Editor’s note: This op-ed was written by Frank Busconi, LICSW, LADC, Manager of Integrated Behavioral Health Services at Fenway Health, as part of our month-long Special Series on Addiction in the LGBTQ Community.
When invited to write about substance use in the LGBTQ community I flashed back to 2001, when I first came to work at Fenway Health and Boston was just beginning to grapple with the extent of methamphetamine use among gay men. I was hired to manage a small HIV and STD prevention program that included community outreach, group prevention activities and community forums. In 2002 I helped organize a community dialogue about methamphetamine. Clearly we’d struck a nerve, as we packed the relatively tight confines of Fenway Health’s former home on Haviland Street. There was curiosity, concern and outright fear among the attendees, a combination of community members, prevention workers and behavioral health professionals. I was all three: a gay man living in Boston, working in a prevention program, and providing behavioral health and addiction therapy. I’ve spent the many years since then providing and managing behavioral health and addiction recovery services at Fenway Health.
Through a focus on methamphetamine, my aim here is to shed light on issues that may not reflect the diversity of all substance use experiences in the LGBTQ community, yet nonetheless highlight key themes. This perspective reflects lessons gleaned from many kind mentors who have contributed over the years to my understanding of the nuances of health behavior, effective intervention, human nature, and the need for empathy. I’d specifically like to recognize and credit Gail Beverley, Doug Hein, Michael Shernoff, Eric Rofes, and Patricia Case.
Methamphetamine has been around for 100 years and amphetamines have been in pharmaceutical and recreational use for about as long. Where methamphetamine intersects with the lives of gay men is around sexual behaviors (increasing drive and the quality of the experience) and what I’ve come to think of as managing internalized homophobia and fear of sex and HIV. My understanding about methamphetamine is inextricably linked to the impact of HIV/AIDS on our community. There were twelve short years between Stonewall in 1969, a pivotal moment in the LGBTQ rights movement, and the first cases of HIV that were diagnosed in 1981. By the time I moved to Boston in 1984 to attend college, an entire generation of the LGBTQ community was traumatized, grief-stricken, emotionally exhausted, and facing high levels of AIDS-related stigma and fear from mainstream America. This is where the writing of Eric Rofes is so helpful. He eloquently described how generations of gay men grew up and struggled to form healthy identities and negotiate everyday life under the significant burden of homophobia, only to encounter the additional lethal threat and stigma of HIV.
Clients have reported to me that methamphetamine melts those stresses away. Meth makes them feel confident, desirable, a sense of belonging, like their sense of their ‘badness’ is temporarily reduced and they are worthy of positive attention. For illustration, allow me to distill the unique stories of scores of gay men that I’ve worked with in nearly seventeen years at Fenway Health into the following composite case history. A gay man between 30 and 50, often with a complex trauma history related to familial rejection or abuse, usually related to being gay or gender nonconforming; a history of bullying related to the same; a sense of isolation and alienation from the community; a history of fraught relationships with fathers, male family members and peers, alongside a deep desire for intimate relationships and friendships with men; and a poor self-image related to early messages of being deficient and deserving of any abuse he has suffered as a result.
The psychoactive and physical effects of methamphetamine include stimulation and disinhibition. Physical and sexual stamina and sensations are enhanced, and people feel more out-going, adventurous and socially confident. The shame and fear associated with acting on sexual desires are also suspended. Meth users report being able to engage in and explore taboo behaviors more freely, and that fear of HIV is reduced – which helps explain why rates of unprotected sex go up. Many men also say meth gives them a sense of community and belonging that they crave, and haven’t found in other ways. There can be a sort of mentoring that occurs. Many men may encounter meth for the first time at a gay bar, club, bathhouse or sex party. More experienced users teach about using, create reliable social opportunities and spaces that are affirming to people for whom this has been a rare experience. These factors may help explain why sexual minority adults report methamphetamine use nearly four times more often than do heterosexuals1. Of course, these factors are highly reinforcing and, for many, begin a process that is similar to all addictions.
Though rates of meth use are relatively high among gay men, methamphetamine use can be as stigmatized within the LGBTQ community as it is in broader society. It’s not uncommon to hear a reference to “the bad gays” who use meth. When I hear this I always respond by reminding people that use of methamphetamine or other substances is understandable human behavior in light of the context of the realities of LGBTQ people’s lives. Seeking relief from distress is something that we all do, sometimes in unhealthy ways.
In treating gay men who use methamphetamine, I use Motivational Interviewing and prepare for significant ambivalence. Being in this process with clients can be alarming. Therapists can bear witness to increasing adverse consequences (changes in mental status and cognitive function, increasing physical problems, increasing problems with daily functioning, loss of jobs, relationships and support) all while the client often remains highly ambivalent about making any change. That’s when I have to remind myself to focus on the process and avoid being attached to an outcome. I avoid offering outright advice, even when I am highly worried about a client’s behavior, because this increases resistance. I strive to maintain an empathic stance and adhere to effective interventions that are part of Motivational Interviewing techniques. I’ve also learned that I can experience deep ambivalence and exhaustion about a client’s stage of change, and how important it is for me to seek support and consultation.
The Addiction Recovery and Wellness Program of Fenway Health offers individual and group counseling for those struggling with addiction, whether to drugs, alcohol or gambling. Multiple groups are offered Tuesday through Thursday, each designed to meet clients where they are. Many participants have the goal of stopping use, but some do not. The groups offer education, reflection, a supportive environment and the experience and expertise of the other participants. Many attendees identify methamphetamine as their substance of choice, and report that sharing this experience with other group members helps them feel validated and heard and motivates them to continue in treatment. Fenway Health also offers Medication Assisted Treatment for opioid addiction, with multiple primary care providers and staff psychiatrists who are credentialed to prescribe buprenorphine and monitor patients’ progress in recovery.
Since 1989, Fenway Health has also offered the unique service of acupuncture to treat substance use problems. Licensed acupuncturists use the National Acupuncture Detoxification Association (acudetox.com) protocol that uses five auricular points to promote reduction in cravings, reduction in withdrawal symptoms, increased calmness, improved sleep, stress reduction, anxiety reduction and improved sense of wellness. The acupuncture treatments are 45 minutes in length and offered in a group room with comfortable chairs where an acupuncturist can serve up to twelve clients at a time. This low barrier service is immediately available to clients after completing a program intake, is offered six days per week and does not require an appointment. For clients who are ambivalent, this service is a good way to engage in treatment. The only requirement is to arrive, sit with needles painlessly placed, and unplug from daily life in our peaceful treatment room. Services are available on a sliding fee scale to anyone concerned about their addictive behaviors, with most participants paying very little or nothing.
Clients of our Addiction Recovery and Wellness Program are able to access a wealth of related supports and services available at Fenway, including a wide array of therapy and support groups; smoking cessation counseling; culturally competent primary care from providers with deep experience serving those who are transgender or living with HIV; specialized counseling and advocacy for those who have experienced intimate partner violence, sexual assault or hate crime; and convenient testing and screening programs for HIV, Hepatitis C, and STIs. AIDS Action, the public health division of Fenway Health, provides outreach education, syringe exchange services and overdose education and naloxone distribution for intravenous drug users, from offices in Cambridge and Jamaica Plain.
Anyone interested in Fenway Health’s Addiction Recovery and Wellness Program is encouraged to call 617-927-6202 to book an intake appointment.
Through my work, I see the challenges of LGBTQ people’s lives and also resilience. Marginalized groups often demonstrate impressive strengths as they negotiate complex cultural, legal and interpersonal oppression and make lives of meaning and value. I have borne witness to remarkable stories of substance use recovery and transformation and this attests to the value of an organization like Fenway Health. Here clients are able to be affirmed for who they are and that has healing value in and of itself.
Frank Busconi is the Manager of Integrated Behavioral Health Services at Fenway Health, where he has worked since 2001. He received his BA from Boston University in 1988, his Master of Social Work from Boston University in 1997, and his Master of Public Health from Boston University in 1999. He holds a UMass Certificate in Primary Care Behavioral Health.
Frank’s clinical interests include LGBT issues; gay men’s health; treatment of mood and anxiety disorders; trauma; mental health and HIV; transgender care; psychodynamic therapy; EMDR; CBT; DBT; addiction treatment; harm reduction; elder care; and substance abuse prevention.
 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2015.