IDU.

A careful review of these reports, however, has demonstrated significant and persistent

methodological problems, ranging from poor or absent control groups and nonrepresentative

population samples (some studies gathered subjects only from gay and lesbian bars) to a failure

to use uniform definitions of substance abuse or of homosexuality itself. Nevertheless, a recent

study was conducted using data from the 1996 National Household Survey of Drug Abuse

(NHSDA), a yearly population-based survey that applies standard epidemiological methods to

determine the prevalence of substance use in the U.S. population. This study has concluded that

homosexually active women are indeed more likely than heterosexually active women to

evidence drug or alcohol dependency (Cochran and Mays, in press).

A sudden increase in the use of methamphetamine, known as "speed," "crystal," "ice," or

"crank," by gay and bisexual men has become a matter of grave concern. A primary route of

administration for this drug is injection. Combined with its disinhibiting and sexually stimulating

effects, gay male injectors of methamphetamine are at extremely high risk for HIV exposure:

The drug causes the abuser to suspend all judgment and leaves him often impotent but extremely

sexually aroused and often an anal-receptive partner in sex (Gorman, 1996;Gorman et al., 1995).

Men who have sex with men (or MSMs--the CDC category used to report its data) may self-

identify as gay (men with homosexual sexual orientations), bisexual (men who feel sexually

drawn to both men and women), or heterosexual (men having sex with men as a purely physical

act and not a reflection of innate sexual orientation). No matter what their sexual orientation,

unprotected sexual contact puts MSMs at risk for HIV. In most reviews of gay men and safer sex

practices, most men who were knowledgeable about safer sex failed to practice it while under the

influence of some substance (Calzavara et al., 1993; Leigh, 1990; Leigh and Stall, 1993; Paul et

al., 1994;Stall, 1987; Stall et al., 1986). Many men from minority backgrounds who have sex

with other men do not self-identify as gay or bisexual, so interventions should be based not on

sexual orientation, but on sexual behavior.

Some women who have sex with women continue to have sex with men. A number of these

women may be injection drug users and share syringes; consequently, they are prone to HIV

infection. Although it is unlikely that female-to-female transmission of the virus will occur,

lesbians have been urged to use safer sex precautions, such as using dental dams during oral sex

(White, 1997).

Lesbians present some specific issues that must be highlighted. Compared with gay men, they

are more likely to have lower incomes (as do women in general when compared with men); are

more likely to be parents (about one-third of lesbians are biological parents); face prejudice as

women as well as for being gay, including the stronger reaction against and willingness to ignore

females with substance abuse disorders; are more likely to come out later in life (about 28 years

of age versus 18 years of age in men); and are more likely to have bisexual feelings or

experiences, so that they are still at sexual risk for HIV infection as well as possible IDU risk

(Banks and Gartrell, 1996; Bell et al., 1981; Bradford and Ryan, 1987; Mosbacher, 1993).

Gay youth also present treatment challenges. Special sensitivity and understanding are nee ded to