Sexual Orientation Disparities in Substance Misuse: The Role of Childhood Abuse and Intimate Partner Violence Among Patients in Care at an Urban Community Health Center

Abstract

This study examined disparities in lifetime substance misuse by sexual orientation among 2,653 patients engaged in care at an urban community health center in Boston, MA, as well as the potential mediating roles of childhood abuse <age 15 (CA) and intimate partner violence (IPV). Violence indicators were highly associated with substance misuse, as was identifying as a sexual minority compared to heterosexual. CA and IPV experiences partly explained disparities in substance abuse by sexual orientation with differences seen by sex. Clinicians should assess history of CA and IPV among sexual minorities presenting with a history of substance abuse disorders. The study's limitations are noted.

RÉSUMÉ

Disparités dans l'orientation sexuelle et l'impact sur la toxicomanie: le rôle des abus durant l'enfance et de la violence conjugale pour les patients masculins et féminins beneficiaires de soins dans un centre de santé communautaire en milieu urbain

Cette étude a examiné les disparités en matière de toxicomanie par l'orientation sexuelle parmi les 2,653 patients participant aux soins dans un centre de santé communautaire en milieu urbain à Boston, Massachusetts, ainsi que les rôles potentiels de médiation de violence contre les enfants de moins de 15 ans, voir maltraitance des enfants (ME) et de la violence du partenaire intime (VPI). Les indicateurs de violence ont été fortement associés à la toxicomanie, ainsi qu'a l'identification en tant que minorité sexuelle par rapport aux hétérosexuels. Les expériences des ME et des VPI expliquent en partie les disparités en matière de toxicomanie par l'orientation sexuelle avec les différences observées selon le sexe. Les cliniciens doivent évaluer les antécédents ME et VPI parmi les minorités sexuelles présentant des antécédents de troubles de toxicomanie.

Mots clés: toxicomanie, la violence, l'orientation sexuelle, les disparités de santé

RESUMEN

Disparidades en la orientación sexual y su impacto sobre el abuso de sustancias: El papel del abuso infantil y de la violencia de pareja (violencia conyugal) en los pacientes masculinos y femeninos que benefician de la atención en un centro de salud comunitario urbano.

Este estudio examinó las diferencias en el uso indebido de sustancias por orientación sexual entre los 2.653 pacientes que beneficiaron de la atención en un centro de salud de la comunidad urbana en Boston, Massachusetts, así como de las posibles funciones de mediación del abuso infantil en los menores de 15 años de edad (AI) asi como los de la violencia por un compañero íntimo (VCI). Indicadores de violencia están altamente asociados con el abuso de sustancias, como lo es la identificacion por minoría sexual en comparación con el heterosexual. Las experiencias AI y VCI explican en parte las disparidades en el abuso de sustancias por la orientación sexual frente a las diferencias observadas por sexo. Los médicos deben evaluar los antecedentes del abuso infantil (AI) asi como los de la violencia por un compañero íntimo (VCI) entre las minorías sexuales que presentan un pasado de trastornos por abuso de sustancias.

Palabras clave: Abuso de sustancias, la violencia, la orientación sexual, las disparidades de salud

Keywords :

• Substance abuse
• violence
• sexual orientation
• health disparities

Notes

2 The reader is reminded that the concepts of “risk factors”, as well as “protective factors”, are often noted in the literature, without adequately noting their dimensions (linear, nonlinear; rates of development; anchoring or integration, cessation, etc.), their “demands”, the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level) which are necessary for either of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether their underpinnings are theory-driven, empirically-based, individual and/or systemic stake holder- bound, based upon “principles of faith”, historical observation, precedents and traditions that accumulate over time, conventional wisdom, perceptual and judgmental constraints, “transient public opinion.” This is necessary to consider and to clarify if these term are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities, “principles of faith” and stakeholder objectives. Editor's note.

3 Treatment can be briefly and usefully defined as a unique, planned, goal directed, temporally structured, multi-dimensional change process, of necessary quality, appropriateness and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users- of whatever types and heterogeneities- which aren't also used with non-substance users. Whether or not a treatment technique is indicated or contra-indicated, and its selection underpinnings (theory-based, empirically-based, “principle of faith-based, tradition-based, etc. continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and well-being treatment-driven models there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Conflict-resolution models may stimulate an additional option for intervention. Each ideological model has its own criteria for success as well as failure. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can include controlled environments Treatment includes a spectrum of clinician-caregiver-patient relationships representing various forms of decision-making traditions/models; (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s).

Substance users, representing a heterogeneous group of people and patterns of use, continue to be treated in “specialized” programs which are distanced from the mainstream of the treatment of non-users—“normed treatment of normed diseases”—all-too-often manifest imparity in availability and delivery of needed services, utilize policies which are stakeholder-–driven and not evidence-based and may be ethically-insensitive. Editor's note.

4 The reader is reminded that the medicalizing and associated diagnoses of types of psychoactive substance use and selected users is relatively recent and is a consensus-based taxonomy which is not empirically informed. Editor's note. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th Ed.; American Psychiatric Association: Washington, DC, 1994.