Life narrative to substance use: voices from LGBTQ people

Purpose – While there is a growing amount of literature showing that lesbian, gay, bisexual, transgender and queer (LGBTQ people) are more at risk to use substances compared to non-LGBTQ people, there is a gap in knowledge about the exploration of the life narrative, before and the turning point of substance use. The purpose of this paper is to discuss life narrative, before and the turning point of substance use. Design/methodology/approach – Ten participants from diverse sexual orientation/gender were invited to join this study including queer, lesbian, transgender, gay, tomboy and bisexuals who were diagnosed with a substance use disorder. The narrative qualitative research was used as the research methodology. Each of the participants had in-depth interviews with the research team once or twice, with each time lasting from 30 to 120 min until the saturation of the data. Thematic analysis and the trustworthiness process were used to analyze the data. Findings – Three themes emerged from this study including the following: life before substance use; life turning point; and motivation to stop using substances. Each theme had several categories to define the theme. Originality/value – The results of this study can help counseling psychologists and clinicians who work with LGBTQ addicts to become aware that there is not only psychological treatment available for LGBTQ addicts needed for recovery, but also a social movement that promotes equality among LGBTQ people, such as advocacy against oppression with regard to family, school, community and the public.


Introduction
Heterosexual discourse based on patriarchal values has overwhelmed people throughout the world, including Thai society, pushing lesbian, gay, bisexual, transgender and queer (LGBTQ) people to become socially marginalized. Although some international mass media have recognized Thailand as an open place for LGBTQ people, there is still social oppression, such as no right to marriage, the lack of opportunity to be accepted as a worker in various careers, and being bullied both physically and psychologically at school and in the workplace because of their gender identity or sexuality [1,2]. As a result, some LGBTQ people develop psychiatric symptoms, such as depression, suicidal ideation or actually committing suicide, [3][4][5] as well as turning their life toward substances to deal with their psychological pain. Many studies revealed that LGBTQ people take more risks to use illicit drugs; in one study reported that homosexual males take more risks in terms of using amphetamines than heterosexual males [6], which was similar to one study showed that homosexual males and females had higher levels of non-medical drug usage and lower levels of abstinence than heterosexual males or females [7]. In addition, it is not only illegal substances, but also legal substances such as alcohol that LGBTQ people use to remedy psychological suffering. One study shows that homosexual females use alcohol more often than heterosexual females [8]. In conclusion, we can assume that LGBTQ people have more risks to use non-medical substance as well as more difficulty being abstinent from drugs in comparison to non-LGBTQ people. However, there is still not enough literature to describe the in-depth road of life among LGBTQ people and why they have to cope with adversity by using illegal drug or alcohol. This leads to the objective of this study that aims to explore the life narrative of Thai substance dependent LGBTQ people. The results of this study can be the guideline for counselors or clinicians to design an appropriate intervention for Thai LGBTQ clients.

Methods
This study employed a narrative research approach that prioritized the story of marginalized persons based on the constructivist paradigm [9]. The narrative inquiry often tells the story from the beginning to the turning point in the story that changes their direction in life.

Participants and setting
The research team conducted in-depth interviews with ten LGBTQ participants who attended the rehabilitative stage in a substance dependence treatment center in central Thailand. All of the participants were diagnosed as having a substance use disorder. The participants included individuals of various sexual orientations/genders, such as transgender females, tomboys, gays, lesbians, bisexuals and queer people, who identified themselves. The personal profile of the participants was listed in Table I. After being approved by the research ethics committee, the research team went to a substance dependence treatment center to build rapport with both the nurses and ex-addict staff members. The researcher asked them to introduce LGBTQ people who were in the process of substance dependence rehabilitation. The research team contacted the participants, explained the objective of the research, invited them to be interviewees and asked to sign the consent forms before collecting the data. Each participant was interviewed one or two times lasting from 30 to 120 min and used voice recordings. The interview guides were created from related theories and studies, but the researcher used them only in the initial interview phase and allowed the data to emerge mainly from participants by probing. The interview guide included the following questions: "Would you please tell me your story and how you got here?" And "What kind of social oppression have you faced in your lifetime and how this is related to your substance use."

Data analysis
Thematic analysis was used to analyze the data [10]. Both inductive and deductive methods were employed to generate the themes and categories [11]. First, the researcher transcribed the voice recording word for word. Then, the researcher read the transcripts about each participant several times to identify the common and emerging themes. Later, codes and categories were generated to support each theme. The results of this narrative research were written into stories in a chronological sequence [12]; beginning with their life before using substances, followed by significant turning points that resulted in substance use and later, their motivation to remain abstinent from drugs and alcohol.

Trustworthiness
Trustworthiness is a method to ensure that the results from a qualitative study are both reliable and valid [11]. The data and triangulation method were used to ensure credibility by collecting data from various sexual orientations/genders of participants such as gay males, transgender women, tomboys, bisexuals and lesbians, as well as using data from different methods, such as interviewing and observations to make sure of the veracity and credibility of the study. Furthermore, the researcher had several debriefing sessions between the researchers and her supervisor, an expert in qualitative research in data analysis process.
The results of data analysis were sent back to all of the participants to prove the credibility of the study before publication. All of the data would be destroyed after the one-year completion of the study by deleting voice recordings and Microsoft word files from both computers and drives.

Ethical considerations
The ethical considerations were approved by the Research Ethics Committee of the Drug Dependence Treatment Center (No. 021/2560 on June 2, 2017). The name of this Drug Dependence Treatment Center is deliberately not identified to ensure the confidentiality of the participants.

Results
The findings were divided into three themes. Each theme had several categories with quotations, their alias, their sexual orientation/gender and their age. These themes may overlap because the events occurred continuously, as follows.
Theme 1: life before using substance Theme 1: life before substance use had predisposing conditions that can cause participants to use substances in a later period in their life, which was divided into five categories. Category 1: family relationship problem. Most of the participants were raised in broken homes, characterized by the loss of parents through abandonment, divorce or death. Some participants were hurt by a lack of emotional support from their families. They often thought about their love-deprived childhoods and needed someone for emotional support or act as a positive role model in order to deal with adversity: My mother has never listened to me or taken care of me. I had to live with my grandmother instead. She never visited me on Mother's Day, so I had to lie in the empty chair while my friends came with their parents or asked a neighbor to come with me that day. (Poy told her story in tears, lesbian, aged 36) My parents were separated since I was a child. I lived with my mother and stepfather. I was bullied many times by relatives around my home, while my mother worked all day to earn money. I often said to my sister that if we had a father to protect us, we would not be bullied like this. (Ef, bisexual, aged 31) Category 2: social oppression toward gender identity. Almost all participants had experiences of being oppressed because of their gender identity. They experienced social oppression in several ways including family, peers, teachers, employers, co-workers, as well as members of the public. Some of them were rejected by parents and physically abused; some were bullied by their peers; and some could no longer work and eventually turned to substance abuse because of social rejection. Also, some participants tried to stop using substances, but they relapsed due to social oppression: If queers couldn't get into a beauty pageant, they could go to be sex workers […] I used to find several jobs but when I passed to the interview phase, they didn't accept me to work with them. It's just because I looked like a woman, but my title was mister. (Pat, transgender, aged 34) My aunt used to ask me if I needed to change from being gay to being a man because she knew a doctor who could treat me. (Man, gay, aged 28) Some staff members didn't accept me as I am, this was the reason I sometimes drank alcohol again. ( Jennie, queer, aged 44) Category 3: internalized homophobia. Some participants had internalized homophobia because of social rejection. Sometimes they denied that they were LGBTQ people. They tried to portray themselves as heterosexual people, as a result of their fear of being rejected by society. If they expressed themselves as a heterosexual men or women, they would be more easily accepted by people, despite the fact that it was not fair to have to hide their true identities due to social stigma: I questioned myself about who I am. I used to post in Pantip that if I already had a girlfriend, but I accidentally had a sexual experience with a man and I enjoyed it. What could I do? (Ef, bisexual, aged 31) I'm not gay or like a tomboy, who have to hide themselves. I'm a lesbian, so I look like an ordinary woman. (Poy, lesbian, aged 36) Category 4: unsatisfied love. The factor of broken relationships or repeated, unsatisfied relationships was common experiences among the participants. Some of them warned themselves not to fall in love with anybody in order to protect their vulnerable hearts. Some of them had dreamed of idealized relationships and tried to find a white knight to save them, but often left them alone and in tears. The pain of unrequited or unsatisfactory love can create the conditions that lead to self-medication through substance abuse and the tendency to relapse after a period of sobriety among LGBTQ people: We had to accept that we didn't have a uterus. It's normal for a man to want to have sex with a woman and leave us. (New, queer, aged 41) Oh! Love was so important. I nearly committed suicide by swallowing twenty paracetamol tablets and had to have my stomach pumped because I needed attention from my boyfriend. He left me and I feared that he had another girlfriend. (Bell, transgender, aged 29) Category 5: sexual or physical abuse. Some participants experienced sexual or physical abuse by their partner or a person they trusted. The trauma from these events caused them to use drugs as a way to manage their pain and feelings of shame. One of the participants was a tomboy, was raped by a man who was a close friend. To add insult to injury, she became pregnant by her rapist. She took revenge by hunting the man down and killing him, which caused her to be imprisoned. After that, she used drugs to heal herself from this shameful event: The father kicked down the door and saw me asleep on the bed and covered in blood. I couldn't wake up. It tore up the inside of my body and the man was not there (the man who raped me). I cried in a hospital and found out later that I was pregnant. This event destroyed my life. Everything went to the end and was never the same. I ran away from my girlfriend because it's so shameful for me. (Ann, tomboy, aged 31) Theme 2: life turning point This theme describes the events or conditions that brought the participants to substance abuse, which can be divided into two categories, as follows.
Category 1: role models and the persuasion of friends. Many participants were hurt after their life crisis and they made the decision to start using drugs. Role models, such as family and friends, showed them how to heal with pains and had brought them into the cycle of addiction. Some of them stayed in a risk situation such as working within nightclub or loved to hang out with friends at night and that this led them to substance abuse: After I fought with my mother, I went to stay with my friends. Then, I woke up at night and saw they used drugs. Finally, I started using drugs because I feared that I couldn't get along with them. (Poy, lesbian, aged 36) I was a waiter in a night cafe and I liked drinking. It started with little and finally I became dependent on alcohol. The environment was important in terms of alcohol and other substances. (Boy, queer, aged 47) Category 2: need benefits from substance use. Participants received something in exchange for using drugs, such as psychological relief from pain, more money or arousal during sex with partners. These benefits induced them to start using drugs: When I had sex with my girlfriend, I felt more endurance and helped her to reach orgasm. I felt proud of myself and enjoyed sex more while using drugs. (Ef, bisexual, aged 31) I had to drink when I worked as a tour guide. I had to work daytime and nighttime so I needed to drink alcohol to help me sleep easier and work more. Drinking helped me to get along with my guests and entertain them better. ( Jennie, queer, aged 44) Theme 3: motivation to stop using substances Although the participants were in the rehabilitative stage of substance dependence treatment, some of them did not decide to stop or decrease their drug intake. However, half of them were aware of the negative outcomes of substance use, and they had the intention to stop using drugs that led to construct a third theme, which can be divided into three categories.
Category 1: social support from family. The participants could feel love, caring and forgiveness from family, although they disappointed them. This family support motivated them to make a strong decision to receive substance treatment and to show gratitude to their parents: My mother wanted me to stay at a substance dependence treatment center, but I didn't until finally she cried and screamed at me and said 'Do you want me to die because of you, I can't bear anymore'. I felt sad because I made her cry and that time she had cancer and was getting chemotherapy so I promised to myself I'd stop using drugs. (Bell, transgender, aged 29) My mother saw me shaking ( from alcohol withdrawal symptoms). I had never been like that before. I couldn't eat in front of people and had to eat in my bedroom because my hand tremor. She said that I had to get treatment. (New, queer, aged 41) Category 2: social support from staff and peers in substance treatment centers. Although most participants did not want to treat themselves, they were forced to stay at substance treatment center but the social support from staffs and peers within substance treatment center was important reason that could change their mind to stop using drugs and improve their life to be a better person: I like to talk with her (staff ) every day because she listened to me. It seemed like she really understood me, by her eyes, voice and gestures. I'm sure that I can stop using drugs. (Man, gay, aged 28) Category 3: occupational reasoning. The participants were aware that they are LGBTQ people and had to take care of themselves in their old age because they may not have their own legal family. They needed a job that could support them financially, and did not use substances anymore because it would cause them to lose their job again: My boss recommended me for treatment here because I can't work anymore. ( Jennie, queer, aged 44) This gender may not have his/her own family so I like to work here as an ex-addict staff and do my best to take care of my life and mother. (New, queer, aged 41)

Discussion
The emerging themes from the life narratives of LGBTQ people can be described by implementing case formulation model [13,14] including predisposing factors, precipitating factors and protective factors that could be employed to explain a psychological disorder like substance use disorder. "The life before using substances" theme can be compared to the predisposing conditions that cause the risks of using substance among LGBTQ people. Some of these conditions are similar to non-LGBTQ people who use substances, such as family relationship problems, unsatisfactory relationships and sexual or physical abuse [15,16]; however, the emerging facts from this study showed the interesting results that the social oppression in regard to gender identity as well as internalized homophobia was important conditions which can turn LGBTQ people toward substance use to heal their pain. The aspect of social oppression may come from within the family, school, peers or in the workplace, and some of the participants turned this oppression on themselves by the way of internalized homophobia. Both homophobia and internalized homophobia effected the mental health and the well-being of LGBTQ people [17,18]. These were the important conditions causing participants to use substances.
The themes of "life turning point" and the "motivation to stop using substances" were similar to the precipitating conditions that activated participants to start using substances, as well as the protective factors that supported them in changing their lives to abstinence from drugs and alcohol. The turning point and motivation to the abstinence of LGBTQ people were not different from non-LGBTQ people. Peers and role models in a family as well as substance treatment centers were key factors leading people to substance abuse [19,20]. However, LGBTQ people have a higher rate of substance use in comparison to non-LGBTQ people because of hostile attitudes, a homophobic culture, maltreatment and discrimination [6,21], so they need something to help to recover from their pain. As a result, a supportive system consisting of family [22] as well as communities such as substance treatment centers, [19,21] which can play a key role in sheltering LGBTQ people from adversity, especially an open-minded and non-discriminatory attitude because of their gender identity.

Conclusion and recommendation
This study aimed to explore the life narratives of Thai LGBTQ people who used substances in a substance treatment center by using narrative qualitative research. The ten participants with diverse sexual orientations/genders were invited to participate. The trustworthiness was used to ensure the results from the qualitative data. There were three emerging themes, including the following: life before using substances; life turning point; and motivation to stop using substances, were the results of the qualitative study based on the experiences of Thai LGBTQ people.
The results of this study can help counseling psychologists and clinicians who work with LGBTQ addicts in order to gain a wider perspective, such as the fact that not only the psychological treatment of LGBTQ addicts needed for recovery (such as counseling for unsatisfied relationships, healing traumatic experiences from sexual/physical abuse and social oppression), but also the social movement that promotes equality. Counseling psychologists can help deliver the message to families, schools, communities and the public that LGBTQ people are no different from non-LGBTQ people. In addition, they need empowerment to face social stigma as well as discrimination. Counseling psychologists should be aware about their own attitudes toward these clients and understand that same-sex attraction and behaviors are normal variants of human sexuality. Furthermore, treatment should include social resources such as family, peers and community in order to aid recovery from substance use.