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Just a Sip? Gay Men and Alcoholism

By Walter Armstrong

Editor's note: This article is a follow-up to Club Drugs in Gayville, in which journalist Walter Armstrong explored the culture of club drugs in the gay men's community. In this follow-up article, Armstrong takes a deeper look at alcohol use and abuse among gay men.

Alcoholism is the granddaddy of gay health problems. It may have little of the urgency or newsworthiness of crystal meth, say, or HIV, but it remains one of our community’s (and nation’s) most insidious and intractable destroyers. While there’s nothing about homosexuality that predisposes a gay man to alcoholism, the centrality of the gay bar to both coming out and going out has long given liquor a presence in gay society and sex that can’t help but be harmful.

Gay bars can’t turn someone who is not an alcoholic into one. But by dint of being our de facto community centers, gay bars do deliver gay men who are alcoholics over to the clutches of the disease at an earlier age—and with a kind of assembly-line efficiency. Their omnipresent influence and temptations also make recovery from alcoholism more difficult for gay men.

Barring a new gay Prohibition or the discovery of the alcoholism gene, the battle with the bottle is bound to remain an iffy “one day at a time” prospect for gay alcoholics. And “Sober Gays” are likely to maintain their statistical dominance in annual gay pride marches nationwide, marching quietly in blocklong contingents as they have for decades.

The Big Myth About Numbers
Almost as stubborn as the disease itself is the notion that alcoholism is at least three times as prevalent among gay men than in the general population. This misconception took root in 1975, when a study by sociologist Lillen Fifield reported that one-third of all gay men were alcoholics, compared to fewer than half that rate in the general population. Other researchers confirmed her count. This statistic may have conformed to that era’s view of the gay path as pathological, but it’s now recognized as boneheaded science: Almost all the surveys and interview were done exclusively at gay bars, which were then the only public gay gathering place. And since bars are, by definition, frequented by people who drink, they have a much higher percentage of people who have drinking problems than a true random sample would yield.

With the advent of AIDS in the 1980s, medical and social scientists descended on the gay community. While this may have only further pathologized gay sex and sexuality, it also resulted in more accurate readings of behaviors like alcoholism. The current consensus is that the rate of alcoholism among gay men, about 12 percent, is only slightly higher than among straight men—and contrary to Boys in the Band stereotypes, it was never much higher.

Alcohol consumption in the U.S. has fallen by 20 percent since Fifield did her dirty work, and there is some evidence to believe that the decline among gay men has been even sharper, starting most dramatically in the mid-‘80s, when widescale efforts to limit HIV transmission encouraged a clean-up-your-act regime across the board. The falling rates of alcoholism may also be a sign that younger gay men are psychologically healthier than older generations, thanks perhaps to greater social acceptance achieved by their elders’ efforts. Yet despite John Barleycorn’s slight fall out of favor, the rates of alcoholics and alcohol abusers have remained more or less constant.

Recent studies have found comparable trends in alcoholism and alcohol abuse between gay and straight men up to age 30. But the big difference occurs after 30, when the incidence of booze-related problems begins a steady decline in the straight world. But alcohol-dependent gay men in their 30s, 40s, and 50s don’t appear to be laying off the sauce. And since alcoholism, like all addictions, is a progressive disease (and little in life get easier with age), a fortysomething alcoholic is likely to have a worse prognosis than one half his age. To explain the fact that gay men do not seem to drink less as they get older, researchers have pointed to the most obvious difference in our lives—marriage and children. (That the responsibilities of parenthood serve as a brake on reckless drinking may surprise the four out of 10 Americans who grew up in an alcoholic household.)

What Is Alcoholism Anyway?
The search for causes of alcoholism in gay men has led researchers into what critics view as errors as incorrect as Fifield’s oversampling. “The main myth is that alcoholism among gay men is different from alcoholism among straights, and that somehow their sexual orientation has something to do with it,” says Thomas Weinberg, professor of sociology at Buffalo State University and the author of Gay Men, Drinking, and Alcoholism. One example, he explains, is the common assumption that gay men drink to escape shame and other conflicts about being gay. “In fact, alcohol abuse and sexual orientation are distinctly different issues, which sometimes happen to coincide in the same individual, he says. “An alcoholic is an alcoholic is an alcoholic.”

Given the stigma attached to the label, it’s important to define alcoholism as precisely as possible, especially when applying it to men who are already labeled gay. An alcoholic is someone who is not a recreational or social drinker—no matter how hard you try, deny, or lie. But the actual number of drinks you down a day is not necessarily the most accurate measurement. Binge drinking, a common college pastime and often a harbinger of alcoholism, is defined as having five or more drinks in one day. That doesn’t mean that having fewer than five means you’re not an alcoholic, however.

Like any addiction, alcoholism is characterized by both physical and psychological dependence. This makes the relationship between the drinker and the drink much more problematic than it is for people who can have a glass of wine or two with dinner and call it quits.

The Anatomy of Alcohol Addiction
A true juicer is cursed with both a craving for alcohol (or intoxication) and an inability to stop drinking. These two problems get worse over time, reinforcing each other and making the cycle of dependence very tough to break. Also over time, alcoholics lose more and more of their lives to their addiction—spending increasing amounts of time thinking compulsively about happy hour, recovering from hangovers, blackouts, and drinking’s countless negative consequence, from lost wallets, work days, and weekends to DUI arrests, HIV transmissions, and liver cancer.

Physical dependence also shows itself in the body’s increasing tolerance levels, which require greater and greater amounts of alcohol to reach the same state of high, and in the symptoms of withdrawal, such as rapid heart rate, excessive sweating, and, in extreme cases and Hollywood melodramas, the DTs.

Some experts believe that alcoholism comes in two different forms, based on how old you are when it grips you. Early-onset alcoholism, defined as prior to age 25, is viewed as the most severe, hardest-to-treat strain; it comprises about 40 percent of the estimated one million American men who have alcoholism. And studies do show that the younger an alcoholic is when he takes his first drink, the less successful he is likely to be at revering from the disease. Yet other experts argue that there are too many exceptions to this rule—and that as with most diseases, alcoholism progresses at different rates in different people.

The Medical Record Isn’t Pretty
It’s well known that alcoholism can take a massive toll on your body. Yet the serious medical consequences often take two decades or more to emerge in full florid bloom. That allows alcoholics sufficient time to make big messes of their youth with the psychological and social complications of the disease. If the rate of progression is hard to predict, the effects have the inevitability and monotony of Greek tragedy.

In a recent study of some 650 men hospitalized for alcoholism at a VA Medical Center and ranging in age from early 20s to late 40s, researchers cobbled together a working model of alcoholism’s ever-worsening effects. Some highlights (so to speak): By the late 20s, binges and morning drinking wreak havoc with careers. By the mid-30s, blackouts, morning shakes, and other physical symptoms emerge; car accidents and drunk-driving arrests are common; first marriages end in divorce. By the early 40s, the body shows the signs of systemic alcohol-related deterioration requiring ongoing hospitalizations. Gay men can add to these effects an increased risk for HIV and other STDs, as well as for addiction to club drugs, to the tally.

Mention your “drinking problem” to your doctor, and he is likely to scare you with horror stories of autopsies he performed on people who died from cirrhosis of the liver, the eight-leading cause of death in the U.S. He may then follow it up with a little lesson like this: About one-quarter of the alcohol in a cocktail passes straight from your stomach into your bloodstream; the rest leaches out through your small intestine. From the blood, it all passes through the liver, which, in its capacity as your body’s filter, bears the brunt of the toxic effect. Your liver takes an hour to process the amount of alcohol in a standard cocktail, so if you’re drinking more than that, the alcohol level in your blood will keep rising.

But your liver isn’t the only GI organ worn down by alcoholism. Stomach ulcers, gastritis (inflammation of the stomach lining), and cancer of the pancreas, which aids in digestion and the metabolism of carbohydrates, are common ailments of chronic alcohol abuse. The cardiovascular problems include high blood pressure and cardiomyopathy (inflammation of the heart muscle). Alcoholism can do a number on your neurology, killing nerves throughout your body and causing structural changes in the brain that certainly don’t make you any smarter. It can also damage your immune system, cause impotence, and (obviously) accelerate any depression or anxiety that you were attempting to medicate when you reached for the bottle in the first place. About 25 percent of all suicides are committed by alcoholics, and most are white men over 35.

A Debate Over Causes and the Gene Hunt
There was a time, not so long ago, when homosexuality itself was believed to be the cause of alcoholism. Starting from the assumption that gay men were neurotically sick, medical science concluded that some error in their brains or backgrounds was to blame—and that it also riddled their lives with symptoms like alcoholism and suicide. The “cure” was to try to make them straight.

We both have and have not come a long way since then. Psychiatry normalized homosexuality in 1974 (at least in parts of the Western world) by removing it from the diagnostic bible of disorders, but even well-intentioned therapists and theorists persist in linking gayness and alcoholism in ways that critics like Weinberg view as harmful. They say that current thinking may point the finger at the harmful effects of homophobia rather than homosexuality itself, but that doesn’t make much difference. It’s hard to know who’s right in this debate.

Most experts agree that alcoholism is caused by a host of factors. The disease seems to run in families, suggesting both a genetic and an environmental source. Estimates are that if you have one alcoholic parent, you face a three times greater risk of developing alcoholism; two alcoholic parents ups that to a five times greater risk.

Addiction studies have popularized the view of substance abuse as “self-medication” rather than the addict’s own moral failure. This shift not only withholds judgment in the interests of psychological insight and behavioral change, but it also offers a more powerful explanation for why addicts are more prone to depression and anxiety than the general population—and, as children, had a higher incidence of physical and sexual abuse, absent or otherwise inadequate parenting, trauma and other problems. From this premise, it’s no great leap to see how growing up gay in a homophobic environment could also increase your risk for early traumas resulting in adult emotional conflicts ripe for self-medication. In order to escape from what you perceive as unbearable feelings and thoughts, you seek intoxication and oblivion in the bottle. One goal of treatment is to strengthen your capacity to experience these feelings, your conflict over your homosexuality, as bearable. Numerous studies have found, not surprisingly, that self-acceptance is a key factor in the successful recovery of gay alcoholics.

On the other hand, experts like Weinberg who advocate “de-gaying” our understanding of alcoholism promote the idea of an addictive personality type. “The general trend in the last decade or two is for people to have multiple addictions,” Weinberg says. “And that's not all. Often even when such a person has stopped drinking, he develops other kinds of dependencies, such as those to eating, gambling, and even shopping.” Since most drugs, from alcohol and pot to crystal and heroin, owe their high to their stimulation of the brain chemical dopamine, many experts believe that addictive personalities have a dopamine disorder that makes them more sensitive to its pleasure-giving or pain-relieving effects. They get drunk differently from people without the disease.

Following the decoding of the human genome in 2003, scientists have been madly scrambling to identify genes and chromosomes associated with every conceivable health problem, and alcoholism is no exception. Among the most promising studies are those focused on genes that regulate dopamine and other brain chemicals. So far about twelve genes have been fingered for their possible involvement in the development of alcoholism. It’s safe to assume that given the complex psychological aspects of the disease, many genes may ultimately be implicated.

Alcoholics Anonymous—and Its Critics
Treatment for alcoholism conjures up images of dramatic “interventions,” white-knuckle stays in rehab, and a lifetime of 12-Step meetings. In fact, for better or worse, Alcoholics Anonymous is the dominant approach in both private hospitals and the treatment community in general. But one of the nation’s leading alcoholism researchers, Harvard psychiatrist George Vaillant, rocked conventional wisdom in the ‘80s when he reported the results of a 40-year study of alcoholic men; 60 percent of those who beat the bottle did so without the benefit of any kind of treatment, including AA. Similarly, an analysis of over 200 studies of a wide range of treatments found that the ones used by American alcoholism programs, again including AA, had the lowest success rate. Meantime, a big federal study comparing the effectiveness of 12-steps to cognitive-behavioral to motivational enhancement reported no difference.

AA certainly works for some people, and its popularity is proof that it fulfills some deep and widespread needs. Many gay alcoholics praise the community, support, and structure that the meetings offer. Yet the model of alcoholism on which AA is based has come under criticism for promoting an abstinence-only, one-size-fits all approach to recovery. Detractors point out that many people who are alcoholics or problem drinkers require treatment more tailored to their specific situation and a more flexible definition of success—one that includes cutting down rather than stopping.

A February 2007 issue of Newsweek reported that "a year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are improved but still drink heavily on occasion, and a quarter have completely relapsed.” Similarly, a 2002 federal study found that 17 percent of alcoholics were engaged in low-risk drinking a year after being diagnosed—a practice that AA dismisses as relapse.

A few medications for alcohol dependence, including naltrexone, piracetam, and acamprosate are on the market, with many more in development. And antidepressants like Prozac that raise and regulate serotonin, dopamine, and other brain chemicals—and improve depression and anxiety—are increasingly effective in helping alcoholics who are in recovery.

Still, in the absence of a cure—and with rates of treatment success stuck at one-third—it’s clear that many alcoholics face a lifetime struggle with their addiction, with occasional or frequent relapses interrupting recovery. And given the likelihood that the severest forms of alcoholism are irreversibly rooted in our DNA, it’s also clear that some people will never be able to drink safely, and abstinence, possibly as practiced in AA, offers the only answer.

AA opened its doors to gay men two years after its founding in 1935, whereas gay-sensitive treatment centers remain few and far between in some parts of the U.S. It’s estimated that there are now more than a thousand gay AA groups nationwide, with 12-step programs for everything from crystal-meth addiction to sexual compulsion increasing the count by half. In sheer numbers, if nothing else, this vast network of sobriety is giving that tired old community institution, the gay bar, a run for its money. When you factor in the proliferation of gyms and health clubs, gay men today have a much less risky environment in which to meet one another, at least as far as booze goes. That suggests that the rates of alcoholism in our community may continue to fall, though each gay man with the disease will have ups and downs as he takes it one day at a time.

About Walter Armstrong: Walter Armstrong is a freelance writer and editor in New York who served as the editor-in-chief of POZ magazine for six years. Armstrong has also worked at Rolling Stone, Men's Journal, Us, GQ, OutWeek and numerous other magazines.