Stress and Substance Use Among Drag Performers

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TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry, we discuss the influence of legislation and other social-based decisions on individual mental health. Stigma combines with negative countertransferential feelings in health care teams and leads to suboptimal treatment outcomes.

Case Study

“Dale Scott” is a 38-year-old gay man and drag show performer who uses the stage name Queen Scottie, with overwhelming anxiety and a 1-month relapse on cocaine use. During his early 20s, he was treated successfully for a generalized anxiety disorder (GAD) and cocaine use disorder in a 3-month residential addiction rehabilitation program and has been clean since the age of 25. During the patient interview, Mr Scott described life with his husband, George, and their dog as being ordinary and routine until a few months ago.

Mr Scott correlated the reemergence of his anxiety disorder and relapse to cocaine use to the proposal of the Texas Senate Bill 12 in March 2023, which criminalizes “sexually oriented performances” in the state of Texas, his current state of residence. Lawmakers touted the bill as prohibiting “drag shows in the presence of a minor.” The bill garnered significantly negative attention towards his previously legal line of work. Although Senate Bill 12 was subsequently ruled unconstitutional by a federal judge in September 2023, the resulting reverberations were jarring, and left many across the LGBTQIA+ community as a whole feeling unsafe and vulnerable.

Mr Scott found the framing of the bill as an ‘honest attempt to protect children,’ a cause which many would undoubtedly rally behind, disingenuous. His anxiety escalated after a couple of particularly difficult experiences as a drag performer. First, he saw a viral video posted on social media of a fellow local drag performer, who he considers a friend, with the caption reading “Pedophile!!!! #ProtectTheChildren.” In another instance, he arrived at his scheduled venue to find dozens of protestors holding signs and a few even holding guns, rallying against the drag show that was due to take place that evening. As he performed that night, he feared that a protestor disguised as an audience member would either recreate the viral moment that his colleague experienced or attempt to physically hurt him. The next day’s media coverage of the protest highlighted that extremist right-wing group members were present at his event. He had also received hundreds of hateful emails and direct messages on social media.

Mr Scott's recent experiences have significantly worsened his anxiety, making routine tasks and his profession as a drag performer feel unsafe. He struggles with worrying, withdrawal, sleep difficulties, irritability, fatigue, and concentration issues. To cope, he began using cocaine again which he reports as initially being limited as a preperformance “energizer,” but quickly escalated to daily use just to “get by.” His use was exerting a destabilizing effect on his relationship with his husband, which was at the breaking point. He had also been increasingly missing work and his unreliability was resulting in several canceled performances and fewer bookings.

Mr Scott denied feelings of guilt, changes in interests, changes in appetite, or feelings of worthlessness, but endorsed feelings of hopelessness. He denied panic attacks, obsessive-compulsive symptoms, manic episodes, or auditory or visual hallucinations. He also denied suicidal or homicidal ideation, previous history of suicidality, or family history of psychiatric illness.

Background Report

The term drag has different connotations but can generally be described as a form of self-expression in which biological men and women present as exaggerated versions of the opposite sex through dress and mannerism exploiting gender stereotypes, typically for performative purposes. Drag provides a sense of community and creative space for members of the LGBTQIA+ community to express themselves and engenders a sense of empowerment among individuals who share similar backgrounds and beliefs. Qualitative studies of drag performers found that participation in drag shows was associated with an increase in positive emotions and quality of life.¹

Emerging from a primarily underground culture of the early 19th and 20th centuries, drag shows have gained mainstream popularity over time, propelled in part by a proliferation of streaming platforms. Advancing from pantomime traditions and speakeasies, drag gained entrée into middle America through, for example, Netflix specials and initiatives like Drag Queen Story Hour; now 35 chapters strong with a nationwide presence aimed at promoting reading literacy and diversity.²

Drag’s rise to prominence has not come without opposition, however. An April 2023 report by the Gay and Lesbian Alliance Against Defamation, the world’s largest LGBTQ media advocacy organization, reported 161 anti-LGBTQ threats targeting drag events across the US since early 2022.³ Pushback extends to the halls of US state legislatures as well. Lawmakers in several states have drafted—and in many cases, passed—legislation to prevent minors from interacting with drag performers. These states include Arizona, Arkansas, Idaho, Kansas, Kentucky, Missouri, Montana, Nebraska, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia.⁴ While the laws vary by state, they are generally aimed at reducing drag performers’ freedom to perform and are simultaneously imposing significant fines and penalties on businesses that host such events.

Pushback on drag shows exerts a negative effect on LGBTQIA+ community members who already face interpersonal prejudice and stigma on the basis of their identity. Minority stress, which manifests as discrimination, victimization, internalized sexual stigma, and pressure to conceal LGBTQIA+ status, is associated with an increased incidence of depression, anxiety, substance use disorders, and suicidality.⁵ Additionally, individuals of the LGBTQIA+ community are nearly 4 times more likely to be victims of violent crime, such as domestic and sexual violence, compared with their heterosexual counterparts.⁶ Despite these compromised circumstances, LGBTQIA+ community members have woefully inadequate safety nets and social support programs.

Unique challenges faced by the LGBTQIA+ community manifest in the field of medicine as well. A recent survey study suggests that approximately 33% LGBTQIA+ adults had at least 1 negative experience or instance of mistreatment during interactions with mental health professionals.⁷ This number increases to 40% for LGBTQIA+ individuals of color and increases even further to 50% for transgender or nonbinary individuals.

Discussion

Mr Scott presented for psychiatric evaluation because of increasing stress, anxiety, and relapse on cocaine use precipitated by worsening work conditions and negative public perception of his work. He describes feeling anxious about numerous things. At work, he fears for his safety and dignity. Specifically, he fears that a protestor will violently attack him or will make a negative and degrading viral moment out of his performance. At home, he worries about how he will be able to provide for his family and whether he will have to uproot his life and move to a different state. During this encounter, it is essential that the psychiatrist remain neutral and put aside any contradictory personal beliefs. In the absence of this, the therapeutic alliance that is essential to psychiatric care is compromised, and Mr Scott would be less inclined to share details of his life and relevant aspects of his psychiatric history. While this case report makes no mention of the psychiatrist’s gender, race, ethnicity, thoughts, or affiliation to the LGBTQIA+ community, Mr Scott undoubtedly exercised discretion when choosing a psychiatrist.

Mr Scott is also anxious about seeing a psychiatrist. These feelings stem from his identity as a gay man and drag show performer. The former impacts his likelihood to seek care as he has had negative encounters with health care providers in the past due to his status as a member of the LGBTQIA+ community. The latter similarly impacts his ability to source and seek care as he fears that his clinician holds similar negative beliefs about drag performers as those held by individuals on social media and the lawmakers that passed Texas Senate Bill 12. He worries that his doctor will not be open-minded enough to empathize with him and will not be able to see past their judgments about his identity.

Diagnostic Considerations

Mr Scott meets many components of the DSM-5 criteria for GAD. These include difficult-to-control anxiety manifesting about various aspects of his life (home and work), difficulty sleeping, increased fatigue, increased irritability, and difficulty concentrating. However, when he initially sought treatment, these symptoms had not yet lasted the 6-month duration criteria for a GAD diagnosis. While his diagnosis can be changed to GAD if the symptoms continue to occur for 6 months, the most appropriate DSM-5 diagnosis at this time is adjustment disorder with anxiety (309.24 F43.22). Additionally, his exposure to potentially traumatic incidents, such as the protest at the venue, may lead to symptoms such as intrusions, avoidance, negative cognition and mood, and hyperarousal, suggestive of acute stress disorder or posttraumatic stress disorder depending on the duration. Treatment considerations should include LGBTQ-affirmative cognitive behavioral therapy (CBT), which has shown preliminary success among sexual minority men^8,9 and gender-diverse sexual minority women.¹⁰ This treatment model places an emphasis on the patient’s cognitive, affective, motivational, behavioral, and self-evaluative experiences in relation to minority stress.¹¹ While most psychiatrists are not formally trained in providing care for individuals of the LGBTQIA+ community, a randomized control trial demonstrated that formal online training on LGBTQ-affirmative CBT improves clinician self-reported cultural competence, minority stress knowledge, and LGBTQ-affirmative CBT knowledge.¹²

Regarding his cocaine use, Mr Scott meets the criteria of cocaine use disorder. These include social impairment, evident via interpersonal problems with his husband related to his use, among other things, and missing work activities due to use. His use of larger amounts and failed attempts to quit or control use despite being aware of the negative consequences of cocaine use are suggestive of impaired control. He also possibly meets pharmacological criteria as he likely has increased tolerance given his rapidly increasing dosage. Finally, he meets the duration criteria since all of these symptoms have manifested within the last 12 months. Considering the symptomology, the most appropriate DSM-5 diagnosis for Mr Scott’s drug use is cocaine use disorder, mild (305.60 F14.10). Admission to an inpatient rehabilitation program may benefit Mr Scott. However, a more sustained treatment than his earlier 3-month residential rehabilitation should be strongly considered. To date, no US Food and Drug Administration (FDA) approved pharmacotherapy exists for stimulant use. Several medications have shown promise as reviewed in the recent AAAP-ASAM Stimulant Treatment Guidelines, but long-term adherence to these oral medication regimens remains suboptimal.^13,14 For Mr Scott, a regimen of supportive behavioral therapy—motivational therapy and cognitive therapy have been demonstrated to be particularly effective—along with medication management for managing initial cravings and withdrawal symptoms would be ideal.^15,16

An alternative to oral medications is being developed through an anti-cocaine vaccine.^17-22 The early vaccine developed more than 25 years ago did not attain FDA approval, but recent improvements in the vaccine and its associated adjuvants offer great promise of sustained immunotherapy for cocaine use disorder in motivated patients, such as Mr Scott. This vaccine work remains under development and is still several years away from final FDA approvals.

Mirza Baig is a medical student at Baylor School of Medicine. Dr Domingo is an assistant professor of psychiatry research at the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX. Dr Kosten is the Jay H. Waggoner Endowed Chair and cofounder at the Institute for Clinical and Translational Research at Baylor College of Medicine in Houston, Texas. He is also a professor of psychiatry, neuroscience, pharmacology, and immunology at Baylor College of Medicine.

References

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2. Bikales J. Drag exploded in popularity. Then came the protests and attacks. Washington Post. August 12, 2022. Accessed August 7, 2024. https://www.washingtonpost.com/nation/2022/08/12/drag-mainstream-attacks-crossroads/

3. Updated report: drag events faced more than 160 protests and significant threats since early 2022. GLAAD. April 25, 2023. Accessed August 7, 2024. https://glaad.org/anti-drag-report

4. Burga S. Tennessee passed the nation’s first law limiting drag shows. Here’s the status of anti-drag bills across the U.S. Time. April 3, 2023. Accessed August 7, 2024. https://time.com/6260421/tennessee-limiting-drag-shows-status-of-anti-drag-bills-u-s/

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7. Medina C, Mahowald L. Discrimination and barriers to well-being: the state of LGBTQI+ community in 2022. Center for American Progress. January 12, 2023. Accessed August 7, 2024. https://www.americanprogress.org/article/discrimination-and-barriers-to-well-being-the-state-of-the-lgbtqi-community-in-2022/

8. Pachankis JE, Harkness A, Maciejewski KR, et al. LGBQ-affirmative cognitive-behavioral therapy for young gay and bisexual men’s mental and sexual health: a three-arm randomized controlled trial. J Consult Clin Psychol. 2022;90(6):459-477.

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12. Pachankis JE, Soulliard ZA, Seager van Dyk I, et al. Training in LGBTQ-affirmative cognitive behavioral therapy: a randomized controlled trial across LGBTQ community centers. J Consult Clin Psychol. 2022;90(7):582-599.

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14. Clinical Guideline Committee Members; ASAM Team; AAAP Team; IRETA Team. The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med. 2024;18(1S Suppl):1-56.

15. Magill M, Ray L, Kiluk B, et al. A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: treatment efficacy by contrast condition. J Consult Clin Psychol. 2019;87(12):1093-1105.

16. McKee SA, Carroll KM, Sinha R, et al. Enhancing brief cognitive-behavioral therapy with motivational enhancement techniques in cocaine users. Drug Alcohol Depend. 2007;91(1):97-101.

17. Martell BA, Orson FM, Poling J, et al. Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients: a randomized, double-blind, placebo-controlled efficacy trial. Arch Gen Psychiatry. 2009;66(10):1116-1123.

18. Orson FM, Wang R, Brimijoin S, et al. The future potential for cocaine vaccines. Expert Opin Biol Ther. 2014;14(9):1271-1283.

19. Kosten T, Domingo C, Orson F, Kinsey B. Vaccines against stimulants. Br J Clin Pharmacol. 2014;77(2):368-374.

20. Kosten TR, Domingo CB, Shorter D, et al. Vaccine for cocaine dependence: a randomized double-blind placebo-controlled efficacy trial. Drug Alcohol Depend. 2014;140:42-47.

21. Heekin RD, Shorter D, Kosten TR. Current status and future prospects for the development of substance abuse vaccines. Expert Rev Vaccines. 2017;16(11):1067-1077.

22. Truong TT, Kosten TR. Current status of vaccines for substance use disorders: a brief review of human studies. J Neurol Sci. 2022;434:120098.