Substance Use Disorders in Lesbian, Gay, Bisexual, and Transgender Clients: Assessment and Treatment

Substance Use Disorders in Lesbian, Gay, Bisexual, and Transgender Clients

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Substance Use Disorders in Lesbian, Gay, Bisexual, and Transgender Clients

Assessment and Treatment

SANDRA C. ANDERSON

Columbia University Press   New York

Columbia University Press

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Copyright © 2009 Columbia University Press

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E-ISBN 978-0-231-51269-5

Library of Congress Cataloging-in-Publication Data

Anderson, Sandra Caughran, 1942–

Substance use disorders in lesbian, gay, bisexual, and transgender clients :

assessment and treatment / Sandra C. Anderson.

p.     cm.—(Foundations of social work knowledge series)

Includes bibliographical references and index.

ISBN 978-0-231-14274-8 (cloth : alk. paper)—ISBN 978-0-231-14275-5 (pbk. :

alk. paper)—ISBN 978-0-231-51269-5 (ebook)

1. Sexual minorities—Substance use.   2. Substance abuse—Treatment.

I. Title.     II. Series

HV4999.S49A53  2009

616.860086'6—dc22

2009007999

A Columbia University Press E-book.

CUP would be pleased to hear about your reading experience with this e-book at cup-ebook@columbia.edu.

References to Internet Web sites (URLs) were accurate at the time of writing.

Neither the author nor Columbia University Press is responsible for URLs that may

have expired or changed since the manuscript was prepared.

This book is dedicated to

Nancy, Christopher, Jennifer, Jason, Sophie, and Evan

Contents

Acknowledgments

1. Introduction

2. Definitions, Prevalence, and Etiology

3. Heterosexism

4. Assessment

5. Practice with Individuals

6. Treatment Related to Specific Drugs

7. Issues Related to Specific Age Groups

8. Issues Related to Diversity

9. Intervention Models

10. Practice with Couples, Families, and Small Groups

11. Conclusions About Practice

12. Case Study: A Lesbian Couple with a Substance Use Disorder

13. Ethical and Legal Issues

14. Policy and Legislative Issues

15. The Future of the Field

References

Index

Acknowledgments

A number of people have been instrumental in the writing of this book. A post–tenure review award from Portland State University allowed me to have a graduate research assistant, Gúy Holady, who was of enormous help in locating and reviewing existing literature on substance use disorders in LGBT populations. Relevant clinical case examples were provided by Michele Pearce and Tia Plympton. I am particularly indebted to Tia, who also contributed a valuable critique of the first draft of the book, and to Outside In, the Portland social service agency where she is an HIV-prevention specialist. Outside In provides healthcare, syringe exchange, housing, and mental health and substance abuse services for homeless and low-income youth and young adults. These services are critical to helping Oregon youth, many of whom are LGBT, successfully transition off the streets.

In addition, I am grateful to the other readers of the first draft of this book. Maria Talbott provided excellent suggestions, as did Ann Fields, whose expertise in motivational interviewing was particularly helpful. I thank them both for their thoughtful critical feedback as well as their friendship. My thanks also to Rick Reamer, editor of the Foundations of Social Work Knowledge Series, and Lauren Dockett, editor at Columbia University Press, who have provided support and helpful ideas since the initiation of this project.

It is impossible to adequately thank my partner, Nancy E. Wilder, who mastered relevant databases, searched diligently for obscure articles, and read and word-processed numerous drafts. Her attention to detail and wise counsel throughout the entire process were invaluable to me. Throughout late nights, weekends, and holidays spent writing, her patience and encouragement were unwavering.

My final thanks go to the most important contributors of all—the clients who have trusted me with their stories for the past forty-four years.

[1]

Introduction

Goals of the Book

Treatment of substance use disorders in lesbian, gay, bisexual, and transgender (LGBT) clients is critically important, yet underexamined, in the professional research and clinical literature. Human service professionals who work with these clients must have access to the latest research on the treatment of substance use disorders as well as current knowledge of the unique challenges of working with LGBT clients. This book aims to bring together the most up-to-date knowledge bases in both of these areas, to provide the reader with state of the art information in treating substance use disorders in LGBT clients. Substance use disorders and sexual orientation and gender identity are defined, and heterosexism, relevant diversity issues, ethical challenges, and assessment and work with LGBT clients are examined. Practice with individuals, couples, families, and small groups, as well as practice at the program level, is discussed. Case materials are derived from the independent practice of the author and from social service agencies that treat LGBT clients with substance use disorders.

Particular attention is given to evidence-based treatment models. To date, there are insufficient numbers of controlled trials demonstrating superior differential outcomes of specific interventions for LGBT clients with substance use disorders. Given this, it is reasonable to first become familiar with treatment models that have proven effectiveness with substance use disorders in heterosexual clients and then apply, adapt, and evaluate these models in respect to LGBT clients. Effective models include motivational enhancement therapy, contingency management, the matrix model, and community reinforcement. It will be made clear throughout the book which treatment approaches have been evaluated with LGBT clients, which have shown some degree of efficacy with these clients, and which remain to be tested with them. Although this book focuses on problems, it should be recognized that the majority of LGBT individuals are well adjusted and do not suffer from substance use disorders.

Connection Between LGBT Issues and Substance Use Disorders

People who are LGBT and those with a substance use disorder often share a history of social oppression and neglect. Although there is no agreement about the exact incidence and prevalence of substance use disorders in LGBT individuals, most studies conclude that these disorders are more prevalent in this population. Gay men report more cigarette smoking than men in general and are at high risk for abuse of specific substances. A high percentage of aging LGBT people suffer from alcoholism, and lesbian and bisexual women report higher incidences of cigarette smoking and heavy drinking than their heterosexual peers. LGBT youth have higher rates of cigarette smoking and alcohol and other drug use than their heterosexual peers. Few studies currently focus on substance use disorders in bisexual or transgender individuals, but the latter group appear to have a high rate of substance abuse, including injection drug use. Specific prevalence rates will be discussed in chapter 2.

The connection between sexual orientation and substance use disorders is often mediated by internalized homo/bi/transphobia, which can result in profound feelings of shame, depression, and self-hatred. Substances can then become part of a person’s coping system. Stress resulting from lack of validation and victimization puts many LGBT individuals at risk for substance use disorders.

In addition, gay bars and dance clubs continue to be an important part of life for many, and club drug use is popular among many gay and bisexual men. Because of the emphasis on body image and sexual prowess in gay male socialization, many use alcohol and other drugs to elevate their self-esteem when searching for sexual partners.

Among youth, alcohol abuse is a gateway to other drugs, since it can lead the user into social environments where other drugs are abused, and experimentation with alcohol and other drugs is beginning at earlier ages. LGBT youth may develop substance use problems, homelessness, and prostitution. Homeless LGBT adolescents involved in prostitution are at very high risk for substance use disorders, hepatitis C, HIV disease, and suicide.

Consequences of Substance Use Disorders

LGBT individuals experience the general consequences of substance abuse and dependence. Substance use disorders are implicated in premature deaths, health problems, employment disruptions, child abuse and neglect, domestic violence, crime, and prenatal development problems, and as a co-occurring feature of many psychiatric disorders. Causes of alcohol-related deaths include liver and pancreatic disease, cardiovascular disease, and various cancers. Gay men and lesbian and bisexual women, with their high rates of cigarette smoking, are at increased risk for cancers, lung disease, and heart disease. In addition, people who smoke are much more likely to drink, and those who are dependent on tobacco are four times more likely than the general population to be dependent on alcohol (Grant, Hasin, Chou, Stinson, and Dawson 2004). Tobacco and alcohol are particularly dangerous when used together, dramatically increasing the risk for certain cancers (Pelucchi, Gallus, Garavello, Bosetti, and La Vecchia 2006).

HIV disease is also highly prevalent among those with substance use disorders. Anal sex is the main transmission route of the HIV virus in gay and bisexual men and, since substance abuse lowers inhibitions, the risk of unsafe sex (unprotected anal intercourse) increases with use (Cabaj 1997; CDC 2007). Unsafe sex practices also increase when HIV positive gay and bisexual men use alcohol, amyl nitrate, crack cocaine, or club drugs (Clatts, Goldsamt, and Yi 2005; Robins, Dew, Kingsley, and Becker 1997).

Sharing drug-injection equipment is another major route of HIV transmission, also putting at risk both LGBT and straight individuals who have sex with injection drug users. In addition to HIV disease, the use of shared injection equipment can result in tuberculosis, cardiovascular disease, pneumonia, and hepatitis. Turning to prostitution to support a substance use disorder results in a high incidence of sexually transmitted diseases when unsafe sex occurs (O’Connor, Esherick, and Vieten 2002).

History of Mental Illness Diagnosis of Homosexuality

Prior to the 1950s there was an entrenched view of homosexuality as a pathology, resulting in its inclusion as a sociopathic personality disturbance in the first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-I; American Psychiatric Association 1952). During the 1950s research findings began to emerge indicating that homosexuality per se did not constitute a psychiatric disorder. For example, Evelyn Hooker (1957) found no difference between nonclinical samples of heterosexual and homosexual men on projective test responses. The 1968 edition of the DSM reclassified homosexuality as an other nonpsychotic mental disorder. On July 17, 1969, bar patrons resisted a police raid of the Stonewall Inn in Greenwich Village in New York City, resulting in the beginning of the gay and lesbian liberation movement. A reflection of this movement was the 1973 removal of homosexuality as a diagnostic category from the DSM (DSM-III; American Psychiatric Association 1980). A diagnosis of ego-dystonic homosexuality was added, addressing individuals who were distressed about their homosexual orientation, but this diagnosis was dropped from the revision of the third edition (DSM-III-R; American Psychiatric Association 1987). Subsequent studies, which will be reviewed in relation to assessment issues, have attributed differences between heterosexual, homosexual, and bisexual people on a wide range of psychological variables to the effects of stress from stigmatization and victimization. All major American mental health associations have taken the position that homosexuality and bisexuality are not mental disorders.

The diagnosis of gender identity disorder (GID) remains in the current edition of the DSM (DSM-IV-TR; American Psychiatric Association 2000). This disorder has been used to pathologize children and adults whose experience of their gender is opposite to that assigned to them at birth. Bartlett, Vasey, and Bukowski (2000) argue that this diagnostic category in children as currently conceptualized should be removed from the DSM. They note that very few children continue to have GID as adolescents or adults, and that the most likely outcome is homosexuality. In adults, this diagnosis is also controversial, but it is currently the only diagnosis that allows transgender individuals to obtain insurance reimbursement for hormone therapy or surgery. Given this rationale for the diagnosis, it is interesting that few are ever actually reimbursed for hormones or sexual reassignment surgery.

History of Diagnostic Criteria for Substance Use Disorders

When addictive behaviors began to be scientifically studied in the 1930s, people addicted to drugs were described as immoral or criminal, which resulted in judgmental and punitive interventions. Currently drug addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences (National Institute on Drug Abuse 2007:5). The most commonly used diagnostic criteria of substance use disorders, the DSM-IV-TR, uses the term dependence instead of addiction, and separates substance dependence and substance abuse. The diagnosis of substance dependence disorder requires the presence of a maladaptive pattern of substance use, resulting in distress or clinically significant impairment and involving at least three of an additional seven symptoms (all of which must occur within the same twelve-month period). The diagnosis of substance abuse is made in the absence of physical and psychological habituation. Both substance dependence and substance abuse will be discussed in detail in the chapter addressing assessment issues.

It should be noted that the DSM criteria have been criticized by those who do not adhere to the disease model of addiction for dichotomizing dependence and abuse (when they view addiction as actually occurring along a continuum), not recognizing that many problem drinkers move in and out of dependent drinking, and using substance abuse instead of the more accurate use and misuse of substances (van Wormer and Davis 2003).

Conclusions

LGBT people have high incidence and prevalence rates of substance use disorders. Stress resulting from the internalization of homo/bi/transphobia and victimization significantly increases their risk for these disorders. Drugs can provide relief and escape from stress, eventually leading to an addictive cycle. Dependence and abuse of particular substances may put LGBT individuals at risk for serious health problems, including HIV disease resulting from unsafe sex and the sharing of dirty drug-injection equipment.

Although homosexuality has been removed from the DSM as a diagnostic category, the controversial diagnosis of gender identity disorder remains. Substance dependence is no longer viewed by most as a sin or crime, but as a chronic brain disease characterized by tolerance, withdrawal, and a pattern of compulsive use.

Beginning in 1991, the Council on Social Work Education (CSWE), the accrediting body of social work education programs, required content on sexual orientation in social work programs. The National Association of Social Workers’ (NASW) Code of Ethics (1996) clearly states that practitioners cannot discriminate against clients or refuse to provide services because of a client’s sexual orientation. In spite of this and similar statements in the ethical codes of other professions, clinical education and supervision related to LGBT issues is quite substandard in social work, psychology, and medicine (Hellman 1996; Makadon 2006; Tesar and Rovi 1998). Corliss, Shankle, and Moyer (2007) found that curricula on LGBT issues extending beyond HIV/AIDS are uncommon in most public health school programs. Social work education related to substance use disorders is also very limited or nonexistent, even though social workers encounter substance use disorders in nearly all settings. While the market demand for professionals trained in substance use disorders is increasing, this continues to be a neglected component of MSW education (McNeece 2003).

Currently CSWE has no standard on substance abuse content for MSW programs (McNeece 2003), and substance abuse education is marginal to core courses. In 2001 a NASW survey found that only 38 percent of social workers reported any formal training in substance use disorders. A 2005 study examined substance abuse content in forty of the fifty MSW programs that were top-ranked by U.S. News and World Report in 2000. It was found that 60 percent offered just one course, 36 percent offered two or more courses, and two programs did not offer any substance abuse courses (Saarela 2005). Forty-five percent mentioned LGBT populations in their substance abuse courses, and 43 percent contained content on HIV disease. No program required a course in substance abuse disorders for MSW students.

Thus, in spite of calls by many experts to increase exposure to content on LGBT issues and substance use disorders, content in these areas continues to be limited. Sexual and gender identity and substance use disorders are interrelated in complex ways. LGBT clients have unique needs, and the professionals who treat those with a substance use disorder need to have solid, empirically based knowledge in both chemical dependency and the specific issues faced by being LGBT.

[2]

Definitions, Prevalence, and Etiology

In this chapter definitions and the prevalence of substance use disorders in the LGBT population are addressed. The etiology of sexual orientation and gender identity as well as the etiology of substance use disorders in the LGBT population is also discussed.

Definitions

The lack of standard definitions is a serious obstacle to understanding the research on substance use disorders, sexual orientation, and gender identity. In some clients it can be difficult to distinguish the boundary between substance abuse and substance dependence. And a person can be labeled lesbian, gay, or bisexual on the basis of attraction, behavior, and/or self-identity. While sexual attraction, behavior, and identity may coincide for some people, they do not for all (Patterson 2000). For example, men who have sex with men (MSM) do not necessarily self-identify as gay. The term MSM is frequently used in the literature and will be used here to include all men who have sex with men, whether they identify as gay, bisexual, or heterosexual. In addition, sexual identities can shift over time. Although some people have a consistent lifelong sexual orientation, others do not. Stein (1998) notes the great variability of patterns of developing sexual orientation, not always following a linear pathway. This variability allows for the fluidity in sexual orientation that is frequently described by women (Baumeister 2000; Bem 1998; Golden 1987).

In the past twenty years there has been a gradual shift away from a dichotomous view of gender and sexual orientation, and bisexuality is now viewed by most as a distinct sexual orientation. Bisexual people have some degree of attraction and/or sexual experience with persons of the same sex and the other sex. Some are self-identified as bisexual, some are attracted to and may be considering sexual experiences with men and women (bi-curious), and some have sexual experiences with men and women and do not identify as bisexual.

It is important to distinguish sexual orientation from gender identity. Gender identity is a person’s internal sense of being male or female, regardless of his or her genitals. The term transgender is an umbrella concept that includes people who believe that the gender they were given at birth, based on their genitals, is at odds with the gender they feel themselves to be. The term may also be used to include all people who are gender variant, such as cross-dressers, drag performers, transsexuals, and those who identify as androgynous (Ellis and Eriksen 2002). Lev (2004) defines gender variant people as those who diverge from what is most common, without the assumption that what is normative is necessarily more functional. Transgender, gender variant people may self-identify as asexual, heterosexual, lesbian, gay, or bisexual.

Cross-dressers (formerly called transvestites) dress in other-gender clothing but do not experience a dissonance between their gender identity and their biologic body and do not wish to change their sex or gender. Most cross-dressers are heterosexual men who cross-dress for stress relief or erotic pleasure (Ellis and Eriksen 2002). Biologic women are not called cross-dressers when they wear men’s clothes because this is much more culturally acceptable. Cross-dressers differ from drag performers (kings and queens), who cross-dress for entertainment or sex-industry purposes (Israel and Tarver 1997; Kirk and Kulkarni 2006).

Transgenderists (more currently referred to as nonoperative transsexuals) live and work in the other gender continuously. They may take hormones and have cosmetic surgery, but do not wish to have sex reassignment surgery (SRS) (Israel and Tarver 1997). Unlike transgenderists, transsexuals experience a profound dissonance between their gender identity and their biologic body. They are the most interested in cross-living and receiving hormones and SRS. Preoperative male-to-female (MTF) transsexuals (or transwomen) are born male, but self-identify as female. Preoperative female-to-male (FTM) transsexuals (or transmen) are born female, but self-identify as male. Many postoperative transsexuals do not continue to call themselves transsexual, preferring to identify instead as simply a man or a woman. Some transgender activists argue that sex reassignment surgery should be abandoned altogether because it does not challenge the binary gender system that limits all of us to the choice of being either male or female.

Finally, androgynous persons may prefer gender neutral pronouns, such as ze or hir. They may wear gender-neutral clothing, may identify as both male and female, or may prefer to not be identified as either male or female (Israel and Tarver 1997). Intersex individuals, born with ambiguous genitals or sexual anatomy or with genitals of both sexes, may also report feeling neither entirely male nor entirely female. Many of these babies are surgically altered at birth, removing the penis when it is determined to be too small for a boy or doing a clitoral reduction when the clitoris is determined to be too big for a girl. This is done to keep intersex individuals within a two-sex gender system and to make parents feel comfortable. The assumption is that a child can be raised successfully in either gender as long as the parents believe in the one assigned by the physicians (Fausto-Sterling 2000). As adults, intersex individuals may identify as transgender and/or have a LGB sexual orientation. Many suffer enormously as a result of being incorrectly assigned to a sex/gender at birth (Chase 2005). The Intersex Society of North America (ISNA) argues that sex reassignment surgery at birth should be stopped and that intersex individuals should have the right to make their own informed decision about surgery (http://www.isna.org). There has been relatively little research on psychiatric or substance use disorders in adult intersex people. For this reason there is as yet no solid knowledge base to guide assessment and intervention with this population.

Prevalence

Lesbian, Gay, Bisexual, and Transgender Populations

The lack of standard definitions complicates efforts to determine the incidence and prevalence of LGBT people in the overall population. It has been estimated that between 1.4 percent and 4.3 percent of women and 2.8 percent and 9.1 percent of men in the United States are lesbian, gay, or bisexual (Laumann, Gagnon, Michael, and Michael 1994). Michaels (1996) reviewed the literature and found that 2.8 percent of males and 1.8 percent of females report a gay, lesbian, or bisexual identity, 9.8 percent of males and 5 percent of females report same-sex sexual behavior since puberty, and 7.7 percent of males and 7.5 percent of females report same-sex sexual desire. More recently, the 2000 U.S. Census found that 1.2 million individuals identified as living with a same-sex partner (Simmons and O’Connell 2003). The 2002 National Survey of Family Growth found that 4.1 percent of the U.S. population aged 18 to 44 years (more than 4.5 million individuals) identified as homosexual or bisexual. Among women in this survey, 1.3 percent self-identified as homosexual and 2.8 percent as bisexual. Among men in this survey, 2.3 percent identified as homosexual and 1.8 percent as bisexual (Mosher, Chandra, and Jones 2005).

Prevalence appears to vary greatly among populations. For example, women and men of color are more likely to identify as bisexual than as gay or lesbian (Chu, Peterman, Doll, Buehler, and Curran 1992; Patheia, Hajat, Schillinger, Blank, Sell, and Mostashari 2006; Ross, Essien, Williams, and Fernandez-Esquer 2003). In fact, most studies likely underestimate the incidence of bisexuality. Hoburg, Konik, Williams, and Crawford (2004) studied 202 undergraduate and graduate students and found that 32 percent of women and 19 percent of men who self-identify as heterosexual also have sexual feelings for persons of the same sex.

Definitions of transgender populations are even more confusing, and prevalence data vary widely among studies. Conway (2002) estimates the prevalence of MTF transsexualism to be 1 in 500, a figure consistent with prevalence in recent studies in other countries. Conway estimates that at least 1 in every 2,500 adult males in the U.S. has had sexual reassignment surgery and become a postop woman. Approximately 800–1,000 MTF operations are performed in the U.S. each year, and another 500–1,000 are performed on U.S. citizens abroad.

Substance Use Disorders in the LGBT Population

There is significant disagreement about the exact incidence and prevalence of substance use disorders in the LGBT population (Anderson 1996). Relatively few studies focus on lesbians and gay men, and even fewer on bisexual or transgender individuals. Given this, there is still substantial agreement that large numbers of this population suffer from substance use disorders.

Most earlier studies, in the 1970s, reported extremely high rates of substance abuse among lesbians and gay men. These studies, although often still quoted, had serious methodological problems. They tended to use small homogeneous samples, often recruited in gay bars, without appropriate control or comparison groups. Measures of substance use were not standardized and sexual orientation was inconsistently defined. Bisexuals were typically grouped with lesbians or gay men or excluded from data analysis because of their small number. Transgender populations were biased toward those who were receiving hormone or surgical treatment (Hughes and Eliason 2002).

More recent studies report high rates of substance use disorders in lesbians and gay men, but these rates are substantially lower than in the earlier studies. Cochran, Ackerman, Mays, and Ross (2004), analyzing data from the 1996 National Household Survey on Drug Abuse, found a moderate elevation of drug, particularly marijuana, use and dependence in gay and bisexual men and women when compared to heterosexual men and women. It was also determined that lesbians reported higher frequency and amounts of alcohol use and greater alcohol-related morbidity than heterosexual women (Cochran, Keenan, Schober, and Mays 2000). Gruskin and Gordon (2006) and Roberts, Grindle, Patsdaughter, and Demarco (2005) also found that lesbians were significantly more likely than heterosexual women to be heavy drinkers. Drabble and Trocki (2005), analyzing data from the 2000 National Alcohol Survey, found that lesbians and bisexual women had lower rates of abstention from alcohol and other drugs and higher rates of alcohol dependence, alcohol-related problems, and history of substance abuse treatment. Ridner, Frost, and LaJoie (2006) studied college students at a southeastern university and found that lesbian/bisexual women were 4.9 times more likely to smoke, 10.7 times more likely to drink, and 4.9 times more likely to use marijuana than heterosexual women.

As discussed by Hughes and Eliason (2002), bisexual men are included in studies of gay men in much greater numbers than bisexual women are in studies of lesbians. This is because of the importance of behavior rather than identity in understanding risk factors associated with HIV/AIDS in men who have sex with men. As with early studies of lesbians, early studies of gay men found high rates of substance use disorders. In more recent comparisons of gay/bisexual men with heterosexual men, however, there were few significant differences in alcohol use (Drabble, Midanik, and Trocki 2005). Stall, Paul, Greenwood, Pollack, Bein, Crosby et al. (2001), in a study of urban gay and bisexual men, also found alcohol use rates comparable to men in the general population. Other drug use, however, was much higher than the use of men in a national sample. Meyer, Dietrich, and Schwartz (2008) found that bisexual persons had more substance use disorders than did gay men and lesbians. In some parts of the U.S., methamphetamine and certain club drugs have replaced alcohol as the drugs of choice of gay and bisexual men. These drugs will be discussed in depth in a later chapter.

There are little empirical data on the prevalence of substance use disorders in the transgender population. Most existing studies are HIV-related and focus on MTF sex workers. Reback and Lombardi (1999) found methamphetamine and crack cocaine to be most prevalent among this subgroup. Clements, Marx, Guzman, Ikeda, and Katz (1998) studied transgender persons in San Francisco, and found that 34 percent of MTF and 18 percent of FTM reported lifetime intravenous drug use. It is clear that rates of substance use disorders are high in some subpopulations of the transgender community, but these rates may not be generalizable to the entire transgender population.

Although data on smoking in the LGBT population are limited, the majority of studies report higher rates than in the general population. Gruskin, Hart, Gordon, and Ackerson (2001) found that lesbians and bisexual women (25.4 percent) were significantly more