It’s virtually impossible to go out in Hillcrest and not see wellness ads targeting gay men in hopes of reducing both the transmission of HIV and the use of crystal methamphetamine. Indeed, meth use is almost synonymous with the gay male party culture today. Noticeably absent is the discussion of meth use in the lesbian population.

And that, argues Dr. Carley Joyce, a researcher in the field of social marginalization, is because we can conveniently pair sexual behavior to substance abuse with the gay meth issue. It’s not so easy, Joyce says, to pin lesbian substance abuse to one particular motivating factor. In fact, she says, lesbian health in general is a very complex field only recently being explored.

In 1999, the Institute of Medicine released a comprehensive study finding there is a tremendous need to identify lesbian-specific responses to health issues. The study serves as a relatively solid, albeit brief, history on lesbian health research:

“Women’s health is a relatively new focus of research study. Theories about human health in general have traditionally been developed from studies of men. In recent years, research has expanded to include an explicit focus on women’s health, as well as the inclusion of women in gender-neutral studies to ensure that findings may be applied broadly and appropriately. During the past two decades the unique health needs of a subgroup of women – lesbians – have been identified for study. Until this time, avoidance and silence dominated both professional and societal attitudes toward lesbian health needs.

“Lesbians are found among all subpopulations of women. Lesbians are as diverse as the general population of all women, and they are represented in all racial and ethnic groups, all socioeconomic strata, and all ages. There is no single type of family, community, culture, or demographic category characteristic of lesbian women.

“Research about lesbians has been conducted in a systematic fashion only since the 1950s…. Initially, research focused on ‘lesbian etiology,’ or the factors that would cause a woman to be a lesbian. The next major phase of research, from the 1960s to the 1980s, explored psychological functioning of lesbians, typically by comparing nonclinical samples of lesbian and heterosexual women to determine whether being lesbian was a form of psychopathology. During the 1970s, researchers – who were often lesbians themselves – began to focus on lesbians as psychologically healthy individuals and to study their social functioning. Research since the 1980s has begun to examine issues related to the development of lesbians across their life spans.

“Until the 1980s, few health care professionals discussed the similarities or differences between lesbians and other women. It was not until 1985 that a high level of interest in lesbian health emerged coincident with the design and implementation of the National Lesbian Health Care Survey. This survey provided a systematic approach to identify the health needs and concerns of lesbians. It also sought to underline the importance of studying lesbians and their health needs in order to improve health care delivery to them. Since then, other scholars and researchers have focused their efforts on this aspect of women’s health.

“As a result, a body of knowledge has begun to develop.”

In part, say many researchers, substance abuse among lesbians can be attributed to the simple fact that lesbians comprise the diversity inherent in womanhood, which is precisely why it is not such a “simple” fact. Beyond being female, there are issues of race, ethnicity, socioeconomic status, prior or current marital status, motherhood, masculinity and femininity, and self-identity as it relates to their sexuality. And all of these factors cause some form of marginalization from mainstream America. In combination, their impact can be complex and devastating.

Take Giovanna, for example. She is a 36-year-old self-identified lesbian. She grew up in a strong Hispanic family, was married, has three kids and is a regular crystal meth user. But not for the reasons you might think. There is no physical pleasure to enhance. No inhibition to overcome.

“I just need to get more stuff done,” Giovanna says. “I work. I take care of the kids. I have my parents to look after. It’s a lot to do.”

As a Latina lesbian, Giovanna is among the populations Joyce studies. In Giovanna’s case, it’s the “triple jeopardy” of sexism, racism and homophobia. The resulting anxiety is what drives many women to use drugs like meth.

Meth is not so uncommon among lesbians. In fact, the most recent Human Dignity Women’s Biannual Report indicated that 75 percent of women served in outpatient drug treatment centers use meth. The U.S. Department of Health and Human Services indicates nearly a quarter of women entering drug treatment centers are using “hard” drugs, such as meth or cocaine. In contrast, 14 percent of men entering treatment are using hard drugs.

Cecily Swanson is an alcohol and drug specialist with Stepping Stone here in San Diego.

“Lesbians who use meth use for very different reasons than gay men,” Swanson says. “With men, there is the sexual component that doesn’t necessarily exist with women. For women, it’s that they can accomplish more, or that they are having self-esteem issues. Women tend to multitask and balance home life. There are pressures to keep their weight in check, and in order to have that extra energy, they look for ways to cope.”

In fact, in most studies of lesbians and substance abuse, there are cases just like Giovanna, where substance abuse points much more to a concern with reducing anxiety than heightening experiences.

And this, avers Joyce, is why there is such a significant disparity between lesbians and heterosexual women in terms of drinking, smoking and prescription drug use.

That a significantly larger percentage of lesbian women use alcohol heavily (when compared to heterosexual women) is a widely accepted fact. But why lesbians drink and abuse drugs differs sharply from the reasons typically discussed in forums addressing substance abuse in the gay community or substance abuse in women.

Lesbians often face issues that heterosexual women do not, and many of them are quite concrete. For Pam, 31 and a mother of two young boys, her prescription drug abuse started when she divorced her husband and fell in love with another woman.

“There was this huge gap of legal protections,” Pam says. “On the one hand, I should have been so happy and felt free, but there was this haunting feeling about protecting my kids if something should happen with my relationship with this woman. There was already pressure from my ex-husband, morality this and morality that. And this woman that I had feelings for, what if the same thing happened that did with my husband? What would the laws do then? It was too much.”

These legal concerns, combined with the social pressures, sent Pam into a 30-to-40-Vicodin-a-day habit. “Usually with an alcohol chaser,” Pam says.

She is now single and shares joint custody of her children with her ex-husband. A condition of regaining full custody is that she continues treatment for her drug and alcohol addictions.

Issues of physical and sexual abuse are also a leading factor in substance abuse for lesbian women. The Lesbian Health Initiative states that 21 percent of lesbians were abused during childhood, and 15 percent have been abused as adults. While this is not an excuse for abuse – or a cause of lesbianism – it certainly needs to be addressed during treatment, Joyce argues.

“There are so many myths out there about lesbian women that simply aren’t true, in and of themselves,” Joyce says. “For instance, ‘Lesbians hate men’ is a prevailing myth. It simply isn’t true. The truth is that there are a lot of lesbians who have a fear of – not hate for – men. And in many cases, that’s because of the abuse.”

In a 1992 survey of San Francisco lesbians and bisexual women, 30 percent had used drugs other than alcohol, one in seven women had experienced violence when drunk or high and 29 percent reported sexual abuse.

Kristen, 32, doesn’t want her past physical abuse to seem like an excuse. Abused as a child by a close male relative, she fears others in the group will think she is using her abuse as a crutch or as her reason for, as she says, “going lesbian.”

“I don’t know if I can say that it’s why I’m a lesbian, but I really do feel more comfortable with women,” Kristen says. “I feel safer. But the problem is that I have these pressures to be a mom and a wife. That’s where my drinking came in.”

Throughout her college days and beyond, Kristen would visit different doctors for prescriptions – the campus doctor, her own personal physician, her gynecologist and so on – getting them to write her prescriptions for Valium, all as a way of coping with the pressures of not being comfortable around men.

“It never occurred to me that I was a lesbian,” she says. “I just didn’t feel safe around men. It wasn’t until years later that I realized I could be intimately and physically satisfied by another woman. Am I a lesbian? I don’t think so in the way that most people have their sexuality defined. I just feel a sense of safety with another woman. And that’s what’s most important to me.”

One interesting concern that Swanson points out is the need for lesbian-specific counseling. For those seeking help with their substance abuse, talking about violence or physical and sexual abuse is tough, Swanson says. And it virtually won’t happen in a co-ed or even a co-sexuality setting.

“Women are less likely to talk about the [physical or sexual] abuse if they are in a co-ed setting,” Swanson says. “And even a group where there are straight women can be uncomfortable for many lesbian women.”

Jessica Chang is a counselor for women in transition. She has worked in the field for two decades, helping women who are trying to find safe emotional and physical spaces for themselves.

“One of the interesting things about lesbian women,” says Chang, a self-identified lesbian, “is the way so many lesbians come into their sexual lives. Notice I didn’t say sexuality. For gay men, being gay is really more about their sexuality. For lesbians, it can either be about their sexuality or about their comfort zone.”

And while finding one’s comfort zone can be a good thing, it can also lead to an equal amount of anxiety. Suddenly, one realizes that their sexual comfort zone is in conflict with society’s prescribed role for them. And, according to some, that is where the substance abuse comes in.

Swanson also talks about the pattern of dual use described by Pam and Kristen.

“It’s very common to see alcohol in conjunction with prescription pills,” Swanson says. “They are both so easy to obtain. Most women can just get on the Internet or go across the [U.S./Mexico] border to get their pills. You don’t even have to do the doctor shopping anymore.”

It’s important to understand that violence and physical abuse are not merely something that happens male-on-female, explains Lori Tollman, a graduate student in women’s studies at San Diego State University.

“One of the biggest misunderstandings is that domestic violence is only happening in heterosexual households,” Tollman says. “It’s important to understand that any time two people live together, regardless of sex, sexuality or gender, there is the possibility of violence. It is not just a [drunken] man in a wife-beater T-shirt flailing on his fragile wife. Sometimes, it’s a [drunken] woman in a wife-beater T-shirt flailing on her fragile wife.”

The Women in Transitions organization based out of Philadelphia provides early intervention and prevention services that include telephone counseling, information and referral services, individual and group empowerment counseling, and advocacy for women who are endangered by domestic violence and substance abuse. These interrelated direct services strive to empower women to make positive changes in their lives and live free of poverty, violence and addictions to alcohol and drugs.

WIT identified five key findings regarding domestic violence and substance abuse. According to Tollman, these finding cross gender and sexual orientation lines.

Violent partners often sabotage a woman’s treatment: stalking her at her program, threatening physical harm unless she leaves the program, and bullying or manipulating her to use a substance or substances as a sign of her love for her abuser.

A woman who manages to continue in treatment but experiences another round of intimate-partner violence may be pressured to use alcohol or other drugs as part of the making-up phase with her abuser.

Threats of physical harm, withholding of financial support or abuse directed toward children, pets or other loved ones can lead women to resort to using substances to buffer their distress.

Some abusers are more violent when sober or abstinent, so substance-abusing battered women may be seen as enabling when they are actually trying to be safe by encouraging drinking or drug use, WIT found.

Part of the pressures of being a lesbian that lead to drug and alcohol abuse is the need to maneuver successfully through multiple areas within our culture.

According to Joyce, it comes back to the same argument: Women have different challenges facing them.

“Traditionally, lesbians who came out later in life were the only gay people to have children,” Joyce explains. “If a gay man came out after he was married, he was left with alimony but not with the kids. And it wasn’t necessary to hide his sexuality. Not so for lesbians. Even after coming out they have to hide their sexuality because women have the historical opportunity of caring for the children.”

Coming to terms with one’s sexuality and maintaining all the elements of motherhood – PTA, soccer coach, Sunday school teacher, etc. – can be straining.

Lilliana was married for 10 years before she realized she was attracted to other women. She had three children, all under the age of 8. Knowing that courts favored the mother for custody of children was of great comfort to her, but the reality of how her newly-discovered sexuality could affect that was overwhelming.

“It wasn’t so much my husband that I was worried about,” Lilliana recalls. “It was the kids’ day care and school teachers, my neighbors and my family. With one word, ‘lesbian,’ I would go from being super-mom to pariah.”

Financially, things weren’t easy either. As a woman, Lilliana already made significantly less than her male counterparts, and as a lesbian, she was convinced she would lose her job.

“I had worked hard to be a mom and still have a career, and a lot of people were supportive,” Lilliana explains. “People are always impressed, I think, when you can have a meaningful relationship with your kids and still maintain a career. But for the few people who found out why we divorced, there wasn’t really much praise.”

There is a certain sense of freedom that comes from coming out, Joyce says, that allows the individual to express who they are for the first time. Not so for many young moms who come out as lesbians.

This was definitely not so for Lilliana. “I didn’t have a chance to celebrate that coming-out process,” she says. “So I guess I did the only thing I could think of, which was really something I had been doing for a long time, just in different ways: escape.”

Lilliana’s escape of choice was alcohol. For her, it was the obvious choice. Discreet, legal and hardly considered problematic.

“At first, it was easy, really,” she says. “After a while, though, I would notice the grocery clerk looking at my cart and giving me this sort of ‘tsk-tsk.’ Even I could see that the bottles of booze were outnumbering the Lunchables. So I did what seemed to make sense at the time. I went to my doctor.”

Not to seek help for her alcoholism, though. Lilliana explains her insurance didn’t cover that, and her fear of having the kids taken away sealed her decision to not disclose her alcohol abuse to her doctor.

Instead, Lilliana went to her doctor to get “something to take the edge off.” Five years later, she had mastered her supply chain for painkillers and alcohol.

“And one day, my mom was bringing the kids back from having them for the weekend,” Lilliana recalls. “She walked in the door, looked deep into my eyes, turned right around and walked back out with the kids in tow.”

Lilliana is now sober, but there are two things she says she is reminded of on a daily basis: the cravings for a chemically-induced escape and the fact that the system simply did not allow for her to seek support.

For Chang, Lilliana’s story is all too familiar.

“It’s very common for lesbians to turn to drugs and alcohol when our system fails them so severely,” Chang says. “The fact is that women in general – and therefore lesbians specifically – make a lot less than their male counterparts. So they are likely living on a smaller budget. Take that and add that women are the primary caregivers for children and you have an even larger financial gap. Now throw in the day-to-day fear of discovery and you have a nightmare.”

There are plenty of treatment options in San Diego for those seeking relief from drugs and alcohol – both inpatient and outpatient programs.

However, Chang says, the systems we have in place do not support lesbian users as a subgroup of the general population.

“I tend to think of it as having a discussion on race and having the entire focus be the struggles of African-Americans,” Chang explained. “While there is no question that it is critical to discuss [African-American struggles] as an issue of race, the issues that Latinos and Asians experience are very different. It’s the same with recovery and therapy groups. You have to break it down so that the discussion will be meaningful for everyone. I don’t think we do that enough with the lesbian population.”

In fact, studies consistently show that for every 2.3 men who enter recovery programs, only one woman does.

But studies also indicate that women enter programs from different avenues. According to the Treatment Episode Data Set, a study that looks at publicly-funded treatment programs, men are much more likely to enter as the result of judicial proceeding. Women are more likely to enter through self-referral or referrals from friends or family.

Perhaps the most striking statistic from the data sheet is that 40 percent of men entering treatment programs are employed, while only 25 percent of women are.

“What we’re talking about when it comes to these statistics,” Tollman explains, “is that women have more connections to family, friends and work. It’s just not as easy for women to step out of their lives and seek treatment. It’s a vicious cycle.”

Swanson points to the gender-specific programs they offer, but agrees it is not enough.

“We have to reach out and get a resource that is lesbian-specific,” Swanson says. “But the way that happens is if we can get the numbers to support it.”

And both Chang and Swanson would agree that the number of users in the lesbian community would support it.

The recovery process itself can be as diverse as those who are in it. Swanson also discusses the role alcohol plays in the lesbian recovery community, as well as in relapse.

“Usually, with gay men, a relapse will be to their drug of choice,” Swanson says. “Meth users usually go back to meth because they miss the physical and sexual sensations they had with the drug. Women, on the other hand, at least in my experience, about eight out of 10 who relapse go to alcohol rather than their original drug of choice.”

There are many reasons why lesbians would choose alcohol as their substance of choice, Swanson says.

“I think it’s a gender thing,” Swanson says. “I think lesbian women drink at home a lot more and are able to hide it. For gay men, drugs typically are used for social reasons, and often that means sexual reasons. But for women, it’s about self-esteem, and so alcohol seems to be that liquid courage to get out there and meet people.”

Joyce argues lesbian women face pressures that no other group faces, from their childhood on up to the current moment of crisis.

“Lesbian women are being asked to deal with all the issues of being a woman and then, on top of that, throw in the issue of sexuality,” Joyce explains. “I think people like Pam and Kristen are far more common than we know, in terms of the way issues that face lesbian women compound each other and lead to a breaking point. The truth is that there are stressors that lesbians have that other groups don’t. I am not saying they have more stressors than, say, transgender persons, I am saying they have different stressors. And when taken together, these various stressors act as exponential compounders.”

But Tollman believes there is hope.

“We must create a community of support for our lesbian sister,” Tollman urges. “We must put the same types of interventions in place, the same public eye on the issue and the same support systems that other groups have. When we see a woman in trouble, we have to have an answer for her, not simply turn our head and feel bad that she has all these stressors. We have to be able to step in and say, ‘Let me help you help yourself, and here is where you can find the help.’”

For Giovanna, Pam, Kristen and Lilliana, that’s not just a hope and a dream, it’s a necessity.