Predominantly homosexual, but more than
  • incidentally heterosexual
  • 5 Predominantly homosexual , incidentally
  • heterosexual
  • 6 Exclusively homosexual

0-----------1---------------2------------------3--
---------------4------------------5---------------
6
15
Recent Surveys
  • CDC Study (1989) self-identification of
    bisexuality in men who have sex with men at 54
    in African Americans, 44 in Hispanics and 11 in
    white men.
  • CDC Study (2002) 4 of females had a sexual
    experience with another female in the past 12
    months. 11 of women had a same-sex sexual
    experience in their lifetime. 2.8 of women
    Identify selves as bisexual
  • Michael's study (1996) indicating 10 of men
    and 5 of women identifying as engaging in
    same-gender sexual behaviors
  • Seil (1996) Transgender studies - 15 in general
    population but culled only from mental health
    data.
  • Bockting (2003) More recent data from studies
    on HIV risk indicate 6 identification on the
    transgender spectrum.

16
Substance Abuse Studies
  • Fifield (1973) In Los Angeles, found that
    lesbians and gay men reported alcohol abuse
    problems at 30-33.
  • McKirnan and Peterson (1989) at the University of
    Illinois Chicago, found alcohol, cocaine, and
    marijuana consumption rates among lesbians and
    gay men at 23.
  • Skinner Otis (1994) Hughes Wilsnack (1997)
    Woody et al. (1999) Cochran Mays (2000) found
    that gay men and lesbians were heavier substance
    and alcohol users than the general or
    heterosexual population.
  • Woody et al. (1999) found that men who have sex
    with men (MSM) were 21 times more likely to use
    nitrite inhalants 47 times more likely to use
    hallucinogens, stimulants, and sedatives.
  • Stall et al. (2001) found that of MSM 52 us
    recreational drugs and 85 use alcohol. Levels of
    multiple drug use (18), three or more
    alcohol-related problems (12), frequent drug use
    (19) and heavyfrequent alcohol use (8) were
    not uncommon

17
TERMS
  • SEX
  • GENDER/GENDER ROLE
  • SEXUAL ORIENTATION
  • GENDER IDENTITY
  • Lesbian
  • Gay
  • Bisexual
  • Transgender
  • Transsexual
  • Heterosexual
  • Queer
  • Male
  • Female
  • Masculine
  • Feminine
  • Intersex

Descriptors
Categories
18
TERMS -
Categories and Descriptors
  • SEXUAL ORIENTATION
  • Lesbian
  • Gay
  • Bisexual
  • Heterosexual
  • Queer
  • GENDER IDENTITY
  • Transgender
  • Transsexual
  • Male
  • Female
  • Queer
  • Intersex
  • SEX
  • Male
  • Female
  • GENDER/GENDER ROLE
  • Male
  • Female
  • Masculine
  • Feminine

19
Treatment Considerations for LGBT Clients
20
LGBT Client Do's and Don'ts
  • Staff Sensitivity
  • Knowledge, skills, and attitudes
  • Assessment Practices and
  • Issues
  • Facilities and Modalities
  • For example, room assignments and shared
    bathrooms
  • Individual, group, and family interventions
  • Discharge and Aftercare

21
DefiningCare
LGBT Affirmative
  • LGBT-tolerant
  • Aware that LGBT people exist and use their
    services
  • LGBT-sensitive
  • Aware of, knowledgeable about, and accepting of
    LGBT people
  • LGBT-affirmative
  • Actively promote self-acceptance of an LGBT
    identity as a key part of recovery

22
Special Assessment Questions
  • Level of comfort being LGBT person ?
  • Stage of coming out ?
  • Family/support/social network ?
  • Health factors ?
  • Milieu of use ?
  • Drug use and sexual identity or sexual behavior
    connections ?
  • Partner/lover use ?
  • Legal problems related to sexual behavior ?
  • Gay bashing ?
  • Same-gender domestic violence ?
  • Out as LGBT in past treatment experiences ?
  • Correlates of sober periods ?

23
Modalities
  • Group counseling
  • Family counseling
  • Individual counseling

24
Myths and Facts about LGBT Clients
25
Myths and Facts About Lesbians and Gay Men
  • Myth Lesbians hate men, are afraid of men, or
    want to be men.
  • Fact Most lesbians do not hate, fear, or want to
    be men. Most lesbians have relationships with men
    in a variety of roles family, friends,
    colleagues, coparents, etc.

26
Myths and Facts About Lesbians and Gay Men
  • Myth Gay men appear and act more feminine.
  • Fact Gay male appearances and behaviors are
    diverse. Some men may look or act hypermasculine
    other men may look or act in a manner more
    associated with being feminine.

27
Myths and Facts About Lesbians and Gay Men
  • Myth Sexual abuse by men or bad relationships
    with men causes lesbianism.
  • Fact There is no research that suggests sexual,
    physical, or emotional abuse by men causes
    lesbianism.

28
Myths and Facts About Lesbians and Gay Men
  • Myth Same-sex sexual behaviors can often be
    blamed on using alcohol and drugs once the
    client achieves sobriety, he will no longer
    desire or seek same-sex sexual relations.
  • Fact Many gay men report using alcohol and drugs
    to cope with their guilt and shame about same-sex
    sexual desire and behaviors.

29
Special Issues for Gay Men
  • Linking of substance abuse and sexual expression
  • Internalized homophobia
  • The role of sexual abuse and violence
  • Limited social outlets

30
Special Issues for Lesbians
  • Multiple stigmas and stressors related to sexism,
    lesbian identity, and substance use
  • Relationships as a major treatment focus for all
    lesbians
  • Relapse to protect themselves from painful
    feelings surrounding their sexuality

31
Myths About Bisexuals
  • Bisexuals are confused about their sexual
    orientation.
  • Bisexuals are afraid to be lesbian or gay because
    of social stigma and oppression from the
    majority.
  • Bisexuals have gotten stuck in the coming out
    process.
  • Bisexuals have knuckled under to the social
    pressure to pass as straight.
  • Bisexuals are in denial about their sexual
    orientation.
  • Bisexuals are not fully formed lesbians or gay
    men.

32
Facts About Bisexuality
  • Women and men (including transgender women and
    men) who identify themselves as heterosexual may
    have had, or may continue to have, sexual
    relations with partners of the same gender.
  • Women and men (including transgender women and
    men) who identify themselves as gay or lesbian
    may have had, or may continue to have, sexual
    relations with partners of the other gender.
  • People of transgender experience, including
    male-to-female and female-to-male individuals,
    may identify themselves as bisexual. This is
    because bisexuality (and sexual orientation
    identity generally) is a separate phenomenon from
    gender identity.

33
Review of Terms
  • Gender femaleness or femininity and maleness or
    masculinity
  • Gender Role masculine or feminine behaviors
  • Gender Identity inner sense of oneself, a
    persons self-concept, in terms of gender
  • Sexual Orientation distinct from gender
    identity, describes one's attraction to, sexual
    desire for, lust for, romantic attachments to
    others lesbian, gay, bisexual, heterosexual.

34
Research and Data
  • In a (1999, 2000) San Francisco study by Dr.
    Kristin Clements at the San Francisco Department
    of PublicHealth AIDS Office
  • HIV prevalence among MTF persons was 35 and 65
    among African-American MTFs.
  • Injection drug use was 34 among MTF transgender
    individuals and 18 among FTM transgender
    individuals.
  • 55 of MTF individuals reported they had been in
    alcohol or drug treatment sometime during their
    lifetimes.
  • .

35
Transgender Research
  • A study from Hollywood, California, (Reback and
    Lombardi1999) reported that the drugs most
    commonly used by MTF transgender individuals were
    alcohol, cocaine/crack, and methamphetamine
  • Other recent studies of transgender health risks
    in urban areas around the country , including
    Boston, New York City, Washington D.C., Chicago,
    Los Angeles and Houston, show similar results
    with higher rates of substance abuse in general
    and higher rates of substance abuse and HIV
    prevalence, particularly among transgender sex
    workers.
  • .

36
Clinical Issues and Implications for Treatment
  • Issues about appearance, "passing" and body image
  • History of hiding or suppressing gender identity
  • Lack of family and social support
  • Isolation and lack of connection to positive,
    proactive transgender community resources
  • Hormone therapy and use or injection history
  • Stigma and discrimination
  • Employment problems
  • Relationship/child custody issues

37
TREATMENT DO'S AND DON'TS
  • DOS
  • Use the proper pronouns based on clients
    self-identity when talking to/about transgender
    individuals.
  • Get clinical supervision if they have issues or
    feelings about working with transgender
    individuals.
  • Allow transgender clients to continue the use of
    hormones when they are prescribed. Advocate that
    the transgender client using street hormones
    get immediate medical care and legally prescribed
    hormones.
  • Take required training on transgender issues.

38
TREATMENT DO'S AND DON'TS
  • DOS
  • Find out the sexual orientation of all clients.
  • Allow transgender clients to use bathrooms and
    showers based on their gender self-identities and
    gender roles.
  • Require all clients and staff members to create
    and maintain a safe environment for all
    transgender clients. Post a nondiscrimination
    policy in the waiting room that explicitly
    includes sexual orientation and gender identity.

39
TREATMENT DO'S AND DON'TS
  • DONTS
  • Dont call someone who identifies as a female he
    or him or call someone who identifies as male
    she or her.
  • Dont project transphobia onto the transgender
    client or share transphobic comments with other
    staff members or clients.
  • Never make the transgender client choose between
    hormones and treatment and recovery.
  • Dont make the transgender client educate the
    staff.
  • Dont assume transgender women or men are gay.
  • Dont make transgender individuals living as
    females use male facilities or transgender
    individuals living as males use female
    facilities.
  • Never allow staff members or clients to make
    transphobic comments or put transgender clients
    at risk for physical or sexual abuse or
    harassment.

40
Health Issues
41
Barriers to Adequate Health Care
  • Many gays and lesbians do not disclose their
    sexual orientation to their healthcare providers.
  • Many LGBT persons are reluctant to use mainstream
    healthcare services.
  • Gay and Lesbian Medical Association Survey (1994)
    results indicate substandard care for LGBT
    patients.

42
Mental Health Issues
  • Recent research indicates that there is a higher
    rate of bipolar and depressive disorders in gay
    men than among heterosexual men.
  • Atkinson et al. found higher rates of lifetime
    depression in homosexual males than heterosexual
    men.
  • Gilman et al. found significantly higher
    prevalence rates of depressive disorders in
    lesbian women compared with heterosexual females.
  • Distinct barriers to mental health service
    utilization have been described for sexual
    minorities that include
  • A tendency to pathologize LGBT identity
  • Lack of LGBT-sensitive care
  • Discrimination and marginalization of LGBT
    clients
  • Unwillingness to address LGBT-related issues in
    treatment
  • Unwillingness to work with partners and lovers of
    LGBT clients.

43
Research on Interpersonal Violence in the LGBT
Community
  • Overall the same rate in same-sex relationships
    as in heterosexual relationships.
  • 8 rate of partner violence in a diverse,
    nonclinical sample of nearly 2,000 lesbians.
  • 17 of gay men reported having been in a
    physically violent relationship (Gay and Lesbian
    Community Action Council 1987).
  • 40 of 228 gay male perpetrators abused drugs
    (Farley 1996).
  • 25-33 of same sex couples report some sort of
    abuse (Page, 2000).

44
Treatment and Outcomes for Methamphetamine
Addiction
45
Pharmacological Treatments
  • None clinically proven!!!
  • Theoretical mechanism of action
  • Increase function of the pre-frontal cortex
  • re-establish inhibitory control, increase logic,
    analytical reasoning, reflective thinking
  • Decrease function of limbic regions
  • reduce cravings and impulsivity extinction of
    conditioned cues
  • Current Clinical Trials are investigating
  • Prometa
  • Buproprion (Wellbutrin)
  • Modafinil (Provigil)
  • Baclofen (Lioresal)

46
Psychosocial Treatments
Four areas to address
Behavioral Disruption
Cognitive Disruption
Emotional Disruption
Family/Relationship Disruption
47
Treatment ModalitiesIncreasing Structure and
Intensity
  • Individual Therapy/Counseling
  • Weekly Support Groups
  • Intensive Outpatient Programming (IOP)
  • Often CBT based
  • Residential Settings
  • Often social model of recovery
  • 12-Step Model may supplement all of the above

48
Manualized Treatment
  • Enhance training capabilities
  • Facilitate research to practice
  • Reduce therapist differences
  • Ensure uniform treatment delivery
  • Worksheets, Pictures and Visual Cues
  • Decrease burden related to cognitive impairment
    (short-term memory loss)
  • Repetition of material across sessions and in
    various formats/structures
  • Handouts increase comprehension of material

49
Treatment Must Address Meth/Sex Fusion
50
Methamphetamine and Sexual Risk
  • Strong connection between MA use, sexual risk
    behaviors, and prevalence of HIV in MSM (Shoptaw
    et al., 2005 Reback, 1997).
  • MSM in Pacific Northwest who reported recent UAI
    were 4 times more likely to have used MA before
    or during sex than those reporting no UAI
    (Hirshfield et al., 2004)
  • 56 of MSM surveyed in 4 U.S. cities who reported
    MA use in past 6 months also reported UAI (CDC,
    2001).

51
Conditioned Response
  • Frequent pairing of drug use and sexual risk
    behaviors creates strong conditioned associations
    between the two behaviors
  • drugs become a trigger for sex
  • sex becomes a trigger for drug use
  • Drug use becomes a means of sexual expression for
    many MSM

52
Policy Model for Methamphetamine Use, HIV
Prevalence and Interventions
Cost/Intensity
Treatment
Prevention
Shoptaw Reback (2006). Journal of Urban Health,
83 (6), 1152-1157
53
Empirically Validated Treatments
54
(No Transcript)
55
(No Transcript)
56
Friends La BreaPrimary Objectives
  • Optimize the gay-specific cognitive behavioral
    therapy (GCBT) intervention by coupling it with a
    contingency management intervention (maximum
    payout 233) to create one behavioral
    intervention for producing sustained HIV sexual
    and methamphetamine risk reductions and
  • Develop a continuing care intervention to support
    and maintain longer-term behavior change
    subsequent to the outpatient intervention.

57
(No Transcript)
58
A Gay-specificCognitive Behavioral Therapy
Intervention
  • In addition to cognitive behavioral therapy,
    the gay-specific treatment intervention (GCBT)
    focused on
  • Gay culture (bars/clubs, social and sexual
    contexts)
  • Gay identity (multiple stigmas, internalized
    homophobia ? low self-esteem, shame, guilt)
  • Gay sex (sex-drug link conditioned response)
  • HIV
  • Recreating a gay life independent from
    methamphetamine use

59
A Gay-specificCognitive Behavioral Therapy
Intervention
Standard CBT GCBT
External Triggers
Sporting Events Gay Pride Festival
Concerts Bathhouse Movies Halloween Relaps
e Justification I just got injured. My
friend just died of I might as well use.
AIDS and using will make me forget for
awhile. One Day at a Time Tomorrow
something I seroconverted even will happen
to ruin though I knew about this.
safer sex. Specific Topics

Coming
Out All Over Again Reconstructing Your Gay
Identity Being
Gay and Doing Gay
Preventing Relapse to High-risk Sex
Living in an HIV World Several session
that involve Aunt Tina
60
www.uclaisap.org
61
(No Transcript)
62
(No Transcript)
63
Contingency Management
  • Significantly longer retention
  • Significantly more clean urine
  • Significantly longer stretches of consecutive
    clean urine samples

64
Demographic Characteristics(N 171)
Variable Category N Ethnicity Caucasian/white
101 59 Hispanic/Latino 37 21


African American/black 8 5

Asian/Pacific Islander 10
6 Multiethnic/Biracial 15
9 Sexual Identity Gay
160 94 Bisexual 11 6 HIV Status HIV
108 63 HIV-
60 35 Unknown 3 2 Age Range (Mean)
19 to 63 years (39.8 yrs) Education Mean
15.0 years
65
Income
66
Usual Route of Meth Administration

67
Methamphetamine Use
Mean S.D. Length of time heavy meth use 3.96
year (4.82) Times used on average day 8.44
times (10.06)

Days used in past 30 days
11.18 days (8.24)
Money spent on meth in past
30 days 472.35 (889.41) Do you feel that you
are addicted to methamphetamine?
91 Yes 9 No
68
Does Methamphetamine and Sex Go Together For You?
69
Sex While High in Past 30 Days
70
HIV Sexual Risk Behaviorsin the Past 30 Days
Mean S.D. Unprotected Insertive Anal
Intercourse 6.59 times (16.25) Unprotected
Receptive Anal Intercourse 6.33 times
(12.98) Have you have sex while high on
methamphetamine (past 30 days)? 91 Yes 9 No Do
you consider your recent sexual behavior to be
compulsive? 70
Yes 30 No
71
STI History
Mean S.D. Number of Lifetime STIs 4.41
(6.20)

72
Among HIV Infected,Those Receiving HIV Medical
Care(n 108)
73
Among Those Receiving HIV Medical Care, Those
Prescribed HIV Medication(n 99)
74
Abuse versus DependenceDiagnostic Statistical
Manual (DSM-IV)
  • 99 of participants met DSM criteria for
    methamphetamine dependence by endorsing 3 or more
    of the following criteria
  • Tolerance
  • Withdrawal
  • Using more than planned
  • Persistent desire to cut down or control use
  • Considerable time spent planning/using/recovering
    from use
  • Interfere with occupational/social/daily
    functioning
  • Continue to use despite knowledge of problems

75
Severity of Addiction

Total Number of DSM-IV Dependence Criteria Met
76
Beck Depression Inventory (N 171)

Mean 17.33 9.99
77
Outcome Findings
78
Methamphetamine UsePrevious 30 Days
mean days
79
Sex While High on MethamphetaminePrevious 30
Days
mean times
80
Unprotected Insertive Anal IntercoursePrevious
30 Days
mean times
81
Unprotected Receptive Anal IntercoursePrevious
30 Days
mean times
82
Beck Depression Inventory
Mean score
83
Conclusions
  • Treatment outcomes demonstrate reductions of
    methamphetamine use and sexual risks
  • Long-term follow-up outcomes also demonstrate
    reductions of methamphetamine use and sexual
    risks
  • While there is no indication of causality in
    these data, there is further evidence that
    reducing methamphetamine use reduces sexual risk
    behaviors among this very high-risk population
  • Policy implications are very strong that
    methamphetamine abuse treatment should be part of
    a comprehensive HIV prevention strategy for
    gay/bisexual men and
  • Los Angeles County, Office of AIDS Programs and
    Policy has awarded funding to continue the
    GCBTCM intervention through June 30, 2009 with
    possible future funding.
  • The City of West Hollywood awarded funding to
    continue the program through September 2010.

84
Implications
  • Policy recommendation for gay/bisexual and other
    MSM methamphetamine users
  • _ Treatment Works!
  • _ Methamphetamine abuse treatment is HIV
    prevention
  • _ Concomitant focus on sexual and drug
    behaviors reduces HIV risk behaviors

85
Final Thoughts Across Models
  • Keep it simple One day at a time
  • Short-term, realistic goals
  • Avoid Depth Psychotherapy in Early Recovery
  • Gaining insight vs. deeper emotional processing
  • Strengthen coping skills prior to deeper
    processing
  • Assess for competing, co-morbid diagnoses
  • Depression, anxiety disorders, psychosis, ADHD
  • Relapse Opportunity for growth gaining data
  • Cognitively reframe beliefs of failure
  • Remain aware of multicultural and diversity
    issues
  • race, ethnicity, religion, SES, education,
    acculturation, gender and sexual identity

86
The End
For more information, please contact
us tefreese_at_ix.netcom.com larkins_at_ucla.edu www.uc
laisap.org or www.psattc.org
About PowerShow.com