Title : 
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Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment

   A Providers
 Introduction to
Substance Abuse
      Treatment for 
Lesbian, Gay, Bisexual,
and Transgender
Individuals

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov

-----------------------------------------------
A Providers 
Introduction to 
Substance Abuse 
Treatment for 
Lesbian, Gay, Bisexual, 
and Transgender
Individuals

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatments
www.samhsa.gov

Rockwall II, 5600 Fishers Lane
Rockville, MD  20857

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All material appearing in this volume may be reproduced or copied without permission from the
Substance Abuse and Mental Health Services Administrations (SAMHSAs) Center for Substance
Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. 

The material appearing on pages 12 and 13 is under copyright and reproduced herein with the
permission of the copyright holders. Before reprinting, readers are advised to determine the copy
right status of all such material or to secure permission of the copyright holders. 

This publication was developed by SAMHSAs CSAT under purchase order 99M004228. Edwin
Craft, Dr.P.H., served as the CSAT Government Project Officer. Saul Levin, M.D., M.P.A., Access
Consulting International, Inc., served as the Project Director for the development of the original
draft document.

This document was edited and prepared for publication by CSATs Knowledge Application
Program (KAP) under contract number 270-99-7072 with Johnson, Bassin & Shaw, Inc. (JBS), and
The CDM Group. Karl White, Ed.D., served as the CSAT KAP Government Project Officer. Lynne
McArthur served as the Project Director. Other JBS personnel included Barbara Fink, M.P.H.,
Deputy Director for Product Development; Nancy Hegle, Quality Control Manager; Frances
Nebesky, Editor; and Tonya Young, Graphic Artist. 

The opinions expressed herein are the views of the authors and do not represent the official posi
tion of CSAT, SAMHSA, or any other part of the U.S. Department of Health and Human Services
(DHHS). 

DHHS Publication No. (SMA) 013498

Printed 2001

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Table of Contents

Foreword ix

Acknowledgments xi

Executive Summary xiii
Substance Abuse in the LGBT Community xiii
Sexual Orientation and Gender Identity xiv
Homophobia and Heterosexism xiv
Cultural Issues xv
Legal Issues xv
Treatment Accessibility, Modalities, and the Continuum of Care xvi
The Coming Out Process xvii
Families of Origin and Families of Choice xvii
Clinical Issues xviii
Related Health Issues xxi
Interpersonal Violence in the LGBT Community xxi
Counselor Competence in Treating LGBT Clients xxii
Administrative Issues xxii
Training and Education xxii
Alliances and Networks xxii
Conclusion xxiii

SECTION I: OVERVIEW

Chapter 1An Overview for Providers Treating LGBT Clients 1
Introduction 1
Substance Use and Abuse in the LGBT Community 1
Definition of Terms and Concepts Related to LGBT Issues  4
Estimates of the Number of LGBT Individuals 5
Homophobia and Heterosexism 6
How Heterosexism Contributes to Substance Abuse  8
Perspectives on Homosexuality 8
Perspectives on Bisexuality 10
Sexual Orientation Over Time 10
Assessing Sexual Orientation 11
Life Cycle Issues 11
Summary 14

Chapter 2Cultural Issues in Working With LGBT Individuals 15
Introduction 15

iii

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Definitions of Terms 15
Cultural Competency Overview 16
General Issues in Cross-Cultural Treatment 18
Dimensions of Culture 19
Introduction to the LGBT Community and Culture 19
Ethnic Minority Groups 22
Summary 27

Chapter 3Legal Issues for Programs Treating LGBT Clients 29 
Introduction 29 
Protecting the Confidentiality of LGBT Individuals in
 Substance Abuse Treatment Programs 30 
Discrimination Against LGBT Individuals 35 
Do LGBT Individuals in Substance Abuse Treatment 
 Have Any Legal Protections?    39 
Recommendations 44 
Resources 45 

Chapter 4Overview of Treatment Approaches, Modalities, and Issues of 
Accessibility in the Continuum of Care 49 
Introduction 49 
Approaches 50 
Levels of Care 50 
Continuum of Care 51 
Accessibility 51 
Specific Issues 53 
Modalities 56 

SECTION II: CLINICIANS GUIDE

Chapter 5The Coming Out Process for Lesbians and Gay Men 61 
Introduction 61
What the Coming Out Process Means for Counselors 61 
Stage Models of Transforming an Identity 62 
Stage One: Identity Confusion 63 
Stage Two: Identity Comparison 63 
Stage Three: Identity Tolerance 64 
Stage Four: Identity Acceptance 64 
Stage Five: Identity Pride 64 
Stage Six: Identity Synthesis  65 
Recovery Issues for Lesbians and Gay Men 65 

Chapter 6Families of Origin and Families of Choice 69 
Introduction 69 
Family of Origin 69 
Family of Choice and Relationships 71 
Parenting Issues 71 
Table of Contents

iv

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Chapter 7Clinical Issues With Lesbians 73 
Introduction 73 
Destructive Myths and Stereotypes 74 
Clinical Issues With Substance-Abusing Lesbians 75 
Counselors Responsibilities 75

Chapter 8Clinical Issues With Gay Male Clients 79 
Introduction 79 
Being Male and Being Gay 81 
Gay Male Social Life 82 
Alcohol and Drug Use and Sexual Activity 83 
Gay Male Life Cycles and Relationships 84 
HIV/AIDS: Loss and Grief 84 

Chapter 9Clinical Issues With Bisexuals 87 
Introduction 87 
Myths 88 
Professional Biases Versus Research 88 
What Counselors Need To Know About Bisexual Clients 88 
Psychosocial Issues 89 
Counseling Strategies 89 

Chapter 10Clinical Issues With Transgender Individuals 91 
Introduction 91 
Definitions 92 
Research Into Substance Abuse and HIV Among Transgender Individuals 94 
Clinical Issues in Substance Abuse Treatment With  
Transgender Individuals  95 

Chapter 11Clinical Issues With Youth 99 
Introduction 99 
Alcohol and Drug Use in LGBT Youth 100 
Stigma, Identity, and Risk 100 
Abuse and Homelessness 102 
Assessment and Treatment 102 

Chapter 12Related Health Issues 105 
Introduction 105 
Gay and Bisexual Men 106 
Lesbian and Bisexual Women 106 
Transgender Individuals 107 
Common Barriers to LGBT Individuals Receiving Adequate Health Care 107 
Common Mental Health Issues That LGBT Individuals May Face 108 
Interpersonal Violence in the LGBT Community 108 
Assessment 109
Interventions 110
Table of Contents

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Chapter 13Counselor Competence in Treating LGBT Clients 115 
Introduction 115 
Counselors Professional Responsibility 116 
Helping Clients Heal From the Negative Effects of 
 Homophobia and Heterosexism  117 
Practical Suggestions for Providing Competent Treatment 118 
Treating LGBT Clients in the Criminal Justice System 119 

SECTION III: PROGRAM ADMINISTRATORS GUIDE

Chapter 14Policies and Procedures 123 
Introduction 123 
Strategies and Recommendations 123 

Chapter 15Training and Education 131 
Introduction 131 
Issues To Consider 132 
Strategies 132 
Addressing the Six Components Effectively 133 
A Training Model 136 

Chapter 16Quality Improvement and LGBT Clients 139 
Introduction 139 
A Framework for Functionally Defining Quality 140 
Collecting Baseline Data 141 
Monitoring Progress 142 
Evaluating Outcomes 145 

Chapter 17Using Alliances and Networks To Improve Treatment 
for Lesbian, Gay, Bisexual, and Transgender Clients 147 
Introduction 147 
Rationale for Alliance Building and First Steps 147 
The Impact of Managed Care on Behavioral Health and LGBT Individuals 148 
Concerns About Managed Care Organizations 153 
Advocacy Efforts and Partnerships To Improve LGBT Care 155 
LGBT Provider Networks 156 

Chapter 18Recommendations 159 
Introduction 159 
Recommendations for Research 159 
Recommendations for Clinicians 160 
Recommendations for Training 161 
Recommendations for Administrators 161 
Table of Contents

vi

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SECTION IV: APPENDIXES

Appendix AGlossary of Terms 163 
Appendix BReferences 167 
Appendix CAcronyms 187 
Appendix DStudies on LGBT Substance Abuse 189 
Table of Contents

vii

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Foreword

The Center for Substance Abuse Treatment
(CSAT) of the Substance Abuse and Mental
Health Services Administration (SAMHSA) is
pleased to present A Providers Introduction to
Substance Abuse Treatment for Lesbian, Gay,
Bisexual, and Transgender Individuals. 

This publication was developed through a 
systematic and innovative process in which 
clinicians, researchers, program and 
administrative managers, policymakers, and
other Federal, State, and independent experts
were brought together for a series of intensive
sessions. These individuals reviewed and 
discussed current administrative and clinical
practices for treating substance-abusing 
lesbian, gay, bisexual, and transgender 
individuals and then wrote and edited the
resulting document. The goal of this process
was to improve and advance substance abuse
treatment for a community of individuals 
whose health care needs are often ignored, 
denigrated, or denied.

This document seeks to inform administrators
and clinicians about appropriate diagnosis 
and treatment approaches that will help ensure 
the development or enhancement of effective
lesbian, gay, bisexual, and transgender
(LGBT)-sensitive programs. Serving as both a
reference tool and program guide, it provides
statistical and demographic information, 
prevalence data, case examples and 
suggested interventions, treatment guidelines 
and approaches, and organizational policies
and procedures.
This publication focuses on the two most
important audiences for successful program
development and implementationclinicians
and administrators. Section I provides an 
introduction for both audiences and includes
information on sexual orientation, legal issues,
and treatment approaches and modalities from
a lesbian, gay, bisexual, and transgender
standpoint. Section II is written for the practic
ing clinician. It offers further information on 
clinical issues of lesbian, gay, bisexual, and
transgender clients; an introduction to 
strategies and methods for improving current
services to LGBT individuals; and steps for
starting LGBT-sensitive programs. Section III,
developed for program administrators, provides
an overview of the issues that need to be
addressed when developing an LGBT program
or when expanding current services for LGBT
clients. It offers the data needed to build a
strong foundation for a program, including an
organizational mission and policies and 
procedures. It provides resources and 
strategies for working with managed care
organizations and building alliances and coop
erative arrangements to coordinate efforts on
behalf of LGBT individuals so that members of
the LGBT population can promote self-help
programs within their own communities.

Besides increasing awareness of the need for
LGBT-sensitive treatment services and helping
all those involved in the treatment process
become more aware of LGBT issues, this 
document also serves an important public
health function. For example, the convergence
of HIV, hepatitis, and substance abuse is a
major concern that has not been adequately
addressed in LGBT communities, especially 

ix

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Foreword
regarding the availability of vaccines for 
hepatitis A and hepatitis B. Educating LGBT
people about these vaccines, the importance
of vaccination, and strategies for preventing 
hepatitis C infection is a responsibility of all
health care providers, not just substance
abuse treatment professionals.

Joseph H. Autry III, M.D.
Acting Administrator
Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., C.A.S., FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
This publication is the result of the 
collaboration of many contributors, and CSAT
gratefully acknowledges the dedication, time,
talent, and hard work that the writers and
reviewers have brought to this publication.

x

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Acknowledgments
This publication was developed by the Center for
Substance Abuse Treatment of the Substance
Abuse and Mental Health Services
Administration in conjunction with many subject
area experts. These experts are identified at the
beginning of each chapter. CSAT acknowledges
the contributions of Edwin Craft, Dr.P.H., M. Ed.,
LCPC, who served as Project Officer; Saul Levin,
M.D., M.P.A., Access Consulting International,
Inc., who served as Project Director; and
Roxanne Kibben, M.A., LADC, NCAC II, who
served as Project Manager for the development
of this publication. The coordinators for the
Program Administrators Section were Ednita
Wright, Ph.D., and Roxanne Kibben. The coordi
nator for the Clinicians Section was Joseph
Neisen, Ph.D. In addition, appreciation goes to
Diann P. Fahey, Triumph Technologies, Inc., who
served as Production and Logistics Coordinator
for this publication. The Project Officer also
acknowledges the important contributions to this
project by Kevin Mulvey, Ph.D., Karl White,
Ed.D., and Lynne McArthur, Barbara Fink, Nancy
Hegle, and Mary Beth Hatem and other staff on
the Knowledge Application Program contract.

Appreciation is also extended to the Steering
Committee, which served as an advisory 
committee to the editors and writers. The
Steering Committee consisted of those 
referred to above, as well as:

E. Bernard Anderson, Jr., M.S., M.A., 
 NCAC, ICADC, C.C.S.
Michael Browning
Patricia Hawkins, Ph.D.
Dominique Rosa Leslie
Therissa Libby

Victor Martinez

Maria Morfin, M.A.
Jos Martin Garcia Orduna
Candace Shelton, M.S., CADAC
Frank Y. Wong, Ph.D.
Additional appreciation is extended to the 
following constituency organizations that partici
pated in the development of this document:

AIDS Action Boston
AIDS Project of Los Angeles 
Gay and Lesbian Medical Association
Gay Mens Health Crisis
Howard Brown Clinic
Human Rights Campaign
Lesbian and Gay Community Service 
 Center of New York City
National Association of Alcohol and 
 Drug Abuse Counselors
National Association of Lesbian and 
 Gay Addiction Professionals
National Association of People With 
 AIDS
Northwest AIDS Foundation, Seattle,  
 Washington
San Francisco AIDS Foundation
Whitman-Walker Clinic

Many Government agencies also participated
in the development and review of this 
document. These agencies included:

Health Resources and Service 
 Administration, HIV/AIDS Bureau
Immediate Office of the Secretary, U.S. 
 Department of Health and Human 
 Services
National Institutes of Health, 
National Institute on Drug Abuse 
and National Institute on 
Alcoholism and Alcohol Abuse

xi

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Substance Abuse and Mental Health  
Services Administration, 
Center for Substance Abuse 
Treatment and Center for 
Substance Abuse Prevention.

Appreciation is also extended to the many
field reviewers who provided valuable 
comments:

E. Bernard Anderson, Jr., M.S., M.A., 
 NCAC, ICADC, C.C.S.
Elizabeth Anello
Sandi Armstrong, LCSW
Rodger Beatty, Ph.D., L.S.W.
Anthony R. DAugelli, Ph.D.
Michele (Mickey) Eliason, Ph.D.
Norma Finkelstein, Ph.D.
Sharon L. Gottovi, M.A., L.P.C., LMFT,
 CSAS
Tonda L. Hughes, Ph.D., R.N.
Jerry Jenkins, M.A.C., NCAC II
Michael W. Kirby, Jr., Ph.D.
Katherine M. Kranz, LICSW, LCDP
Wayne T. Lang, M.D.
Theresa Lemus, R.N., LADC
Cameron Lewis
Emilia Lombardi
Kevin McGirr, R.N., M.S., M.P.H.
Kathryn Miller, Ph.D.
Greg Millett, M.P.H.
William R. Olcott
Barbara Ann Perina, CASAC, NCAC I
Mel Pohl, M.D.
Ben Price, C.S.W., C.P.S.
David W. Purcell, J.D., Ph.D.
Steve Riedel, M.S.Ed., C.D.C. III
Karen Glass Sarraga, M.S.W., C.S.W.
Peg Shea

Steven Shoptaw, Ph.D.
Ruth Slaughter
Thurston Smith, NCAC I
Ken South, M.Div.
Jacque Stock
Susan B. Sulzman, C.S.W, M.A.C.,  
 CASAC
Mary Ellen Tinsley
Mike Wagner, M.A.C.
Acknowledgments

xii

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Executive Summary

This publication presents information to 
assist providers in improving substance abuse
treatment for lesbian, gay, bisexual, and trans-
gender (LGBT) clients by raising awareness
about the issues unique to LGBT clients.
Sensitizing providers to these unique issues
will, it is hoped, result in more effective 
treatment and improved treatment outcomes.
Effective treatment with any population should
be sensitive and culturally competent.
Substance abuse treatment providers, 
counselors, therapists, administrators, and
facility directors can be more effective in treat
ing LGBT clients when they have a better
understanding of the issues LGBT clients face.
With this knowledge, treatment providers can
reexamine their treatment approaches and take
steps to accommodate LGBT clients.

Substance Abuse in the LGBT Community

Precise incidence and prevalence rates of 
substance use and abuse by LGBT individuals
are difficult to determine for several reasons: 

  Reliable information on the size of the LGBT
population is not available.

  Epidemiologic studies on alcohol and drug
abuse rarely ask about sexual orientation.

  Research studies cannot be compared
because of inconsistent methodologies. 

Studies indicate that, when compared with the
general population, LGBT people are more
likely to use alcohol and drugs, have higher
rates of substance abuse, are less likely to
abstain from use, and are more likely to 
continue heavy drinking into later life. Some
studies have found that approximately 30 
percent of all lesbians have an alcohol abuse 
problem (Saghir et al., 1970; Fifield,
DeCrescenzo & Latham, 1975; Lewis, 
Saghir & Robins, 1982; Morales & Graves,
1983). Studies that compared gay men and
lesbians with heterosexuals have found that 20
to 25 percent of the gay men and lesbians are
heavy alcohol users (compared with 3 to 10
percent of the heterosexuals studied) (Stall &
Wiley, 1988; McKirnan & Peterson, 1989;
Bloomfield, 1993; Skinner, 1994; Skinner &
Otis, 1994; Hughes & Wilsnack, 1997).
Marijuana and cocaine use has been found
higher among lesbians than among heterosex
ual women (McKirnan & Peterson, 1989). 

Although LGBT persons use and abuse alcohol
and all types of drugs, certain drugs seem to
be more popular in the LGBT community than
in the majority community. Studies have found
that gay men and men who have sex with men
(MSM) are significantly more likely to have
used marijuana, psychedelics, hallucinogens,
stimulants, sedatives, cocaine, barbiturates,
and MDMA (methylenedioxymethampheta-
mine) and are much more likely to have used
poppers (Woody et al., 1999; Stall & Wiley,
1988). Party drugs, such as MDMA (also
known as ecstasy or X-T-C), Special K or 
ketamine, and GHB (gamma hydroxybutyrate),
are increasing in popularity among some seg
ments of the LGBT population. Party drugs are
often used during circuit parties and raves, and
they can impair judgment and result in risky
sexual behavior (Ostrow et al., 1993). Abuse of
methamphetamine has increased dramatically
in recent years (Drug Abuse Warning Network,
1998; Derlet & Heischober, 1990; Morgan et
al., 1993; National Institute on Drug Abuse,
1994; Gorman, Morgan & Lambert, 1995;
CSAT [Center for Substance Abuse
Treatment], 1997b) among some segments 
of the LGBT community. HIV and hepatitis C
infections are linked with methamphetamine
use (CDC [Centers for Disease Control and

xiii

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Prevention], 1995) and can lead to significant
dependence and addiction. Some LGBT
methamphetamine users inject the drug, 
putting them at risk for HIV, hepatitis B, 
and hepatitis C. 

Sexual Orientation and Gender Identity

Understanding the appropriate terminology 
is essential to understanding LGBT clients.
Sexual orientation, sexual behavior, gender
identity, and gender role are different concepts.
Sexual orientation is the affectional or loving
attraction to another person. Heterosexuality is
the attraction to persons of the opposite sex;
homosexuality, to persons of the same sex;
and bisexuality, to both sexes. Sexual orienta
tion can be considered as ranging along a
continuum from same-sex attraction only at
one end of the continuum to opposite-sex
attraction only at the other end. Sexual 
behavior, or sexual activity, differs from sexual
orientation and alone does not define someone
as an LGBT individual. Sexual identity is the
personal and unique way that a person 
perceives his or her own sexual desires and
sexual expressions. 

Biological sex is the biological distinction
between men and women. Gender is the 
concept of maleness and masculinity or
femaleness and femininity. Gender identity is
the sense of self as male or female and does
not refer to ones sexual orientation or gender
role. Gender role describes the behaviors that
are viewed as masculine or feminine by a 
particular culture. Transgender individuals are
those who conform to the gender role expecta
tions of the opposite sex or those who may
clearly identify their gender as the opposite of
their biological sex. In common usage, 
transgender usually refers to people in the
transsexual group that may include people who
are contemplating or preparing for sexual 
reassignment. A transgender person may be
sexually attracted to males, females, or both.
Sexual orientation and gender identity are 
independent variables in an individuals 
definition of himself or herself. How an 
individual learns to acknowledge, accept, and
then act on a sexual orientation that is different
from that of the majority is shaped by cultural,
religious, societal, and familial factors. 
Transgender clients face a somewhat similar
challenge in coming to terms with a gender
identity that differs from their biological gender.
An LGBT individual differs in the effect of 
sexual orientation on self-definition and in the
degree of affiliation with other LGBT persons. 

LGBT people and homosexual behavior are
found in almost all cultures and throughout 
history. Homosexuality was considered a 
mental illness until 1973 when the American
Psychiatric Association dropped the classifica
tion of homosexuality as a mental illness. It is
now considered a normal variation of human
sexual and emotional expression, allowing, it is
hoped, a nonpathological and nonprejudicial
view of the LGBT community.

Homophobia and Heterosexism

Having a general understanding of heterosex
ism and homophobia is important for substance
abuse treatment providers working with LGBT
individuals. Heterosexism and homophobia
describe the forms of bigotry against LGBT
people. Heterosexism resembles racism or
sexism and denies, ignores, denigrates, or 
stigmatizes nonheterosexual forms of 
emotional and affectional expression, sexual
behavior, or community. Homophobia is
defined as the irrational fear of, aversion to, or
discrimination against LGBT behavior or per
sons. Internalized homophobia describes the
self-loathing or resistance to accepting an
LGBT sexual orientation and is an important
concept in understanding LGBT clients.

It is likely that all substance abuse treatment
programs have LGBT clients, but staff 
members may not realize that they are treating
y
Executive Summar

xiv

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LGBT clients. Most treatment programs do not
ask about sexual orientation, and many LGBT
people are afraid to speak openly about their
sexual orientation or identity. LGBT clients 
cannot anticipate the reaction they will receive
when mentioning their sexual orientation. 

How Heterosexism Contributes to
Substance Abuse

Heterosexism can affect LGBT people by 
causing internalized homophobia, shame, and 
a negative self-concept (Neisen, 1990, 1993).
Some LGBT individuals may resort to substance
abuse to cope with the negative feelings.
Counselors and clients should recognize that
these effects result from prejudice and discrimi
nation and are not a consequence of ones 
sexuality. It is not surprising to find that many
LGBT individuals in therapy report feeling isolat
ed, fearful, depressed, anxious, and angry and
have difficulty trusting others. It is argued that
the stigma and resulting tension of being a
member of a marginalized community such as
the LGBT community cause some members of
the marginalized community to manage these
additional stressors by using mind-altering 
substances. Substance use, especially alcohol
use, is a large part of the social life of some
segments of the LGBT community.

Cultural Issues

Culturally sensitive treatment often results in
more effective treatment. A lively debate in the
LGBT community continues about what com
prises LGBT culture. LGBT people are from all
cultural backgrounds, ethnicities, and racial
groups; can be any age; can have attained any
educational or income level; and live in all 
geographic areas in the United States. 

The size of the LGBT community is not known.
Reliable data are difficult to obtain. Michaels
(1996) thoroughly analyzed the limited 
available data and estimated that, in the United
States, 10 percent of men and 5 percent of
women report same-gender sexual behavior
since puberty; 8 percent of men and 7.5 per
cent of women report same-gender desire; and
3 percent of men and 1 percent of women
report a homosexual or bisexual identity. The
data on the number of transgender people are
more limited. In addition to understanding a
clients ethnic background, counselors should
keep in mind how the clients culture views
LGBT individuals and the effect this viewpoint
has on the client. Each ethnic minority group
has norms and values about LGBT members
and behavior. Providers may be helpful to a
client if they remember these multilayered, and
sometimes opposing, influences on the client.
For the LGBT person from an ethnic or racial
minority, coping with ones sexual orientation
takes place amid a tangle of cultural traditions, 
values, and norms. LGBT persons of color
cope with trying to fit into the gay and lesbian
communities in the face of racism and 
discrimination. For some, the added burden of
these issues makes finding a comfortable place
in society even more complex and difficult.
Major ethnic minority groups in the United
States react differently to issues of sexual 
orientation. It is important for the provider to
assess how an LGBT client from a minority
group feels about his or her culture. Some 
may be alienated from their culture, whereas 
others may be supported by it. 
Legal Issues 

Although Federal and a number of State
statutes protect recovering substance abusers
from many forms of discrimination, LGBT 
individuals are not afforded the same 
protections in many areas of the country.
Disclosure of ones sexual orientation can lead
to employment problems or the denial of hous
ing and social services. LGBT individuals may
lose custody of their children if their sexual 
orientation becomes known during a custody
dispute. Even in those States that have 
enacted statutes prohibiting discrimination on
the basis of sexual orientation, LGBT 
Executive Summar y
xv

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individuals have sometimes been denied 
protection. LGBT individuals regard protecting
information about their sexual orientation and
substance abuse histories as critically 
important. Programs that treat this population
must be particularly sensitive about 
maintaining clients confidentiality, because the 
consequences of an inappropriate disclosure
can be devastating. Programs can safeguard
information about clients substance abuse 
histories and sexual orientation status by: 

  Respecting clients confidentiality and 
establishing a written policy that ensures that
information about their sexual orientation is
confidential and that prohibits disclosure of
such information to anyone outside the 
program without their consent

  Cautioning clients to think carefully about
how self-disclosure information will be
received and whether their privacy will be
respected before disclosing their sexual 
orientation to others

  Educating staff members and clients about
regulations affecting LGBT persons in their
jurisdiction 

  Encouraging clients to conduct a legal 
inventory of their employment, marital, and
parental statuses and assess what steps
they might take to protect themselves and
their rights. 

Treatment Accessibility, Modalities, and the
Continuum of Care

Substance abuse treatment for an LGBT 
individual is the same as that for other types of
clients and primarily focuses on stopping the
substance abuse that interferes with the 
well-being of the client. It differs in the need for
the client and counselor to address the clients
feeling about his or her sexual identity and the
impact of homophobia and heterosexism. Even
if the LGBT client is candid about his or her
identity, he or she may be harboring the effects
of societys negative attitudes, which can result
in feelings of doubt, confusion, fear, and sorrow
(Diamond-Friedman, 1990). The client may
have had problems in traditional health care
systems and may distrust health care 
professionals, requiring extra sensitivity from
substance abuse treatment providers
(Mongeon & Ziebold, 1982). 
Accessibility

Due to homophobia and discrimination against
LGBT individuals, some may find it difficult or
uncomfortable to access treatment services.
Substance abuse treatment programs are often
not equipped to meet the needs of this 
population. Heterosexual treatment staff 
members may be uninformed about LGBT
issues, may be insensitive to or antagonistic
toward LGBT clients, or may falsely believe
that sexual identity causes substance abuse or
can be changed by therapy. These beliefs by
providers become barriers to treating the LGBT
client. 

Modalities

Some issues arise when treating LGBT clients
using typical treatment modalities for groups,
couples, or families. Groups should be as
inclusive as possible and should encourage
each member to discuss relevant treatment
issues or concerns. Other clients in therapy
may have negative attitudes toward LGBT
clients. Staff members should ensure that
LGBT clients are treated in a therapeutic man
ner and should tell other clients that 
homophobia will not be tolerated. It should be
the LGBT client who decides whether to 
discuss issues relating to his or her sexual 
orientation in mixed groups. Providing 
individual services eliminates the mixing of 
heterosexual and LGBT clients in treatment
groups and decreases the likelihood that 
heterosexism/homophobia will become an
issue. However, in a mixed group led by
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Executive Summar

xvi

-----------------------------------------------
trained and culturally competent staff
members, LGBT clients may have a powerful
healing experience by gaining acceptance and
support from non-LGBT peers. Family and 
couple counseling can be difficult because of
alienation owing to the clients sexual identity.
Often, LGBT couples are not treated with sen
sitivity, and support is not offered to partners.

Levels of Care

LGBT substance abusers should be assessed
to determine the range of services and levels
of care they require. Knowledge of the type
and amount of a drug used by a client, the 
danger of a medically complicated withdrawal,
the difficulty of withdrawal, and the impact of
social and psychological stressors helps a
counselor determine the level of care a client
needs. Whatever the planned treatment, the
level of care should match the clients needs.

Continuum of Care  

The continuum of care refers to services 
provided in addition to program services and
services received after discharge such as 
followup and monitoring activities, outreach,
recruitment, and retention. The types of ser
vices offered for LGBT clients may differ
because of the health status of the clients or
their partners; their living arrangements; the
type and stability of their employment; their
level of comfort about their sexual orientation;
and their previous experience with service
providers and service systems.

Discharge Planning

Specific concerns related to discharge planning
include an analysis of the clients social sup
port, living arrangements or environments,
employment status, type of employment, and
ongoing issues related to his or her sexual
orientation or identity. Possible support sys
tems include the clients family of origin and
family of choice, partner, friends, and others
and should focus on individuals who support
his or her efforts to maintain recovery. LGBT
clients may live in an environment that is not
conducive to recovery (e.g., they have a part
ner or roommate who is actively using or their
social life revolves around bars and parties).
The Coming Out Process

The term coming out refers to the 
experiences of some, but not all, gay men and
lesbians as they explore their sexual identity.
There is no correct process or single way to
come out, and some LGBT persons do not
come out. The process is unique for each 
individual, and it is the choice of the individual.
Several stages have been identified in the
process: identity confusion, comparison, 
tolerance, acceptance, pride, and identity 
synthesis (Cass, 1979). 

When developing a plan and treating LGBT
clients, providers should consider which stage
the client is in. To be most helpful, counselors
need to recognize a clients comfort level with
his or her feelings about his or her sexual iden
tity and treat the client accordingly. A client
who is uncomfortable with his or her sexual
identity may not want to attend LGBT
Alcoholics Anonymous (AA) meetings or 
discuss feelings about sexual orientation.
However, these meetings could be helpful for a
client who is more comfortable with his or her
sexual identity. A provider may do harm if he or
she forces openness by questioning a clients
sexuality before the client is ready. As with
many decisions, a provider can best serve his
or her clients by assuming little and gauging
the best form of care for reducing the clients
fears and anxiety. 

Families of Origin and Families of Choice

Providing support for LGBT clients and their
families is a significant element of substance
abuse treatment. Like other clients, LGBT 
individuals in treatment are involved in 
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multidimensional situations and come from
diverse family backgrounds. A family history
and a review of the dynamics of the family of
origin are part of a thorough biopsychosocial 
assessment. Questions should be asked with
sensitivity. An LGBT client may have 
unresolved issues with his or her family of 
origin stemming from the familys reaction to
the disclosure of his or her sexual identity. A
negative and intolerant reaction can have a 
devastating effect on the LGBT individual.
Family dynamics are important in working
with LGBT individuals, and counselors can
put their understanding of these dynamics to
work in counseling LGBT clients and their
families. An LGBT client may have close
connections to what is called a family of
choicea legal spouse or unrelated individu
als who support and care about the client. 
A support group that works with families of 
origin is known as PFLAG (Parents, Families
and Friends of Lesbians and Gays). 

Substance abuse counselors need an 
understanding of the dynamics of LGBT
interpersonal relationships. This understand
ing includes awareness of the internal and
external problems of same-sex couples and
the diversity and variety of relationships in
the LGBT community. Although many 
individuals have a life partner, others are 
single or in nontraditional arrangements.
Providers need to be aware of their own
biases when working with individuals who
find themselves outside the cultural norm of
a heterosexual, monogamous, and legally
sanctioned marriage. 

Many LGBT individuals are parents and have
children from a heterosexual marriage, have
adopted children, or have children through
some other means. Substance abuse treat
ment providers should expect to work with
increasingly more LGBT clients who are 
parents, either as part of a couple or as single
parents, and should consider parenting issues
during treatment and discharge planning.
Clinical Issues 

Lesbians, gay men, bisexuals, and 
transgender individuals have unique 
difficulties. Unless counselors carefully
explore each clients individual situation 
and experiences, they may miss important
aspects of the clients life, which may affect
recovery. Many factors contribute to the
prominent role of substance use and abuse
in LGBT people. Legal prohibitions against
LGBT behavior and discrimination have limit
ed LGBT peoples social outlets to bars, 
private homes, or clubs where alcohol and
drugs often play a prominent role. Growing
up in a society that says they should not
exist and certainly should not act on their
sexual feelings, LGBT clients may have inter
nalized this homophobia. Relapse prevention
requires an understanding of the social life
many gay men will return to after discharge
from treatment, whether as part of the
singles circuit party group or as part of a
same-sex couple raising children. For
lesbians, the party scene is generally 
not as intense.

LGBT people may be victims of antigay 
violence and hate crimes such as verbal and
physical attacks. Some victims may turn to
alcohol or drug use. It is important that
substance abuse counselors obtain training
and education about interpersonal violence
and stigmatized client populations. 

Clinical Issues With Lesbian Clients

Lesbians resemble other women in that their
patterns of substance use vary. However,
fewer lesbians than heterosexual women
abstain from alcohol; rates of reported alco
hol problems are higher for lesbians than for
heterosexual women; and drinking, heavy
drinking, and problem drinking show less
decline with age among lesbians than among
heterosexual women (Hughes & Wilsnack,
1997). Risk factors for abusing alcohol
y
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include relying on womens bars for socializing
and peer support; the negative effects of
sexism and heterosexism; additional stressors
related to coming out or passing as
heterosexual; and the effects of trauma from
violence or abuse. The traumas experienced
by some lesbians may affect their behavior and
emotional state. One study reported that 21
percent of lesbians were sexually abused as
children and 15 percent were abused as adults
(Bradford, Ryan & Rothblum, 1994). 

Clinical Issues With Gay Male Clients

In spite of growing acceptance of gay people,
social outlets for gay men still tend to be 
limited. The gay ghetto, the section of town 
where gay people feel comfortable, usually is
identified by the presence of gay bars. The
number of gay coffee shops, bookstores, and
activities that do not involve alcohol and drug
use is increasing, but gay bars and parties that
focus on alcohol and drug use are still very 
visible elements of gay social life.

HIV/AIDS continues to be a major factor in 
gay male life. The percentage of HIV-infected 
people in the United States who are gay has
steadily dropped. But many gay men in 
treatment may be HIV seropositive, have AIDS,
or have a sense of loss from losing friends. 
For some gay men, sex and intimacy may be 
disconnected. Substance use allows them to
act on suppressed or denied feelings but
makes it harder to integrate intimacy and sex. 

In general, the stereotypical American male
can be described as powerful, independent,
emotionally reserved, and career motivated.
Males who do not fit this stereotype may have
trouble fitting in or feel uncomfortable. Many
gay men do, however, grow up different from
their heterosexual peers, and some have traits
more commonly associated with females.
Being effeminate is sometimes condemned in
the gay community, and this characteristic adds
to gay mens shame. 
Clinical Issues With Bisexual Clients

Bisexual identity is not necessarily defined 
by sexual behavior. An assessment of a 
self-identified bisexual client includes sexual 
behavior and identity issues and the range 
of psychosocial issues that may complicate 
substance abuse treatment. The current 
conceptualization of bisexuality is that it is a
sexual orientation. Providers may have biases
about bisexuals, believing that they are psy
chologically or emotionally damaged, are 
developmentally immature, or have a 
borderline personality disorder, with changing
sexual behavior manifesting as a symptom of
poor impulse control or acting-out behavior.
Bisexuals may feel alienated not just from the
heterosexual majority but also from the lesbian
and gay community. Internalized biphobia may
result in a struggle toward self-acceptance.

Clinical Issues With Transgender Clients

The psychiatric model views transsexualism 
as psychopathological and classifies it as a
gender identity disorder. Many in the transgen
der community disagree with this classification. 

The little research available about the 
prevalence of substance abuse in the 
transgender community suggests extremely
high rates. Substance abuse among transgen
der people can involve multiple patterns of
abuse and multiple problems; treatment must
be multimodal to correspond to a clients 
particular pattern of abuse (Lewis, Dana &
Gregory, 1994). 

Issues in substance abuse treatment for
transgender clients include societal and
internalized transphobia, violence,
discrimination, family problems, isolation, lack
of educational and job opportunities, lack of
access to health care, and clients low self-
esteem. Many transgender people have had
negative experiences with providers of health
care, and they may be distrustful of providers.
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Hormone therapy is an often overlooked
clinical issue. Hormone treatment is a standard
medical practice for transsexuals, and clients
may need assistance in maintaining regular,
legally prescribed hormone therapy while in
treatment for substance abuse. It is important
that both the clinician and the client understand
that hormone therapies can affect mood, espe
cially when taken improperly. Transgender
clients may face an additional risk from using
street or black market hormones. Because
testosterone must be injected, obtaining or
using needles may be relapse triggers for
clients in early recovery.

Transgender clients may face issues with 
inpatient treatment and placement in housing
and shelters. Logistics such as rest room use
and sleeping arrangements need to be sensi
tive to both transgender clients and other
clients. Evidence suggests that transgender
individuals have a higher rate of exposure to
violence and discrimination than lesbians and
gay men, and such experiences can influence
a transgender clients ability to complete and
maintain successful recovery from substance
abuse. Some transgender clients have been
prostitutes or sex workers, resulting in clinical
issues that can also block recovery if they are
not adequately addressed.

Cases involving transgender individuals
illustrate the need for staff to ask open-ended
questions regarding gender and sexual 
orientation. In this way, those who are or are
perceived to be transgender persons are given
the opportunity to disclose this at their own
comfort level. These types of questions also
allow those whose transgender status is invisi
ble to disclose their status to the counselor if
they sense that he or she might have an
understanding of transgender issues.
Clinical Issues With Youth

The available research on LGBT youth has
focused on lesbian and gay male adolescents;
little information is available on bisexual identity
development or transgender youth. Some 
studies of gay youth show high rates of alcohol
and drug use (Remafedi, 1987; Rotherman-
Borus, Hunter & Rosario, 1994), whereas other
studies show rates that are comparable with
those of adolescents in general (Boxer, 1990;
Bradford & Ryan, 1987; Herdt & Boxer, 1993).
LGBT youth use alcohol and drugs for many of
the same reasons as their heterosexual peers:
to experiment and assert their independence,
to relieve tension, to increase feelings of self-
esteem and adequacy, and to self-medicate for
underlying depression or other mood disorders.
LGBT youth, however, may be more vulnerable
as a result of the need to hide their sexual
identity and the ensuing social isolation. As a
result, they may use alcohol and drugs to deal
with stigma and shame, to deny feelings for
persons of the same sex, or to help them cope
with ridicule or antigay violence. LGBT youth
have the same developmental tasks as their
heterosexual peers, but they also face addition
al challenges in sorting out their sexual identity. 

The age at which identity development and
coming out occurs is decreasing, with most
adolescents initial awareness of feelings for
someone of the same sex occurring at age 10;
first experiences with someone of the same
sex at ages 13 to 15; and initial self-
identification as lesbian or gay at ages 15 
to 16 (DAugelli & Herschberger, 1993; Herdt &
Boxer, 1993; Rosario et al., 1996). Adolescents
may not have developed the coping strategies
that LGBT adults have to contend with the
added stressors (Hunter & Mallon, 1999).
LGBT youth are at high risk for antigay vio
lence such as physical attacks, verbal and
physical abuse, and harassment (DAugelli &
Dark, 1995; Dean, Wu & Martin, 1992). 
Youth of color and those who are openly or
stereotypically gay are more likely to be
y
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victimized, and anecdotal reports suggest that
transgender youth may be at the greatest risk. 

Related Health Issues

An LGBT client may face a variety of additional
health problems when entering treatment. LGBT
clients in recovery have similar health concerns
and face many of the same physical and mental
health crises as other clients in recovery.

Many people who abuse substances have 
co-occurring mental health disorders, such as
affective disorders, eating disorders, or other
psychiatric illnesses. Substance abuse clouds
good judgment and contributes to dangerous
behaviors that can lead to illness, such as
HIV/AIDS, sexually transmitted diseases
(STDs), hepatitis, and injuries. People who
abuse substances may have neglected their
health, and some may have been the victims of
domestic violence or hate crimes resulting in
posttraumatic stress disorder. When consider
ing these factors, providers of substance abuse
treatment for LGBT clients should, as with any
client, screen for other health problemsfor
possible co-occurring mental health disorders,
poor nutrition, poor dental care, liver disease,
STDs, HIV/AIDS, and sexual abuse. In this
way, substance abuse treatment providers can
assist their LGBT clients in accessing appropri
ate medical care and treatment for their health
and mental health concerns.

LGBT individuals have been marginalized by
some health professionals, who historically
labeled an LGBT sexual orientation deviant or
pathological. As a result, LGBT individuals may
not disclose their sexual orientation to health
care providers (Cochran & Mays, 1988), and
many LGBT individuals, particularly transgen
der individuals, may be reluctant to use main
stream health care services. Their hesitation to
seek health care may result in late diagnosis
and poor treatment outcomes. The substance
abuse treatment provider may need to help 
LGBT clients overcome discomfort in seeking
health care when in recovery. 
Gay and bisexual men who are sexually active
with multiple partners are at risk for contracting
STDs, HIV/AIDS, and hepatitis A and hepatitis B
through sexual contact. Hepatitis C also may be
spread by sexual contact, although transmission
via infected needles is probably a far more 
significant route and is of concern to all injection
drug users. All clients should be screened for
hepatitis B and hepatitis C and referred for 
hepatitis A and hepatitis B vaccinations.

Knowledge about health concerns unique 
to lesbian and bisexual women is limited.
Alcoholic women have more fatty liver disease,
alcoholic hepatitis, cirrhosis, and osteoporosis
than nonalcoholic women (Woolf, 1983). Many
lesbians have had heterosexual contacts and
are at risk for both pregnancy and STDs
(OHanlan, 1995). Lesbian and bisexual
women who use injectable drugs are at high
risk for hepatitis B, hepatitis C, and HIV/AIDS
and should be screened for these diseases.
Some lesbian and bisexual women are sex
workers and have been exposed to STDs, HIV,
and trauma. Transgender individuals have
many health concerns. One study showed a
35-percent HIV prevalence rate among 
male-to-female (MTF) transgender individuals
and a 65-percent HIV prevalence rate among
African-American MTF transgender individuals.
Both MTF and FTM (female-to-male)
transgender individuals encounter risks related
to taking hormones. 

Interpersonal Violence in the LGBT
Community

Little research has been done on the 
relationship between substance abuse and 
interpersonal violence in the LGBT community,
but it is estimated that interpersonal violence
occurs at the same rate in same-sex relation
ships as in heterosexual relationships (Island & 
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Letellier, 1991; Lobel, 1986). Rates of violence in
same-sex relationships range from 8 to 46 
percent (Elliot, 1996). As with all their clients,
practitioners should assess their LGBT clients for
evidence of involvement in interpersonal violence
and act appropriately.

Counselor Competence in Treating LGBT
Clients

LGBT clients can be found in all types of
treatment settings: residential, intensive
outpatient, outpatient, crisis intervention, 
and the criminal justice system. 

In the counseling competencies model, a 
counselor should respect the client and his or
her frame of reference; recognize the impor
tance of cooperation and collaboration with the
client; maintain professional objectivity; 
recognize the need for flexibility and be willing
to adjust strategies in accordance with client
characteristics; appreciate the role and power
of a counselor as a group facilitator; appreciate
the appropriate use of content and process
therapeutic interventions; and be nonjudgmen
tal and respectfully accepting of the clients 
cultural, behavioral, and value differences.
These best-practice methods are critical when
working with LGBT clients. 

In the counseling competencies model, a 
counselor is responsible for self-monitoring,
obtaining proper supervision, and adhering to
professional and ethical standards. Establish
ing the proper ethos of care for LGBT clients
requires that counselors monitor themselves
and be aware of and work through their feel
ings about LGBT clients. Counselors must be
aware of countertransference, the process of
counselors seeing themselves in their clients,
overidentifying with their clients, meeting their
personal needs through their clients, or react
ing to a client because of their own unresolved
personal conflicts (Corey, 1991). 
Administrative Issues

A substance abuse treatment programs 
commitment to promote sensitive care for
LGBT clients can be included in its mission
statement and administrative policies and 
procedures. Providing staff training and
education on LGBT issues helps increase
awareness of the issues. A programs policies
and procedures can address the inclusion of
LGBT issues in its advertising, community
relations, administrative and personnel policies,
training, and program design.

Adding LGBT issues to a quality improvement
program may be helpful as well. To furnish 
quality treatment, providers should evaluate
their programs and collect appropriate 
demographic data to establish baseline infor
mation about LGBT clients. They should design
and implement appropriate client satisfaction
measures that provide specific feedback about
how well their organization is serving its LGBT
clients. Providers should develop better 
LGBT-specific outcome data. The data should
include the numbers of clients served, overall
satisfaction results, and treatment outcomes
among identified LGBT clients as compared
with the general treatment population. 

Training and Education

Training providers to sensitively serve LGBT
individuals may improve treatment outcomes.
Some options include sexual orientation sensi
tivity training to promote better understanding
of LGBT issues, LGBT-specific training, and
educational programs to ensure that quality
care is provided. The comfort level, experience,
and competence of staff serving LGBT
individuals should be assessed before and
after training.

Alliances and Networks 

A substance abuse treatment program seeking
to improve care to LGBT individuals has many
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allies throughout both the health care commu
nity and the LGBT community. The program
administrator who effectively identifies and
works with his or her allies will have taken an
important step toward ensuring that his or her
program is successful. This cooperation will be
particularly important in building local support
to serve LGBT clients and to work effectively
with managed care organizations. 

For managed care and other health care
provider networks to improve LGBT sensitivity,
their provider panels can include LGBT
providers and LGBT-sensitive providers. LGBT
programs may want to join provider networks
to ensure provision of culturally competent
services.

Conclusion

Because each client brings his or her unique
history and background into treatment, 
furthering our understanding of individuals 
different from ourselves helps ensure that
clients are treated with respect, while improving
the likelihood of effective substance abuse
treatment interventions. It is hoped that the
information in this publication helps providers
improve their ability to provide competent and
effective treatment. A substance abuse treat
ment provider who is knowledgeable about the
unique needs of LGBT clients can enhance
treatment. A provider who understands and is
sensitive to the issues surrounding sexual and
gender identity, homophobia, and heterosexism
can help LGBT clients feel comfortable and
safe while they confront their substance abuse
and start their journey of recovery. It is hoped
that this volume will assist administrators and
clinicians in forming a better understanding of
LGBT people, their problems with substance
abuse, and the unique challenges they face
and that the knowledge providers gain from it
about designing programs for LGBT clients will
be used to create a more comfortable
treatment environment.
Executive Summar y
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SECTION I: 
OVERVIEW

-----------------------------------------------
Chapter 1
An Overview for Providers 
Treating LGBT Clients

Robert Paul Cabaj, M.D., San Mateo County Mental Health Services, San Mateo, CA
Michael Gorman, Ph.D., San Jose State University, San Jose, CA
William J. Pellicio, LICSW, LCDP, Addiction Technology Transfer Center of New England,
  Brown University, Providence, RI
Dennis J. Ghindia, Ph.D., Rhode Island College School of Social Work, Providence, RI
Joseph H. Neisen, Ph.D., New Leaf Services for Our Community, San Francisco, CA

Introduction

For substance abuse treatment providers to
deliver skilled care to lesbian, gay, bisexual,
and transgender (LGBT) clients, they need to
be aware of issues specific to the LGBT com
munity. This chapter presents an overview of
the use and abuse of substances in the
LGBT community and a brief introduction 
to the concepts of gender identity, sexual
orientation, homophobia, and heterosexism.

Substance Use and Abuse in the LGBT
Community

In a discussion of the epidemiology of 
substance use and abuse among LGBT 
individuals, the following two questions 
are of interest to providers: 

  What is the epidemiology of substance
use and abuse among LGBT individuals? 

  Do LGBT individuals use or abuse more
substances than heterosexuals or the
general population? 

Epidemiology is the study of the patterns of
disease and health problems in populations
and the factors that influence these patterns.
Prevalence refers to the number of people
in a given population who are affected by a 
particular disease at a certain time; it is 
frequently expressed in percentages.
Incidence refers to the number of new
What providers will learn
from this chapter: 

  The epidemiology of 
substance abuse among
the LGBT population

  The types of substances
abused

  Definitions of key terms

  Characteristics of LGBT
individuals

  How differences in LGBT
life experiences may
shape the substance
abuse issues

  Life cycle issues for LGBT
individuals

1

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view for Providers Treating LGBT Clients
An Over
cases of a disease or condition, such as 
alcoholism or drug abuse, in a given population
over a specified time (such as a year).

Rates of substance use and abuse vary from
population to population. The numerous 
reasons for the varying rates include biological,
genetic, psychological, familial, religious, 
cultural, and historical circumstances. The
LGBT population is similar to the general 
population in that numerous factors predispose
its members to substance abuse. However,
some clinicians argue that the additional stigma
and resulting tension of being a member of a
marginalized community such as the LGBT
community cause some members of the 
marginalized community to seek to manage
these additional stressors by using mind-
altering substances.

The precise incidence and prevalence rates of
substance use and abuse by LGBT individuals
have been difficult to determine for several 
reasons. Reliable information on the size of the
LGBT population is not available. Scientific
studies of LGBT individuals substance abuse
do not always clearly define the difference
between substance use and substance abuse,
making it difficult to compare studies. Many
studies have methodological flaws, such as the
use of convenience samples that only infer or
estimate substance abuse among the LGBT
population. However, several promising studies
are under way that, it is hoped, will provide
additional information. The Substance Abuse
and Mental Health Services Administrations
(SAMHSAs) Center for Substance Abuse
Treatment (CSAT) will continue to report the
results of these studies as they are completed.

To provide background information for this 
publication, the authors conducted a review of
the epidemiological literature, and 16 studies
were chosen to highlight the extent of 
substance use or abuse problems in the LGBT
population. The table in appendix D, Studies
on LGBT Substance Abuse, presents a 
comparison of the studies. Studies were 
included if they focused on the LGBT 
population and substance abuse but did not
focus primarily on the human immunodeficien
cy virus (HIV). These studies are considered
classics and have been cited in numerous 
articles about LGBT individuals substance
abuse. The summary is by no means 
exhaustive; however, it provides the context 
for exploring the issue and has implications for
future research.
Publication dates of articles about the selected
studies range from 1970 to 2000. Of the 16
studies, 10 focused primarily on substance
abuse in the lesbian population, 3 focused on
both lesbians and gay men, 1 focused 
exclusively on gay men, 1 focused exclusively
on men who have sex with men (MSM), and 1
focused on transgender individuals. Eleven of
the studies used convenience samples, and
five used population-based data. Most of the
studies reported on alcohol use. 

These studies generally state that gay men
and lesbians have greater substance abuse
problems than non-LGBT men and women. In
seven studies, comparisons between the LGBT
population and the heterosexual population
could not be made. Studies by Saghir and 
colleagues (1970); Fifield, DeCrescenzo, and
Latham (1975); Lewis, Saghir, and Robins
(1982); and Morales and Graves (1983) found
that approximately 30 percent of all lesbians
have an alcohol abuse problem. Studies that
compared gay men or lesbians with heterosex
uals (Stall & Wiley, 1988; McKirnan &
Peterson, 1989; Bloomfield, 1993; Skinner,
1994; Skinner & Otis, 1996; Hughes &
Wilsnack, 1997) found that gay men and 
lesbians were heavier substance and alcohol
users than the general or heterosexual popula
tion. From these studies, it is clear that 
substance abuse treatment is needed and 
that providers need to know more about this 
community to provide competent treatment.  

2

-----------------------------------------------
Types of Substances Abused

Over the past several years, the concerns
about the epidemic of HIV-related conditions
have led to an increased number of studies of
both gay and bisexual men and injection drug
users. Although LGBT persons use and abuse
alcohol and all types of drugs, certain drugs
seem to be more popular in the LGBT 
community than in the majority community. 

Woody and colleagues (1999) compared a
convenience sample of MSM at high risk for
HIV who participated in a vaccine prepared
ness study with a nationally representative
sample of men from the 1995 National
Household Survey on Drug Abuse (NHSDA).
The study found that these MSM were 21 times
more likely to use nitrite inhalants. They were
also much more likely (four to seven times) to
use hallucinogens, stimulants, sedatives, and
tranquilizers than the men in the NHSDA 
sample. The study also found that weekly use
by this MSM sample was 2 times more likely
for marijuana, cocaine, and stimulants and 33
times more likely for inhalant nitrites. 

A study by Cochran and Mays (2000) found
that people with same-sex partners were more
likely to use substances than were people with
opposite-sex partners. Closer examination of
the data (Cochran et al., in press) comparing
MSM with heterosexual men and comparing
lesbians with heterosexual women showed little
difference between MSM and heterosexual
male substance abuse but showed that rates of
alcohol use were much higher for lesbians than
for heterosexual women. For example, lesbians
used alcohol twice as often in the past month,
were five times more likely to use alcohol every
day, were more than twice as likely to get
intoxicated, and were four times more likely to
get intoxicated weekly than heterosexual
women.

Another study of lesbians using self-reported
data stated that rates of alcohol use in the 
lesbian population were higher than those in
the general population, but not as high as rates
in other studies, and that the most significant
predictor of alcohol use was reliance on bars
as a primary social setting (Heffernan, 1998).
Designer Drug Use

Abuse of methamphetamine, also known as
meth, speed, crystal, or crank, has increased
dramatically in recent years (Drug Abuse
Warning Network, 1998; Derlet & Heischober,
1990; Morgan et al., 1993; National Institute 
on Drug Abuse, 1994; Gorman, Morgan &
Lambert, 1995; CSAT, 1997b), particularly
among gay men but also among male-to-
female (MTF) transgender individuals and,
increasingly, among some groups of lesbians.
What makes the current epidemic so discon
certing is its relationship to the HIV epidemic
(Ostrow, 1996; Gorman et al., 1997). 

Amphetamines and methamphetamine 
currently are the most popular synthetic 
stimulants in the United States, and abuse of
them can lead to significant dependence and
addiction. The drugs may be drunk, eaten,
smoked, injected, or absorbed rectally. They
have a half-life of approximately 24 hours.
They work by releasing neurotransmitters, and
users suffer the same addiction cycle and 
withdrawal reactions as those suffered by crack
cocaine users. These substances increase the
heart rate, blood pressure, respiration rate, and
body temperature. They cause pupil dilation
and produce alertness, a sense of euphoria,
and increased energy. After prolonged use,
users often experience severe depression 
and sometimes paranoia. They may also
become belligerent and aggressive.

Methamphetamine use appears to be integral
to the sexual activities of a certain segment of
gay men, especially in some urban communi
ties. The so-called party drugs, such as MDMA
(methylenedioxymethamphetamine) (also
known as ecstasy or X-T-C),Special K or 
An Over
view for Providers Treating LGBT Clients

3

-----------------------------------------------
An Over
ketamine, and GHB (gamma hydroxybutyrate),
are increasingly popular at dances and 
celebrations, such as circuit parties and raves.

MDMA is a synthetic drug with hallucinogenic
and amphetamine-like properties. The effects
are reminiscent of lysergic acid diethylamide-
25 (LSD). Ketamine, a white crystalline powder
that is soluble in water and alcohol, is a 
dissociative anesthetic, a synthetic drug that
produces hallucinations, analgesia, and 
amnesia and can cause euphoria. Users can
experience impaired thought processes, 
confusion, dizziness, impaired motor 
coordination, and slurred speech. Liquid X
(GHB) possesses euphoric properties, and
overdoses can cause electrolyte imbalances,
decreased respiration, confusion, and 
hypertension, as well as seizure-like activity
and vomiting.

Party drugs can impair judgment and increase
sexual risk taking. Research has shown a 
connection between use of nitrite and high-risk
sexual behavior (Ostrow et al., 1993), and
there is compelling evidence that HIV and 
hepatitis C infections are linked with 
methamphetamine use. Studies in several
cities indicate that gay and bisexual men who
used speed, alone or in combination with other
drugs, appear to have much higher seropreva
lence rates than either heterosexual injection
drug users or gay and bisexual men who do
not use these drugs (Harris et al., 1993; Diaz
et al., 1994; Gorman, 1996; CDC [Centers for
Disease Control and Prevention], 1995; Hays,
Kegeles & Coates, 1990; Waldorf & Murphy,
1990; Paul, Stall & Davis, 1993; Paul et al.,
1994). This finding is particularly apparent for
individuals who inject these drugs and who
share needles or injecting equipment. Although
most LGBT meth users probably snort, ingest,
or smoke the drugs, a sizable number also
report histories of injection drug use. Within the
substance-abusing population in general, and
the LGBT population in particular, injection
drug users represent an often hidden and 
stigmatized group. Public health efforts have 
targeted mostly heterosexual injection drug
users of heroin. A number of injection drug
users inject methamphetamine, and a number
of these are LGBT individuals. 
Information on the needle hygiene of
methamphetamine users or LGBT injection
drug users is lacking. Some HIV-positive 
individuals appear to be self-medicating for
depression or specific HIV-related symptoms
by using methamphetamine because it reduces
lethargy, raises libido, and can be an 
antidepressant. Mixing these drugs can be
dangerous, and some deaths have been 
documented from using party drugs while 
taking protease inhibitors. 

Definition of Terms and Concepts Related
to LGBT Issues

Understanding how certain terms are used is
essential to understanding homosexuality. It is
important to recognize the difference between
sexual orientation and sexual behavior as well
as the differences among sexual orientation,
gender identity, and gender role.

Sexual orientation may be defined as the
erotic and affectional (or loving) attraction to
another person, including erotic fantasy, erotic
activity or behavior, and affectional needs.
Heterosexuality is the attraction to persons of
the opposite sex; homosexuality, to persons
of the same sex; and bisexuality, to both
sexes. Sexual orientation can be seen as part
of a continuum ranging from same-sex
attraction only (at one end of the continuum) to
opposite-sex attraction only (at the other end of
the continuum).

Sexual behavior, or sexual activity, differs
from sexual orientation and alone does not
define someone as an LGBT individual. Any
person may be capable of sexual behavior with
a person of the same or opposite sex, but an
individual knows his or her longingserotic 
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4

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and affectionaland which sex is more likely
to satisfy those needs.

It is necessary to draw a distinction between
sexual orientation and sexual behavior. Not
every person with a homosexual or bisexual
orientation, as indicated by his or her fantasies,
engages in homosexual behavior. Nor does 
sexual behavior alone define orientation. A 
personal awareness of having a sexual orienta
tion that is not exclusively heterosexual is one
way a person identifies herself or himself as an
LGBT person. Or a person may have a sexual
identity that differs from his or her biological
sexthat is, a person may have been born a
male but identifies and feels more comfortable
as a female. Sexual orientation and gender
identity are two independent variables in an
individuals definition of himself or herself.

Sexual identity is the personal and unique
way that a person perceives his or her own
sexual desires and sexual expressions.
Biological sex is the biological distinction
between men and women. 

Gender is the concept of maleness and 
masculinity or femaleness and femininity. Ones
gender identity is the sense of ones self as
male or female and does not refer to ones
sexual orientation or gender role. Gender role
refers to the behaviors and desires to act in
certain ways that are viewed as masculine or
feminine by a particular culture. 

A culture usually labels behaviors as masculine
or feminine, but these behaviors are not 
necessarily a direct component of gender or
gender identity. It is common in our culture to
call the behaviors, styles, or interests shown by
males that are usually associated with women
effeminate and to call the boys who behave
this way sissies. Women or girls who have
interests usually associated with men are
labeled masculine or butch, and the girls are
often called tomboys. 
Transgender individuals are those who 
conform to the gender role expectations of the
opposite sex or those who may clearly identify
their gender as the opposite of their biological
sex. In common usage, transgender usually
refers to people in the transsexual group that
may include people who are contemplating or
preparing for sexual reassignment surgery
called preoperativeor who have undergone
sexual reassignment surgerycalled 
postoperative. A transgender person may be
sexually attracted to males, females, or both.

Transvestites cross dress, that is, wear
clothes usually worn by people of the opposite
biological sex. They do not, however, identify
themselves as having a gender identity 
different from their biological sex or gender
role. The motivations for cross dressing vary,
but most transvestites enjoy cross dressing
and may experience sexual excitement from it.
The vast majority of transvestites are hetero
sexual, and they usually are not included in
general discussions about LGBT people.

Gender identity disorder (GID) was 
introduced in the latest edition of the
Diagnostic and Statistical Manual of Mental
Disorders (DSMIV) (American Psychiatric
Association, 1994). Although GID is listed as a
mental illness, most clinicians do not consider
individuals who are confused or conflicted
about their biological gender and their personal
sense of their gender identity to be mentally ill.
Considerable work needs to be done to 
augment the small amount of research 
available on the development of a transgender
identitythat is, how a person becomes aware
of a sexual identity that does not match his or
her biological sex or gender role.

Estimates of the Number of LGBT
Individuals

The true number of people who identify 
themselves as LGBT individuals is not known.
Because of a lack of research focusing on the
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LGBT population and the mistrust that makes
many LGBT people afraid to be open about
their identity, reliable data are difficult to obtain.
The popular estimate that 10 percent of the
male population and 5 to 6 percent of the
female population are exclusively or predomi
nately homosexual is based on the Kinsey
Institute data (Kinsey, Pomeron & Martin, 1948;
Kinsey et al., 1953) addressing sexual 
behavior. Kinsey proposed the Kinsey Scale, 
a continuum that rated sexual behavior on a
scale from zero to six. Zero represented 
exclusive heterosexual behavior and six 
represented exclusive homosexual behavior.
The survey reported that 37 percent of
American men had at least one homosexual
experience after adolescence; 5 to 7 percent
had bisexual experiences but preferred 
homosexual ones; and 4 to 5 percent had
homosexual experiences exclusively. 

These data illustrate how widespread male
homosexual behavior is, not necessarily the
number of gay men. The same research 
indicated that the majority of those surveyed
reported behavior in a range Kinsey termed
bisexual. Again, the classification is based only
on reported behavior. For many minority popu
lations, bisexualitybut not homosexualityis
acceptable (or at least admittable on surveys).
For example, in the 1989 Centers for Disease
Control and Prevention 8-year review of
acquired immunodeficiency syndrome (AIDS)
cases among gay or bisexual men, 54.2 per
cent of African Americans were reported to be
bisexual, 44.2 percent of Hispanics were
reported to be bisexual, and 11.3 percent of
Caucasians were reported to be bisexual. 

Michaels (1996) thoroughly analyzed the 
limited available data and concluded that 
determining prevalence rates of sexual 
orientations is extremely difficult because the
data are widely disparate. He estimates that in
the United States, 9.8 percent of men and 5
percent of women report same-gender sexual
behavior since puberty; 7.7 percent of men and
7.5 percent of women report same-gender
desire; and 2.8 percent of men and 1.4 percent 
of women report a homosexual or bisexual
identity. 

The data on the number of transgender people
are even more limited. Some psychiatric 
literature estimates that 1 percent of the 
population may have had a transgender 
experience, but this estimate is based only 
on transgender people who might have sought
mental health services (Seil, 1996).

Homophobia and Heterosexism

Having a general understanding of 
heterosexism, homophobia, and antigay bias 
is important for substance abuse treatment
providers working with LGBT individuals. Alport
(1952) defined prejudice as a negative attitude
based on error and overgeneralization and
identified the three interdependent states of
acting out prejudice as verbal attacks, discrimi
nation, and violence. Verbal attacks can range
from denigratory language to pseudoscientific
theories and findings, which serve as a founda
tion for discrimination and violence. Following
this theory, prejudice and discrimination against 
LGBT individuals is formed, in part, by 
misinformation such as the following: 

  All gay men are effeminate, and all lesbians
are masculine.

  LGBT persons are child molesters.

  LGBT individuals are unsuitable for 
professional responsibilities and positions.

  LGBT persons cannot have fulfilling 
relationships.

  LGBT persons are mentally ill.

Once negative generalizations are formed
about a group of people, some members of 
the majority group feel that they can treat the 
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6

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other group differently. As the acceptance of 
negative stereotypes spreads, discrimination
and violence can result. 

Heterosexism and homophobia are used to
describe the prejudice against LGBT people.
Heterosexism is a prejudice similar to racism
and sexism. It denies, ignores, denigrates, or
stigmatizes any nonheterosexual form of 
emotional and affectional expression, sexual
activity, behavior, relationship, or socially 
identified community. Heterosexism exists in
everyoneLGBT individuals as well as 
heterosexualsbecause almost everyone is
brought up in a predominately heterosexual
society that has little or no positive recognition
of homosexuality or bisexuality. Heterosexism
supports the mistaken belief that gay men
because they are attracted to menare in
some way like women, and lesbians, in turn,
are in some way like men.

Homophobia, although a popular term, lacks
precise meaning. Coined in 1972 to describe
fear and loathing of gay men and lesbians, it 
also has been used by gay men, lesbians, and
bisexuals to describe self-loathing, fear, or
resistance to accepting and expressing sexual
orientation (Weinberg, 1983). Antigay bias is
another phrase to describe the first concept,
and internalized homophobia is another
phrase for the latter. Internalized homophobia
is a key concept in understanding issues facing
gay men, lesbians, and bisexuals in substance
abuse treatment. 

Examples of heterosexism in the United States
include the following:

  The widespread lack of legal protection for
individuals in employment and housing

  The continuing ban on lesbian and gay 
military personnel

  The hostility and lack of support for lesbian
and gay committed relationships (except in
Vermont) as seen in the passage of Federal
and State laws against same-gender 
marriages
  The enforcement of outdated sodomy laws
that are applied to LGBT individuals but not
applied to heterosexual individuals.

Examples of heterosexism in the substance
abuse treatment setting are as follows:

  Gay-bashing conversations

  Cynical remarks and jokes regarding gay
sexual behaviors

  Jokes about openly LGBT staff members

  Lack of openly LGBT personnel 

  Lack of inclusion of LGBT individuals family
members or significant others in treatment
processes.

Substance abuse treatment providers should
remember that LGBT clients do not know the
reaction they will receive when mentioning their
sexual orientation. For example, public opinion 
measures indicate that homosexuality is not
widely accepted. In 1996, Gallup Poll data
showed 50 percent of respondents reported
that homosexuality was unacceptable and only
45 percent found homosexuality an acceptable
lifestyle. In addition, Herek (1989) found that as
many as 92 percent of lesbians and gay men
reported that they have been the target of
threats, and as many as 24 percent reported
physical attacks because of their sexual 
orientation. 

It is likely that all substance abuse treatment
programs have LGBT clients, but staff 
members may not be aware that they are treat
ing LGBT clients. Most treatment programs do
not ask about sexual orientation, and many
LGBT people are afraid to speak openly about
their sexual orientation or identity. Treatment
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programs also may not realize that they have
LGBT staff members, who can be a great
resource for treating LGBT clients. 

How Heterosexism Contributes to
Substance Abuse

When treating LGBT clients, it is helpful for
providers to understand the effect of heterosex
ism on their LGBT clients. The role of 
heterosexism in the etiology of substance
abuse is unclear. Heterosexism instills shame
in LGBT individuals, causing them to 
internalize the homophobia that is directed
toward them by society (Neisen, 1990, 1993).
Some LGBT individuals may use intoxicants to
cope with shame and other negative feelings.
Some LGBT individuals learn to devalue 
themselves and value only heterosexual 
persons instead. The negative effects of 
heterosexism include the following:

  Self-blame for the victimization one has 
suffered

  A negative self-concept as a result of nega
tive messages about homosexuality

  Anger directed inward resulting in destructive
patterns such as substance abuse

  A victim mentality or feelings of inadequacy,
hopelessness, and despair that interfere with
leading a fulfilling life

  Self-victimization that may hinder emotional
growth and development.

Recognizing that heterosexism is a type of 
victimization helps the counselor and client
draw a parallel with recovery from other types
of victimization, whether they are culturally or
individually based. It is crucial that counselors
and clients recognize that these effects result
from prejudice and discrimination and are not 
a consequence of ones sexuality. It is not 
surprising to find that many LGBT individuals 
in therapy report feeling isolated, fearful,
depressed, anxious, and angry and have 
difficulty trusting others. Meyer (1993) reports
that the victimization of gay males in our 
society results in mental health consequences
for individuals. A skilled substance abuse 
treatment counselor should be attentive to the
negative effects that prejudice produces when
working with LGBT clients.
Perspectives on Homosexuality

Homosexuality, as a specific category, was 
not described in the medical or psychiatric 
literature until the early 1870s. The fledgling
psychoanalytic movement regarded homosexu
ality as a topic of special interest. Sigmund
Freud believed a persons sexual orientation, 
in and of itself, did not impair his or her judg
ment or cause problems, and Freud set a
positive tone when he supported homosexual
colleagues in medical and psychiatric societies.
Even so, European psychoanalytic
organizations did not welcome gay men and
lesbians as members in the early years of
psychiatry, and many American psychiatrists
and psychoanalysts promoted the attitude that
homosexuality was a mental disorder. 

Bieber and colleagues (1962) proposed that
childhood influences and family upbringing
were responsible for producing male 
homosexuality and described the classic 
combination of a distant, uninvolved father and
an overinvolved mother. They did not consider
biology or genetics as playing a role. Other 
psychoanalytic writing also refuted a biological
component to female homosexuality, seeing it
as caused primarily by early developmental
disturbances. 

Alfred Kinsey introduced new perspectives on
homosexuality with his studies of sexual
behavior (Kinsey, Pomeron & Martin, 1948;
Kinsey et al., 1953). Although his studies have
been criticized for a variety of reasons, such as
poor sampling methods, the studies greatly
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8

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increased Americans awareness of sexuality
and the range of sexual behavior.

The psychologist Evelyn Hooker (1957)
demonstrated that no discernible differences
existed between the psychological profiles of
gay men and those of heterosexual men, effec
tively beginning the debunking of the theory
that homosexuality is a mental illness.
Psychiatrist Judd Marmor (1980) recognized
that homosexuality could not be explained in a
single dimension and helped support exploring
the biological, genetic, psychological, familial,
and social factors involved in the formation and
expression of a homosexual orientation.

In 1973, the American Psychiatric Association,
after extensive scientific review and debate,
stopped classifying homosexuality as a mental
illness. Homosexuality is now seen as a normal
variation of human sexual and emotional
expression, allowing, it is hoped, a 
nonpathological and nonprejudicial view of
homosexuality as well as of LGBT people. 
LGBT people and homosexual and bisexual
behavior are found in almost all societies and
cultures in the world and throughout history
(Herdt, 1996). But the degree of tolerance and
acceptance of them has varied considerably in
different periods of history and from country to
country, culture to culture, and community to
community. Anthropological studies that have
observed homosexual behavior in other 
cultures may help put homosexuality in global
perspective and may contribute to understand
ing some of the issues facing American LGBT
individuals who are from ethnic or cultural
minority groups, such as African Americans
(Jones & Hill, 1996), Asian Americans
(Nakajima, Chan & Lee, 1996), Latinos/
Latinas/Hispanics (Gonzalez & Espin, 1996),
and Native Americans (Tafoya, 1996).

The genetic and biological contributions to 
sexual orientation have been studied 
increasingly in recent years. Unfortunately, 
the biological studies often grow out of the 
confusion between sexual orientation and 
gender identity. Many studies have tried to
demonstrate that physical traits in gay men
resemble those of women or have tried to 
identify traits in lesbians that resemble those 
of males. These views are based on the belief
that, if a man wishes to be with a man, he must
somehow be like a woman, and a woman 
wishing to be with a woman must, in some
way, be like a man.               
The Kinsey Institute has supported surveys
and studies of both sexual behavior and sexual
orientation and concluded that homosexuality
must be innate, that is, inborn, and is not 
influenced developmentally by family 
upbringing (Bell & Weinberg, 1978; Bell,
Weinberg & Hammersmith, 1981; Weinberg &
Williams, 1974). The studies noted the diversity
and variety of gay men and lesbians, 
recognizing that there was no uniform way to
be or become gay or lesbian in our society. 

Lesbianism and female homosexuality have
also been studied from a nonpathological 
perspective. Magee and Miller (1998) reviewed
these efforts and found no psychodynamic 
etiologies to female homosexuality and that
each lesbian is unique and without stereotypic
characteristics.

Studies of intersexual people, that is, people 
with sexually ambiguous genitalia or true 
hermaphrodites, are often analyzed.
Hermaphrodites have both male and female
reproductive organs. These studies ultimately
are about gender role expectations and do not
contribute to our understanding of homosexuality.

The most promising areas of study involve
genetics and familial patterns. Although the
gene has not been identified, Hamer and
Copeland (1994) have reported a linkage 
on the X chromosome that may influence 
homosexual orientation. The genetic and 
familial patterns studied by Pillard, Bailey, 
and Weinrich and their colleagues (Bailey et
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al., 1993; Bailey & Pillard, 1991; Pillard, 1996)
have demonstrated the most consistent and
verifiable data. Pillard found that gay men are
much more likely to have gay or bisexual male
siblings than heterosexual malesbased on
the incidence of homosexualitybut are not
more likely to have lesbian sisters than are het
erosexual males. Lesbians are more likely to
have lesbian sisters but are not more likely to
have gay brothers. 

Combined with other twin and heritability 
studies, this research helps explain the 
probable genetic substrate of sexual 
orientation, with different genetic influences 
for male homosexuality, male heterosexuality,
female homosexuality, female heterosexuality,
and, possibly, bisexuality. Although the 
complex set of behaviors and feelings of homo
sexuality could not be explained by a single
factor, a genetic basis seems to be the 
foundation on which other complex biological,
familial, and societal influences work to shape
the development and expression of sexual 
orientation (LeVay, 1996).

Perspectives on Bisexuality

Bisexuality has also existed throughout 
recorded history. Freud believed in innate
bisexuality and that an individual evolves 
into a heterosexual or a homosexual, rarely 
a bisexual (Freud, 1963). Many bisexuals still
find themselves contending with this lack of
acknowledgment that a bisexual orientation
can be an endpoint in itself and not just a 
step toward heterosexuality or homosexuality. 

It is helpful for providers to know that the 
clinical issues facing bisexuals often are 
problems resulting from the difficulty of
acknowledging and acting on a sexual 
orientation that is not accepted by the 
heterosexual majority but also not accepted 
by many gay men and lesbians.
Some people of color in the United States or
people from different cultures may define 
themselves as bisexual, even if they focus
exclusively on people of the same sex
(Gonzalez & Espin, 1996). This perspective
may be their way of coping with the stigma of
homosexuality. Reviews that discuss theory
and clinical issues include those by Weinberg,
Williams, and Pryor (1994); Klein and Wolfe
(1985); and Fox (1996). 

Sexual Orientation Over Time

Although this chapter presents sexual 
orientation as belonging to one of three 
categorieshomosexual, bisexual, or 
heterosexualclearly sexual feelings, sexual
behaviors, and sexual orientation may vary
over time. As Kinsey found, sexual behavior
ranges over a continuum from sexual activity
with people of the same sex exclusively to 
sexual activity with people of the opposite sex
exclusively, and most peoples behavior falls 
somewhere in between. Sexual orientation also
follows the same continuumfrom sexual
interest in people of the same sex exclusively
to sexual interest in people of the opposite sex
exclusively.

The mapping of sexual orientation over time
has not been well studied. It seems that most
people have a fairly stable and fixed sexual 
orientation, once they become aware of their
sexual orientation. Nevertheless, some 
peoples sexual orientation may vary. Womens
orientation may be more changeable than
mens, possibly because of societys homopho
bia and because men are more uncomfortable
with a nonheterosexual identity. Some people
may not become fully aware of their orientation
for years and may seem to change sexual 
orientation when, in fact, they are just 
becoming conscious of their true orientation.
This knowledge may help providers support
their LGBT client whose confusion about 
sexual issues is interfering with recovery 
from substance abuse.
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10

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Some types of therapies claim to be able to
change a persons sexual orientation. These
conversion therapies or reparative therapies
are often practiced by religiously based 
therapists or by some psychoanalysts who still
consider homosexuality a mental illness. These
therapies treat people who are uncomfortable
with being gay, lesbian, or bisexual andrather
than helping an individual become comfortable
with his or her inborn and natural sexual 
orientationmake the individuals even more
uncomfortable and ashamed about being 
different. These attempts to change orientation
may result in a temporary change of behavior.
A gay man may stop having sex with other
men or have sex with women, but his actual
sexual orientation, expressed in his sexual 
fantasies, desires, or thoughts, possibly will not
change. Almost all major mental health and
medical organizations have condemned these
therapies as ineffective and potentially harmful
because they make the person feel guilty and
ashamed (Haldeman, 1994).

Assessing Sexual Orientation

If a substance abuse treatment provider is 
concerned that a client is confused about 
his or her sexual orientation, some evaluation
tools are available to help assess a clients
feelings. Coleman (1987) devised a relatively
simple assessment tool to help map out or
identify the sexual orientation of clients 
(see exhibit 11). The questionnaire considers
the combination of sexual behavior, fantasies,
feelings, and self-identification that contributes
to sexual orientation. This tool may be a useful
way to introduce a discussion about sexual
orientation with clients who are uncomfortable
with the topic. It may also help people under
stand the complexity of sexual expression and
their comfort level with it. However, providers
should be sensitive to the individual situation of
the client in both administering and interpreting
the instrument. 
Life Cycle Issues 

LGBT individuals face many of the same
issues all people face as they progress through
life. However, LGBT youth may have an 
especially difficult time. During adolescence,
teens are under pressure to conform, and
extraordinary effort and courage may be
required for an LGBT teenager to come out to
peers and family. Gay and lesbian youth may
be subject to sexual abuse or exploitation
sometimes related to their insecurity and low
self-esteem. LGBT youth may face significant
stress in coping with the attitudes of peers,
teachers, and parents.

Older adolescent and young adult LGBT 
people focus on identity development through
school, career choices, and sexual exploration
and relations. Their social life often revolves
around bars or other settings that promote drug
and alcohol use (DAugelli, 1996). When LGBT
adolescents come out to their family, the result
can range from understanding and support to
verbal and physical abuse. Some youth run
away from home and live on the streets 
(Savin-Williams, 1994). 

Many LGBT people consider becoming part of
a couple an important part of life. Although
there are no legal sanctions for such relation
ships, except in Vermont, the majority of gay
people are in relationships, and many are as 
committed as traditional heterosexual couples
(Klinger & Cabaj, 1993). Some LGBT people
are parents; they have had or adopted children
(Patterson, 1995). LGBT clients belong to a
family of origin. Depending on the circum
stances, the relationship may be healthy or
strained. Some LGBT people create their own
family of choice consisting of a close network
of friends that serves the needs often met by
traditional families. Treatment providers need
to consider an LGBT clients partner, children,
family of origin, and family of choice when 
providing care.
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      Exhibit 11: 
Colemans Assessment Tool
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An Over
Assessment of Sexual Orientation
 Eli Coleman, Ph.D.
1986
Name or Code Number:_______________________________Age:_________Date:_________

What is your current relationship status:
(check one box only)

Single, no sexual partners
Single, one committed partnerDuration:________________________________________
Single, multiple partners
Coupled, living together (Committed to an exclusive sexual relationship)
Coupled, living together (Relationship permits other partners under certain circumstances)
Coupled, living apart (Committed to an exclusive sexual relationship)
Coupled, living apart (Relationship permits other partners under certain circumstances)
Other_____________________________________________________________________

In terms of my sexual orientation, In the future, I would like to
I identify myself as. . . identify myself as. . .
(check one box only) (check one box only)

Exclusively homosexual Exclusively homosexual
Predominantly homosexual Predominantly homosexual
Bisexual Bisexual
Predominantly heterosexual Predominantly heterosexual
Exclusively heterosexual Exclusively heterosexual
Unsure Unsure

In terms of my comfort with my current sexual orientation, I would say that I am. . .
(check one box only)

Very comfortable
Mostly comfortable
Comfortable
Not very comfortable
Very uncomfortable

Continued

Source: Coleman, 1987

12

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          Exhibit 11: 
Colemans Assessment Tool (continued)
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INSTRUCTIONS:

Fill in the following circles by drawing lines to If the entire circle is male or female, 
indicate which portion describes male or female simply indicate the appropriate symbol
elements. Indicate which portion of the circle is in the circle (M or F).
male by indicating (M) or female by indicating (F).

Example: M F Example:          F

Fill in the circles indicating how it has been up to the present time as well as how you would like to
see yourself in the future (ideal).

UP TO THE PRESENT TIME FUTURE (IDEAL)

Physical Identity Physical Identity
I was born a biological. . . Ideally, I wish I had been born
as a biological. . .

Gender Identity Gender Identity
I think of myself as physically. . . Ideally, I would like to think of
myself as physically. . .

In my sexual fantasies, I imagine In my sexual fantasies, I 
myself as physically. . . imagine myself as physically. . .

Sex-Role Identity Sex-Role Identity
My interests, attitudes, appearance, I wish my interests, attitudes, 
and behaviors would be considered appearance, and behaviors would 
female or male (as traditionally be considered female or male 
defined). . . (as traditionally defined). . .

Sexual Orientation Identity Sexual Orientation Identity
My sexual activity has been with. . . I wish my sexual activity would be
with. . .

My sexual fantasies have been with. . . I wish my sexual fantasies 
would be with. . .

My emotional attachments (not 
necessarily sexual) have been with. . . I wish my emotional attachments
(not necessarily sexual) would be
with. . .

13

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view for Providers Treating LGBT Clients
Older LGBT individuals may experience a
sense of loss related to the aging process and
associated changes in their physical attractive
ness and capacities. This state may be further
compounded by the lack of a partner or a
legally sanctioned relationship. Consequently,
their sense of a purpose and a future may
become hazy and may be expressed in 
emotional and substance abuse problems
(Kertzner & Sved, 1996).

Older LGBT people face the same concerns as
other older persons regarding living arrange
ments and loss of loved ones and social 
supports. These concerns may be exacerbated
for some LGBT people by HIV-related losses
and limited familial support, that is, not having
children and being isolated from their family of
origin. Some people in this age group may
need treatment for substance abuse or 
emotional issues avoided or ignored over the
years (Berger & Kelly, 1996).
Summary

It is hoped that the information in this chapter
helps providers improve their ability to 
provide competent and effective treatment.
Treatment can be enhanced by a substance
abuse treatment provider who is knowledge
able about the unique needs of LGBT clients. A
provider who understands and is sensitive to
the issues surrounding sexual and gender
identity, homophobia, and heterosexism can
help LGBT clients feel comfortable and safe
while they confront their substance abuse and
start their journey of recovery.

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14

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Chapter 2
Cultural Issues in Working
With LGBT Individuals

Ednita Wright, Ph.D., Syracuse University, Syracuse, NY
Candace Shelton, M.S., CADAC, Consultant, Tucson, AZ
Michael Browning, Day One, Pasadena, CA
Jos Martin Garcia Orduna, Latina/o Lesbian, Gay, Bisexual & Transgender Organization  
  (LLEG), Washington, DC
Victor Martinez, Latina/o Lesbian, Gay, Bisexual & Transgender Organization (LLEG) 
  Washington, DC
Frank Y. Wong, Ph.D., Center for Health Services Research and Policy, George
Washington University School of Public Health and Health Services, Washington, DC

Introduction

This chapter presents information to help
providers understand cultural issues relevant
to treating lesbian, gay, bisexual, and 
transgender (LGBT) clients. To provide 
culturally competent treatment, providers
must possess attitudes that reflect openness
to other cultures, values, and beliefs; a 
willingness to assess and change their own
beliefs; and the ability to appreciate diversi
ty. Providers need to know about the social
and cultural context in which their clients live
and abuse substances and be receptive to
information that may differ from their 
personally held views (CSAT [Center for
Substance Abuse Treatment], 1998a).

Providers can play an important role in the
healing process of LGBT individuals by
being aware of the community, traditions,
and heritage of their LGBT clients. The 
information that follows includes broad 
generalities intended as starting points for
providers in their work with individual clients.
It is not intended as a thorough discussion
of the topic. 

Definitions of Terms

Culture refers to the customary beliefs,
social norms, and material traits of a racial,
religious, or social group. It affects the group
What providers will learn
from this chapter:

  What cultural competence
is

  How cross-cultural issues
affect substance abuse
treatment

  What the dimensions of
culture are

  Treatment issues that are
unique to different ethnic
groups 

  Perspectives on gay 
culture

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Cultural Issues in Working With LGBT Individuals
members viewpoints: how they act; how they
think; and how they see themselves in relation
to the rest of the world. Culture is transmitted
through language, symbols, and rituals. 

Ethnicity describes a population or group 
having a common cultural heritage that is 
distinguished by customs, characteristics, 
language, and common history. 

Diversity refers to differences in geographic
location (rural, urban), sexual orientation, age,
religion or spiritual practice, socioeconomic 
status, and physical and mental capacity.

Important reference materials on cultural 
competency include the following: 

  CSATs publication Cultural Issues in
Substance Abuse Treatment, 1999b

  CSATs Technical Assistance Publication
(TAP) 21 Addiction Counseling
Competencies: The Knowledge, Skills, and
Attitudes of Professional Practice, 1998b.

Cultural Competency Overview

Cultural competency is a set of academic and
interpersonal skills that assists individuals in
increasing their understanding and appreciation
of cultural differences and similarities within,
among, and between groups (Woll, 1996). It
requires a willingness and an ability to draw on
community-based values, traditions, and 
customs and to work with knowledgeable 
persons of and from the community in develop
ing focused interventions, communications, and
other supports. A culturally competent program
is defined by CSAT (1994a) as one that
demonstrates sensitivity and understanding of
cultural differences in treatment and program
design, implementation, and evaluation. Within
the treatment setting, cultural competency is a 
fundamental component that helps individuals
develop trust as well as an understanding of
the way members of different cultural groups
define health, illness, and health care (Gordon,
1994). 
Substance abuse treatment providers may use
their understanding of the client and the clients
cultural context to develop a culturally appropri
ate assessment, identify problems, and choose
appropriate treatment strategies for the client.
A culturally competent model of treatment
acknowledges the clients cultural strengths,
values, and experiences while encouraging
behavioral and attitudinal change. Treatment
services that are culturally responsive are 
characterized by the following:

  Staff knowledge of the clients first language

  Staff sensitivity to the cultural nuances of the
client population

  Staff backgrounds representative of those of
the client population

  Treatment modalities that reflect the cultural
values and treatment needs of the client 
population

  Representation of the client population in
decisionmaking and policy implementation.

These aspects alone do not constitute cultural
competency, nor do they automatically create a
culturally competent system. Culturally 
competent systems include both professional
behavioral norms for treatment staff and the
organizational norms that are built into the
organizations mission, structure, management,
personnel, program design, and treatment 
protocols. In other words, culturally competent
systems need to implement cultural 
competency in attitudes, practices, policies,
and structures (Mason, 1995).

Interpreting behavior without considering its
cultural context can lead to poor, sometimes
detrimental, treatment outcomes. The covert
prejudice of the treatment staff and language

16

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and cultural differences undermine efforts to
help clients recover from substance abuse
(CSAT, 1999b). However, if practitioners are to
move from accommodation to inclusion in their
helping practices, they must alter practices to
meet the needs of their clients.

Assimilation and Acculturation

Assimilation and acculturation are key 
concepts in cultural competency. The extent of 
a persons assimilation or acculturation 
influences individual behavior and may affect
the treatment outcome. When working with
LGBT people from minority populations,
providers must assess their level of
acculturation and assimilation.

  Assimilation is adaptation to a new culture
by taking on a new identity and abandoning
the old cultural identity.

  Acculturation refers to accommodation to
the rules and expectations of the majority
culture without entirely giving up cultural
identity.

The four interpersonal styles represented
below may be exhibited by clients in treatment
and should be assessed by counselors during 
substance abuse treatment (Bell, 1981). These
styles are fluid, meaning individuals can move
among them depending on the context or stage
of their development or both.

Assimilated individuals consciously or 
subconsciously reject their culture of origin in
favor of their adopted culture. These clients
may resist placement in a group with clients of
their own ethnicity or may prefer a clinician
from their adopted culture.

Bicultural, or multicultural, individuals are
proud of their cultures and can function in, fulfill
their needs through, and be proud of the 
dominant culture. Their emotional, educational, 
economic, and spiritual needs are usually 
fulfilled in a diverse, integrated living environ
ment that honors two (or more) cultures. A
bicultural or multicultural client is likely to be
comfortable in any clinical setting with relative
ease. However, one of the difficulties of this
interpersonal style is cultural or racial 
schizophrenia (Bell, 1981): the feeling of not 
belonging to either community. These clients
face special challenges that may need to be
addressed in treatment.
Culturally immersed individuals have rejected
mainstream culture, and their emotional and
spiritual needs are met exclusively in their 
ethnic community or in the gay community. The
effectiveness of their treatment may depend on
the ability of the provider to be supportive as
clients work through issues related to being a
person from a minority group.

Traditional individuals are defined as carriers
of the community ethos. They neither overtly
accept nor reject their ethnic identity.
Traditional persons have most of their 
emotional, spiritual, and, to some degree, 
educational needs met through their ethnic
community and have limited contact with the
dominant culture or any outside communities.
Their economic needs are met primarily in the
context of the majority culture and sometimes
involve power imbalances that increase their
distrust of other groups. For traditional 
individuals, entering into a mainstream 
treatment program is usually a frighteningly 
foreign experience that calls for sensitivity by
treatment staff. 

The heterogeneity of ethnic culture emphasizes
the need for providers to appreciate clients
cultural context and individuality. This 
emphasis allows for more culturally appropriate
interventions and focuses on the importance of
matching client and provider according to
interpersonal styles rather than ethnicity alone.
Cultural Issues in Working With LGBT Individuals

17

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Cultural Issues in Working With LGBT Individuals
General Issues in Cross-Cultural Treatment

Our culture guides how we act and think as
well as how we come to understand who we
are and how we fit into the world. Cultural
norms are rules of conduct that are internalized
by the members of the group and embody the
fundamental expectations of the group. Cultural
rules resemble family rulesoften the
strongest are the ones not spoken. Because
cultural rules are usually reinforced by parents
or special people in ones life, the rules are
hard to defy. In addition to cultural norms, five
general aspects of culture need to be 
considered if cross-cultural treatment is to 
be effective. They are as follows:

Values of a culture play an important role in
determining how one behaves. Cultural values
vary among different groups. For example,
some cultures admire assertive behavior, but
some Asian cultures consider such behavior
rude or disrespectful. In American Indian
culture, silence is highly valueda difficulty for
counselors who are trained to assess 
commitment by verbal expression.

Language is the primary tool for our work.
Certainly, a client whose native language is 
not spoken in treatment is at an extraordinary 
disadvantage. All languages are complex, and
immigrants find adjusting to the nuances of a
new language difficult. The meaning of many
words or phrases varies depending on context,
tone, audience, and intended message. For
some clients, using bilingual services and staff
greatly increases the effectiveness of treatment.
However, translation into the clients primary
language is not enough. Materials or oral trans
lations need to be adapted to be culturally
appropriate for the intended audience.
Historical factors such as discrimination and
how a person interprets anothers actions also
impact communication and need to be 
considered. Counselors should verify with the
client that the message is understood as
meant. This verification should be done in a
sensitive manner that does not embarrass the
client.
Nonverbal behavior is extraordinarily 
powerful. Interpretations of touches, gestures,
and eye contacts are shaped by personal
experience and culture. For instance, a person
in a prison community does not use direct eye
contact because it is a sign of disrespect in
that circumstance. In the Latino culture, touch
ing the person being addressed is a sign of
attentiveness. It is important for counselors to
be sensitive to a clients style of nonverbal
communication and to consider the degree of
familiarity and the context of the contact.
Counselors should ask clients about any
nonverbal behavior they do not understand. If
counselors question clients in a nonthreatening
way, the clients usually are willing to explain.

Learning styles vary among individuals and 
cultures. Typically, treatment programs use a
Western learning style of formal, often written
instruction. For example, many treatment 
centers require that clients read literature from
Alcoholics Anonymous and write out the step
work without assessing whether the clients
understand the information. Nonliterate clients
or those with low reading comprehension
would be better served if culturally appropriate
audiotapes or videotapes also were used.
Clients from a cultural group with a tradition of
storytelling also may welcome alternative forms
of communication and the use of a variety of
methods to transmit information.

Healing is the essential task of treatment. With
all clients, counselors need to create an 
environment where clients can heal. It is critical
for counselors to assess each clients sources
of comfort, to understand the individuals
beliefs and customs around healingwhat will
make the client feel betterand to understand
the persons definitions of illness and health. 

The Western health care tradition tends to
compartmentalize health issues and assumes

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that healing should be left to those who know
bestmedical personnel. However, this
assumption is being challenged by some 
people and health care providers who are
seeking alternative treatment methods such as
folk medicines, acupuncture, herbs, and 
massage. Some health care providers and
patients are also forming new treatment 
partnerships instead of the authoritarian model
of physician-patient. Substance abuse 
counselors need to determine what the client
believes will make him or her healthy and what
needs to be included in the treatment plan.
This determination is particularly important
because what a person believes will make 
him or her healthy has a great impact on the 
recovery process. Clients resistance to a 
particular treatment method can sometimes be
traced to their healing belief system.

Dimensions of Culture 

Many people experience some form of 
discrimination, prejudgment, bias, closemind
edness, or other exclusionary attitudes
because of their race, ethnic origin, gender,
sexual orientation, religion, or class.
Discrimination toward minority groups can
come from those of the majority culture; toward
other minority groups or the majority culture,
from a minority person or group; or toward an
LGBT individual, from someone in the majority
culture, other ethnic groups, and the individ
uals own ethnic group.

Little research has been done on the
interactions among ethnic diversity, homosexu
ality, and substance abuse. Providers need to
remember that LGBT clients from ethnic 
minority groups may have additional problems
that will affect their recovery from substance
abuse. LGBT members of an ethnic minority
group need to learn the norms of the 
mainstream culture, their own minority culture,
and gay culturenorms that may conflict.
Juggling the demands of these norms may be
confusing and problematic, and the substance
abuse treatment provider may need to help the
client negotiate the confusing and contradicting
norms while the client is in treatment. An LGBT
individual may have a stronger connection to
his or her ethnic group than to the LGBT com
munity, or the dominant allegiance may be to
the LGBT community. It is important that
providers invite clients to explain their cultural
context and how they feel about their place in
society, assess with clients their placement on
the continuum from assimilated to traditional,
and explore the meaning of these variables in
their clients recovery. It is of utmost impor
tance for counselors to be aware of how their
own cultural values, biases, and attitudes influ
ence their practice and how they affect their
behavior toward coworkers and clients. 
Introduction to the LGBT Community and
Culture

Substance abuse treatment providers need to
be aware that LGBT persons do not fit the
prevalent stereotype of well-dressed, middle-
class urban dwellers; drag queens; or
masculinely dressed females. LGBT people
live and work in all segments of society. They
are from every minority, cultural, racial, and
ethnic group. They are members of every
nationality, religion, and age group and are
from every educational and socioeconomic
level. Although some urban centers have popu
lations that are more accepting of LGBT
lifestyles than others, and thus are magnets for
LGBT persons, LGBT people live in rural,
urban, and suburban areas and in every State.
LGBT clients can ask for substance abuse
treatment services anywhere in the country and
not only in large urban areas. 

The LGBT minority group differs from other
minority groups in that LGBT persons do not
come from a common geographic area or have
certain physical characteristics in common. 
Cultural Issues in Working With LGBT Individuals

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Cultural Issues in Working With LGBT Individuals
Gay Culture

There is a lively debate in the LGBT 
community over what constitutes gay culture. 
Is it several cultures within one culture? Do 
lesbian, gay, bisexual, and transgender people
each have their own cultures? Gay culture is as
diverse as all its members. However, there is 
no question that many LGBT individuals 
experience a way of life that is considered a 
culture. Although lesbian, gay, bisexual, and 
transgender individuals from different 
backgrounds experience their communities 
differently, they share the belief in the 
legitimacy of their way of life. Substance abuse
treatment providers should understand that the
gay community possesses common knowledge,
attitudes, and behavioral patterns and has its
own legacy, argot, folklore, heritage, and history.

Gay culture is different in the degree to which it
is submerged within other cultures and in the
way that these cultures tend to affect it. LGBT
peoples behavior is still stigmatized, and
because there is usually no way of identifying
LGBT people apart from their own disclosure
or identification with gay culture, gay culture is
essentially hidden in the larger community.

In contrast to how members of ethnic cultures
are marginalized, LGBT individuals may
receive disapproval and censure from those
whom they most trust and rely onparents,
relatives, religious leaders, teachers, and
friends. Most members of ethnic minorities 
can escape discrimination by returning to a
supportive family or neighborhood. This is not
always true for LGBT persons. When they are
growing up, their positive role models are not
easy to identify. This isolation sets LGBT
minority members apart from ethnic minority
group members who are usually in close
proximity to other members. The LGBT culture
is one that is not developed, taught, or
transmitted by families.
Although homosexuality has existed throughout
the ages and in many different cultures, gay
culture as it is known today began to emerge in
1969, when the New York City police raided a
popular gay bar, the Stonewall Inn. At the time,
raids of gay bars were conducted regularly with
little resistance. However, that night the event
erupted into a violent protest as the crowd
fought back. The protests that followed, known
as the Stonewall Riots, gave birth to the gay
rights movement. Before Stonewall, public
expression of LGBT life and experience 
was rare.

The gay rights movement spawned calls for gay
pride and civil rights. Since Stonewall, some
aspects of gay culture have blossomed. Gay
media, books, magazines, movies, newspapers,
and Internet sites abound. Attention is lavished
on gay heroespublic figures who are out and
who work to improve the lives of LGBT
individuals. Many large companies market their
products or services to the lesbian and gay
community. Several LGBT organizations exist,
and many companies have LGBT employee
organizations.

Part of gay culture is a celebration of being
gay. Gay pride celebrations are held in June to
mark the anniversary of the Stonewall Riots. At
gay pride celebrations, the invisible LGBT
minority makes itself visible and celebrates its
uniqueness, the struggle for civil rights, the 
cultural gains, and its heroes. The event 
usually consists of a parade, musical entertain
ment, and art events showcasing LGBT
authors and performing artists and is attended
by representatives of LGBT social and service
organizations. Gay pride celebrations provide
an opportunity for substance abuse treatment
providers to reach out to the LGBT community.

An aspect of the debate within the gay 
community about gay culture involves gay
rights. Because public acceptance is important,
many LGBT persons want to advance the 
message that LGBT individuals are no 

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different from non-LGBT persons. Some LGBT
persons worry that highlighting the similarities
and the positive aspects of gay culture will
mean the loss of that culture as the LGBT
community is accepted into mainstream 
culture. Some believe that the gay community
should try to transform mainstream society
rather than join it. Another aspect of the debate
involves some LGBT individuals who believe
there is only one way to be gay and do not
honor LGBT persons with other lifestyles or
opposing views. Bisexuals have complained
that lesbians and gay men do not accept 
bisexuality as a legitimate sexual orientation
but regard it as a developmental phase on the
way to acceptance of lesbianism or homosexu
ality exclusively. Substance abuse treatment
providers should keep in mind that this 
disagreement may be very confusing to clients
who are questioning their sexual orientation or
to self-identified LGBT clients who may feel
unaccepted by the LGBT community because
they have a different lifestyle. 

Values. Compassion and authenticity are
important ideals for LGBT individuals. The 
abilities to invent their own relationships, 
cultivate the arts, build a community, and 
create a culture are sources of pride in the
LGBT community.

Language. Some LGBT individuals disapprove
of the words used to describe them, and the
reasons can be helpful in understanding LGBT
clients. For some LGBT people, the term
homosexual overemphasizes sexuality and
seems to indicate that the sex act is more
important to homosexuals than it is to 
heterosexuals. It also resurrects memories of
when homosexuality was considered a 
psychiatric disorder. Hence, the words homo,
bi, queer, or gay are preferred by some
LGBT persons. However, some LGBT persons
are offended by the term queer. Some les
bians may prefer to be called dyke or gay,
instead of lesbian. Transgender persons may
prefer the less clinical term trans. It is 
important to call a transgender client by his or
her preferred name and always to use the 
gender designation that the client has chosen.
Given these conflicting opinions, providers
should ask a self-identified LGBT client what
he or she prefers to be called. The choice is a
conscious and sometimes rather emotional
decision and should be honored. A providers
sensitive use of language can be an important
sign of respect and can help create a healing
environment for LGBT clients. When clients are
confused and questioning their sexual
orientation, the provider should be sensitive 
to the clients confusion.
LGBT individuals have a creative vocabulary
on the subject of sexual orientation because
they may often use code words for safety 
reasons. For example, a gay man or lesbian
uses the following to acknowledge someone
with a same-sex preference: one of us, family,
member of the church, cousin, colleague, or
brother or sister. The vocabulary varies, and
providers should listen carefully and ask ques
tions about the meaning and use of unfamiliar
terms.

Nonverbal behavior. LGBT individuals rely
tremendously on nonverbal cues to establish
whether the situation is safe for them to be
themselves. As they walk into a treatment cen
ter, they will be looking for evidence that they
are accepted and welcome. Do they see a 
rainbow-colored flag? A Straight But Not
Narrow bumper sticker? Is there a mission
statement that includes a commitment to 
honoring diversity or a commitment to treating
LGBT clients? Do they see gay or lesbian staff
members? Until the LGBT client feels a degree
of safety, he or she will be guarded. A provider
who is unaware of this may believe that he or
she is seeing the clients real personality when,
in fact, the client is on alert and hiding it from
the provider. It is important for providers to sig
nal respect, openmindedness, and acceptance
by using appropriate gestures and vocabulary.
Cultural Issues in Working With LGBT Individuals

21

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Cultural Issues in Working With LGBT Individuals
Learning styles. Much of what is taught by
institutions and teachers does not reflect the
personal experiences of many LGBT people.
Experiential learning techniques such as role-
plays may be more appropriate, and peers with
similar experiences are likely to have influence.
Any materials used in treatment that acknowl
edge the LGBT experience will be more effec
tive than those that do not mention it.

Healing. LGBT individuals may distrust the
medical establishment and may be somewhat
more likely than the general population to rely
on the personal experiences of those they trust
or other LGBT persons to select providers and
treatments.

Ethnic Minority Groups

The cultural norms and beliefs of an ethnic
group can have a significant impact on an
LGBT persons feelings about his or her sexual
orientation or gender identity, his or her ability
to express that identity, and how other mem
bers of the ethnic group treat the LGBT person.
Although an LGBT orientation conflicts with 
mainstream cultural values, it may be just as,
or even more, unacceptable in some ethnic
minority groups. Many ethnic groups value
strong family ties and traditional gender roles
and expect that their children will carry on the
family name and traditions through marriage
and children. Some families see LGBT
behavior as arising from a decadent Western
society and as a rebellion against the family
and traditional beliefs, instead of as a part of a
persons identity. Consequently, LGBT behavior
is difficult for family and friends to understand
and tends to become invisible.

Some LGBT individuals of color may be
accepted by their parents but feel alienated
from their ethnic community. Some may 
distance themselves from their cultural 
communities and turn to the LGBT community
for support and validation. Support groups for
LGBT African Americans, Latinos, and
Asian/Pacific Islanders are active in large
cities, but many LGBT individuals of color find
themselves in predominantly white, middle-
class LGBT communities. It is assumed that
the LGBT community with its experience of 
discrimination would be tolerant of diversity.
However, ethnic minorities are discriminated
against by some LGBT individuals. LGBT 
people of color may feel they have double
minority status that may compound negative
consequences such as a poor self-image, low
self-esteem, inadequate coping mechanisms,
and substance abuse. LGBT ethnic minorities
face greater challenges than their counterparts
in mainstream society, and it is important for
substance abuse treatment providers to
validate these experiences and challenges.
American Indian/Alaska Natives

The number of LGBT individuals in American
Indian and Alaska Native communities is not
definitely known, although it is believed to
resemble the parameters of the dominant 
population. From self-reports and the small
amount of research findings available, American
Indians and Alaska Natives in gay or lesbian
relationships report a higher degree of bisexuali
ty than do their Caucasian counterparts.

Historically, some American Indian and Alaska
Native communities viewed the role of a native
person who was different from other communi
ty members as having a strong spiritual 
component. Being different was seen as a
result of a spiritual experience and a path 
chosen by the Creator or the Spirits for that
person. Many American Indian and Alaska
Native communities used the term two-
spirited to describe LGBT individuals.
Traditionally, American Indian and Alaska
Native nations were taught to celebrate the
differences and to see all their members as
sacred beings fashioned by the Creator. At
least 168 of the more than 200 Native
American languages still spoken today have
terms for genders in addition to male and

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female. Many LGBT people prefer the term
two-spirited because it expresses their sense
of combining a male and female spirit. It is also
considered empowering for a person to choose
what to be called as opposed to accepting a
label given by another. This may be particularly
true for this group. In the past, the culture, lan
guage, and religion of American Indian and
Alaska Native people were oppressed by the
majority culture. Christian missionaries used
their influence in converting many traditional rit
uals into Christian rituals. Many native children
were sent to government-run boarding schools
and were prohibited from speaking their native
languages and practicing their native customs.
Along with erasing traditional roles, the tradi
tional respect for two-spirited people also was
diminished. 

While American Indian and Alaska Native
clients are in treatment, it is important to deter
mine their level of acculturation, their tribal 
affiliation, and the degree to which their sexual
or gender identity is accepted by their tribal
community and family. In many communities,
being accepted by ones family is a measure of
health and connectedness. If the family has dif
ficulty accepting the clients sexual orientation, 
recovery from substance abuse may be 
hindered. Reintegrating the individual into his
or her family may help in the recovery process.
Becoming reconnected with family is seen as
necessary for health in native tradition.
Achieving awareness of ones sexual orienta
tion or identity may occur in a different way for
native men and women than for their 
non-Indian LGBT counterparts. 

Values. Some common tribal values are the
importance of sharing and generosity, alle
giance to ones family and community, respect
for elders, noninterference, orientation to the
present time, and harmony with nature.
Respect for individual autonomy within the
community, respect for family, and honoring the
earth are entwined, and each person depends
on others for meaning and existence.
Traditional beliefs support the existence of a
Supreme Creator and the view that each
human has many dimensions such as the
body, mind, and spirit. Like humans, plants and
animals are part of the spirit world that coexists
and intermingles with the physical world. 

Language. Words are to be honored and 
not wasted. Language is used to impart 
knowledge, often through stories. The legends
and stories often have specific meanings and
involve intricate relationships. Use of symbol
ism, animism, subtle humor, and metaphors 
is important. Direct questioning is not as impor
tant. Practitioners need to be aware of both 
their language and nonverbal behavior when 
communicating with this group.

Nonverbal behavior. Their emphasis on 
observant, reflective, and integrative skills
leads American Indian and Alaska Natives to
behavior patterns of silence, listening, non-
verbal cues, and learning by example. Some
traditional natives would view a firm handshake
as intrusive and rude; eye contact is used
minimally; and a passive demeanor is
appropriate.

Learning styles. Historically, their survival
depended on learning the signs of nature, so
observation is central to American Indians and
Alaska Natives. Learning is accomplished by
watching and listening and through trial and
error. Cultural norms and values are passed
from generation to generation through rituals,
ceremonies, and the oral tradition of story
telling. The relationship with a teacher is 
important, but trust needs to be established.

Healing. Wellness is harmony of the mind,
body, and spirit, and native people feel they are
responsible for their own wellness. Healing is
interconnected with the whole person and root
ed in spiritual beliefs connected to the earth
and nature. Some traditional practices are the
talking circle, sweat lodge, four circles, vision
quest, and sun dance and involve community
Cultural Issues in Working With LGBT Individuals

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Cultural Issues in Working With LGBT Individuals
healers, elders, and holy persons (CSAT,
1999b).

African Americans

Homophobia in the African-American 
community is often more intense than in the
dominant community. In the past, the sexual
orientation of African-American lesbians and
gay men was often known by the community
although it was not discussed. Many African-
American individuals, particularly men, call
themselves bisexual instead of gay. Many
African-American LGBT individuals operate in
separate spheres and may perform community
service in the African-American community, but
they primarily socialize within the African-
American LGBT community. Identifying oneself
as an LGBT individual publicly may put an
African American at risk for losing his or 
her most important support systemthe 
African-American community.

Many LGBT African Americans say that they
do not feel welcome or comfortable in 
predominantly Caucasian LGBT settings (e.g., 
clubs, bars, pride events), and racist incidents
have been reported. Diversity in the LGBT
service provider community is essential to
accommodate for the distrust between African
Americans and Caucasians. Many service
provider agencies targeting African Americans
were formed during the height of the HIV/AIDS
epidemic.

Focus groups consisting of African-American
gay men and lesbians conducted in California
by Michael Browning of Day One in Pasadena,
a member of this publications Steering
Committee, clearly stated that they did not
want to be called queer and considered it a
negative term. Substance abuse treatment
counselors need to refrain from using the term,
especially if they are working with African
Americans.
Focus group members stated that religion
remains important to many gays and lesbians
in African-American communities, even though
some have had negative experiences with
organized religious groups. Many treatment
programs have some religious context
(whether spoken about or not), and focus
group members felt that including spiritual
activities, music, and practices that are more 
indigenous to African-American communities
would be helpful in treatment.

Values. Interpersonal relationships are highly
valued, and the identity of African Americans is
tied to their group identity. The self is consid
ered an extended self, and this group orienta
tion contrasts with the wider cultural norm of
individualism. The community, social 
organizations, neighborhoods, and kinship 
relationships provide aid and support. 
African-American families vary from nuclear 
to extended. Female-headed households 
predominate in some socioeconomic levels, but
marriage is still highly valued. Rearing children
is considered a communal responsibility. 

Language. Language is passionate and full of
action. Dialects and slang are used in some
geographic locations and need to be 
understood by providers. Same-gender-loving
is a term used by many African-American
LGBT individuals. The appropriate form of
address is by title (e.g., Ms., Dr., Rev., Mrs.)
rather than first name, unless permission is
given to use the more informal address.

Nonverbal behavior. Body language is
expressive and used extensively to help 
communicate. Movement, thought, and 
nonverbal behavior are spontaneous, and
many African Americans are highly aware of
nonverbal cues. Touch is important; however,
observing personal space is one key to
whether a person feels respected, and
providers need to follow the clients lead. 

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Learning styles. Learning styles tend to be
relational rather than analytical. Oral communi
cation predominates in knowledge transmission.
Tradition is highly valued over the visual and the
written word. Teachers and students need to
develop a trusting relationship. Storytelling is
used to teach about life and pass on cultural 
values. The use of storytelling and African
proverbs can enhance insights into treatment.

Healing. Healing occurs through laying on of
hands, prayer, herbs, and the like. One is sick
when one cannot do for oneself any longer,
and recovery from illness usually is seen as
possible with the help of God. For many, God
and the spiritual community are based in the
Christian church and organized religion.

Asian/Pacific Islanders

Asian/Pacific Islanders consist of more than 
60 culturally distinct groups, practice several
types of religion, and speak more than 100 
languages and dialects. Their degree of 
acculturation and assimilation varies. The
Asian/Pacific Islander cultures have few char
acteristics in common. For some Asian/Pacific
Islander groups, the traditional Asian/Pacific
Islander approach to health and illness centers
around balance and harmony. The ultimate
goal is to attain a perfect balance among 
systems of the individual, society, and the 
universe at large (Wong et al., 1998).
Cohesiveness of the group is an important
value, and because of this, shame is a 
frequently used social constraint to control 
or deter expressions of homosexual behavior
(Wong et al., 1998).

Some Asian/Pacific Islander cultures believe
that if one is vigilant in maintaining balance in
ones relationships, then one cannot become
ill. It is only when one is out of balance that
disease occurs. In addition, prevention as 
conceptualized by most Asian/Pacific Islanders
dictates that, as long as primary prevention
behaviors are practiced, there is no reason for
secondary prevention efforts, such as making
regular visits to a physician (Wong et al.,
1998). Providers need to understand this 
cultural value and adapt their prevention and
treatment efforts accordingly.

Values. This culture is heavily based on 
interdependence, and family is central. The
individual is expected to subsume his or her
needs to those of the larger groupfamily,
community, or other groups. Varying from ones
prescribed role can cause shame and loss of
face for the family. Authority and age are highly
respected and honored; thus, there may be
discomfort in addressing providers, particularly
older ones, by their first names.

Language. Some of the languages spoken by
Asian/Pacific Islanders do not have words for
lesbian, gay, bisexual, or transgender. Without
descriptive words, the formation of an LGBT
identity may be precluded and an ambiguous
social role for LGBT individuals may result. In
other words, the behaviors may be practices
that lack social legitimacy and may not be 
discussed. Thus, communication may be 
indirect, particularly about personal issues or
sexual behavior. Initial communication during
treatment may need to be indirect with a 
gradual increase in directness about the issue.

Nonverbal behavior. Nonverbal behaviors are
as varied as the communities themselves. In
some groups, bowing is important, as are 
related behaviors such as using both hands to
present a business card to a colleague, the
elderly, and people in authority. Same-sex
touching (e.g., holding hands) is not uncom
mon in most Asian/Pacific Islander cultures; it
is a gesture of affection, not sexual feeling. 

Learning styles. Hierarchical societies support
deference to authority (e.g., physicians, health
care providers, teachers, the elderly). The
learning style is likely to be traditional; 
information is disseminated or transmitted
in one direction, from teacher to student.
Cultural Issues in Working With LGBT Individuals

25

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Cultural Issues in Working With LGBT Individuals
Healing. Self-reflection through meditation is
one traditional way to confront personal issues
and increase self-knowledge. Ethics, as 
outlined by philosophers such as Lao Tzu 
and Confucius, provide standards for human
behavior and regaining a healthy balance.
Asian Americans who are Muslim, Christian, or
Hindu may have very different beliefs. Eastern
medicine is complex, and many recently
arrived Asian Americans may still use 
traditional cures. 

Hispanic Americans/Latinos

Hispanic Americans (also called Latinas and
Latinos) are defined as individuals of Mexican,
Puerto Rican, Cuban, Central or South
American, or other Spanish cultures or origins,
regardless of their race (CSAT, 1999b). LGBT
Hispanics, regardless of the differences among
the nationalities represented, have many com
mon values, including strong religious faith,
altruism, family values, and spirituality. They
contribute greatly to their community, 
regardless of the fact that they may come from
diverse and separate cultural systems and
socioeconomic realities. 

In treating Hispanic clients, the family is the
cornerstone. The support network consists of
the family and a host of other individuals who
may or may not be related. For new immi
grants, the stress of learning a new language,
new cultural norms and behavior, and the
sense of loss from leaving family and other
loved ones behind can be overwhelming. 

Homosexuality may be privately acknowledged,
but it is usually not discussed openly.
Hispanics may be more reluctant to self-identify
as LGBT than members of the mainstream 
culture. The perception of sexuality as an 
indication of identity is often overridden by
identification with the community. Mainstream
culture tends to label a person who has a
sexual encounter with someone of the same
gender as gay, bisexual, or lesbian. In Hispanic
culture, some men who have sex with men do
not consider themselves gay if they play the
dominant role in the sexual act. When treating
Hispanic clients, providers should respect this
distinction.
Values. Group needs and objectives, family
values and ties, and trust (confianza) are
respected. Traditional values, some of which
are rooted in the Catholic faith, are honored.
Many Hispanic Americans consider religion
central to their lives. Latino/Latina clients
appreciate recognition of the emotional, family,
and spiritual challenges related to substance
abuse problems. Clients likely will maintain a
high level of privacy about subjects of a 
personal nature (illness, addiction, sexual
behavior). 

In most families, the family respects strong
gender roles. Machismo, the strong sense of
masculine pride or exaggerated masculinity,
and other traditional male attitudes can be 
barriers to seeking treatment for substance
abuse and to coming out. Males are the center
of the family, and many gay, bisexual, and
transgender men find it difficult to acknowledge
their sexual and gender identities.

Drinking is a socially accepted behavior in
some families, and young children are allowed
to drink beer and tequila as a rite of passage.
Caseres and Cortifias (1996) report that for gay
Latinos the bar can be a surrogate home
where they can find their other family, who 
fulfill[s] some of their needs of emotional 
support in a nonjudgmental context . . . the 
bar life nurtures, relieves guilt, and becomes
an emotional shelter where they can find a
new, positive, and valuable world.

Language. Using nonscientific, nontechnical
terms and descriptions applicable to the clients
cultural background (Mexican, Colombian,
Puerto Rican, etc.) is recommended. The use
of Latino, Chicano, or Hispanic differs among
groups and communities. An interpreter may

26

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be necessary to successfully treat some
Hispanic clients or their families, and bilingual
staff members are an excellent resource. 

Nonverbal behavior. A professional and
respectful physical contact, such as shaking
hands at every greeting, helps create a safe
space for the client. Maintaining eye contact
denotes attention and understanding.

Learning styles. Family members, especially
heads of families, are a source of guidance,
counseling, and instruction. It is important to
empower individuals to learn about their 
situation and to know that they can seek 
support within their own community. It is 
necessary to remember that for most Hispanic
Americans the learning process is based in the
context rather than the process. Using a 
hypothetical third person when giving examples
to avoid embarrassment and discomfort about
intimate subjects is an effective approach.
Healing. Healing is influenced by strong 
religious beliefs that are often based on 
traditional Catholicism, although other practices
may be followed. Spirituality and religious
beliefs are generally very strong and can 
influence the decisionmaking or behavioral-
change processes.

Summary

The information in this chapter is only a 
skeletal framework to introduce providers to the
complex issues of cultural competency, ethnici
ty, and gay culture. Providers can help their
LGBT clients by understanding their struggle
and creating a safe and supportive treatment
space. Cultural values and norms are powerful
forces, and providers should be mindful that
often it is hard for clients to abandon long-held
cultural beliefs, even if they are harmful. The
experience of expanding their knowledge of the 
cultural backgrounds of their clients can be
rewarding and worthwhile for providers.
Cultural Issues in Working With LGBT Individuals

27

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Chapter 3
Legal Issues for Programs Treating 
LGBT Clients

Margaret Kent Brooks, J.D., Consultant, Upper Montclair, NJ1

Introduction

Lesbian, gay, bisexual, and transgender
(LGBT) individuals with substance abuse
problems are doubly stigmatized. As 
substance abusers, they are viewed by
many as weak in character and moral fiber.
As lesbian, gay, bisexual, and transgender
individuals, they are reviled by some as
deviant and immoral. They may encounter
bigotry from employers, human service
workers, criminal justice officials, the 
general public, and even their own families. 

Two Federal (and a number of State)
statutes protect recovering substance
abusers from many forms of discrimination.
However, in most areas of the country,
LGBT individuals have no legal protection
against discrimination in employment, 
housing, or access to social services.
Protections fought for and won by women,
racial minorities, and individuals with 
disabilities simply are not available for LGBT
persons. Disclosure of sexual orientation
can lead to an individuals being fired or
being denied access to housing and social
servicesall with legal impunity. LGBT 
individuals may even lose custody of their
children if their sexual orientation becomes
known during a custody dispute. 

Even in those States that have enacted
statutes prohibiting discrimination on the
basis of sexual orientation, LGBT individuals
have sometimes been denied protection.
Little wonder that LGBT individuals regard
protecting information about their sexual 
orientation and substance abuse histories as

1Based on original text by Ken South, M.Div., Consultant, Rockville, MD, and Roxanne Kibben, M.A., LAADC, 
NCAC II, R. Kibben Company, Minneapolis, MN.
What providers will learn  
from this chapter:

  How programs can protect
the confidentiality of LGBT
clients

  The legal barriers facing  
LGBT individuals   

  The legal issues raised by
HIV/AIDS  

  What policies programs
should adopt to ensure
that clients and staff are
fairly treated

29

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Legal Issues for Programs Treating LGBT Clients
critically important. Programs that treat this
special population need to be particularly 
sensitive about maintaining clients 
confidentiality, for the consequences of an
inappropriate disclosure can be far reaching.
(For a compendium of the law regarding 
discrimination against LGBT individuals, see
www.lambdalegal.org.)

This chapter examines ways programs can
safeguard information about clients substance
abuse histories, sexual orientation, and HIV
status. It then describes how the lack of legal
protection against discrimination can affect
LGBT individuals in a variety of areas and how
programs can help these clients protect them
selves. Finally, the chapter outlines the laws
protecting clients with histories of substance
abuse and/or HIV/AIDS from discrimination.

Protecting the Confidentiality of LGBT
Individuals in Substance Abuse 
Treatment Programs

Confidentiality Requirements

Concerned about the adverse effects stigma
and discrimination have on clients in recovery
and how stigma and discrimination might deter
people from entering treatment, Congress
passed legislation (42 U.S.C. 290dd-2) and
the U.S. Department of Health and Human
Services issued a set of regulations (Vol. 42 of
the Code of Federal Regulations [CFR], Part 2)
to protect information about clients substance
abuse treatment.

The Federal law and regulations severely
restrict communications about identifiable
clients by programs specializing, in whole or
in part, in providing treatment, counseling,
and/or assessment and referral services for
substance abuse problems (42 CFR 2.11).
Although the Federal regulations apply only to
programs that receive Federal assistance, this
includes indirect forms of Federal aid, such as 
tax-exempt status or State or local government
funding coming (in whole or in part) from the
Federal Government. 
The regulations for communications are more
restrictive in many instances than, for example,
either doctor-patient or attorney-client privilege.
They protect any information about an individ
ual who has applied for or received any 
substance abuse-related assessment, 
treatment, or referral services from a program.
They apply from the time the individual makes
an appointment and apply to former clients as
well. They apply to any information that would
identify the individual either directly or by 
implication as a substance abuser. They apply
whether or not the person seeking information
already has that information, has other ways of
getting it, has some form of official status, is
authorized by State law, or comes armed with
a subpoena or search warrant. Violating the
regulations is punishable by a fine of up to
$500 for a first offense and up to $5,000 for
each subsequent offense (2.4). 

Programs can find detailed information about
compliance with the regulations in Technical
Assistance Publication 13 Confidentiality of
Patient Records for Alcohol and Other Drug
Treatment (CSAT [Center for Substance Abuse
Treatment], 1999a), available from the
Substance Abuse and Mental Health Services
Administrations (SAMHSAs) National
Clearinghouse for Alcohol and Drug
Information (NCADI) at 8007296686. What
follows is a brief description of some of the 
regulations major provisions.

When May Confidential Information Be
Shared With Others?

The confidentiality regulations permit disclosure
without the clients consent in several 
situations, including medical emergencies,
reporting child abuse, and communications
among program staff. (For a full discussion of
these exceptions, see CSAT, 1999a.)  

30

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Consent: Rules About Obtaining Consent
To Disclose Treatment Information

The most frequently used exception to the 
regulations general rule prohibiting disclosure
is client consent. (Parental consent must also
be obtained in some States. See below.) The
regulations requirements regarding consent
are strict and somewhat unusual and must be
carefully followed.

Most disclosures are permissible if a client has
signed a valid consent form that has not
expired or been revoked (2.31). To be valid, a
consent form must be in writing and must 
contain each of the items specified in 2.31:

1.  The name or general description of the 
program(s) making the disclosure

2.  The name or title of the individual or 
organization that will receive the disclosure

3.  The name of the client who is the subject of
the disclosure

4.  The purpose or need for the disclosure

5.  How much and what kind of information will
be disclosed

6.  A statement that the client may revoke (take
back) the consent at any time, except to the
extent that the program has already acted
on it

7.  The date, event, or condition upon which the
consent will expire if not previously revoked

8.  The signature of the client (and, in some
States, his or her parent)

9.  The date on which the consent is signed
(2.31(a)).

A general medical release form, or any consent
form that does not contain all of the elements
listed above, is not acceptable. (See the 
sample consent form in exhibit 31.) 
A number of items on this list deserve further
explanation and are discussed under the 
bullets below.

  The purpose of the disclosure and how
much and what kind of information will be
disclosed

These two items are closely related. All 
disclosures must be limited to information that
is necessary to accomplish the need or 
purpose for the disclosure, and this purpose or
need must be specified on the consent form. It
would be improper to disclose everything in a
clients file if the recipient of the information
needs only one specific piece of information. 

Once the purpose or need has been identified,
it is easier to determine how much and what
kind of information will be disclosed, tailoring it
to what is essential to accomplish the specified
need or purpose. That, too, must be written
into the consent form.

As an illustration, if a client needs to have his
or her participation in counseling verified in
order to be excused from school early, the 
purpose of the disclosure would be to verify
treatment so that the school will permit early
release, and the amount and kind of informa
tion to be disclosed would be times and dates
of appointments. The disclosure would then be
limited to a statement saying, Susan Taylor
(the client) is receiving counseling at XYZ
Program on Tuesday afternoons at 3 p.m.

  The clients right to revoke consent

The client may revoke consent at any time, and
the consent form must include a statement to
this effect. Revocation need not be in writing. If
a program has already made a disclosure prior
to the revocation, acting in reliance on the
clients signed consent, it is not required to try
Legal Issues for Programs Treating LGBT Clients

31

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              Exhibit 31:
Consent for the Release of Confidential Information
Legal Issues for Programs Treating LGBT Clients
I, ____________________________________________________________________, authorize
(Name of client)

_______________________________________________________________________________
(Name or general designation of program making disclosure)

to disclose to ____________________________________________________________________
(Name of person or organization to which disclosure is to be made)

the following information:___________________________________________________________
(Nature of the information, as limited as possible)

_______________________________________________________________________________
_______________________________________________________________________________
I understand that the program will NOT be disclosing information about my sexual orientation.

I understand that the program will be disclosing information about my sexual orientation.

_____________________________
(Clients initials)

The purpose of the disclosure authorized herein is to: ____________________________________

_______________________________________________________________________________
(Purpose of disclosure, as specific as possible)

_______________________________________________________________________________
I understand that my records are protected under Federal regulations and cannot be disclosed without my
written consent unless otherwise provided for in the regulations. I also understand that I may revoke this
consent at any time except to the extent that action has been taken in reliance on it, and that in any event
this consent expires automatically as follows:

_______________________________________________________________________________
(Specification of the date, event, or condition upon which this consent expires)

___________________________________________/____________________________________
(Signature of client)  (Date)

_______________________________________________________________________________
(Signature of parent, guardian, or authorized representative when required)

32

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to retrieve the information it has already 
disclosed.

The regulations also provide that acting in
reliance includes the provision of services
while relying on a consent form permitting 
disclosures to a third-party payer. (Third-party
payers are health insurance companies,
Medicaid, or any party other than the 
adolescents family that pays the bills.) Thus, a
program can bill the third-party payer for 
services provided before the consent was
revoked. However, a program that continues to
provide services after a client has revoked a
consent authorizing disclosure to a third-party
payer does so at its own financial risk.

  Expiration of consent form

The form must also contain a date, event, or
condition on which it will expire if not previously
revoked. A consent must last no longer than
reasonably necessary to serve the purpose for
which it is given (2.31(a)(9)). Depending
upon the purpose of the consented disclosure,
the consent form may expire in 5 days, in 6
months, or in a longer period. 

The consent form does not have to contain a
specific expiration date but may instead specify
an event or condition. For example, if an 
adolescent has been placed on probation at
school on the condition that she attend 
counseling at the program, the consent form
can be drafted to expire at the completion 
of the probationary period. Or, if a client is 
being referred to a podiatrist for a single 
appointment, the consent form should stipulate
that consent will expire after he or she has
seen Dr. X. (See below for further discussion
about making referrals.)

  The signature of the client (and the issue
of parental consent)

A minor must always sign the consent form in
order for a program to release information even
to his or her parent or guardian. The program
must get the signature of a parent, guardian, or
other person legally responsible for the minor
in addition to the minors signature only if the
program is required by State law to obtain
parental permission before providing treatment
to a minor (2.14). 
In other words, if State law does not require the
program to get parental consent in order to 
provide services to a minor, then parental 
consent is not required to make disclosures
(2.14(b)). If State law requires parental consent
to provide services to a minor, then parental
consent is required to make any disclosures.

Note that the program must always obtain the
minors consent for disclosures and cannot rely
on the parents signature alone. (For a full 
discussion of this issue and what programs can
do when minors applying for treatment refuse
to consent to parental notification in those
States requiring parental consent to treatment,
see Legal and Ethical Issues, in Treatment
Improvement Protocol 32 Treatment of
Adolescents With Substance Use Disorders
(CSAT, 1999c).

Where LGBT minors are concerned, the issue
of parental consent can be a particularly 
delicate matter. Minors in States requiring
parental consent for treatment can specify on
the written consent form that their sexual 
orientation will not be disclosed to parents (see
exhibit 31).

   Required notice against redisclosing
information

Once the consent form has been properly 
completed, there remains one last formal
requirement. Any disclosure made with patient
consent must be accompanied by a written
statement that the information is protected by
Federal law and that the recipient cannot 
further disclose or release such information
unless permitted by the regulations (2.32).
Legal Issues for Programs Treating LGBT Clients

33

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Legal Issues for Programs Treating LGBT Clients
This statement, not the consent form itself,
should be delivered and explained to the 
recipient of the information at the time of 
disclosure or earlier. (Of course, a client may
sign a consent form authorizing a redisclosure.)

Using Consent Forms 

The fact that a client has signed a valid 
consent form authorizing the release of 
information does not mean that a program
must make the proposed disclosure, unless the
program has also received a subpoena or court
order (2.3(b)(1); 2.61(a)(b)). In most cases,
the decision whether to make a disclosure
authorized by a clients signed consent is up to
the program, unless State law requires or 
prohibits a particular disclosure once consent is
given. The programs only obligation under the
Federal regulations is to refuse to honor a 
consent that is expired, deficient, or otherwise
known to be revoked, false, or incorrect
(2.31(c)). 

In general, it is best to follow this rule: Disclose
only what is necessary, for only as long as is
necessary, keeping in mind the purpose for 
disclosing the information.

  Using consent forms to seek information
from collateral sources

Making inquiries of families, partners, schools,
employers, doctors, and other health care
providers might, at first glance, seem to pose
no risk to a clients right to confidentiality. But it
does.

When a program that offers assessment and
treatment for substance abuse asks a family
member (including a parent), partner, 
employer, school, or doctor to verify information
it has obtained from the client, it is making a
disclosure that the client has sought help for
substance abuse. The Federal regulations 
generally prohibit this kind of disclosure unless
the client consents.
How then is a program to proceed? The 
easiest way is to get the clients consent to
contact the family member (including a parent),
partner, employer, school, health care facility,
etc. In fact, the program can ask the client to
sign a consent form that permits the very 
limited disclosure that he or she has sought
assessment or treatment services in order to
gather information from any one of a number of
entities or persons listed on the consent form.
Note that this combination form must still
include the name or title of the individual or
name of the organization for each collateral
source the program may contact. If program
staff are making inquiries by telephone, they
must inform the parties at the other end of the
line orally and then by mail about the 
prohibition on redisclosure.

Of course, the program should never disclose
information about the clients sexual orientation
to a collateral source, unless the client 
specifically consents to disclosure to that 
particular person or agency. The consent form
provided in exhibit 31 allows the client to
choose whether to consent to disclosure of 
this information. 

  Using consent forms to make periodic
reports or coordinate care

Programs serving LGBT individuals may need
to confer on an ongoing basis with other 
agencies, such as mental health or child 
welfare programs. Again, the best way to 
proceed is to get the clients consent (as well
as parental consent when State law requires).
Take care in wording the consent form to 
specify the purpose of the communication and
the kind and amount of information to be 
disclosed. For example, if the program needs
ongoing communications with a mental health
provider, the purpose of the disclosure would
be coordination of care for Simon Green and
how much and what kind of information will be
disclosed might be treatment status, 
treatment issues, and progress in treatment. 

34

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If the program is treating a client who is on 
probation at work and whose continued 
employment is contingent on completing 
treatment, the purpose of disclosure might be
to assist the patient to comply with the employ-
ers mandates or to supply periodic reports
about attendance, and how much and what
kind of information will be disclosed might be
attendance or progress in treatment.

Note that the kinds of information that will be
disclosed in these two examples are quite 
different. The program might well share
detailed clinical information about a client with
a mental health provider if that would help in
coordinating care. Disclosure to an employer
should be limited to a brief statement about the
clients attendance or progress in treatment.
Disclosure of detailed clinical information to an
employer would, in most circumstances, be
inappropriate.

The program should also give considerable
thought to the expiration date or event the 
consent form should contain. For coordinating
care with a mental health program, it might be
appropriate to have the consent form expire
when treatment by either agency ends. A 
consent form permitting disclosures to an
employer might expire when the clients 
probationary period ends.

Programs should exercise great care about
sharing information about clients sexual 
orientation. Disclosure of such information
might be therapeutically important when a 
substance abuse program is coordinating a
clients care with a mental health provider. It
would not be appropriate to disclose this infor
mation to a clients employer. Programs should
get clients consent in writing before making
any disclosures about sexual orientation.

  Using consent forms to make referrals

Programs treating LGBT individuals may need
to refer clients to other health care or social
service agencies. The program can, of course,
give the client the name and telephone number
of an outside gynecologist, psychologist, or
training program and allow him or her to initiate
the call. However, if a staff member at the 
program makes the call to set up an 
appointment, he or she must keep in mind that
such a call may result in disclosure that the
client has a substance abuse problem. If the
staff member identifies the client as attending a
substance abuse treatment program, directly or
by implication, the referral requires the clients
consent in writing (as well as parental consent
in States requiring it). 
Unless the client has consented, the program
should not disclose the clients sexual 
orientation when making a referral.

HIV and Confidentiality

Almost all States now have laws protecting
information about individuals HIV status. The
laws vary widely in the strength of the protec
tion they offer. All allow for disclosure of HIV-
related information in certain circumstances.
Administrators should educate themselves
about the HIV confidentiality protections offered
by their individual States. 

Discrimination Against LGBT Individuals

In much of the United States, discrimination
against individuals because of their sexual 
orientation is legal. Although some States have
extended their laws against racial and gender
discrimination to cover discrimination on the
basis of sexual orientation, in most places
LGBT individuals can be denied employment or
fired, barred from housing, and excluded from
health and social services. 

LGBT individuals are disadvantaged legally in
other areas as well. In most States, same-sex
couples in a committed relationship are 
prohibited from marrying. This means that
same-sex partners must make special 
Legal Issues for Programs Treating LGBT Clients

35

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Legal Issues for Programs Treating LGBT Clients
arrangements if they wish to bequeath their
assets to each other after death. Few 
jurisdictions provide unmarried partners of
employees the health insurance benefits 
married partners take for granted; even fewer
require private employers to offer unmarried
partners these benefits. Partners may have 
difficulty visiting their loved ones in hospitals
that have family only policies. LGBT 
individuals are often denied the right to adopt 
children. 

Because of the lack of protection under the
law, LGBT individuals may suffer severe or
painful consequences if their sexual orientation
becomes known. They risk losing custody of
their own children in disputes with former
spouses or families of origin because of their
sexual orientation. (A diagnosis of substance
abuse can be yet another strike against them
in such cases.) In addition, LGBT individuals
can be discharged from the military if their 
sexual orientation becomes known.

Thus far, only one State has enacted 
legislation that recognizes what it terms civil
union between two individuals of the same
sex. The statute was passed in response to a
decision of the Supreme Court of Vermont
(Baker v. State of Vermont) finding that the
States denial of marriage licenses to same-sex
couples effectively excludes them from a
broad array of legal benefits and protections
incident to the marital relation, including access
to a spouses medical, life, and disability 
insurance, hospital visitation and other medical
decisionmaking privileges, spousal support,
intestate succession, homestead protections,
and many other statutory protections. The
court held that the State is constitutionally
required to extend to same-sex couples the
common benefits and protections that flow from
marriage under Vermont law. 

The Vermont Supreme Court did not order the
State to offer marriage licenses to same-sex
couples. Rather it required the State legislature
to craft an appropriate means of addressing
this constitutional mandate [through any one]
potentially constitutional statutory scheme from
other jurisdictions [that provide] an alternative
legal status to marriage for same-sex couples,
impose similar formal requirements and 
limitations, create a parallel licensing or 
registration scheme, and extend all or most of
the same rights and obligations provided by the
law to married partners. Ultimately, the State
legislature chose to enact a civil union (cu)
statute, and same-sex couples in Vermont
have already been cued.  (It remains unclear
whether other States will recognize such
unions between individuals who travel to
Vermont for the purpose of being cued.)
The Vermont Supreme Court based its decision
squarely on the common benefits clause of the
Vermont constitution, a provision it interpreted
as offering stronger protection to Vermont citi
zens than the Federal equal protection clause.
The advantage of the courts resting its 
decision on the Vermont constitution is that the
U.S. Supreme Court cannot review or overturn
the decision. The disadvantage is that other
States lacking a similar clause are less likely to
adopt the courts reasoning.

For up-to-date information on the laws regard
ing discrimination against LGBT individuals,
see www.lambdalegal.org.

What Can Be Done To Help LGBT Clients?

There are a number of ways that programs can
adjust their policies and procedures to protect
clients, educate them, and help them deal with
the discrimination they may face. 

1. Confidentiality

Programs should establish written policies that
ensure that information about sexual 
orientation is confidential. The policy should
prohibit disclosure of such information to 
anyone outside the program, unless the client

36

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consents. Any exceptions to this rule should be
approved in advance by the program director.

2. Caution on Self-Disclosures

As part of the recovery process, substance
abuse treatment programs often encourage
clients to acknowledge to others that they have
abused alcohol and drugs. Of course, 
disclosure of this information is not always
advisable. While there are laws protecting 
alcoholics and former drug abusers from 
discrimination in employment, housing, and
access to health care (see below), it is not
always easy to enforce those legal protections.
Clients should be advised to think carefully
before disclosing information about their 
substance abuse histories.

LGBT clients should also be cautioned to think
carefully before disclosing their sexual 
orientation to others. Such disclosures will
rarely be advisable unless clients are fairly
sure how the information will be received.
Because LGBT clients often have no legal 
protection against discrimination on the basis
of sexual orientation, they should continue to
share this information only with those they are
confident will respect them and their privacy. 

3. Education

Programs should educate staff and clients
about State and local laws and regulations
regarding LGBT persons. Some jurisdictions
have enacted statutes protecting LGBT 
individuals from some forms of discrimination.
Other jurisdictions have enacted statutes
designed to make life more difficult for LGBT
individuals. The confidentiality afforded HIV-
related information also varies from place to
place. Programs should use the resources 
listed at the end of this chapter to educate
themselves and their clients about LGBT legal
issues. The Web site maintained by the
Lambda Legal Defense and Education Fund is
particularly informative.
4. Legal Inventory

Programs can help their clients review their
employment, marital, and parental statuses
and assess what steps they might take to 
protect themselves and their rights. 

Example 1: Barbara A., a 23-year-old lesbian,
is contemplating a divorce. She has three
young children and very much wants to retain
custody. She worries that her spouse will use
her sexual orientation (and/or treatment histo
ry) when the issue of child custody arises. 

The program should encourage Barbara to
share information about her sexual orientation
and substance abuse treatment with her attor
ney. Depending on Barbaras relationships with
her spouse and the childrens grandparents,
her attorney may advise her to consider 
seeking a negotiated custody agreement.
Information about her sexual orientation (and
substance abuse history) is less likely to be
used against Barbara in this context than 
during a heated court battle. 

Example 2: Harry B. is in a committed 
relationship with Stephen C. Harry is worried
about what might happen if his high blood
pressure causes him to have a stroke. What if
he becomes unable to make decisions about
his own medical care? He feels very strongly
that he would not want to prolong his life 
following a massive stroke. He wonders
whether Stephen will be allowed to make 
medical decisions for him. 

The program can help Harry explore the
options available to him, which may include
(depending upon State law) signing advance
directives about his health care and/or signing
a legal document appointing Stephen his proxy,
enabling him to make health care decisions
should Harry become incapacitated. This legal
document is often called a health care proxy
or a medical power of attorney. 
Legal Issues for Programs Treating LGBT Clients

37

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Legal Issues for Programs Treating LGBT Clients
Example 3: Ellen W. and Jean C. have grown
old together. Ellen has a considerable fortune
she inherited from her father; Jean has few
assets. Ellen wants to make sure Jean will
inherit her property.

State law generally controls rules of inheri
tance. However, in most (although not all)
instances these rules can be overridden once
an individual makes a will naming a beneficiary
or establishes a trust for the benefit of a named
individual. In this respect, LGBT individuals are
no different from heterosexuals who are
unmarried and have only distant blood 
relatives. They, too, must make a formal will or
set up a trust if they do not want a third cousin
to inherit their assets.

5. Respect for LGBT Clients

Programs treating LGBT individuals should
take steps to ensure that staff and other clients
respect the privacy, safety, and humanity of this
population. 

  Programs should screen staff members to
ensure that they are willing to work with
LGBT individuals. Written descriptions of job
responsibilities should include treatment of
LGBT individuals.

  Program rules should require that clients
exhibit respect for one another without
regard to race, gender, religion, national 
origin, or sexual orientation. Programs
should establish grievance procedures for
clients who want to complain about violation
of the rules. All complaints should be 
handled promptly.

  Programs should treat the partners of LGBT
clients as they do members of traditional
families. Many LGBT clients are alienated
from their families of origin and will not want
them to visit. However, visits by a partner
may be welcomed. 
For a comprehensive list of Standards of
Practice for Provision of Quality Health Care
Services for Gay, Lesbian, Bisexual, and
Transgendered Clients, see the Web site
maintained by the Gay, Lesbian, Bisexual, and
Transgender Health Access Project at
www.glbthealth.org.

6. Program Safety for LGBT Individuals

All clients should be informed at admission that
the program will not tolerate sexual harassment
or sexual overtures between persons of the
same or different gender. Programs should
establish effective grievance procedures and
respond to any violations of the rules promptly. 

Written personnel policies should include 
prohibition of harassment in the workplace,
including harassment of LGBT staff by other
staff and sexual harassment between persons
of the same (or different) gender. Programs
should establish effective disciplinary proce
dures and respond to complaints promptly.

Programs treating minors should be particularly
attentive to this issue, as an incident involving
a minor can result in serious legal conse
quences. The minors parents may sue a 
program that is negligent in this area, and child
protective services may intervene if there is an
allegation of abuse.

7. Affirmative Action/Cultural Competency

Providing effective treatment for LGBT 
individuals requires programs to make every
effort to employ LGBT individuals in visible
jobs. Personnel policies should include a
nondiscrimination hiring clause that 
encompasses LGBT persons (see chapter 14,
Policies and Procedures), and programs 
should offer domestic partner benefits 
whenever possible. 

38

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Do LGBT Individuals in Substance Abuse
Treatment Have Any Legal Protections?

Yes, in areas unrelated to sexual orientation,
they do. The Federal Rehabilitation Act (29
U.S.C. 791 et seq. (1973)) and the Americans
with Disabilities Act (ADA) (42 U.S.C. 12101
et seq. (1992)) prohibit discrimination against
individuals with disabilities, a group defined
as including individuals who are alcoholics or
have a history of drug abuse. Together, these
laws prohibit discrimination based on 
alcoholism or a history of drug abuse in the
services, programs, or activities provided by:

  State and local governments and their
departments, agencies, and other 
instrumentalities (29 U.S.C. 794(b) and 
42 U.S.C. 12131(1) and 12132)

  Most providers of public accommodations,
including hotels and other places of lodging,
restaurants and other establishments serving
food or drink, places of entertainment
(movies, stadiums, etc.), places the public
gathers (auditoriums, etc.), sales and other
retail establishments, service establishments
(banks, beauty shops, funeral parlors, law
offices, hospitals, laundries, etc.), public
transportation depots, places of public dis
play or collection (museums, libraries, etc.),
places of recreation (parks, zoos, etc.), 
educational establishments, social service
centers (day care or senior citizen centers,
homeless shelters and food banks, etc.), and
places of exercise and recreation (42 U.S.C.
12181(7) and 12182).

The Rehabilitation Act and ADA (Rehabilitation
Act and key implementing regulations: 29
U.S.C. 793 and 29 CFR Part 1630; 794(a),
(b)(1), (b)(3)(A) and 45 CFR Part 84;
Americans with Disabilities Act and key imple
menting regulations: 42 U.S.C. 12111(2) and
(5) and 12112 and 28 CFR Part 35, Subpart C,
and 29 CFR Part 1630) also provide 
protection against discrimination by a wide
range of employers, including:
  Employers with Federal contracts worth more
than $10,000

  Employers with 15 or more employees

  Federal, State, and local governments and
agencies

  Corporations and other private organizations
and individuals receiving Federal financial
assistance

  Corporations and other private organizations
and individuals providing education, health
care, housing, or social services and parks
and recreation sites

  Labor organizations and employment 
committees.

The Rehabilitation Act and ADA also classify
individuals with HIV/AIDS as individuals with
disabilities and prohibit employers, government
agencies, and places of public accommodation
from discriminating against them on the basis
of seropositivity. Because gay men, other men
who have sex with men, and injection drug
users constitute the largest portion of persons
diagnosed with AIDS in the United States, this
protection is important. For a detailed discus
sion of the scope of protection offered and how
these statutes have been applied in cases of
individuals with HIV/AIDS, see Treatment
Improvement Protocol 37 Substance Abuse
Treatment for Persons With HIV/AIDS (CSAT,
2000), available from SAMHSAs NCADI at
8007296686. Many States also have laws
protecting people with HIV/AIDS from discrimi
nation. Local HIV/AIDS and gay and lesbian
advocacy groups and resource centers are
often able to provide information and advice
about both Federal and State laws in this area. 
Legal Issues for Programs Treating LGBT Clients

39

-----------------------------------------------
These laws can be helpful to LGBT clients and
the programs treating them. If a program refers
a client to a vocational rehabilitation training
program or a dentist and he or she is rejected
because of a history of drug abuse or HIV 
positivity, there is legal recourse. Programs
should also be aware that they, too, are most
likely covered by these laws; for example, they
may not discriminate against clients with
HIV/AIDS or against job applicants or employ
ees with HIV/AIDS or histories of substance
abuse. 
(Note that ADA specifically excludes 
transvestism, transsexualism, pedophilia, 
exhibitionism, voyeurism, gender identity 
disorders not resulting from physical 
impairments, and other sexual behavior 
disorders from the definition of disability.
Psychoactive substance use disorders resulting
from current illegal use of drugs are also
excluded.)
Legal Issues for Programs Treating LGBT Clients
Case History #1

Bill is a 41-year-old African-American man who has applied for admission to an inpatient alcohol treatment
facility. Bills history of substance abuse goes back 20 years but includes several years of sobriety and
active participation in Alcoholics Anonymous. He is in a committed relationship with Harold (36), his partner
of 5 years. Bills wife died of a drug overdose 3 years ago, and he has custody of his two young children,
Melissa (6) and Philip (4). The children live with Bill and Harold in their rented townhouse. Bills late wifes
parents have never accepted him and have always blamed Bill for their daughters drug problems. 

Bill has been teaching seventh grade English for the past 10 years. Only a very few colleagues in the school 
system know about his sexual orientation and his relationship with Harold. Bill was referred to the treatment
facility by the school districts Employee Assistance Program (EAP); his employer-provided Health
Maintenance Organization (HMO)-based health insurance will cover his treatment. He must satisfactorily
complete treatment to retain his job. Bill has signed a form consenting to disclosures about his progress in
treatment to the districts EAP.

What legal issues does this case present?

1)  Disclosures of treatment information to the districts EAP: Bill should sign a consent form that complies
with 42 CFR Part 2 so that the facility can release information to the districts EAP about his progress in
treatment. The consent form should be limited to disclosure of general assessments of Bills progress in
treatment. Giving the EAP detailed treatment information would not be appropriate and should not be
authorized by the consent form Bill signs. There should be no disclosure of any information about Bills
sexual orientation or his living arrangements. Public school systems are generally reluctant to employ 
an openly LGBT person. Disclosure of this information could result in Bills losing his job (and his health
insurance). Bill should sign a consent form that gives him the option of permitting or prohibiting 
disclosure of this information (see exhibit 31).

Continued

40

-----------------------------------------------
2)  Disclosures of treatment information to the districts HMO: The HMO will require information about Bills
need for treatment in order to make a decision about covering that treatment. It will also demand that the
facility update the information periodically. Bill must sign a consent form to permit the program to disclose
information to the HMO. Disclosures to the HMO should be as limited as possible, but this may prove 
difficult. Many managed care organizations require programs to submit detailed information periodically
before they will authorize continued treatment (or benefits). Bill has every reason to be concerned that
his admission to treatment may trigger a flow of information that might, through school reviews of person
nel or HMO records, result in his losing his job. The Federal rules prohibit HMOs from redisclosing infor
mation to the district, but there is no assurance that the HMO will refrain from doing so. Therefore, and
although this can be difficult, there should be no disclosure of any information to the HMO about Bills
sexual orientation or his living arrangements. Bill should sign a consent form that gives him the option of
permitting or prohibiting disclosure of this information (see exhibit 31). 

3)  Disclosure of information about Bills sexual orientation to his in-laws: Disclosure could spark an attempt
to challenge Bills custody of his children. In many States, the combination of Bills sexual orientation and
his history of alcohol abuse could be used by relatives to try to wrest custody from him. If Bills in-laws do
file a court case seeking custody and their attorney issues a subpoena for Bills treatment records, the
program can, working with Bills attorney, ask the court to issue an order restricting the scope of the infor
mation the program will be required to provide. For detailed information on dealing with subpoenas and
court orders, see Treatment Improvement Protocol 24 A Guide to Substance Abuse Treatment for
Primary Care Clinicians (CSAT, 1997a), available from SAMHSAs NCADI at 8007296686. 

What policy issue does this case present?

How will Harold be listed on the intake form: as spouse and/or next of kin?

Facilities may set their own individual policy about how they treat life partners. At the very least, programs
should allow clients to sign a consent form specifying whom the program can call in emergencies.
Legal Issues for Programs Treating LGBT Clients
Case History #2

Denise is a 16-year-old white female who entered an inpatient treatment program after being hospitalized
twice: once for alcohol poisoning and once after a suicide attempt. Denises parents are working profession
als with a comfortable income and large home in the suburbs. Denise has been living at home but does not
get along with her two older sisters or her younger brother. She has been habitually truant. 

Denise has confided in her counselor that for some time she has been having a hard time with her attraction
to and feelings about other girls. Denise characterizes her parents as homophobic and is terrified about
what might happen if they find out. Once, when her father found her watching an episode of the TV program
Ellen, he screamed at her: Why would you want to watch that disgusting smut? I will not have that stuff in
my house! 

Denise has signed a consent form permitting her counselor to speak with her parents about her substance
abuse treatment.

After Denise has been in the program for a month, a staff member discovers her acting out sexually with
another girl. 

Continued

41

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Legal Issues for Programs Treating LGBT Clients
What legal issues does this case present?

1)  Does the facility have to tell Denises parents about her sexual attraction to other girls? No. Denise has
consented to communications with her parents about her substance abuse treatment. Denises fears 
about her parents reaction may be entirely realistic. Disclosure of this information to Denises parents at    
this time would certainly destroy any therapeutic relationship developing between Denise and her 
counselor. Such disclosure may also be a violation of professional ethics.

Now that Denises counselor knows Denises concern, she could ask her to sign a new consent form that
specifically requires the program to withhold information about her sexual orientation from her parents
(see exhibit 31).

2)  Can Denises counselor discuss her discovery with other facility staff? Yes, the counselor can discuss her
discovery with other program staff. The Federal confidentiality regulations contain an exception permitting
communication of information between or among program staff members who have a need for the infor
mation in connection with their treatment responsibilities. 

3)  Should Denises counselor discuss her discovery with other staff? Yes, the counselor should tell other
staff, including the program director, about her discovery. The sexual acting out may have affected either
Denise or the other girl, and failure to disclose it might create a legal risk for the program.
  If one girl makes an unwanted advance to another girl, the program has a responsibility to help the
victimized child. The information is important to the other girls treatment counselor. He or she
should be working with the girl to help her cope with this experience. 

  The information is also important to the program director. If the other girl was an unwilling target or
participant, her parents might sue the program for failing to protect their child. Moreover, if such an
incident is swept under the rug, the aggressor may act out again, in which case the program could
be put in real jeopardy.

What policy issues does this case present?

1)  Program rules regarding client behavior. If the program does not have rules about sex between clients, it
should adopt rules now. If the program does have rules, the treatment staff and the program director
should discuss whether the acting out violated any program rules and, if so, what the program should do.

2)  Preventive measures. The program director should consider whether the program can take additional
steps to ensure such incidents do not occur in the future. 

42

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Case History #3

Frankie is a 66-year-old retired postal worker who has been in and out of 12-step programs and outpatient
treatment for 10 years. This will be his first inpatient treatment episode. Frankie came to the intake session
with Janice, his female partner of 16 years. The couple lives together in a home they purchased 12 years
ago. They are not legally married, but their friends and family consider them husband and wife. They have
two grown children (one each from previous marriages) and five grandchildren. Frankie expects that
Medicare will pay for his treatment. Janice works for the city and is covered by the citys HMO plan. 

After intake, Frankie is settled in a room with another male patient. On Frankies first night at the facility, a
nurse observes that Frankie has female genitals. Frankies roommate demands that he be moved out of the
room. The nurse has told her supervisor that she's not going to work with that 'weirdo in Room 112. 

What legal issues does this case present?

1)  Who is responsible for the cost of Frankies care? Since Frankie and Janice are not legally married, and
cannot be, Janice is not responsible for the cost of Frankies treatment. Janice may want to support part
of the costs of treatment, but there is no legal requirement that she do so, and unless her employer 
provides health benefits to domestic partners, her HMO will not contribute.

2)  Will Medicare cover Frankies treatment if his declared gender is not in accord with his biological sex?
Ask Frankie whether Medicare identifies him as male or female. If he gives a different gender from what
appears on the original Medicare application, there may be problems with payment.

3)  Who is considered next of kinJanice? or Frankies child?  Since Frankies and Janices relationship is
not State sanctioned, Frankies child is considered his next of kin. However, if Frankie would prefer to
name Janice as his next-of-kin for visiting and emergency-notification purposes, the program should
respect his wishes. 

4)  Can the program fire staff who refuse to work with Frankie because he is transgendered? Yes. Unless
the staff person is protected by a union contract with a provision covering this situation, he or she can be
fired at any time, unless the action is taken because he or she is female, a member of a minority group,
or disabled. In the United States, most employment is at will, which means that either the employer or
employee can end the relationship at any time and for any reason, unless that reason violates one of the
civil rights statutes discussed above.

What policy issues does this case present?

1)  What policies should the program have in place to ensure that LGBT individuals are treated fairly?
Programs should have written policies in place that require staff to be willing to treat all clients without
regard to race, gender, disability, or sexual orientation. Job descriptions should make treatment of clients
(regardless of their status) an integral part of the responsibilities of each position. Staff should be
screened before hiring to ensure they are willing to abide by the programs treatment rules and should be
required to attend educational and sensitivity training about LGBT individuals.

2)  Should the program move Frankie away from his objecting roommate? Yes. No one should have to
endure a hostile roommate. Moving Frankie avoids a difficult situation and helps with his treatment. 
With Frankies consent, the program should conduct a sensitivity session to educate clients about 
transgendered individuals as well as those who are lesbian, gay, or bisexual. 
Legal Issues for Programs Treating LGBT Clients

43

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Legal Issues for Programs Treating LGBT Clients
Recommendations

The following are some recommendations for
improving substance abuse treatment for LGBT
clients.  

1.  Improve knowledge among staff members
about the laws affecting LGBT individuals
with substance abuse histories. These
include:

a. Federal and State antidiscrimination laws
protecting individuals with disabilities that
apply to alcoholics and individuals with
histories of drug abuse

b. Federal and State antidiscrimination laws
protecting individuals with disabilities that
apply to individuals with HIV/AIDS

c. Federal confidentiality laws and 
regulations

d. State laws protecting HIV-related 
information

e. State and local laws that apply to LGBT
individuals.

2.  Ensure that staff members respect LGBT
clients by:

a. Establishing written job descriptions that
require treatment of all clients without
regard to their sexual orientation

b. Screening out job applicants who
express overt bias

c. Establishing clear, written program 
policies requiring equal treatment of
clients without regard to their sexual 
orientation and enforcing program policy
through a disciplinary process 
d. Providing staff members with training
to increase their awareness of and
sensitivity to LGBT issues

e. Establishing a procedure for clients to
complain about bias.

3.  Ensure that clients respect LGBT 
individuals by:

a. Establishing program rules requiring
respect for clients without regard to
their race, gender, religion, national
origin, or sexual orientation

b. Providing clients with education and
information about LGBT individuals

c. Establishing grievance procedures for
clients wishing to lodge complaints

d. Enforcing program rules promptly.

4.  Ensure that LGBT staff and clients are safe
while attending the program by:

a. Establishing personnel policies 
prohibiting harassment in the 
workplace, including harassment of
LGBT staff by other staff and sexual
harassment by persons of the same or
a different gender

b. Informing clients at admission that the
program does not tolerate sexual
harassment or sexual overtures or
activities by persons of the same or a
different gender

c. Enforcing the rules promptly

d. Establishing grievance procedures for
both staff and clients who may wish to
complain about harassment and
responding promptly to complaints.

44

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5.  Take all steps necessary to ensure the 
confidentiality of information about clients
substance abuse treatment as well as their
sexual orientation by:

a. Providing staff with training about the
Federal confidentiality regulations

b. Establishing written policies about the
confidentiality of information about sexual
orientation and instructing staff about
those policies

c. Educating clients about the importance of
respecting the confidentiality of their 
fellow clients.

6.  Establish personnel policies that attract and
retain LGBT staff by:

a. Actively recruiting such individuals

b. Offering such individuals partners the
same benefits offered married couples.

7.  Educate LGBT clients about:

a. The confidentiality protections they enjoy
(and those they lack)

b. The antidiscrimination laws that protect
them, as well as the ways in which their
rights are not protected

c. The steps they can take to protect 
themselves.

Resources

Confidentiality of Substance 
Abuse Treatment Records

Confidentiality of Patient Records for Alcohol
and Other Drug Treatment. Technical
Assistance Publication (TAP) 13 (CSAT,
1994b), 36 pp. BKD156.
This guide provides an overview of Federal
alcohol and drug treatment confidentiality laws
and regulations as well as options for dealing
with a wide variety of situations. The appendix
includes sample forms for patient consent and
qualified service organization agreements.
(Although the printed version of this publication
is currently out of stock, it can be viewed and
printed from PREVLINE, at www.health.org.)

Checklist for Monitoring Alcohol and Other
Drug Confidentiality Compliance. TAP 18
(CSAT, 1996), 52 pp. PHD722X.

This TAP is a reference for the substance
abuse treatment provider on maintaining and
protecting patient confidentiality and records.

Welfare Reform and Substance Abuse
Treatment Confidentiality: General Guidance
for Reconciling Need To Know and Privacy.
TAP 24 (CSAT, 1999d), 40 pp. BKD336. 

This report provides guidance for alcohol and drug
treatment providers on resolving confidentiality
issues that arise in the context of welfare reform.

Legal Issues Associated With Development
and Implementation of a Provider-Sponsored
Managed Care Organization. Volume 6
(SAMHSA, 1998), 65 pp. BKD296.

This publication summarizes the legal issues
that substance abuse treatment service and
mental health providers address in organizing
provider-sponsored managed care organizations
(MCOs) and implementing managed care 
programs through contract negotiation and the
delivery of services and care through provider
contracts.

Legal Action Center
153 Waverly Place
New York, NY 10014
Ph: 8002234044
www.LAC.org
Legal Issues for Programs Treating LGBT Clients

45

-----------------------------------------------
Legal Issues for Programs Treating LGBT Clients
The Legal Action Center is the only law and
policy organization in the United States that
fights discrimination against people with 
histories of addiction, AIDS, or criminal records
and advocates for sound public policies in
these areas. The center provides:

  Legal services, including impact litigation

  Policy advocacy and research

  Training, technical assistance, and 
education.

LGBT Rights

A Legal Guide for Lesbian and Gay Couples 
(10th Ed.) (Curry et al., 1999).

This manual outlines the differences between
legally married couples and same-sex partners. 

Advocates for Youth
1025 Vermont Avenue, NW, Suite 200
Washington, DC 20005 
Ph: 2023475700, Fax: 2023472263
www.advocatesforyouth.org

Advocates for Youth (formerly Center for
Population Options) is dedicated to creating
programs and promoting policies that help
young people make informed and responsible
decisions about their sexual and reproductive
health. It provides information, training, and
advocacy to youth-serving organizations, 
policymakers, and the national and 
international media. Advocates for Youth also
sponsors the Youth Resource Web site at
www.youthresource.com (for LGBT youth). 

American Civil Liberties Union (ACLU)
132 West 43rd Street 
New York, NY 10036
Ph: 2129449800
www.ACLU.org
The American Civil Liberties Union is a 
nonprofit, nonpartisan, 275,000-member public
interest organization devoted exclusively to
protecting the civil liberties of all Americans
and extending those rights to groups that have
traditionally been denied them. It files court
cases to expand and enforce individuals civil
rights and educates legislatures and the public
on a broad array of issues affecting individual
freedom in the United States. 
ACLU Lesbian and Gay Rights Project
125 Broad Street 
New York, NY 10004
Ph: 2125492627

The goal of the ACLU Lesbian and Gay Rights
Project is equal treatment and equal dignity for
lesbians, gay men, and bisexuals. That means
even-handed treatment by the government;
protection from discrimination in jobs, housing,
hotels, restaurants, and other public places;
and fair and equal treatment for lesbian and
gay couples and families.

Human Rights Campaign (HRC)
919 18th Street, NW
Washington, DC 20006
Ph: 2026384160, Fax 2023475323 
www.hrc.org

HRC is the largest national lesbian and gay
political organization. Its mission is to create an
America where lesbian and gay people are
assured of basic equal rights and where they
can be open, honest, and safe at home, at
work, and in the community. With a national
staff and volunteers and members throughout
the country, HRC: 

  Lobbies the Federal Government on gay, 
lesbian, and AIDS issues

  Educates the public

  Participates in election campaigns

46

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  Organizes volunteers

  Provides expertise and training at the State
and local levels. 

Lambda Legal Defense and Education Fund
120 Wall Street, Suite 1500
New York, NY 100053904
Ph: 2128098585, Fax: 2128090055
www.lambdalegal.org

Lambda is the Nations oldest and largest legal
organization working for the civil rights of 
lesbians, gay men, and people with HIV/AIDS. 

National Center for Lesbian Rights (NCLR)
870 Market Street, #510
San Francisco, CA 94103
Ph: 4153926257, Fax: 4153928442
www.NCLRights.org

NCLR is committed to advancing the rights and
safety of lesbians and their families through 
litigation, public policy advocacy, free legal
advice and counseling, and public education.
NCLR also provides representation and
resources to gay men and bisexual and 
transgendered individuals on key issues that
affect lesbian rights.

National Gay and Lesbian Task Force (NGLTF)
(Main office) 
1700 Kalorama Road, NW
Washington, DC 200092624
Ph: 2023326483, Fax: 2023320207 
TTY: 2023326219

National Gay and Lesbian Task Force (Policy
Institute)
121 West 27th Avenue, Suite 501
New York, NY 10001
Ph: 2126049830, Fax: 2126049831 
www.ngltf.org

NGLTF is a leading progressive civil rights
organization that has supported grassroots
organizing and advocacy since 1973. Since its
inception, NGLTF has been at the forefront of
every major initiative for lesbian, gay, bisexual,
and transgender rights. In all its efforts, NGLTF
works to strengthen the gay and lesbian 
movement at the State and local levels while
connecting these activities to a national vision
of change. 
Servicemembers Legal Defense Network 
P.O. Box 65301
Washington, DC 200355301
Ph: 2023283244, Fax: 2027971635 
www.sldn.org

On July 19, 1993, the Clinton administration
announced a new policy regarding gays in the
military. Dubbed Dont ask, dont tell, dont
pursue, the policy was intended to stop 
military officials from asking troops about their
sexual orientation, end witch hunts, and stop
harassment of lesbian and gay service mem
bers. Suspect service members still face an
untimely end to their careers. Most service
members do not realize that the new policy
affords little protection or privacy for lesbian
and gay personnel, and most service members
do not know what their legal rights are under
the new policy. 

Its Time, America! (ITA!) 
www.gender.org/ita/

ITA is the first nationally organized grassroots
civil rights group seeking to secure and 
safeguard the rights of all transgender individu
als. The mission of Its Time, America! is to
educate and influence the U.S. Congress,
State and local governments, and transgender
and nontransgender political organizations on
the issues and concerns of transgender people
and to take steps to safeguard and secure their
rights as American citizens.

Queer Resources Directory
www.qrd.org
Queer Legal Resources
www.qrd.org/www/legal/
Legal Issues for Programs Treating LGBT Clients

47

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Legal Issues for Programs Treating LGBT Clients
The Queer Resources Directory contains tens
of thousands of files about various topics of
interest to LGBT individuals. It bills itself as
having one of the most extensive collections of
materials devoted to LGBT legal issues on the
Internet. The collection includes:

  Tables listing the important legal cases 
dealing with LGBT and AIDS issues for each
year from 1992 to the present 

  Case and issue archives by subject

  Statewide gay rights statutes and same-
gender marriage resources

  Lesbian/Gay Law Notes, edited by Professor
Arthur Leonard, a monthly summary of the
cases important to gay/lesbian and HIV/AIDS
jurisprudence

  National Journal of Sexual Orientation Law,
an electronic legal journal devoted to sexual
orientation and the law

  QueerLaw and QueerLaw-Digest, with 
information about companies with 
nondiscrimination policies that include sexual
orientation; companies and organizations
that provide domestic partner benefits;
States that criminalize sexual acts between
people of the same gender; State laws on
age of consent for sexual acts between 
people of the same gender; and sodomy and
age-of-consent laws worldwide

  Lists and links to groups that work on legal
issues of interest to LGBT individuals. 

Gay, Lesbian, Bisexual and Transgender
Health Access Project

JRI Health
100 Boylston Street, Suite 860                 
Boston, MA 02116

Ph: 6179882605
Fax: 6179882629
www.glbthealth.org

The Gay, Lesbian, Bisexual and Transgender
Health Access Project is a collaborative, 
community-based program funded by the
Massachusetts Department of Public Health.
The Projects mission is to foster the 
development and implementation of 
comprehensive, culturally appropriate, quality
health promotion policies and health care 
services for gay, lesbian, bisexual, and 
transgendered people and their families.

48

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Chapter 4
Overview of Treatment Approaches,  
Modalities, and Issues of Accessibility 
in the Continuum of Care

Robert Paul Cabaj, M.D., San Mateo County Mental Health Services, San Mateo, CA
Mickey Smith, LGSW, C.A.C., Whitman-Walker Clinic, Washington, DC

Introduction

This chapter advises providers on 
approaches, modalities, and accessibility 
in the continuum of care relevant to the 
lesbian, gay, bisexual, and transgender
(LGBT) populations seeking substance
abuse treatment services. Although the
issues discussed may be similar to those 
of the larger population, some differences
exist. This chapter provides information
about accessibility and attributes of pro
grams that are helpful for LGBT clients.

Substance abuse treatment for LGBT 
individuals is the same as that for other 
individuals and primarily focuses on 
stopping the substance abuse that interferes
with the well-being of the client. However,
some LGBT clients will need to address
their feelings about their sexual orientation
and gender identity as part of their recovery
process. For some LGBT clients, this will
include addressing the effects of internalized
homophobia. Clinicians sometimes see
relapses in LGBT persons with lingering
negative feelings about their sexual 
orientation or gender identity.

Substance use, especially alcohol use, is
woven into the fabric of the lives of many
LGBT individuals. The greater use and 
presence of alcohol and drugs in settings
where LGBT people socialize (in conjunction
with the denial produced by the use of these
substances) may help to explain the greater
predisposition to substance abuse among
LGBT individuals.
What providers will learn
from this chapter:

  The special issues that
need to be addressed 
in working with LGBT 
individuals

  The levels of care and the
types of treatment that
appear to work best for 
LGBT individuals

  The major issues of 
accessibility related to 
substance abuse 
treatment for LGBT
populations

  How a program can be
made accessible for LGBT
populations

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Even if the LGBT individual is open about his
or her identity, it is virtually impossible to deny
the effects of societys negative attitudes,
which can result in feelings of doubt, confusion,
fear, and sorrow (Diamond-Friedman, 1990).
Often referrals or appropriate treatment are 
difficult to secure due to the lack of 
understanding of these issues by treatment
program administrators and staff. Finding a
program that can both address LGBT clients
treatment needs and be supportive of them as
individuals can be very difficult.

Members of the LGBT community often face
problems in traditional health care systems and
are stigmatized within programs by staff and
other clients (Mongeon & Ziebold, 1982).
Service providers should develop a basic 
understanding of how they can best serve
these populations to help ensure successful
treatment outcomes. In addition, due to the
multicultural and varied backgrounds of LGBT
clients, treatment approaches and modalities
may need to be tailored to meet the needs of
these individuals.

The growing body of literature on working with
LGBT substance abusers can help clinicians
understand the issues and improve treatment
(Cabaj, 1996; Finnegan & McNally, 1987;
Gonsiorek, 1985; Ziebold & Mongeon, 1985).

Approaches

Abstinence-based and treatment-readiness
approaches to substance abuse disorders are
the two major approaches presented in this
chapter. For the purpose of this publication,
treatment readiness refers to the level of 
readiness that individuals may exhibit relating
to changing alcohol and drug use behaviors.
When undergoing treatment for substance
abuse, LGBT individuals have many of the
same issues as the larger population, but they
may have additional issues as well. LGBT
clients may be coping with coming out; their
sexual orientation and gender identity; societal
stigmas; HIV/AIDS; death and dying; 
discrimination; same-sex relationships; and
homophobic family members, employers, and
work colleagues. At times, these issues have a
negative impact on a persons ability to change
his or her alcohol and drug use patterns and
other harmful behavior.
Providers need to understand that a part of 
substance abuse recovery for many LGBT 
individuals is accepting themselves as gay, 
lesbian, bisexual, or transgender and 
finding a way to feel comfortable in society. 

Levels of Care

Levels of care refers to the intensity and 
duration of services being provided by a 
program to clients, including inpatient, 
residential, therapeutic, partial hospitalization
or day treatment, intensive outpatient, 
outpatient, aftercare and followup, and 
monitoring services.

LGBT substance abusers should be assessed
to determine the range of services and levels 
of care they require. The type of drug and the
amount used by a client, the danger of a 
medically complicated withdrawal, the difficulty
with withdrawal and craving, and the need to be
away from social and psychological stressors
will help a counselor determine the level of
care a client needs. Whatever the planned
treatment, it should be LGBT sensitive and
supportive.

Although they abuse alcohol and some of the
same substances as non-LGBT substance
abusers, certain LGBT individuals may abuse
other drugs that influence the level and 
duration of care they need. For example,
methamphetamine abuse is nearly epidemic in
gay men in some parts of the United States
(Freese et al.,  2000). Abuse of this drug often
results in strong cravings and frequent relapses
and may require extensive and highly focused
treatment.
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Outpatient care will serve the vast majority of
LGBT substance abusers, just as it does 
non-LGBT substance abusers. Many larger
urban communities have residential programs
for LGBT people as well as LGBT-supportive
inpatient or outpatient recovery programs.

Continuum of Care

The continuum of care refers to continuing
available services and may include provision of
additional services while individuals are in the
program; ongoing support and services after
discharge (regardless of treatment completion);
followup and monitoring activities; and 
outreach, recruitment, and retention. Some of
these services may be different for LGBT
clients due to factors such as the health status
of the clients or their partners, their living
arrangements, the type and stability of their
employment, their work hours, their level of 
openness about their sexual orientation/
sexuality, and their experience with previous 
service providers or systems.

Accessibility

Due to the homophobia and discrimination they
experience, LGBT individuals may find it 
difficult, and sometimes uncomfortable, to
access treatment services. Substance abuse
treatment programs are often not equipped to
meet the needs of this population. Heterosexual
treatment staff may be either uninformed about
LGBT issues, insensitive to their concerns, or
antagonistic toward such individuals. These 
attitudes may be based on misperceptions or
personal beliefs. A harmful result of this 
insensitivity is that some professionals or other
clients may falsely believe that an LGBT 
persons sexual orientation/gender identity
caused his or her alcohol and drug use. Ones
sexual orientation/gender identity should not be
viewed as in need of changing. Such factors
become barriers when the LGBT population
seeks access to appropriate treatment.
Some LGBT individuals may express difficulty in
participating in non-LGBT focused treatment,
stating that heterosexuals may not understand
LGBT issues and problems. This can be 
problematic for the treatment staff, but it does
not have to impede services. This attitude may
be a defense mechanism, or the person may
have experienced problems with heterosexual
treatment providers in the past. Whatever the
cause, it should be managed in a therapeutic
manner. Encourage individuals to discuss 
previous experiences or why they have these 
feelings or attitudes toward heterosexuals. It is
also important for counselors not to assume that
they know why such statements are made or
that they completely understand these experi
ences. Be sensitive to the LGBT individuals
experience and facilitate these issues within a
therapeutic context.

Often negative feelings or attitudes are based
on real experiences and should be acknowl
edged as such. Making the program accessible
to the LGBT community may require some
changes. Programs that use observers to
administer urine screens need to consider the
clients concerns and ask which gender 
observer they prefer. Staff may not know what
gender the client considers herself or himself,
and this could result in uncomfortable situations.

If possible, designate a separate, non-gender-
specific toilet and shower facility for some LGBT
clients, particularly in residential treatment set
tings. Transgender individuals may be in the
process of change or may be living as the 
gender opposite the one they were born with,
which may result in these individuals using rest
rooms different from what one would expect.

Heterosexual staff and clients should not
assume that LGBT individuals are any more
likely to flirt or act out sexually than their 
heterosexual counterparts. Rules regarding
sexual interactions, flirting, and dating in treat
ment settings should be the same for LGBT
persons as for heterosexual individuals. 

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Degrees of LGBT Sensitivity

In addition to addressing issues of accessibility,
it is important for program administrators and
staff to create a supportive environment for
LGBT individuals. The impact on the client of
anti-LGBT bias and internalized homophobia
should be considered when developing the
treatment plans of LGBT people with 
substance abuse problems. Few programs 
provide education to staff about LGBT people,
and many programs may be unaware that they
have LGBT clients. Some LGBT clients may be
too frightened to come out during treatment or
feel they have been given permission to be
open about their sexual identity (Hellman et al.,
1989). Staff attitudes are crucial in helping
clients feel comfortable and safe; training 
counselors about homosexuality will help
clients feel safe.

Substance abuse treatment programs can be
rated on a spectrum from LGBT-hostile to LGBT-
affirming. Exhibit 41, which was adapted from
Neisen (1997), provides a brief overview of the
components identified on the spectrum.

It is hoped that only a few programs are openly
hostile toward LGBT people; it is essential 
that any LGBT individuals seeking help for 
substance abuse problems are not treated 
at these programs. Unfortunately, many 
substance abuse treatment programs are
unaware of the importance of sexual 
orientation and operate as if everyone is 
heterosexualunaware that LGBT people
exist. In such settings, LGBT people most likely
will not talk about their sexual orientation or
gender identity and will not be able to integrate
their sexuality and acceptance of a gay, 
lesbian, bisexual, or transgender identity into
recovery. Internalized homophobia/transphobia
and coping with anti-LGBT societal bias most
likely will not be discussed.
Some substance abuse treatment programs
may be LGBT tolerant, that is, aware that
LGBT people exist and use their services.
Such awareness is usually due to an LGBT
staff member. Even so, accepting ones sexual 
orientation and dealing with homophobia 
most likely will not be addressed. 

LGBT-sensitive programs are aware of, 
knowledgeable about, and accepting of LGBT
people. Many well-established programs are
training staff about LGBT concerns to make
them LGBT sensitive. The material in this 
document is part of that effort. LGBT-sensitive
programs acknowledge the existence of LGBT
people and treat them with respect and dignity.
These programs usually care for LGBT people
in the same way that they treat other clients
but recognize the difficulties and challenges
facing LGBT people in recovery. Some 
programs may also have specific therapy
groups for LGBT people. 

Fewer programs are LGBT affirmativethat
is, they actively promote self-acceptance of an
LGBT identity as a key part of recovery. These
programs affirm LGBT individuals sexual 
orientation, gender identity, and choices; 
validate their values and beliefs; and acknowl
edge that sexual orientation develops at an
early age. An LGBT-affirmative program, the
Pride Institute, released data showing a very
successful treatment rate when acknowledging
ones sexual orientation is considered a key
factor in recovery (Ratner, Kosten & McLellan,
1991). At a 14-month followup with verified
reports, 74 percent of all patients treated 5 or
more days abstained from alcohol use 
continuously, and 67 percent abstained from all
drugs. These data can be compared with data
from four similar, sometimes LGBT-sensitive
but non-LGBT-affirmative treatment programs
with unverified reports taken at followups
ranging from 11 months to 24 months after
treatment, which had abstinence rates of 43,
55, 57, and 63 percent.

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    Exhibit 41: 
LGBT Sensitivity Model
Over
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Anti-LGBT        Traditional        LGBT-Naive         LGBT-                LGBT- LGBT-
Treatment Treatment Treatment         Tolerant            Sensitive Affirming
Treatment          Treatment Treatment

No LGBT          No LGBT          No LGBT         Minimal LGBT     Moderate   Highest level
sensitivity sensitivity sensitivity         sensitivity           level of LGBT       of LGBT
sensitivity             sensitivity
Antagonistic      No realization     Realization       Recognition        Several clients     Program
toward LGBT    that there are     that there are    that there are      and/or staff are     primarily
individuals        LGBT clients      LGBT clients    LGBT clients       open with their     targets LGBT
                                           LGBT identity      population
Treatment         No acknowl- As an agency,  Some staff          Several                All workshops
focuses            edgment            has not yet       may verbalize     workshops          specifically for
exclusively on   or discussion begun to          that it is okay      and/or groups      LGBT clients;
heterosexuals   of LGBT   address the      to be an LGBT    focus on              workshops
and excludes    issues; it is     special issues   individual;           LGBT issues;  and groups
LGBT clients     assumed    of the LGBT     however, such     they may have     affirm the
everyone is        population       discussions         LGBT groups       LGBT
heterosexual                are limited to       or a track for      individual,
individual            LGBT issues;       have LGBT-
sessions             groups are           specific
generally mixed    materials, 
etc.; groups 
and work
shops are not 
mixed with 
heterosexuals
No specific       No specific No specific       No specific         Some specific      All treatment
LGBT  LGBT                LGBT LGBT LGBT components
treatment          treatment treatment treatment treatment are LGBT
components      components       components     components        components         specific             

Adapted from Neisen, 1997

Specific Issues

Substance abuse and sexual identity formation,
which includes awareness and acceptance of
sexual orientation and gender identity, are
often enmeshed for many LGBT people. Some
counselors and clinicians working with LGBT
clients substance abuse see addressing these
issues as essential to recovery, and failure to
do so may result in a difficult recovery process. 
Substance abuse treatment programs that are
LGBT sensitive are more likely to have more 
successful outcomes with LGBT clients.

Exhibit 42 presents principles of care that 
are appropriate for any client. Program 
administrators and staff need to be aware 
of issues that may be specific to the LGBT 
population with respect to the continuum of 
care, including outreach, identifying the extent of
alcohol and drug use, and discharge planning.

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  Exhibit 42: 
Principles of Care
view of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care
Principles of care that should be part of any substance abuse treatment program for LGBT populations are
listed below. These principles are adapted from a mental health care practical guide to developing programs
for working with people living with or affected by HIV/AIDS (Acuff et al., 1999). 

Be flexible and client centered
Clients will present with a wide range of substance use and psychosocial needs. While some clients may
benefit from group modalities, others may need individual counseling or may benefit from supportive 
treatment. To meet the individuals needs, services need to be flexible but consistent and thorough.

Be coordinated, integrated, and comprehensive
Service systems should establish formal linkages and networks to enhance service coordination and 
integration. Likewise, providers working in a multidisciplinary setting should use a team approach to meet
each clients needs.

Be consistent with each clients cultural needs and expectations
Programs may need to employ multilingual and multicultural staff as well as individuals representing LGBT popu
lations. Sensitivity training is essential for staff members who are not culturally matched with the client base.

Promote self-respect and personal dignity
Effective service delivery depends on recognizing an individuals self-worth and contributions to his or her
community. Society and the traditional health care system, along with substance abuse treatment programs,
typically may have stigmatized LGBT clients and left them with little sense of self-respect or dignity.
Programs must ensure that staff and the service delivery system do not stigmatize the clients further.

Promote healthier behaviors
Service providers can work with clients to practice healthier behaviors, to practice safer sexual behaviors, to
strengthen supportive relationships, and to comply with medication regimes for HIV and psychotropic 
communitiesor other professionals and agencies may provide positive examples for clients currently in
treatment or receiving services.

Empower persons in substance abuse treatment to make decisions in collaboration with the service
provider
Service providers must not assume that they know what is best for individuals but must include clients in
treatment planning. All segments of the community, including consumer and advocacy groups, should be
involved in the process of establishing, delivering, and improving services.

Reduce barriers to services for hard-to-reach populations
LGBT populations are varied, which can cause difficulties in reaching segments of the community.
Individuals may be homeless, work as street hustlers/prostitutes, be in jail/prisons, or come from a variety of
cultural/ethnic backgrounds, thus creating the need to develop effective outreach and retention mechanisms.

Develop and deliver services that are clinically informed and research based
It is important not to assume that services that are effective for the larger population will be as effective or
appropriate for the LGBT populations; clinical issues often are different and need to be acknowledged and
treated. Evaluations of current clinical services for the LGBT community may need to be undertaken, or
research from other such undertakings can be used to develop appropriate services.

Work to create a treatment/recovery community 
Programs can play a role in developing a community of individuals, agencies, and organizations that work in
partnership to develop a treatment/recovery community. Making use of individuals who have successfully
completed treatment (alumni), individuals in the recovery communities, or other professionals and agencies
may provide positive examples for clients currently in treatment or receiving services.
Over
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Identifying the extent of alcohol and drug use is
an issue that is important to all individuals
entering substance abuse treatment regardless
of their sexual orientation. Traditional assess
ment forms may need to be modified or 
redeveloped for the LGBT populations to
include more inclusive language (refer to
Colemans Assessment Tool in chapter 1).

Without culturally competent training, the
assessor may be uncomfortable and miss
biopsychosocial information important to 
effective treatment planning. Also, collecting
collateral information may be different for the
LGBT population: Some LGBT clients may not
have close relationships with their family of 
origin; it may be clinically appropriate to gather
collateral information from a partner and close
friends (who may be identified by clients as
their family of choice). However, it cannot be
assumed that all LGBT clients are estranged
from their families of origin. Many have 
supportive and close families. It may be helpful
to include these individuals in treatment to
expand clients recovery support system.

Special Assessment Questions

In formulating a treatment plan for LGBT indi
viduals with a substance abuse problem, some
additional factors may need to be assessed.
Following are a sample.

  Determine the individuals comfort with being
an LGBT person. Evaluate the persons 
comfort level with his or her sexuality and
expression of sexual feelings. If the person is
a transgender individual, determine his or
her level of comfort with, and acceptance of,
that identity. 

  If appropriate, determine the stage where 
the individual is in the coming-out process
(whether as a gay, lesbian, bisexual, or
transgender person). Learn about his or her
experience and the consequences of coming
out.
  Determine the extent of the individuals 
support and social network, including
whether there are any current relationships
or past relationships and the individuals 
relationship with his or her family of origin. 

  Determine whether there are any health 
factors of concern, including the individuals
HIV status.

The substance abuse counselor can ask the
same questions about alcohol or drug use as he
or she uses for non-LGBT individuals. Specific
information about the patterns of, and situations
involved in, the use of alcohol and drugs by
LGBT individuals can be helpful in planning
treatment and preventing relapse. For example:

  Look at the most recent alcohol and drug
use: Was it with family, friends, a significant
other, a lover, or a date? With work col
leagues? Where was it? At a circuit party?
Alone? At a sex club or bathhouse? At a 
lesbian, gay, bisexual, or transgender bar or
at a straight bar? 

  Is there current or past intravenous or 
injection drug use? If so, what drugs are
used? Are amphetamines (speed, crystal,
crank) used? Are amphetamines used to
enhance sexual intensity?

  What is the frequency of the alcohol and drug
use? Does it correlate with the socializing?

  What is the drug of choicethe drug the
client enjoys or seeks most? What does it
seem to do or accomplish? Provide 
relaxation? Provide freedom from guilt?
Enhance sexual behavior?

  If the client has a significant other, does that
person believe there is a problem? Does he
or she have his or her own substance abuse
problems?

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  Has the client had legal problems due to his
or her use of alcohol and drugs, including
driving under the influence? Has the client
ever had legal problems related to sexual
behavior or police harassment?

  Has the client ever been attacked or 
assaulted (gay bashed) because he or she
was thought to be an LGBT person?

  Has the client had social problems or lost
partners, family, or friends because of alco
hol and drug use? Has there been domestic
violence? Was it by a same-sex lover?

  Has the client had treatment in the past for
substance abuse? If so, was his or her 
sexual orientation or sexuality discussed?

  What is the longest time the client did without
alcohol and drug use, and what allowed that
to happen?

Modalities

Typical modalities for substance abuse 
treatment include individual, group, couples,
and family counseling, but LGBT individuals
can face other unique problems if they are
treated by traditional programs through group,
couples, or family modalities.

The group modality may be difficult for LGBT
individuals if heterosexism/homophobia is
demonstrated by staff and other group 
members. Groups should be as inclusive as
possible and should encourage each member
to discuss relevant treatment issues or con
cerns. If a group combines heterosexuals and
LGBT individuals, provide sensitivity training
relating to LGBT issues and concerns; ensure
that all clients are aware that groups will be
mixed. Placing LGBT individuals in therapy
groups with homophobic clients may lead to
difficult situations and/or hostility toward the
LGBT individuals. 
Staff need to ensure that LGBT clients are 
treated in a therapeutic manner and should 
provide a strong verbal directive that homopho
bia and hostility will not be tolerated. If it does
occur, staff must take strong action on behalf of
LGBT clients. LGBT clients should not be
required to discuss issues relating to their 
sexuality or sexual orientation in mixed groups if
they are uncomfortable. On the other hand, in a
mixed group setting led by adequately trained, 
culturally competent, and LGBT-supportive staff,
LGBT clients may have the powerful experience
of gaining acceptance and affirmation from
peers. The acceptance and care that can come
from members of groups could be healing for
LGBT persons.

Often, intensive programs provide groups for
special populations (e.g., women, profession
als, those with HIV/AIDS, racial/ethnic 
minorities) to address their multidimensional
needs (CSAP [Center for Substance Abuse
Prevention], 1994). If a program has enough
LGBT clients, it may start an additional or 
separate group for them. This may provide a
safe or more cohesive venue for discussing
issues specific to LGBT clients. However,
attendance should be voluntary. When LGBT-
or gender-specific groups are held, therapists
should regularly direct attention to safe-sex
practices and sexual feelings about and 
experiences with same-sex individuals.

Family counseling can be difficult due to issues
relating to the clients sexual identity/ 
orientation, substance abuse, and, in some
cases, HIV/AIDS diagnosis, which have caused
distance and alienation. LGBT clients are more
likely to seek support for their partners if they
view the program as LGBT sensitive. 

If a program provides treatment primarily
through an individual modality, many of these
issues may not be relevant. Providing one-to
one services may decrease the difficulty of
mixing heterosexual and LGBT clients in 
treatment groups and decrease the likelihood
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that heterosexism/homophobia will become an
issue. LGBT individuals will be able to discuss
issues revolving around their sexual orienta
tion/identity without fearing that non-LGBT 
individuals will be hostile, will be insensitive, 
or will minimize LGBT issues.

Discharge planning

Specific concerns related to the discharge
planning process for LGBT clients may include
an enhanced analysis of their social support,
their living arrangement/environment, their
employment status or type of employment, and
ongoing issues that clients have identified 
related to their sexual orientation/identity.
Social support involves the amount of support
available to clients, which can increase their
likelihood of remaining abstinent or in recovery.
Social support often includes the family of 
origin and family of choice (e.g., sexual partner,
friends, or others) and should focus on individ
uals who support clients efforts to create such
significant changes. LGBT individuals may live
in an environment that is not conducive to their
ongoing abstinence/recovery (e.g., they have a
partner or roommate who actively uses alcohol
and drugs, or they live in close proximity to
drug dealers or open air drug markets).
Although these issues or concerns may be
similar to those individuals from the larger 
population may face, it is important to assess
and provide appropriate referrals for LGBT
clients. Clients employment status or type of
employment may also interfere with their 
ongoing abstinence/recovery. Specific issues
may be the type of work the individuals perform
(e.g., bartender, sex industry worker) or status
(e.g., not in stable employment, disabled).
Issues related to their sexual orientation/
identity may interfere with their recovery after
discharge if ongoing support or counseling is
not provided to meet needs indentified by
clients.
Aftercare/Recovery

Aftercare and support for recovery may be a
problem, depending on the geographic location
and any difficulties the client may have
expressed concerning acceptance of his or her
sexual orientation (there may be no LGBT-
sensitive counselors or programs in the clients
community). 

Twelve-step recovery programs and 
philosophies are, of course, the mainstays in
recovery and in staying clean and sober. As an
organization, Alcoholics Anonymous (AA)
clearly embraces LGBT individuals as it
embraces anyone concerned about alcohol
problems and has literature specifically for
LGBT individuals. Although open to all, AA
meetings involve a random group of people
and may reflect the perceptions and prejudices
of those individuals and the local community
and not be supportive of openly gay members
(Kus, 1989). Many communities now have
LGBT-specific AA, Narcotics Anonymous (NA),
and Al-Anon meetings. Many LGBT people,
however, mistakenly link AA and religion and
resist attending since many religious 
institutions denounce or condemn homosexual
ity. For example, because of the moral 
condemnation of some religious bodies, 
references to a higher power or God in the
12-step model may, in fact, create fear of 
prejudice rather than assurance of support.
While AA advises same-sex sponsors, 
recovering LGBT individuals require some 
flexibility, in that same-sex sponsorship may
create problems. Many times AA respects this
need. In locations where they are available,
counselors should consider exposing their
LGBT clients to LGBT-specific 12-step 
meetings so that any problems or issues 
relating to those meetings can be addressed
while the clients are in treatment.

Some groups similar to AA have formed to
meet the needs of LGBT people, such as
Alcoholics Together. Many large cities sponsor

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roundupslarge, 3-day weekend gatherings
focused on AA, NA, lectures, workshops, and
alcohol and drug-free socializing. Some LGBT
people entering recovery, however, may not
have come out publicly or may not feel 
comfortable in such meetings, especially if a
discussion of sexual orientation was not part of
the early recovery process.

Twelve-step programs such as AA and NA 
recommend avoiding emotional stress and 
conflicts in the first 6 months of recovery.
However, for LGBT persons, the risk of a
relapse may be increased if they cannot begin
to work through these issues. Discussions
about sexual orientation and learning to live
comfortably as an LGBT person are essential
for recovery, even if these topics are emotion
ally stressful.

On the other hand, waiting 6 months to deal
with this issue may be helpful. The client will
have the increased confidence that 6 months
of sobriety brings as well as a clear head. Just
like many other people in recovery, LGBT 
individuals may find some of the suggestions
and guidelines of AA, NA, and some treatment
programs difficult to follow. Giving up or 
avoiding their old friends, especially fellow
LGBT substance users, may be difficult when
clients have few other contacts. Staying away
from bars, parties, or circuit parties may be 
difficult if those are their only social outlets.
The counselor may need to provide special
help on how not to drink or use drugs in such
settings or, better yet, help clients find social
environments that support recovery. Clients will
need to learn how to adjust to clean and sober
socializing, without the use of alcohol or drugs
to hide their social anxiety.
Many localities now have LGBT health, mental
health, or community centers, almost all of
them with a focus on recovery and substance
abuse treatment. National organizations, such
as the National Association of Lesbian and
Gay Addiction Professionals, the Association of
Gay and Lesbian Psychiatrists, the Gay and
Lesbian Medical Association, the Association
of Lesbian and Gay Psychologists, the National
Association of Alcoholism and Drug Abuse
Counselors LGBT Special Interest Group, and
National Gay Social Workers, may help with
appropriate referrals.

Additional things the newly sober client should
learn are how to have safer sex while clean and
sober, how to deal with the damaging effects of
substance abuse on employment and relation
ships, and the adjustment to recovery couples
must make that will heal the client and avoid the
negative impact of codependent relationships.

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Over
view of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care
Case Example

Ruth is a 47-year-old African-American lesbian living in a large midwestern city. She is currently in
an inpatient substance abuse treatment program that is gay sensitive. She has talked openly
about being lesbian, and her partner of the past 25 years has been part of the treatment program.

Ruth was admitted for help with her crack cocaine use. She grew up in a very poor part of the city
but had developed supports and strengths at her local Baptist church. Ruth and her mother went
to regular services and many social functions, and she developed many friendships. She did well
in school and liked sports. She was surprised one day in the ninth grade when she read a story
about a lesbian teacher and felt a sudden awareness of sexual feelings for other women. She
went home to talk about it with her mother, who said she should talk to the minister. When Ruth
told him about her feelings, he became very upset, said she was an abomination before God.
Although some clergy are LGBT supportive, this minister asked Ruths mother to keep Ruth away
from the church until she recovered her senses. Ruths mother agreed.

Very upset and confused, Ruth ran away from home. She became homeless and discovered that
she could escape her feelings by using crack cocaine. To get money for food and drugs, she
began to work as a streetwalker. At a special celebration for a homeless center a few years later,
she met a city worker who happened to be black and lesbian. They formed an improbable relation
ship, and her partner brought Ruth off the streets and into a loving living arrangement. In the last
25 years, Ruth went back to school and worked as a substance abuse counselor. She has been
clean and sober most of that time. She relapsed recently after her mother died and the old 
minister refused to let her attend the funeral in her old Baptist church.

Her lover was still supportive but was getting frustrated and angry. The lover had a history of
severe depression and was treated with psychotherapy and medications; she again sought help
from a therapist. That therapist convinced the lover to bring Ruth in for couples counseling. After
being suspended from work for absenteeism, Ruth finally agreed. The therapist helped Ruth
accept that she had relapsed and that she needed to get clean and sober. The couples therapy
work was suspended while Ruth entered an out-of-town inpatient treatment program. Ruth said
she was too embarrassed to seek help locally since she might run into her fellow counselors and
current or former clients.

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view of Treatment Approaches, Modalities, and Issues of Accessibility in the Continuum of Care
Suggested Interventions

This case presents a unique situation but touches on several important themes: treatment level,
location, and type; racism and homophobia; mental health or emotional stresses and relapse; and
religion. A counselor working with Ruth will have many challenges.

  Relapse is possible at any time. LGBT people in long-term recovery may be very embarrassed
about relapsing and use that as an excuse to avoid 12-step or other interventions. LGBT 
substance abuse counselors may feel that they have even fewer treatment options, especially if
they wish to preserve a sense of personal confidentiality. In Ruths case, the out-of-town location
may not have been necessary from a clinical point of view (that is, the treatment at a local site
may have been just as good as the site chosen), but the client accepted the intervention and
referral. Since getting back on the path of recovery is so important, this concession made 
perfect sense.

  Relapse can be triggered by many things. Though nothing like a death or a reaction to prejudice
causes the substance abuse, the emotional reaction to such events may be the trigger that
brings on a relapse. Ruth will have to face several emotional challenges in her early recovery,
and her substance abuse counselor will need to help her pace the rate at which she confronts
the issues to help her remain clean and sober. The death of her mother, the homophobia of her
church, her concern about the effect of her behavior on her lover, her return to work, and 
revisiting her own internalized homophobia all will be part of her long-term recovery.

  Religion and spirituality may play a very important part in recovery from substance abuse for many
LGBT people. If the clients church is an issue, the counselor may need to help the client find an
LGBT-accepting church or a different church branch. Some organized religious groups and 
churches have congregations for LGBT people. Most religious groups will have some LGBT-
sensitive, if not even openly LGBT, clergy who may be very helpful. Counselors will need to know
the difference between religion and spirituality and help the LGBT client understand that difference.
Such a client may find spiritual comfort even if he or she cannot find religious comfort.

  Psychotherapy usually does not work for substance abusers who are actively using. In Ruth and
her lovers case, couples therapy would probably not have been helpful. The therapist was very
aware of the need to recognize this fact and used the couples meetings to help the lover shape
an intervention, which led to Ruth beginning treatment. After Ruth is clean and sober for several
months, the couple could start therapy if it is still needed. Meanwhile, the lover can continue to
seek the help she needs to manage her own depression.

  Ruth herself will also need to see how much of her life has been affected by racism and 
homophobia. If it has not been explored in past counseling, it will need to be looked at to help
shore up her recovery. In the same way that not acknowledging the effects of homophobia may
make relapse more likely, so, too, will not addressing the impacts of racism.

  Since the lover is so involved in Ruths life and recovery, she should play a role in the early
recovery process. Ruths inpatient treatment counselor will need to include her just as she would
the significant other of a non-LGBT person.

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  SECTION II: 
CLINICIANS GUIDE

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Chapter 5
The Coming Out Process 
for Lesbians and Gay Men

Emily B. McNally, Ph.D., C.A.C., Naples, FL

What providers will learn
from this chapter:

  The definition of the 
coming out process and
what is known about it

  Potential interaction
among substance abuse,
recovery issues, and the
coming out process

  Ways counselors can use
their understanding of 
coming out to help lesbian
and gay clients
Introduction

This chapter presents information on the
coming out process so substance abuse
treatment providers will understand what
lesbian, gay, bisexual, and transgender
(LGBT) clients may experience and how
their support will help LGBT clients deal 
with this issue. 

The term coming out refers to the 
experiences of some, but not all, gay men
and lesbians as they work through and
accept a stigmatized identity. The coming
out process for many gay and lesbian 
people is a way of transforming a negative
self-identity into a positive identity. This
process is especially important to people
who are trying to recover from substance
abuse. For many people, feeling positive
and hopeful about themselves is at the heart
of recovering from addiction. It is notewor
thy, however, that for many reasons not all
gay men or lesbians come out. Many people
who are attracted to, love, and/or are sexual
with people of the same sex do not consider
themselves gay or lesbian and do not go
through any of the stages presented in this
chapter. 

What the Coming Out Process Means 
for Counselors

The coming out process is a very important
one. Many recovering LGBT clients spend
years working through issues related to
coming out (both to themselves and to oth
ers) and working through their internalized
homophobia to feel good about themselves.

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The Coming Out Process for Lesbians and Gay Men
If all goes well, they will eventually be able to
say, I am who I am, and I accept myself as
myself. Because many recovery programs
value authenticity and honesty, the process of
coming out for many gay men and lesbians is
crucial to becoming and staying sober. 

Counselors who can accept and validate
clients feelings, attractions, experiences, and
identities can play an important part in those
clients sobriety. Clients who drank and used
drugs to medicate their negative feelings about
being gay need to have those experiences
understood. Others who used substances to
accept their gay feelings and behaviors may
need help in sobriety to work through those
experiences again in a sober way. The coming
out process does not happen according to a
schedule. Some people may have come out
during their teen years, and others may be
working through the process during middle age
or later.

No correct way exists to move through the
coming out process. Some people may decide
that they do not want to take on a gay or 
lesbian identity and may choose not to disclose
their feelings and experiences to anyone.
Counselors need to validate the needs of each
client and find a way to understand their 
experiences. 

A major issue for every client is how to become
and stay healthy. To be most helpful, coun
selors need to assess at which stage of coming
out the client is and understand the risks and
needs of the client at that stage. For example,
it is not advisable to refer a client in the first or
second stages to gay or lesbian Alcoholics
Anonymous (AA) meetings or to suggest that
the client discuss his or her sexual identity in
group therapy. The counselor may be the only
person a fragile client can trust during the early
stages. Or, if an LGBT client is in the fourth
stage and distrusts straight people, attending
gay or lesbian AA meetings or finding a gay or
lesbian sponsor might be beneficial. In general,
counselors who can view coming out as a 
lifelong process of growth can help their 
clients with recovery and self-acceptance.
Stage Models of Transforming an Identity

Stage models provide a useful description of
the process by which some people come to call
themselves gay or lesbian. The models also
suggest a way of looking at how substance use
and recovery interact with being gay or lesbian
and with the ways people experience their 
sexual identities. Bisexual and transgender
people may have some of the same issues 
and problems during recovery and learning to
accept themselves. The available coming 
out models do not address the issues of  
transgender individuals, although some models 
discuss gender roles while addressing sexual
orientation (DeCecco & Shively, 1985; Bockting
& Coleman, 1993). Fox (1995) addresses the
development of bisexual identity. In general, it
is a false assumption that bisexual, transgen
der, gay, and lesbian processes are parallel,
even when some similarities are noted.

Stage models are general guides to help 
counselors understand the coming out process;
however, there are several points to remember.
The models are not linear, and people do not
necessarily move through them in order. One
stage is not better than another, and people
should not be seen as more advanced and
mature if they are in a later stage. 

William Cross (1971), an African-American
psychologist, created one of the first models
describing how a person with a stigmatized
identity undergoes an identity transformation
and then learns to manage and integrate this
new identity. His stage model described the
process by which a Negro recovered from the
effects of discrimination by transforming inter
nalized racist cultural values and attitudes and
developed a positive identity. Similarly, Cass
(1979) proposed a model for the process by 

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which gay men and lesbians transform their
stigmatized identities from negative to positive. 

A number of other models exist, usually with
four or five stages and with some variations in
focal point (Coleman, 1981/1982; Kus, 1985;
Sophie, 1985/1986; Troiden, 1988; Woodman,
1989). For example, whereas Cass (1979)
focused on ego functioning, Hanley-
Hackenbrucks (1989) model examined 
superego functioning and the ways people
changed their superegos from critical to
ambivalent to accepting of themselves.
McNally (1989) interviewed lesbian recovering
alcoholics and proposed a model that
described how lesbians transform their 
identities from active alcoholic to sober ones,
how they came to feel positive about them
selves as lesbians, and how their alcohol
abuse and recovery interacted with the stages
of developing a sexual identity. It is also note
worthy that these stage models resemble
Prochaska, Norcross, and DiClementes (1994)
stages-of-change model, a model originally
developed to determine treatment readiness. 

Stage One: Identity Confusion

Most identity stage models suggest that the
first stage involves some denial and confusion
regarding ones feelings of attraction and sense
of self. Cass (1979) stage one is Identity
Confusion, which occurs when people see
their behavior as homosexual and face a crisis
about who they are. Many people use alcohol
and drugs to manage the painful feelings of
this stage. They may drink or use drugs to
cope with their anxiety and shame or to 
socialize or be sexual with a person of the
same gender. They may use substances to
help block out unwanted feelings of attraction
toward people of the same sex or to keep from
ascribing personal meaning to behaviors they
consider unacceptable. Consider the examples
of Joe and Mary.  For many years, Joe
drank to drown out a sexual experience in high 
school in which he had sexual and loving 
feelings toward his best friend. He was terrified
that he might be gay and did not want to bring
shame to his religious family. Mary drank to
cope with the confusion of being sexual with
Sally, her roommate, and to avoid seeing 
herself as a lesbian.
Stage Two: Identity Comparison 

In stage two, Identity Comparison, people
begin entertaining the possibility that they may
be gay or lesbian. In this stage, anxiety can be
considerable, as people deal with their denial
about their sexuality. People in this stage are
often in emotional pain and are quite vulnerable.
Substance abuse may be the primary way they
have to deal with the pain associated with an
experience that breaks through their denial and
shatters their sense of heterosexual identity.

The examples of Matt and Joan are 
instructive. Matt always thought that he was
heterosexual, but when he became emotionally
and sexually involved with his college 
roommate, he began to question his identity
and feelings. When his roommate broke off the
relationship, Matt was devastated. He drank
excessively to cope with his feelings about the
breakup and his identity confusion. He went in
and out of several detoxification and rehabilita
tion facilities during this stage of confusion,
secretly struggling with inner turmoil and
anguish. He finally received help when a 
counselor identified his conflict and helped him
describe his feelings, offering him some hope
of resolving his conflict if he stayed sober.

Joan was so frightened when she felt attracted
to a lesbian she met at work that her drinking
increased and her job was in jeopardy. When
she entered treatment to save her job, Joan
whispered to her counselor that she might be
one of them but did not want to be and could
not talk about it. Her counselor reassured Joan
it was her choice whether to discuss it.
The Coming Out Process for Lesbians and Gay Men

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The Coming Out Process for Lesbians and Gay Men
Stage Three: Identity Tolerance

In stage three, Identity Tolerance, people
begin to have a greater level of commitment to
a new identity (I probably am gay/lesbian.).
These feelings increase the sense of alienation
and isolation. In response, people seek out gay
and lesbian individuals and try to connect with
the gay community and culture. If a lesbian or
gay man is in treatment at this point, the coun
selor can help by suggesting attendance at
gay- or lesbian-affiliated AA or Narcotics
Anonymous (NA) meetings. If people remain
open to this growth process, their self-image
may change and they can say, I am gay or I
am lesbianan assertion that marks the 
beginning of the next stage. 

Some people identify themselves as bisexual
before they identify themselves as gay or 
lesbian. This stance may be easier because
they believe others may be more accepting of
them as bisexual than as gay or lesbian.
Because the transition from identity tolerance
to identity acceptance is a highly individual
process, it is important that counselors not
force clients into declaring they are gay or les
bian but respect and support individuals in their
process. Although some individuals may see
themselves as bisexual as part of their coming
out process, other individuals are clearly 
bisexual and need to be accepted as such.

Stage Four: Identity Acceptance

The Identity Acceptance stage is character
ized by increasing contacts with other gay and 
lesbian individuals. It also involves experiences
that help normalize a gay or lesbian identity
and way of life, and this stage can introduce
new opportunities for drinking. Consider the
experiences of Veronica and John. Veronica
told her counselor that when she began to
come out, her drinking just took off and went
through the roof! She spent much of her time
in gay bars and drank heavily at every opportu
nity to socialize and be sexual.
John had been quite close to his family, but he
believed family members would reject him if
they found out he was gay. While he was
enjoying his new gay and lesbian friends and
his activities in the gay community, he used
marijuana and drank heavily every day to med
icate his anger and sadness about the loss of
his family. Thus, as people increasingly
become able to accept rather than tolerate
their homosexual self-image, their substance
abuse problems may, in some cases, become
more severe.

People in the early stages often have fragile
identities and find it difficult to cope with 
non-LGBT people who do not understand the
need to be with people similar to them. They
may disclose their identities to intolerant people
in unsafe situations. For example, Ed felt so
good about being gay and falling in love with
Jorge when he got sober that he wanted to
tell his boss and coworkers his happy news.
His counselor was able to help him exercise
some restraint. Jan, for instance, was happy
about coming out as a radical lesbian feminist
separatist and claimed her identity with a great
deal of enthusiasm. However, she refused to
enter a rehabilitation facility that treated men
and would go only to a womens program that
she felt would be sensitive to her needs as a
lesbian. There her counselor could respect her
political or emotional position while helping her
recover. 

Stage Five: Identity Pride

If people move to Identity Pride, stage five in
Cass model, they do so with an awareness of
the difference between their acceptance of
their own homosexuality and societys rejection
of it. There is a tendency to get angry, to split
the world into gay and straight, and to respond
to heterosexism by rejecting the dominant 
heterosexist culture. People may become
active in the lesbian/gay community and spend
the majority of their time with others who share
their feelings and perspectives. 

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Collettes drinking and political activity as a
feminist have been deeply and passionately
intertwined for many years. She angrily tells
her counselor that he does not understand
anythingno man can possibly understand
her; no heterosexual can, either. She tells him
that everyone she knows drinks the same way
she does and that she cannot imagine how she
can carry on her work as an activist without
drinking. If she stops drinking, she will lose
everything and everyone who means anything
to her. Her counselor listens with concern and
tries to empathize with her terror and rage in
the face of what she believes is the loss of her
whole way of life. 

Stage Six: Identity Synthesis 

In stage six, Identity Synthesis, an awareness
develops that the dichotomy of them and us
is not valid. Anger decreases, pride becomes
less aggressive, and the gay or lesbian identity
is more integrated with other aspects of the
individual. It may be difficult for people to attain
this level of identity integration and synthesis if
they have been drinking heavily and using
drugs for a considerable length of time. 

Counselors should explore the meaning of
clients stating they have been out for 30 years
or they have been gay since the age of 7. The
length of time they consider themselves gay or
lesbian does not necessarily predict whether
people have worked through the process of
claiming a positive gay or lesbian identity or of
feeling good about themselves as gay men or
lesbians, especially when they have spent many
years abusing alcohol or drugs. Clients mean
ing of the word out may be highly individual. A
client who describes herself as out for 2 years
may mean that 2 years ago her mother discov
ered that she was involved with a woman.
Recovery Issues for Lesbians and Gay Men

People who have been using alcohol and
drugs for many years may have anxiety and
confusion about who they are and how to make
sense of the experiences and feelings they
encountered during their active addictions.
Counselors need to help people in recovery
begin to address the task of struggling with the
question, Who am I, now that Im clean and
sober? People in recovery need help sorting
out various aspects of themselves, such as,
What does it mean to be a man? A woman?
Gay? Lesbian? Straight? 

If we look at gender identity and sexual identity
on a continuum with male and female being the
endpoints of gender and gay and straight being
the endpoints of sexual identity, we can see
that society forces people to one or the other 
of the endpointseven though this may not 
actually characterize their feelings or 
experiences. An important part of treatment
may be helping people tolerate ambiguity and
diversity. Counselors may be the first people to
tell substance abusers that whoever they are is
okay, that they do not have to declare them
selves gay or straight or bisexual, and that an
important part of recovery may be to spend
time exploring who they are. Clients may need
to explore the meanings of their various 
feelings and experiences. At the same time,
other individuals may arrive in treatment stating
they are okay about being gay but in reality
are still struggling with self-acceptance.
Counselors can help these individuals to 
identify the pain masked by their addiction and
to accept who they are and the identity they
may wish to embrace. In addition, some out
clients may find that their gay or lesbian friends
may not understand or may resent their 
recovery efforts. Counselors can alert clients to
this issue and can assist them in making 
choices about how and with whom they share
their recovery.
The Coming Out Process for Lesbians and Gay Men

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The Coming Out Process for Lesbians and Gay Men
Case Example

Lee is a 43-year-old Asian-American married woman who has been relapsing for over a year and
is currently in an aftercare relapse group. She is quiet and shy, never offering to say much in the
group about herself, but she is quite supportive and helpful to others when they discuss their 
problems. However, when people in the group ask her about problems in her life with sobriety, 
her husband and children, or other relationships, she looks at the floor and seems quite 
uncomfortable. She responds in short, whispered phrases and then falls silent. Lees counselor
notices that, after a woman in the group comes out as a lesbian, Lee becomes even more anxious
and agitated. She asks the lesbian client why she has to come out and flaunt her sexuality.

During an individual session with Lee, the counselor asks her if something is going on in her life
that makes her feel uncomfortable with the lesbian client. Lee says no. The counselor asks
whether Lee has ever been approached by a lesbian. Lee says no. The counselor asks whether
Lee has ever had any lesbian feelings herself. Lee says no. The counselor feels frustrated, but
tries again. She asks whether anything of a sexual nature happened when Lee was drinking that
upset her in any way. Lee is silent, looking at the floor. She begins to cry and tells the counselor
that she cant talk about anything. She says she is too afraid. She doesnt want to lose her family.
She cant bring shame on herself and her whole family. The counselor reassures Lee that 
whatever they talk about is confidential and will not go any farther.

Through much crying and sobbing, Lee tells the counselor that she is terrified that she might be a
lesbian. She says that she sometimes has dreams and fantasies about being sexual with women,
and once when she was drinking, a woman flirted with her at a party. She thinks they might have
been sexual, but shes not sure; she was having blackouts at the time. She doesn't know what to
do. She doesnt feel attracted to her husband and thinks this must mean shes a lesbian, but she
doesnt want to be a lesbian. Lee cries and expresses deep despair and shame, but relief, too, at
finally telling someone what she thought she could never disclose. The counselor, too, knows that
Lee finally has a chance to stop relapsing and to begin her sobriety.

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Suggested Interventions

What stage a person is in should determine which interventions are appropriate for and sensitive
to the patients needs. In the example above, the counselor created a safe atmosphere for Lee by
asking questions in private rather than in the group and by asking them in a way that reassured
Lee, while telling her that she could talk about herself. The counselor might follow up on Lees 
disclosure with some private sessions and refer her to a knowledgeable therapist to help her with
her feelings and concerns about her sexual orientation. Because clients in stages one and two
usually are frightened, confused, and vulnerable, they need help and support from counselors to
talk about their feelings and experiences. Because of their shame and anxiety, clients are 
vulnerable to relapse, and counselors need to help them by talking freely about their sexual 
identity, raising the issues, and discussing them openly.

Guided by the stage model, counselors need to intervene in ways that fit the clients particular
needs, desires, culture, experiences, and feelings. For example, if a person in stage four wants 
to come out to his parents, boss, and family, a counselor could help the client explore the possible
positive and negative consequences of such disclosures. Clients in this stage may not know where
to socialize with other sober gay or lesbian people. Referral to sober resources is important. If a
client comes out to himself or herself while in treatment and begins to move into stage three, a
counselor might need to help the client with family or job issues, religious guilt, and other problems
that could threaten the clients sobriety. Making a referral to gay and lesbian AA/NA or other 
support group meetings at this time and to gay or lesbian therapists is quite important to clients to
help them maintain their sobriety and cope with all the complex and difficult issues related to being
gay and lesbian and recovering from substance abuse.
The Coming Out Process for Lesbians and Gay Men

67

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Chapter 6
Families of Origin and Families of Choice

Philip T. McCabe, C.S.W., CCGC, C.A.S., CDVC, Ocean Grove, NJ

Introduction

This chapter addresses the family dynamics
that are important in working with lesbian,
gay, bisexual, and transgender (LGBT) indi
viduals and how counselors can put their
understanding of these dynamics to work in
counseling LGBT clients and their families.

Like nongay clients, LGBT individuals 
seeking recovery are involved in 
multidimensional situations and come from
diverse family backgrounds. Family, 
relationships, friends, social interactions,
work issues, self-esteem, increased 
understanding of self-identity, and 
community support all are part of the focus
of the treatment and recovery process.
During the course of treatment, it is 
important to identify stressors that can 
trigger a return to substance abuse and
addiction. LGBT individuals, in particular,
need an intake assessment that is compre
hensive, inclusive, and culturally sensitive. 

Family of Origin

Family of origin refers to the birth or 
biological family or any family system 
instrumental or significant in a clients early
development. Taking a family history and
reviewing the dynamics of the family of 
origin should be part of a thorough biopsy-
chosocial assessment. Counselors should
exercise great care in asking sensitive 
questions, particularly about members of the 
family of origin. The clients cultural norms
will be particularly important during this 
What providers will learn
from this chapter:

  What a counselor needs to
know about relationships
and families when coun
seling LGBT clients

  The difference between
families of origin and 
families of choice

  How a counselor can
identify unresolved issues
with a clients family of 
origin that could trigger 
a relapse

  How a counselor can be  
sensitive to an LGBT
clients family of choice 
in treatment

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questioning and should be respected for an
assessment to be effective.

LGBT clients often will have unresolved issues
about their family of origin, particularly regard
ing sexual orientation or gender identity. As
they do with all clients, counselors need to
review the clients role in his or her family of
origin, because unresolved issues with the
family of origin can act as emotional triggers to
a relapse. 

The following questions can help the counselor
gather relevant information and assess what
unresolved issues might interfere with clients
ability to maintain sobriety.

  What were the rules of the family system? 

  Was there a history of physical, emotional,
spiritual, or sexual trauma? 

  Were all family members expected to behave
or evolve in a certain way? 

  What were the familys expectations with
regard to careers, relationships, appearance,
status, or environment? 

  In general, was sex ever discussed?

Concerning sexual orientation and gender
issues, counselors can begin by reviewing with
clients how differences were perceived in the
family. The following questions would be 
appropriate to explore:

  Was anyone else in the family acknowledged
to be or suspected of being a lesbian, gay,
bisexual, or transgender individual? 

  How did the family respond to other 
individuals coming out or being identified as
LGBT individuals?

  Is the client out to his or her family?
  If the client is out, what type of response did
he or she receive?

The family of origins response to ones 
disclosure of an LGBT identity can have a 
long-lasting andif it is negative and 
unacceptingoften devastating effect on an
individual. Responses can range from abusive,
rejecting, or avoiding to tolerant, supportive, or
inclusive. LGBT individuals need to process
these messages, roles, rules, images, and
stereotypes about sexuality in addition to the
messages they receive from society in general.

What makes the LGBT experience different
from the experience of other cultural minorities
is that LGBT individuals experience prejudice
and, most frequently, a disconnection from
other members of their minority group. Even in
a multicultural family, an adolescent is able to
look beyond his or her immediate family to the
cultural community and find someone to identi
fy with. This typically is not true for LGBT 
individuals, who usually grow up without 
information on or contact with other LGBT 
individuals.

In his book, Healing the Shame That Binds
You, John Bradshaw, Ph.D. (1988), refers to
the toxic shame that is created in childhood
and stays until the individual learns to purge it.
Similar processes have been explored by
authors who write about recovery and families,
for example, Janet Woititz, Adult Children of
Alcoholics (1990); Earnie Larsen, Stage II
Recovery (1991); Ann Wilson Schaef, When
Society Becomes an Addict (1988); and
Michael Picucci, The Journey Toward
Complete Recovery (1998), as well as numer
ous others who acknowledge the importance of
resolving these conflicts from our childhood
and our family of origin.
Families of Origin and Families of Choice

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Family of Choice and Relationships

Providing support for LGBT clients and their
families of choice is a crucial element of 
substance abuse treatment, just as it is for all
clients. A family of choice is made up of indi
viduals who are significant to the client, and it
needs to be included in any assessment. It
includes individuals who have died or are no
longer an immediate part of clients lives,
sometimes because of addiction, HIV/AIDS, or
other life events. A family of choice does not
necessarily exclude blood relatives. By defini
tion, it includes those who, by their support,
nurturing, and understanding, have earned a
significant place in the LGBT individuals life.

Substance abuse counselors and treatment 
centers need to create a safe place for healing.
This safety needs to include respect, under
standing, and support for the life partners and
significant others of their LGBT clients. It cannot
be overstated that these individuals must be
included in services similar to those offered to
the spouses of heterosexual clients.

In order to work effectively with LGBT clients,
substance abuse treatment counselors need to
have some understanding of the dynamics of
LGBT interpersonal relationships. This includes
awareness of the internal and external 
problems of same-sex couples and the 
diversity and variety of relationships in the
LGBT community. As noted previously, not all 
individuals in relationships with people of the
same sex, or engaging in same-sex behavior,
consider themselves lesbian or gay. The coun
selor needs to be sensitive to the individuals
self-identification. Counselors also need to be
aware of the lack of universal terminology with
regard to significant others in the LGBT 
community. The terms lover or significant
other can mean different things depending 
on cultural or generational differences.
Interpersonal relationships span a spectrum of
emotional significance that is as diverse as
LGBT communities. Although many individuals
seek out a life partner, others are single or may
find themselves in nontraditional arrangements.
Counselors need to be aware of their own 
biases when working with individuals whoas
a result of their affectionsfind themselves
outside the cultural norm of a heterosexual,
monogamous, and legally sanctioned marriage.
Lesbian, gay, and transgender (LGT) 
individuals with a previous history of 
opposite-sex relationships add a new level 
of complexity to their relationships that 
approaches that of bisexual individuals. Like
their heterosexual counterparts, some LGT
individuals maintain close contact with their
opposite-sex partners. Others consider such
relationships to be part of a previous life
before coming out. 

One particular stressor for LGBT individuals in
interpersonal relationships is the level of 
comfort with ones sexual orientation. A couple
could, for instance, consist of one person who
is closeted while the other is out. When 
couples are at different stages of self-
acceptance regarding sexual orientation, it can
be a source of great tension within the unit.

Parenting Issues

A common misconception is that LGBT 
individuals are not partnered and do not have
children. The reality is that many LGBT 
individuals are coupled, have children, and
exercise the same responsible parenting as
their heterosexual counterparts. Many LGBT
individuals have children from previous 
heterosexual marriages. Moreover, as more
LGBT couples adopt, become foster parents,
or use alternative routes of insemination to
become pregnant, substance abuse treatment
counselors can expect to be working with more
LGBT clients who are parents, either as part of
a couple or as single parents.

When children are added to a family system,
parent-child relationships, the role of 
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stepparents or members of the blended family,
and the birth parent (if any) must be factored
into the family dynamic. Counselors may have
a concern that children growing up in LGBT
families are likely to become LGBT individuals,
but this concern is unfounded. As we have
seen in chapter 1, the etiology of sexual 
orientation is so complex that the sexual 
orientation of parents or family members is not
an issue.
Individuals in treatment need to be concerned
about losing custody of their children. See
chapter 3 for a discussion of this issue and
other legal issues of particular concern to
LGBT parents.
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Chapter 7
Clinical Issues With Lesbians

Dana G. Finnegan, Ph.D., C.A.C., Naples, FL

What providers will learn      
from this chapter:

  The range of diversity
among women who see
themselves as lesbians or
whose sexual/emotional/
affectional feelings and
behavior are primarily
directed toward women

  The myths and stereotypes
about lesbians that need
to be explored and 
corrected

  The clinical issues and 
concerns specific to 
lesbian clients

  How counselors need to
respond to issues specific
to lesbians who are 
substance abusers
Introduction

Perhaps the most important thing a 
counselor needs to bear in mind when 
working with lesbian clients is that there is
no one lesbian clientthat there is 
tremendous diversity among lesbians. As
women, lesbians share the diversity inherent
in womanhood; they also share the 
experience of dealing with sexism. The
range of their experiences, perspectives, life 
situations, and statuses can hardly be 
overstated. Lesbians are from all races and
ethnic groups, all socioeconomic levels and
ages, all areas of the country and indeed of
the world. Some lesbians are sexual with
men at times, yet see and identify 
themselves as lesbians. Some women have
same-sex relationships, but do not see
themselves as lesbians. There are also
women who choose to self-identify as 
lesbians on the basis of their emotional
attraction to other women and in spite of
being sexually attracted to men.

While some lesbians have children or want
to have them, others do not. Some women
have known they were lesbians since the
age of 5 or 6 years (but were without the
vocabulary to describe it at the time). Others
become aware of their attractions to other
women only in later life, often after having
been in a heterosexual marriage for a 
number of years. Some lesbians are very
comfortable with and public about their 
lesbian identity. Others have great difficulty
taking on a lesbian identity and may keep it
secret and hidden, whether from shame 
(internalized homophobia) or from a need to 

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protect their jobs or maintain relationships.
Some lesbians may look and act masculine, 
whereas others may look and act feminine.
Many lesbians are not at all distinguishable
from the general population of women.

Lesbians exhibit great diversity in their drinking
or drug-taking behavior as well. There is no 
single pattern of such behavior among lesbians
who are substance abusers. In this sense,
again, they also may be indistinguishable from
the general population of women.

Destructive Myths and Stereotypes

Counselors need to be aware of the numerous
myths and stereotypes that our society toler
ates and sometimes promotes even though
they are inaccurate and can be destructive.
Such awareness enables counselors to check
out their own belief systems and help work with
their lesbian clients on issues specific to their
sexual orientation. 

One set of myths is that lesbians hate men,
that they are afraid of men, or that they want to
be men. The truth of the matter is that a small
number of lesbians may hate men, but so do
some heterosexual women. A small number
may be afraid of men (as are some heterosex
ual women) and often for good reasons (e.g.,
rape, sexual abuse, physical violence, sexism).
It can certainly be said that many lesbians and
many heterosexual women want the same
power that men have by virtue of having been
born male. Most lesbians do not hate men;
they are not afraid of men, nor do they want to
be men. Likewise, the idea that all lesbians are
masculine or butch is not true.

Another myth is that lesbians do not have 
stable relationships and are either particularly
loath or anxious to form committed 
relationships. A number of younger lesbians
engage in serial dating and are not monoga
mous. Like their straight counterparts, some
might be judged promiscuous, but it is more
accurate to see them as following the mores 
of their peers and their generations culture.
Conversely, a myth exists that lesbians form
committed relationships instantly and stay
together as long as they possibly can. Again
like heterosexual women, some lesbians may
form lasting committed relationships too soon
for their own good, whereas others may not.
A pervasive myth to consider is that life as a
lesbian is onlyor predominantlyabout being
sexual or that a lesbian identity is purely a 
sexual identity. Although being lesbian most
certainly is about being sexually attracted to
other women, many lesbians also talk about
the power and importance of their emotional
and affectional feelings and attractions for
other women.

Common myths also suggest that there is a
sexual cause for lesbianism, such as having
had bad sexual relationships with men, or 
having been sexually abused by men, or not
being sufficiently sexually attractive to men.

An offshoot myth is that lesbians are sexual
predators, that they are always looking to
seduce one another and heterosexual women.
This myth strains credulity since women are
not known to be sexual predators and indeed
receive strong messages from our society 
discouraging sexual aggression. 

One other set of myths that needs to be 
challenged relates to the idea that sexual 
orientation is a matter of choice. These myths
merit some discussion here, although a fuller
treatment is provided in chapter 1. It is true that
lesbians can change their sexual behavior.
Many women who eventually self-identify as
lesbians live for years behaving as heterosexu
als. They may take husbands and have and
raise children. Despite appearances, however,
they cannot always be said to have changed
their sexual orientation. Two related myths are
(1) that lesbians would prefer to be heterosexual
and would, in fact, choose to change their 
Clinical Issues With Lesbians

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sexual orientation if they could, and (2) that 
sexual orientation is caused by a hormonal 
imbalance and could be changed by taking 
the right hormones.

What is important about the myths are the
underlying assumptionsthat heterosexuality
is superior to homosexuality: more moral,
healthier, and more natural. These beliefs can
make life in recovery harder to negotiate.

Clinical Issues With Substance-Abusing
Lesbians

Too little is written on the incidence, 
prevalence, and patterns of substance use
among lesbians. Many formal studies have 
generalized from gay males to lesbians, 
whereas others have used unreliable sampling
methods. In the literature that is available, cer
tain risk factors are noted repeatedly, such as:

  The reliance of many lesbians upon womens
bars for socializing and peer support

  The interaction of sexism, stress, and 
substance use

  Issues related to coming out such as 
alienation from loved ones upon revealing
ones lesbianism, the emotional 
dissonance of passing as heterosexual,
and the use of substances to reduce the
anxiety of these conflicts

  The interaction of trauma (discriminatory
experiences, physical or sexual assault
because of ones lesbianism) and substance
use.

The traumas that lesbians may have suffered
need to be recognized and understood as 
integral parts of their behavior, outlook, and
emotional makeup. For example, the research
findings of the National Lesbian Health Care
Survey (Bradford, Ryan & Rothblum, 1994)
reported that 21 percent of lesbians had been
sexually abused as children and 15 percent as
adults. (However, it is a myth that being sexual
ly abused makes a woman a lesbian. That is
false, even though some lesbians believe the
myth.) For every lesbian client, the trauma of
alcohol and drug abuse is added to the nega
tive effects of homophobia and heterosexism.
Finally, there may be other traumas, such as
being African American or Latina in a preju
diced society. Attention to trauma issues may,
therefore, be a key part of the overall recovery
process of the substance-abusing lesbian. 
In their 1997 review, Hughes and Wilsnack
note some general patterns in lesbians use of
alcohol, including:

  Fewer lesbians than heterosexual women
abstain from alcohol. 

  Rates of reported alcohol problems are 
higher for lesbians than for heterosexual
women. 

  Drinking, heavy drinking, and problem 
drinking among lesbians show less decline
with age than among heterosexual women.

Along with addressing the above concerns,
counselors will find lesbian clients with a 
variety of issues as women and as homosexual
persons. The roles partners and children play
in the clients use of alcohol and drugs and
recovery are particularly important (see chap
ters 2 and 6), as are confidentiality and legal
concerns (see chapter 3).

Counselors Responsibilities

Because myths and stereotypes pervade our
culture and influence our thinking and our
behaviors, it is important for counselors to be
aware of them and to help their lesbian clients
not be further injured by them. This means
counselors need to assess their beliefs in the
myths so they do not impose them on their
clients. Counselors need to be able to help
Clinical Issues With Lesbians

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their lesbian clients deal with the effects of
homophobia and heterosexism as they affect 
their clients recovery. All people struggling to
recover from alcoholism or drug addiction are  
vulnerable and easily hurt and can relapse
when wounded or unsupported. Negative 
experiences can undermine or destroy the 
strength necessary to recover. An informed and
sensitive counselor can make an enormous 
difference in a lesbian clients treatment and
recovery.
Clinical Issues With Lesbians
Case Examples

Example #1: Rita, 52, a very attractive woman dressed in high heels and a form-fitting suit, is wearing 
tasteful, but dramatic, makeup. She looks like anything but an alcoholic. She is from the Dominican
Republic and separated from her husband; she has two children, but is currently living alone. She is seek
ing treatment for problems Im having because of my drinking. She will lose her 7-year position in her
company if she doesnt stop drinking, she is estranged from her family, and she has lost all her friends
because of her drinking. Rita has tried Alcoholics Anonymous (AA) but is having great difficulty finding a
sponsor (Nobody is very warm or accepting); she is also having trouble relating to other women in the
program (Theyre not very friendly. Maybe because Im Latina.). When asked about her relationships with
others, she looks embarrassed and mumbles something noncommittal. When the counselor directly asks,
Have you been in any long-term relationship with anyone in the past 10 years? Rita stammers out that
she had lived with a friend for 5 years. The counselor then asks if Rita can say more about the nature of
the relationship, the quality of it, and the reasons for its ending. Rita answers in vague terms that she and
her friend argued about how much Rita drank and that the friend finally left. As Rita continues her descrip
tion, her vagueness suggests that the difficulty she is having talking about it might stem from a lesbian
relationship (or her fear that it might have been one). The counselor must now decide whether to ask for
more information.

Acting on the basic premise that Ritas secretiveness indicates a high level of anxiety about this subject
and that her anxiety probably makes her distance herself from others for fear of being found out, the coun
selor presses on. How? Not by using the term lesbian or by going directly for this particular topic. Instead,
the counselor asks such questions as, Were you close to one another? Was your friend emotionally 
supportive of you? And the counselor can empathize, saying such things as, The breakup must have
been very painful for you. When he or she left, how did you cope with the loss? Now the counselor has
introduced the possibility that the friend is a woman and offers Rita the opportunity to edge a little closer to
being able to talk about the fact that this close relationship was with a woman. It is important to note here
that the counselor is not using any label (such as lesbian) and is only indirectly exploring the quality and
nature of the relationship. If and when Rita can begin to talk in more detail about this relationship, the
counselor needs to continue the exploration in this restrained manner because the topic is so frightening 
to Rita. Such restraint on the counselors part is crucial because Rita has been able to pass for straight,
something that has been of great importance to her because the Latino culture and her family are extreme
ly homophobic. Restraint is also crucial because it creates the safety essential to engendering the patients
willingness to participate in her treatment and recovery.

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Example #2: Andrea, 23, has been drinking alcohol since she was 12. She also became addicted to her 
mothers Valium and uses it to smooth out her hangovers and to come down from her occasional cocaine
highs. Andrea has known since she was about 9 that she is attracted to girls and has been sexually active
since the age of 14. She is totally out as a lesbian and says she has no problems about her sexual identity. 
But she is troubled by her inability to sustain any relationship for longer than a few months. She also says that
since shes achieved sobriety, she doesnt know how to meet women who want to date her. She has become
shy and uncertainshe says, retarded. The counselor needs to help Andrea assess where she is in the
development of a sober and clean identity and how that relates to her sexual orientation. She has not 
been able during her formative years to learn the necessary developmental lessons of adolescence.
Furthermore, she tended to act out her feelings when drunk or drugged, including a lot of sexual feelings. She
never learned how to date or communicate or relate emotionally to others. The counselor needs to point out to
Andrea that she will probably need to go back and come out again in some form, now that shes clean and
sober, and that she will need to learn the tasks of adolescence that she missed learning.
Clinical Issues With Lesbians
Suggested Interventions

Although the responsibilities involved in counseling substance-abusing lesbians may seem daunting, there is
no denying the importance and influence of the caring counselor. Counselors who dont know a lot about
lesbians can still offer much of value to their clients if they start with what they know about women and take
the time and make the effort to understand the special problems of lesbians.

Some suggestions for treatment are as follows: 

  Empower the clientthis should be the primary goal, no matter how it is reached.
  Honor diversity. 
  Use nonjudgmental language. 
  Avoid labeling. 
  Do not confront, but support and explore.
  Respect the clients position, whatever that may be (Im not a lesbian; Im confused; Im a 
lesbian and proud of it!). 
  Respect some lesbians unwillingness to attend AA or Narcotics Anonymous because they consider 
these programs male institutions with no room for them as women, and especially as lesbians, or 
because of the emphasis on powerlessness, which they feel emphasizes their status as victims.

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Chapter 8
Clinical Issues With Gay Male Clients

Robert Paul Cabaj, M.D., San Mateo County Mental Health Services, San Mateo, CA

Introduction 

Many factors may contribute to the 
prominent role of substance use and abuse
in gay men. At one point, American psycho
analysts even postulated that homosexuality
itself caused alcoholism. We know now, of
course, that homosexuality, repressed or
not, does not cause alcoholism, because 
alcoholism and substance abuse are the
result of the complex interactions of genetic,
biological, familial, and other psychosocial
factors.

However, the psychological effects of 
heterosexism, antigay bias, and internalized
homophobia may make gay men more
prone to using alcohol and other sub
stances, and that use, in turn, may lead to
substance abuse or dependency and may
trigger the genetic expression of alcoholism
and drug abuse. Higher rates of alcoholism
have been documented in societies or 
cultures in turmoil or undergoing social
changea description that can be said to
apply in the case of lesbian, gay, bisexual,
and transgender (LGBT) individuals (Cassel,
1976). For most of the 20th century, societal
pressures forced most gay people to remain
in the closet, hiding their sexual orientation
or not acting on their feelings. Legal 
prohibitions against homosexual behavior,
overt discrimination, and the failure of 
society to accept or even acknowledge gay 
people have limited the types of social 
outlets available to gay men to bars, private
homes, or clubs where alcohol and drugs
often played a prominent role. The role mod
els for many young gay people just coming
What providers will learn
from this chapter:

  The social, cultural, 
psychological, and 
developmental issues and
treatment considerations 
specific to gay men

  Some of the societal, 
cultural, and emotional
factors and expectations
with which gay males
must contend

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out are often gay people using alcohol and
drugs at bars or parties. 

Some gay men, in fact, cannot imagine 
socializing without alcohol or other mood-
altering substances. Brought up in a society
that says they should not act on their sexual
feelings, gay men are very likely to internalize
this homophobia. Often their first homosexual 
sexual experience was while drinking or being
drunk to overcome fear, denial, anxiety, or
even revulsion about gay sex. For many gay
men, this linking of substance use and sexual
expression persists and may become part of
the coming out and social and personal identity
development processes. Even after coming
out, many gay men will use mood-altering 
substances to temporarily relieve persistent
self-loathing, which is then reinforced in the
drug withdrawal period. 

Given the lack of widespread acceptance of
homosexuality and bisexuality in our society at
this time, the stages of developing a gay identi
ty may be intimately involved with substance
use. Swiss psychoanalyst Alice Miller (1981)
sheds light on the link between the psycho-
dynamic forces in developing a gay identity
and the use of substances in her work on the
emotional lives of children who are talented or
otherwise different. Her description of how 
parents influence the emotional development 
of these children has strong parallels with the 
development of a gay identity. Parental 
reactions shape and validate expressions of
childrens needs and longings. Parents reward
what is familiar and acceptable to them and
discourage or deemphasize behavior or needs
they do not value or understand. To get
rewards, children eventually learn to behave
the way parents expect and to hide or deny the
longings or needs that are not rewarded. 

Many gay men fit Millers description of being
aware of being different early in life. They 
recognize that their loving and sexual needs
and longings make them different from others
around them. Some male children who will
grow up to be gay may desire a closer, more
intimate relationship with their father, but this
desire often is not encouraged or even 
understood. The prehomosexual child learns
to hide such needs and longings, creating a
false self. Real needs and desires often are
repressed or rejected as wrong, bad, or sinful.
Dissociation and denial become major 
defenses to cope with this conflict. 
The psychology of being different, and of 
learning to live in a society that does not
accept difference readily, shapes sexual 
identity development as a boy emerges from
childhood and the latency period. Accustomed
to the rewards of the false self, the child 
suppresses his more natural feelings. He 
usually has no clear role models to show him
how to be gay. 

In latency, boys who will become gay, 
especially boys who may be effeminate, may
fear other children and become more isolated.
In adolescence, gay sexual feelings can
emerge with great urgency but with little or 
no permission for expression. Conformity is 
certainly encouraged, which may support 
further denial and suppression of gay feelings.
Adolescents often reject and isolate those who
are different, so the gay adolescent further
develops a disconnection between his feelings
and his external behavior.

These same factors may also help explain the
many problems facing gay youthsuch as
depression, suicidal thoughts (or attempts),
and running away from home, as well as drug
useeven if they have accepted their sexual
orientation (Savin-Williams, 1994). Gay youth
are subject to sexual abuse and violence and
sometimes are introduced to sex via hustling or
prostitution. They may be otherwise used or
exploited sexually by others. The extreme 
difficulty many gay men have in coming out
and integrating sexuality and personal identity
makes sense from this perspective.
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Substance use serves as an easy relief, can
provide acceptance, and, most important, 
simulates the comforting dissociation or 
disconnection developed in childhood where
feelings become separated from behavior.
Alcohol and drugs cause a dissociation of 
feelings, anxiety, and behavior and may, in a
sense, mimic the emotional state many gay
men develop in childhood to survive. The
symptom-relieving aspects help fight the
effects of homophobia, allow forbidden
behavior, provide social comfort in bars (or
other unfamiliar social settings), and alleviate
somewhat the familiar experiences of 
disconnection and isolation.

The easy availability of alcohol and drugs at
gay bars or parties and the limited social
options other than at bars and parties 
encourage the use of substances early in the
coming out and gay socialization process. For
gay men especially, sex and intimacy are often
split. Substance use allows them to act on feel
ings long suppressed or denied but also adds a
new disconnection and makes it harder to 
integrate intimacy and love. As some longings
and needs find easy relief with sex and/or 
substance use, the much more challenging
needs for love and intimacy may be ignored.

Substances help many gay men brace 
themselves for the rejection that they expect
from others. They allow for denial and even
blackouts about sexual behavior, including
risky sexual behavior. They certainly can make
living in the closet with its built-in need for
denial and dissociation possible or even easier
(the I-was-so-drunk-I-didnt-know-what-I-did-
last-night scenario often used in high school
and college). 

The state that accompanies internalized 
homophobia and the one that occurs with 
substance abuse are very similarthe dual
oppression of homophobia and abuse
described by Finnegan and McNally (1987).
The following traits are seen in both: denial;
fear, anxiety, and paranoia; anger and rage; guilt;
self-pity; depression, with helplessness, hope
lessness, and powerlessness; self-deception and
development of a false self; passivity and the
feeling of being a victim; inferiority and low self-
esteem; self-loathing; isolation, alienation, and
feeling alone, misunderstood, or unique; and
fragmentation and confusion. These close 
similarities make it very difficult for gay men who
cannot accept their sexual orientation to recog
nize or successfully treat their substance abuse.
Providers need to know that self-acceptance of
ones sexual orientation may be crucial to 
recovery from substance abuse. 
Being Male and Being Gay

Cultural expectations about what it means to
be male, regardless of ones sexual orientation,
add social and personal pressures. These 
cultural expectationsbasically gender role
expectationsvary by culture and ethnicity and
can present quite different issues, for example,
for gay men of color than for Caucasian gay
men.

In general, however, the stereotypical male in
America can be described as powerful, 
masculine, independent, emotionally reserved,
and career motivated, rather than relationship
motivated. Boys and men who do not seem to
fit this stereotypeor who do not wish to act
like this stereotypemay have trouble fitting in
or being comfortable with themselves. 

Part of societal heterosexism is confusion
about what homosexuality is and what gay
men are. Since most heterosexuals cannot
imagine what it is like to be attracted to 
someone of the same sex or to be gay, they
often mistakenly assume that a gay man is in
some way like a woman. If a man wants to be
with another man emotionally or sexually, they
think, then gay men see themselves as like
women. Cultures, especially Latin-based cul
tures, stigmatize any man who is like a woman.
Some have speculated that this may be one
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basis for antigay bias in America and a major
factor in homophobia.

Gay men are not like women even though they
are attracted to other men. Certainly men may
be effeminatethat is, having some traits that
are in general culturally attributed to women.
Yet effeminacy has nothing to do with sexual
orientation. Many effeminate men are hetero
sexual. Unless a gay man is also transgender,
he does not think he is a woman or wish to be
a woman.

Many gay men do, however, grow up differently
from their heterosexual peers, and a good 
percentage of gay boys and men have traits
and behaviors that are more commonly 
associated with girls or women. Examples of
this include avoiding rough and tumble play
and being less aggressive and less interested
in sports than sterotypical heterosexual males.
These traits do not cause homosexuality, but
they may lead to a child being stigmatized.
Many gay men report being made fun of in
school, feeling isolated, and avoiding contact
with the more macho types of boyswhich,
of course, adds to the stress of being different.

The alleged link between being gay and being 
effeminate or weak sometimes is believed even
by gay men and makes them more ashamed of
their gay feelings than they might be otherwise.
Gay men who are more passive or who enjoy
being the passive or receiving sex partner may
feel deep shame and embarrassment about that
behavior and desire, and that shame may con
tribute to their using alcohol and drugs to try to
cope.

Some gay men may feel pressureeven or
especially by other gay mento be more
butch, masculine behaving, or macho than
they feel comfortable with. This conflict may
lead to acting more reserved or aloof in 
general, making it hard for them to relax. This
pressure to be aggressive may also lead to
alcohol and drug use, especially to drugs that
make one feel more sexual or enhance sexual 
performance, such as amphetamines or amyl
nitrate. This desire to be ultramasculine also
contributes to the focus on looks and body
image for many gay men, including working
out at the gym and the use and abuse of
steroids.  
Gay Male Social Life

Gay men are an extremely diverse group, and
generalizations, even about large subsets of
gay men, tend to be more harmful than 
accurate. A few examples illustrate the point.
Life for a gay man in a small midwestern town
bears little resemblance to that of a gay man
living in Los Angeles or rural Texas. A Latino
gay may have a social environment quite 
different from that of a Caucasian gay man or
an African-American gay man, even in the
same city. A single, 18-year-old gay man lives
a life quite different from that of a 65-year-old
gay man in a committed relationship. Gay
youth who have run away from home may find
little to recognize in the life of a gay university
professor living in a well-furnished apartment.
Such diversity cannot easily be squeezed into
neat stereotypes. In attempting to capsulize
and target gay demographics, media 
concerns and advertising agencies have 
taken on a daunting challenge.

The popular media portrays gay men in various
stereotypes. A gay man is young, beautiful,
and materialistic and focused on sex and party
ing. A gay man is into leather. A gay man
dresses in drag (as a woman) and is extremely 
effeminate. Although some gay men may fit
each of these stereotypes, the majority resists
acting in ways that can be neatly summarized,
or indeed fit any stereotype.

Young gay men just coming out, however, with
limited role models or none at all, may believe
these are indeed the ways to act if one is a gay
man. If they do not comply with the stereotypes
they see, they may feel they do not fit in. Gay
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men of all ages may feel pressure to somehow
be like the image of the gay man they see in
the popular gay press or the general mediato
be young, thin, well-built, usually Caucasian,
and sexually focusedand feel that there is
ageism, lookism, and even racism in the
gay community. Although these isms may
exist in certain individuals, they certainly 
cannot be attributed to all gay men.

Gay men of color sometimes describe feeling
invisible in settings where most of the other
gay men are Caucasian, but this experience
varies by city and region of the country.
Besides the general antigay bias in our society,
gay men of color may also face racismfrom
heterosexuals as well as other gay people. In
addition, they may have specific cultural or eth
nic issues about homosexuality or ways of hav
ing sex with which to contend (as may many
Caucasian gay men). For example, many cul
tures do not condemn sex between men but at
the same time do not acknowledge or discuss
it, especially if the man is married to a woman
or considers himself straight (or bisexual).

In spite of growing awareness and acceptance
of gay people, social outlets for gay men still
tend to be limited in both scope and location.
The gay ghetto, the section of town where
gay people feel comfortable being and getting
together, usually is identified by the presence
of gay bars. The number of gay coffee shops,
bookstores, and activities that do not involve
alcohol and drugs is increasing, but gay bars
and parties that focus on alcohol and drug use
are by far the best advertised and most identifi
able elements of gay social life.

An activity that seems unique to gay people
mostly men, though some lesbians take 
partis the circuit party. These parties are 
weekend-long gatherings that focus on 
dancing, sexual activity, and alcohol and drug
use. Attended primarily by gay men in their
early twenties to late forties, these parties are
held all across the country (and indeed, around
the world), forming a circuit of connected 
activities frequented by many of the same 
people who travel from event to event. The
parties encourage drug useto enhance the
dancing (like at a rave) and sexual activity.
The designer drugsecstasy, gamma
hydroxybuturate (GHB), Special-K, and 
othersas well as amphetamines (speed or
crystal)are heavily used and promoted.
Fatalities have even been associated with the
use of these drugs at some parties.
Alcohol and Drug Use and Sexual Activity

Many people think of gay men as sexually
obsessed, in part as a result of the general
medias focus on gay male sexual activity and
reporting on and concern over human 
immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS). Gay men
are probably no more sexually obsessed or
active than males in general, and certainly
interest level and activity vary with age. Still,
there are important links between sexual activi
ty and alcohol and drug use that add to the risk
of gay men developing substance abuse prob
lems and that pose challenges for recovery.

As noted earlier, many gay men may feel 
particularly ashamed or uncomfortable about
having sex with another man. This 
manifestation of internalized homophobia can
lead to sexual activity in inappropriate places
such as parks or public bathrooms, and it can
strengthen the link between alcohol and drug
use and sexual activity.

A small subsection of gay men focus on sexual
activity with many partners and/or with great
frequency. Many have discovered that using
nitrates, cocaine, and, primarily, amphetamines
greatly enhances sexual intensity and activity.
Amphetamines, in particular, seem to increase
and prolong sexual feelings and sexual 
stamina. Many gay men who use 
amphetamines also develop a side effect 
associated with amphetaminestransient
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impotence. Sexual desire is still greatly
enhancedfor up to 14 hoursthus these
men are at greater risk for HIV infection if 
precautions are not taken.

Gay Male Life Cycles and Relationships

At each stage of their lives, gay men face 
challenges unique to being gay. Adolescents
who are gay, bisexual, or questioning whether
they are gay or bisexual, for example, face
possible taunts or threats from their peers.
Their families may reject them, and some gay
youth run away from home. Such gay youth
may end up homeless and may also get into
drug use (especially intravenous [IV] use) and
turn to prostitution. Anecdotal reports exist of
gay youth who were living on the street
attempting to become infected with HIV for the
purpose of qualifying for medical and social
services as well as disability income and 
housing programs.

Their suicide risk, including thoughts, attempts,
and successful suicides, may be three times
that of other youth (Rotheram-Borus, Hunter &
Rosario, 1994). Gay youth who do not leave
home may also have more problems with
schoolwork, sexual abuse, and alcohol and
drug use than their nongay counterparts.
Experimentation with drugs and sex is likely to
be part of the development of gay youth even 
if they are accepted by family and self-
acceptingjust as with any adolescent or
young adult.

Young gay men and middle-aged gay men
may face discrimination and antigay bias in
school, at work, and from friends and family.
Most gay men form relationships, but same-sex
relationships are not readily accepted or even
acknowledged in America (Cabaj, 1988; Cabaj
& Purcell, 1998). Gay people still are fighting
for the right to same-sex marriages. Many gay
men have childrenby marriage or a relation
ship with a woman, by adoption, or by a copar
enting relationship with a lesbian friend, for
exampleand face the struggles of raising
children with little support from society or even
from other gay people. Such pressures may
contribute to alcohol and drug use.
Older gay men face the same issues as all
older people but may feel more isolated and
disconnected from others because of growing
up gay at a time of even more prejudice
against and denial of gay people. Many gay
men, however, have developed strengths from
personal networks that serve them well in 
coping with older life. Some older men will be
facing the loss of a long-term relationship; such
gay widows may have few social supports. Of
course, alcohol and drug use may be a major
part of an older gay mans life, and he needs
interventions appropriate to his age as well as
his sexual orientation. The emphasis in gay
culture on youthful looks and perfect bodies
may also impact the gay man as he ages.

All gay menall LGBT people in generalalso
face the possibility of violence and hate crimes
directed at them because of their sexual 
orientation. Such violence ranges from verbal
to physical attacks; many victims of such 
violence turn to alcohol or drug use. 

Domestic violence is also a real possibility with
gay couples and is greatly underreported. As
with all couples, there is a link between alcohol
and drug use and domestic violence. Finally,
gay people are subject to physical and sexual
abuse when growing up and are at the highest
risk for alcohol and drug use associated with
such abuse (Island & Letellier, 1991).

HIV/AIDS: Loss and Grief

HIV/AIDS continues to be a major factor in gay
male life. Though not a gay disease,
HIV/AIDS has long been associated with gay
men. Behaviorsrisky sex or sharing needles,
for exampleare the risk factors, not the 
orientation. Still, gay men are at greater risk,
since so many gay men are HIV-infected, and
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having sex or sharing needles in an unsafe
way with another gay man may increase the
risk of exposure to the virus. For more 
information, please refer to the Center for
Substance Abuse Treatments Treatment
Improvement Protocol 37, titled Substance
Abuse Treatment for Persons With HIV/AIDS
(2000). 

The percentage of HIV-infected people in the
United States who are gay has steadily
dropped, but there are still many infected gay
men. There are recent increases in the HIV-
infection rates in younger gay men, especially 
in urban areas (Centers for Disease Control
and Prevention, 1998). 
New infections are, of course, due to exposure
to HIV through risky behaviors. Studies of gay
men who have risky sex and know about pre
cautions for safer sex report that they were
much more likely to have risky sex after alcohol
or drug use (Stall & Wiley, 1988). 

Almost every gay man has lost friends or
lovers to AIDS, and almost every gay man
knows someone who is HIV infected. The grief
and loss gay men feel and share is profound
and has to be a consideration in working with
any gay man.
Clinical Issues With Gay Male Clients
Case Example

Greg is a 28-year-old, hearing-impaired, HIV-infected, Caucasian gay man living in a large west coast city in
a gay ghetto. He works as a sign language interpreter for an AIDS organization. He is single, loves to go to
parties, works out at the gym almost every day, and tries to maintain his health by following his HIV 
medication regime carefully. He loves to go to circuit parties and even helped develop a special area for
other hearing-impaired participants to meet and sign the announcements made at these events.

He used to drink alcohol, but stopped after he learned his HIV status. He does, however, use crystal meth
(amphetamines, speed, crank) to allow himself to party longer and get sexually motivated and aroused. He
does not see that as a problem, since he only uses on weekends, has a low sexual drive otherwise because
of the many HIV medications and a low testosterone level, and has many friends who do the same thing. He
has missed some Mondays and even a few Tuesdays at work, but everyone there assumes these absences
are due to his HIV status. He used to snort the crystal but now shoots it intravenously to get a more rapid
effect. Again, he does not see that as a problem since he needs to be economical in his use on the week-
endmore bang for the buck. He has a fair amount of sex, usually as a passive partner, since the crystal
makes it difficult for him to get an erection. Because he is already HIV infected, he says he does not worry
about safer sex practices.

Although almost all of his friends also use crystal, a few friends have talked to Greg recently about how 
haggard he looks and how they think he may be tweaking, that is, shooting crystal too often. They dont
want to tell him what to do, but they also think he should be more careful when having sex because he
might infect someone else or get a different strain of the HIV virus. Greg says they should mind their own
business because he works for an AIDS organization, knows what he is doing, and can stop the 
crystal use any time he pleases.

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Clinical Issues With Gay Male Clients
Suggested Interventions

This case points out many of the issues discussed in this chapterthe frequent link between substance use
and social activities for gay men, the special role of amphetamines, the concerns about HIV/AIDS. Greg has
many reasons to feel different: being deaf, being gay, being HIV positive, having a low sex drive. He has a
great deal of denial and will need much support to see the impact of substance abuse on his life. The 
primary care provider who manages Gregs HIV care may be the best person to intervene. Ideally, all HIV
medical providers should be well versed in substance abuse treatment. If the primary care provider is able to
refer this client to a substance abuse counselor, the counselor will need to keep many points in mind in the
intervention and treatment planning including the following:

1)  Denial is part of all substance abuse. Denial seems to be particularly strong with amphetamine use and
abuse. Many gay men who use speed use it intravenously and still do not consider themselves as 
having a problem. Point out the current and possible effects of the amphetamine use, such as health
problems, loss of time at work, and the concern of friends who want to help break the denial.

2)  Many gay men will say they are out and quite comfortable being gay. Although this statement is usually
true, gay men have not always addressed the internalized homophobia that they picked up from growing
up in a homophobic society. Some gay men, such as Greg, may have very subtle self-esteem problems
and not recognize that their drug or alcohol use, poor selection of dates or lovers, or lack of ambition on
a job may be related to shame and doubt about being gay. Just being out to others does not mean that
someone really has dealt with the issues he has had to live with as a result of growing up gay. The 
substance abuse counselor working with Greg will have to communicate with Greg about his self-
acceptance and any shame and doubt he is dealing with, even if he is out with his close circle of friends.

3)  Gay men with disabilities and substance abuse problems face extra barriers to accessing care and to 
living clean and sober lives. Finding a counselor or program that has other deaf staff or staff who can
sign may be difficult. Finding 12-step programs that have services for the hearing impaired may be an
additional challenge. There are, luckily, many sensitive programs for hearing-impaired gay people. The
counselor working with Greg can help him find a 12-step program with such sensitivity in their local 
community, since most large cities have specific gay- and lesbian-identified services.

4)  If Greg is able to accept the fact that he has a substance abuse problem, ongoing self-care will remain a
challenge unless he is able to find new social outlets that do not involve alcohol and drugs or unless he
is able to develop new friendships with people who do not have substance abuse problems. Gregs 
counselor will need to work with him to explore other social avenues or work on a program that will allow
Greg to develop the skills to avoid alcohol and drug use in his old social environment. The counselor will
have to help Greg talk to his current friends about not bringing him drugs or trying to convince him it is
okay to use just a little. It may be hard to make new friends, but it may be necessary. It is also the coun
selors responsibility to encourage Greg to engage in safer sex practices and to provide or refer him to
information regarding such practices, including their benefits (e.g., preventing reinfection that could forfeit
a successful HIV medication regime).

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Chapter 9
Clinical Issues With Bisexuals

Donald McVinney, MSSW, ACSW, C.S.W., CASAC, New York, NY

Introduction

This chapter presents information to help
providers who treat bisexual clients. The
information includes some of the misconcep
tions about bisexuals that might interfere
with their treatment, some of the psychoso
cial issues that may arise when treating
bisexuals for substance abuse, and some
counseling strategies effective in treating
bisexual women and men.

Counselors working with self-identified
bisexuals need to assess their clients 
sexual behavior and identity issues and
also focus on a range of psychosocial
issues that may complicate substance
abuse treatment of bisexual clients.

Bisexual identity is not exclusively or 
necessarily defined by sexual behavior.
Indeed, the contemporary conceptualization
of bisexuality is that it should be understood
as a sexual orientation in and of itself and 
distinct from heterosexuality and homo
sexuality. The current view has developed
over time. Our understanding of bisexuality
has not been historically fixed and, in fact,
has shifted along a continuum of validation
to a denial of its very existence. Sigmund
Freud, for example, writing in 1925, affirmed
his belief in the constitutional bisexuality of
all human beings (Fox, 1996, p. 148) and
reaffirmed this again in 1937. In stark con
trast Bergler wrote in 1959 that Bisexuality
. . . is an out and out fraud, suggesting that
bisexuals were in denial about their homo
sexuality (Fox, 1996, p. 149). Although it is
not uncommon for gay men and lesbians to
What providers will learn 
from this chapter:

  The myths and miscon
ceptions about bisexuals
that might interfere with
their treatment

  What substance abuse
counselors need to know
about bisexual women
and men (including trans-
gender women and men
who identify themselves
as bisexuals) in treatment

  Psychosocial issues unique
to bisexuals in treatment

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look back at their coming out process and
recall a time in their lives when they self-
identified as bisexual, this does not negate 
the fact that some individuals clearly are 
bisexual and that bisexuality can be under
stood as a distinct sexual orientation.

Myths

For some bisexuals, their bisexual identity is
continuous and fixed across their lifespan. For
others, sexual orientation may be more fluid
and marked by changes from heterosexual to
either lesbian or gay or vice versa. This 
observation may be behind some of the more
common myths and misperceptions regarding
bisexual individuals. 

These mistaken beliefs are prevalent among
lesbians and gays as well as among the 
heterosexual population and unfortunately 
may also be internalized by bisexual individu
als, thus complicating their treatment. Some 
of the more persistent myths are listed below. 

 Bisexuals are confused about their sexual 
orientation.

 Bisexuals are afraid to be lesbian or gay 
because of social stigma and oppression 
by the majority.

 Bisexuals have gotten stuck in the 
coming out process.

 Bisexuals have knuckled under to the 
social pressure to pass as straight.

 Bisexuals are in denial about their sexual 
orientation.

 Bisexuals are hypersexual and will have 
sex with anyone.

 Bisexuals are not fully formed 
lesbians or gay men.
Professional Biases Versus Research

Since professionals are also influenced by the
dominant culture and social environment, 
service providers may bring their own biases to
their work with bisexuals. They may be inclined
to view individuals who used to have, or who
continue to have, sexual relations with both
men and womentransitionally, sequentially,
or concurrentlyas psychologically or emotion
ally damaged, as developmentally immature, or
as having a personality disorder. Individuals
classified under the last category are generally
labeled as having a borderline personality dis
order, with changing sexual behavior manifest
ing as a symptom of poor impulse control or
acting-out behavior. According to Fox (1996),
however, research has found no evidence of
psychopathology or psychological maladjust
ment in bisexual women and men (p. 154).
After reviewing the literature, Fox reported that 
numerous studies have found just the opposite.
In particular, self-identified bisexuals have been
found to possess, among other attributes, high
self-esteem, high self-confidence, and a 
positive self-concept independent of social
norms (p. 155).

What Counselors Need To Know About
Bisexual Clients

To provide effective treatment to bisexual
clients, providers will need to understand that
bisexuality is a nonlinear, complex phenom
enon. For example:

  A variety of sexual behaviors may be
engaged in by bisexual women, bisexual
men, and transgender individuals at any time
because behavior and identity can be 
separate issues.

  Bisexual identity may be formed early in ones
life and remain intact across the lifespan. This
is known as continuous bisexuality.
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  Desire may be experienced by bisexuals as
sexual attractions to same-sex or opposite-
sex partners at different times during their
lives. This is known as sequential
bisexuality. For example, a bisexual woman
may have engaged in sexual relations 
exclusively with men in her twenties and in
sexual relations exclusively with women in
her thirties.

  Bisexuals may express sexual desire toward
men and women at the same time. This is
known as concurrent bisexuality. For 
example, a bisexual man may be attracted to
and will actively date men and women during
the same timeframe.

  Women and men (including transgender
women and men) who identify themselves as
heterosexual may have had, or may continue
to have, sexual relations with partners of the
same sex.

  Women and men (including transgender
women and men) who identify themselves as
gay or lesbian may have had, or may 
continue to have, sexual relations with 
partners of the opposite sex.

  People of transgender experience, including
male-to-female and female-to-male 
individuals, may identify themselves as
bisexual. This is because bisexuality (and
sexual identity generally) is a separate 
phenomenon from gender identity.

Psychosocial Issues

The fact that bisexual identity and bisexual
behavior are separate phenomena may be
due, in part, to a variety of social factors that
mediate between identity and behavior. These
variables include the following: 

  Race or ethnicity

  Family norms and parental upbringing
  Community or cultural norms and standards,
especially culturally constructed gender roles
(acting male or female)

  Religious values and beliefs

  Political views (For example, identifying with
the majority or with socially oppressed
groups may be a political stance. Therefore,
some bisexuals may identify themselves as
gay or lesbian in order to make a political
statement.)

  Legal issues, such as not having the legal
sanction of a recognized sexual partnership
through the institution of marriage

  Environmental factors, as in the case of 
individuals in institutions, such as prisons,
jails, or exclusive private schools, who may
engage in sex with partners of the same sex
only while they are in the institutional 
environment

  Financial considerations, such as the need to
engage in prostitution and hustling, 
especially as a function of substance use, in
which individuals are paid to engage in 
sexual behavior that is inconsistent with their
sexual identity.

All of these social factors may result in, or 
contribute to, separating identity and behavior
by bisexual women and men (including 
transgender women and men who identify
themselves as bisexual).

Counselors should develop their sensitivity to
these social issues and to issues of gender,
age, psychological development, socio
economic status, and modes of sexual 
expression and desire.

Counseling Strategies

Recovery from substance abuse and addiction
for bisexuals will be facilitated by empathetic,
Clinical Issues With Bisexuals

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nonjudgmental counselors who support clients
in:

  Becoming more self-accepting

  Healing from the shame caused by 
heterosexism and internalized biphobia
  Referring bisexual clients to either straight 
or gay/lesbian 12-step fellowships, or both,
depending on what is more appropriate to
their recovery needs.
Clinical Issues With Bisexuals

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Chapter 10
Clinical Issues With
Transgender Individuals

Dominique Rosa Leslie, ReDiscovery Consulting, San Francisco, CA
Barbara Ann Perina, CASAC, NCAC I, Human Service Centers, Inc., Elmhurst, NY
Mariano C. Maqueda, Ph.D., Human Service Centers, Inc., Elmhurst, NY
Introduction

This chapter presents a brief introduction 
to issues facing transgender clients and the
substance abuse treatment providers caring
for them. The chapter provides an 
explanation of the term transgender, a brief
overview of the theoretical models that
describe transgender identity development,
and the clinical issues specific to transgen
der clients.

Transgender is an umbrella term that
encompasses a variety of people including
transsexuals, cross dressers, and drag kings
and queens, as well as bigender and
androgynous individuals (Tewksbury &
Gagne, 1996). Transgender, as a term,
came into common usage during the 1980s.
Previously, people with mixed gender and
sexual characteristics were described as
transsexuals and transvestites, terms that
come from the psychiatric vocabulary.
Transgender comes from the transgender
community itself and is, therefore, the 
preferred term in working with transgender
individuals.

The psychiatric model views both 
transsexuality and transvestitism as 
psychopathological in nature. Transsexuality
is viewed by this model as an insufficient
identification with the same-sex parent or 
overidentification with the opposite-sex 
parent in infancy or early childhood.
Transvestitism, understood as an abnormal
dependence on wearing female attire for
sexual arousal, was also traced to early 
What providers will learn
from this chapter: 

  The definition of 
transgender

  The different theoretical
models used to describe
the development of gen
der identity in transgender
women and men

  Transgender-specific 
clinical issues 

  Treatment dos and
donts in dealing with
issues related to transgen
der men and women

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Clinical Issues With Transgender Individuals
childhood experiences (Warren, 1997; Docter,
1990; Denny, 1994). 

In addition, medical models of transsexuality
currently are being explored. These models
focus on physiological etiology and range from
prenatal hormonal effects on the fetus to differ
ences in brain structure. However, neither the
psychiatric nor medical models for defining
transgender individuals have been accepted by
the transgender community.

Research on the various theories of the 
medical model of transgender experience has
led the transgender community to question the
role the psychiatric and medical fields play in 
providing services. In order to avoid 
malpractice issues, medical doctors currently
require two letters from psychotherapists 
supporting sex reassignment before they will
approve a transsexual for sex reassignment
surgery. The transgender community strongly
advocates that the current psychiatric 
classification for gender identity disorder (GID),
302.85, should be eliminated from the
Diagnostic and Statistical Manual of Mental
Health (Fourth Edition) (DSMIV). These 
concerns have caused a vigorous and ongoing
discussion about how well the medical and
psychiatric fields serve the needs of the 
transgender community.

In a society and culture that perceives them as
sick, abnormal, and having a disorder, it is
no surprise that transgender individuals 
sometimes seek escape from hatred, violence,
discrimination, and misunderstanding through
the use of alcohol and drugs. Transphobia (the
irrational fear and dislike of transgender individ
uals) is a part of our culture. Because they live
in a society that discriminates against them,
condones violence against them, and denies
them basic civil rights, many transgender 
individuals have internalized the prejudices of
their culture and ended up hating themselves.
Substance abuse treatment providers may be
some of the few people to whom transgender
individuals will talk about their feelings and
pain. The substance abuse counselor has an
opportunity while helping transgender individu
als with their substance abuse issues to refer
them to resources to help them cope with their 
transgender issues. 
Definitions

As our understanding of transgender 
individuals and human sexuality improves, 
the terminology used by the transgender and
medical communities continues to evolve.
Substance abuse treatment professionals
should use the definitions included here as a
guide, with the caution that some transgender
clients or health professionals may use slightly
different definitions.

Transgender includes a continuum of gender
expressions, identities, and roles that challenge or
expand the current dominant cultural values of
what it means to be male or female. 

Ones gender identity is the gender (male or
female) with which one identifies. A person may
be biologically male and have a female gender 
identity (male-to-female, or MTF) or be biologi
cally female and have a male gender identity
(female-to-male, or FTM). Gender role refers to
how individuals present their gender in the world
(e.g., through the clothes they wear). The gender
one defines as ones identity is a matter distinct
from sexual orientation.

Ones sexual orientation may be described as
the sex or gender one is attracted to (see
chapter 1). Many MTF transsexuals identify
themselves as heterosexual (they are female
identified and attracted to men). However,
transgender individuals, including transsexuals,
may identify themselves as heterosexual,
bisexual, lesbian, or gay. Gender identity and
sexual orientation are not the same thing, and
all people have both. The common 
misconception about MTF individuals is that
they are gay. This is often not true.

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The terms sex and gender are often 
confused in common usage. Sex refers to the
biological characteristics of a person at birth,
while gender relates to his or her perception of
being male or female and is known as the gen
der role. Many transgender individuals are born
one sex and identify themselves as the opposite
gender (for example, they are born biologically
male and identify themselves as female).

Intersexed individuals are born with 
ambiguous biological sex characteristics. These
individuals often are put through genital surgery,
and their sex is decided by the doctor, 
sometimes with or without the parents consent.
These individuals may later grow up to have
gender identities that are the opposite of the
manufactured sex constructed for them at birth
and have feelings similar to transgender 
individuals. An international organization has
been formed to help and advocate on behalf of
individuals who are born intersexed or with
ambiguous sexual characteristics.

Transsexuals are transgender individuals with
the biological characteristics of one sex who
identify themselves as the opposite gender.
There are FTM and MTF transsexuals.
Transsexuals usually desire to change their
bodies to fit their gender identities. They do this
through hormone treatment and gender 
reassignment surgery (sex change surgery).
Transsexual individuals who have embarked on
this process are often known as preoperative
transsexuals (before the sex reassignment 
surgery). Transsexuals requesting this surgery
must live and work as someone of the gender
to which they are changing for at least 1 year
prior to surgery and be evaluated by therapists.
The costs of hormones, therapy, and surgery
are highly restrictive and are not covered by
most medical insurance. Some transsexuals
identify themselves as nonoperative transsexu
als because they have decided not to have 
surgery, either for medical or for other personal
reasons. Transsexuals who are HIV positive
are routinely denied surgery, and the surgeries
currently available for FTM individuals are not
functional or realistic. These nonoperative 
individuals make up the group most commonly
referred to as transgender. They live and work
as the gender opposite the one they were born
with. Transsexuals who have completed their
sex reassignment surgeries can and do live 
as someone with the new gender would and are
legally either female or male. They are some
times referred to as post-op (i.e., postoperative)
transsexuals. Most will live as women or men,
without being noticed. For personal or political
reasons, however, they may continue to identify
themselves as transsexuals even though 
technically they no longer fit the definition.
Cross dressers or transvestites are 
transgender individuals who usually identify
themselves as of the same gender as their sex;
however, they like to dress in clothing of the
opposite sex for erotic or personal pleasure.
Although by far the largest category of 
transgender individuals, they usually live a very
closeted existence. Many of them are 
heterosexual men, married with families, often
in stereotypically masculine jobs, who, on
occasion, dress as females. A number of
national and international organizations exist to
provide safe places for cross dressers to meet,
usually at social gatherings in private homes or
private membership bars or clubs.

Drag queens (i.e., gay men who dress in
female clothing) and female impersonators (who
perform in clubs or cabarets) are not transgen
der individuals. The choice that these individuals
make to dress in the clothing of the opposite sex
is not a matter of gender identity. The same is
true of drag kings (i.e., women who dress in
mens clothing) and male impersonators.

Bigendered transgender individuals may 
identify with both genders, or as some 
combination of both, while androgynous
transgender individuals usually do not identify
with either gender; that is, they identify as 
neither male nor female.
Clinical Issues With Transgender Individuals

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Clinical Issues With Transgender Individuals
These general definitions are not meant to be
used as diagnostic criteria. In fact, it is
extremely important that individuals presenting
for treatment be allowed to self-identify 
whenever possible. Questions about whether
someone is or is not a transgender individual
should be asked privately and respectfully.

Research Into Substance Abuse and HIV
Among Transgender Individuals

The little research that has been done on the
prevalence of substance abuse in the 
transgender community suggests significantly
high substance abuse rates. Some of the best
information available comes from studies of
HIV prevalence.

Substance use also plays a significant role in
the high HIV prevalence in MTF transgender
individuals (transgender women) (Longshore,
Annon & Anglin, 1998; National Institute on
Drug Abuse, 1994; Longshore et al., 1993).
There are more than 15 studies that concluded
that transgender individuals (primarily MTF
transgender sex workers) have a high rate of
HIV infection.

The most recent study on HIV prevalence in
transgender individuals conducted by the San
Francisco Department of Public Health AIDS
Office (Clements et al., 1998) investigated
more than 515 individuals with transgender
experiences, which included MTF (sex workers
and nonsex workers) and FTM transgender
individuals (transgender men). The study
showed that

  35 percent of the MTF transgender 
individuals in the study tested HIV positive

  63 percent of the African-American MTF
transgender individuals in the study tested
HIV positive

  1.6 percent of the FTM transgender 
individuals in the study tested HIV positive.
Although the FTM individuals studied had a low
HIV prevalence rate, they commonly reported
engaging in many of the same HIV risk 
behaviors as the MTF individuals.

The same study is one of the best available 
on substance abuse among transgender 
individuals. It showed a lifetime rate of 
intravenous drug use of

  34 percent among MTF transgender 
individuals

  18 percent among FTM transgender 
individuals.

Longshore and Hsieh (1998) found that 
substance use treatment does influence 
peoples HIV risk behavior. Treatment can help
reduce transgender individuals risk of HIV
infection if they remain in treatment; however,
discrimination and prejudice against transgen
der individuals can make access to service
agencies and health care resources problemat
ic (Transgender Protocol Team, 1995; San
Francisco Department of Public Health, AIDS
Office, 1997; Bockting, Robinson & Rosser,
1998; Moriarty, Thiagalingam & Hill, 1998). 

A study from Hollywood, California, reported
that the drugs most commonly used by MTF
transgender individuals were alcohol,
cocaine/crack, and methamphetamine (Reback
& Lombardi, 1999). In the Clements and 
colleagues (1998) study conducted in San
Francisco, 55 percent of the MTF individuals
reported they had been in alcohol or drug 
treatment sometime during their lifetimes.

In addition, violence and discrimination have
been found to have negative effects upon gay,
lesbian, and bisexual youth, encouraging 
substance abuse, prostitution, and suicide
(Savin-Williams, 1994; Kreiss & Patterson,
1997; Rodgers, 1995). Garnets, Herek, and
Levy (1992) stated that experiences of violence
and harassment can significantly affect the

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mental health of gay men and lesbians, which
in turn could influence their substance use as
well as their experience in treatment.
Experiences of violence and harassment 
could similarly affect transgender individuals.
Transgender individuals are likely to 
experience some form of discrimination,
harassment, and/or violence sometime in their
lives. The first major study (Lombardi et al.,
submitted for publication) on violence and dis
crimination against transgender people in the
United States found that:

  60 percent experienced some form of
harassment and/or violence sometime during
their lives

  37 percent experienced some form of 
economic discrimination.

Clinical Issues in Substance Abuse
Treatment With Transgender Individuals

Ratner (1993) points out that treating 
substance-abusing gay men and lesbians
means being aware of their unique problems in
order for treatment to be effective. The same
can be said for transgender substance
abusers. Aspects such as societal and 
internalized transphobia, violence, discrimina
tion, family issues, isolation, lack of education
and job opportunities, access to health care,
and low self-esteem, among others, need to be
addressed in the treatment environment.

Like all potential clients, transgender substance
abusers bring a variety of experiences with
substances and readiness to change into the
treatment setting. Many transgender people
have had one or more negative experiences
with institutions, including those that provide
health care. They may be unusually distrustful
of professionals and treatment recommenda
tions. It is vital to remember that these clients,
like all clients, need to be met with sensitivity
and respect. Clients should be allowed to 
self-identify and cannot be judged on the basis
of their self-identification.
Conducting a comprehensive biopsychosocial
assessment is very important with transgender
individuals. Because all assessments should
be designed to elicit the full spectrum of rele
vant information, it is appropriate to ask each
client about his or her sexuality, gender identity,
and comfort with his or her sex role. It is vital
that counselors avoid the common pitfall of
focusing on gender issues as the assumed root
cause of the addiction problem. When inquiring
about the clients substance use, counselors
need to recognize that substance abuse
among transgender people can involve multiple 
patterns of use, misuse, and abuse; that 
multiple causal variables combine to produce
problems; that treatment should be multimodal
to correspond to a clients particular pattern of
abuse; and that treatment outcomes vary from
individual to individual (Lewis, Dana & Gregory,
1994). Using this broader view, treatment
providers can better understand substance
abuse problems with transgender people and
diagnose and treat them less dogmatically.

Another point is to recognize that transgender
people will bring unique issues into the 
treatment setting. Some of these issues are
obvious, like the lack of family and social 
supports, isolation, low self-esteem, internal
ized transphobia, etc., but other issues may not
be as obvious. Getting these other issues to
surface will require an environment that is 
sensitive and nonjudgmental. This is especially
true when attempting to access inpatient med
ical or inpatient substance abuse rehabilitation
services. Clinicians working with transgender
people must have a solid and reliable referral
network that they are sure can work with 
transgender clients in the most sensitive 
manner possible.

Hormone therapy is an often overlooked 
clinical issue. Many transgender clients will be
on estrogen or testosterone therapies upon
Clinical Issues With Transgender Individuals

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Clinical Issues With Transgender Individuals
entering treatment. Clients should not be asked
to choose between hormones and substance
abuse treatment. Hormone treatment is a 
standard and accepted medical treatment for
transsexuals, and clients should be supported
by providers to maintain regular, legally pre
scribed hormonal treatment under proper med
ical care without interruption. It is important that
both the clinician and the client understand that
both estrogen and testosterone therapies can
affect mood, especially when taken improperly.
There may be additional risks associated with
using and/or self-injecting street or black
market hormones. This is a particular concern
for transgender men, since testosterone must
be injected. Obtaining or using needles may be
relapse triggers for clients in early recovery.

The issues and difficulties with inpatient 
treatment and the placement of preoperative or
nonoperative transsexuals extend to housing
and homeless shelters. The housing issues
that face homeless transgender people are a
major issue in recovery. Very often the stigma
and discrimination that transgender individuals
face in the homeless services system are their
justification for reengaging with individuals who
are not a positive recovery influence and
increase their relapse potential. 

Additional relapse triggers or significant clinical
issues for transgender clients might include (1)
the inability to find, engage in, or maintain
meaningful or gainful employment simply
because they are transgender; (2) a lack of 
formal education or job skills because they
were forced to leave school or home prior to
obtaining those basic skills; (3) being HIV 
positive, asymptomatic, and healthy and 
desiring sex reassignment surgery but having
trouble obtaining it due to their HIV status; (4)
the overall lack of accepting social supports
who are sober and positive role models; (5)
issues of sexual orientation as well as gender
identity; and (6) stress resulting from their
invisibility and the dissonance caused by
passing (blending into the mainstream).
An additional clinical issue is that many 
substance abuse treatment providers feel they
cannot identify or empathize with transgender
people, thereby creating a barrier in developing
a therapeutic relationship. It is worth noting 
that many of the issues faced by transgender 
men and women may be those faced by 
non-transgender men and women. Many 
transgender women have sexual abuse 
histories, have co-occurring eating disorders 
or depression, or have never been in a sober
relationship or experienced sober sex. Due to
their particular invisibility, less is known about
transgender men, but clinicians might expect to
see a variety of mens issues in such clients.
To provide the best care possible, it is the 
responsibility of clinicians to enhance their
knowledge of substance abuse issues along
with their understanding of any issues that will
help clinicians understand the treatment needs
of their clients. 

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DOS

  Use the proper pronouns based on their 
self-identity when talking to/about 
transgender individuals.

  Get clinical supervision if you have 
issues or feelings about working with 
transgender individuals.

  Allow transgender clients to continue the use
of hormones when they are prescribed.
Advocate that the transgender client using
street hormones get immediate medical care
and legally prescribed hormones.

  Require training on transgender issues 
for all staff.

  Find out the sexual orientation of all clients.

  Allow transgender clients to use bathrooms 
and showers based on their gender 
self-identity and gender role.

  Require all clients and staff to create and 
maintain a safe environment for all 
transgender clients. Post a nondiscrimination 
policy in the waiting room that explicitly
includes sexual orientation and gender identity.
DONTS

  Dont call someone who identifies himself as
a female he or him or call someone who 
identifies herself as male she or her.

  Dont project your transphobia onto the 
transgender client or share transphobic 
comments with other staff or clients.

  Never make the transgender client choose
between hormones and treatment and 
recovery.

  Dont make the transgender client educate
the staff.

  Dont assume transgender women or men
are gay.

  Dont make transgender individuals living as
females use male facilities or transgender
individuals living as males use female 
facilities.

  Never allow staff or clients to make 
transphobic comments or put transgender
clients at risk for physical or sexual abuse or
harassment. 
Clinical Issues With Transgender Individuals

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Case Example

A 24-year-old African-American pre-op transsexual presents for intake at your residential drug treatment 
program. She is dressed in female attire and tells you she has been living full time as a female for more
than 5 years. She has had a legal name change and has identification that states she is a female. She tells
you she is revealing that she is transsexual because she doesnt want there to be any trouble. She also
tells you she has been in treatment before and says she had a very bad experience, including the fact that
the staff refused to address her as a female and other clients sexually and verbally harassed her. She says
she has a long history of abusing heroin and alcohol and that she is ready to change her life and wants to
enter your residential treatment program.
Clinical Issues With Transgender Individuals
Suggested Interventions

Accept her into your residential treatment program and house her as you would other women in your 
program. If rooms for women are dorm-type rooms, this should be acceptable. If smaller, more private
rooms are available, housing her in a single room is also acceptable. If only group showers are available,
have a special time at which she can use them. If individual showers for women are available, this is 
preferable. Insist on all staff referring to her and treating her as female. She should also find outside support
for transgender individuals, if it is available. Address any issues clients have, as you would any other coun
seling issues, in individual counseling. Staff and client education about transgender and transsexual issues
will help alleviate some of these concerns.

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Chapter 11
Clinical Issues With Youth

Caitlin Ryan, M.S.W., ACSW, Health Services and Policy Consultant, Washington, DC
Joyce Hunter, D.S.W., HIV Center for Clinical and Behavioral Studies/NYSPI, New York, NY

Introduction

Adolescence is a time of significant physical
and psychosocial development. As 
adolescents develop, they rely increasingly
on peers for information and support. They
must also learn how to deal with boundaries
and begin to integrate various aspects of their
identity. Experimentation, exploration, and
risk taking characterize adolescence, and
many adolescents explore the use of alcohol
and drugs. In fact, most adolescents have
tried alcohol and drugs at least once by age
18 (Johnston, OMalley & Bachman, 1995).
According to the 1998 National Household
Survey on Drug Abuse (Office of Applied
Studies, 1999) 21.3 percent of youth ages 12
to 17 years reported using an illicit drug at
least once in their lifetime, while a Centers 
for Disease Control and Prevention (CDC) 
survey found that more than half of high
school students reported having at least 
one drink during the preceding 30 days 
(CDC, 1996).

Adolescents who use alcohol and drugs are
more likely to engage in sexual intercourse,
to have sex at younger ages, and to have
more partners; they are less likely to use
condoms during their sexual activity than
youth who do not use alcohol and drugs
(MacKenzie, 1993). Many adolescents
report using alcohol before sexual 
intercourse. Of these, more than half report
having five or more drinks before having
sex, which impairs their judgment and
increases the potential for high-risk 
behaviors such as anal intercourse
(Fortenberry, 1995). Adolescents who 
What providers will learn
from this chapter:

  The stresses and 
challenges experienced 
by LGBT youth that
increase their risk for 
substance abuse and 
related health and mental
health concerns

  The role of stigmatization
in increasing vulnerability
to and risk for substance
abuse

  How to approach 
assessment and treatment
with LGBT youth

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use crack cocaine, in particular, are at high risk
for HIV infection. A study of HIV-positive ado
lescents found that two-thirds of girls and more
than half of boys reported using crack; of
these, four out of five reported exchanging sex
for money, drugs, food, or shelter (Futterman et
al., 1993). 

Because adolescents are developing physically
and psychologically, substance use can impair
their intellectual, emotional, and social develop
ment. Drug experimentation in adolescence
may be a part of their development. However,
the transition from use to abuse is a 
maladaptive response defined by a failure to
successfully achieve the developmental tasks
of adolescence (Duncan & Petosa, 1994).

Alcohol and Drug Use in LGBT Youth

Most of the available research about this 
population has focused on lesbian and gay
adolescents; little information is available on
bisexual identity development during 
adolescence (and related risks). Even less is
known about the experiences and needs of
transgender youth. Information about 
substance use among lesbian, gay, and 
bisexual youth is limited, and there are virtually
no studies targeting transgender youth. Early
community-based studies of urban gay youth
show high rates of alcohol and drug use
(Remafedi, 1987; Rotherman-Borus, Hunter &
Rosario, 1994), while others show rates that
are comparable to adolescents in general
(Boxer, 1990; Bradford & Ryan, 1987; Herdt &
Boxer, 1993). In a recent study among a multi-
ethnic group of self-identified lesbian, gay, and
bisexual youth (N=154; 66 percent gay/lesbian;
31 percent bisexual), 93 percent of females
and 89 percent of males reported using licit or
illicit substances, with alcohol the most popular
licit drug and marijuana the most popular illicit
drug (Rosario, Hunter & Gwadz, 1997).

The lack of information is mirrored by a lack of
assessment, prevention, and treatment 
services. Recently, some providers and 
agencies have attempted to address these
gaps (e.g., Ryan & Futterman, 1998; Simpson,
1994; Travers & Schneider, 1996). However,
more research is needed on the level of 
substance abuse among these youth as well
as treatment and relapse prevention strategies.
Lesbian, gay, bisexual, and transgender
(LGBT) youth use alcohol and drugs for many
of the same reasons as their heterosexual
peers: to experiment and assert independence,
to relieve tension, to increase feelings of self-
esteem and adequacy, and to self-medicate for
underlying depression or other mood disorders.
However, LGBT youth may be more vulnerable
as a result of the need to hide their sexual
identity and the ensuing social isolation. As a
result, they may use alcohol and drugs to deal
with stigma and shame, to deny same-sex 
feelings, or to help them cope with ridicule 
or antigay violence.

Stigma, Identity, and Risk

LGBT youth have the same developmental tasks
as their heterosexual peers, but they also face
additional challenges in learning to manage a
stigmatized identity. This extra burden puts
LGBT youth at increased risk for substance
abuse and unprotected sex and can intensify
psychological distress and risk for suicide.

Sexual orientation evolves over a period of
time. However, studies have documented a
decreasing age of identity development and
coming out among lesbian and gay youth, with
initial awareness of same-sex attraction at, on
average, age 10; first same-sex experiences at
13 to 15; and first self-identifying as lesbian or
gay (initial coming out) at around age 15 to
16 (DAugelli & Herschberger, 1993; Herdt &
Boxer, 1993; Rosario et al., 1996). Studies of
more recent generations of lesbian and gay
youth suggest that the period between 
becoming aware of same-sex attraction and 
Clinical Issues With Youth

100

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self-identifying as lesbian or gay is much shorter
than in previous generations (see exhibit 111). 

Although people may be more aware that an
adolescent may be gay, they are generally no
more tolerant and may even be less accepting
of homosexuality in adolescents. In fact, 
violence and harassment against LGBT youth
appear to be increasing. For those youth who
choose to self-disclose or are found out, coping
with this stressful life event is most challenging.
Adolescents at this point in their lives have not
developed coping strategies and are more 
likely than adults to respond poorly to these
stressors. These youth must adapt to living in a
hostile environment and learn how to find 
positive environments (Hunter & Mallon, 1999).

      Exhibit 111:  
Sexual Identity: Age of Onset

*Studies of adults who remembered their experiences
as children and adolescents
**Studies of adolescents who described their 
experiences as they were happening or right after they
happened

From very early ages, children and adolescents
are exposed to negative stereotypes about
homosexuality. They learn to hide same-sex
feelings and attractions to avoid rejection and
ridicule. As they begin to realize that they might
be gay, these negative stereotypes may
increase their feelings of conflict, identity 
confusion, or even self-hate. Adolescents may
repress, deny, or attempt to change these 
feelings through a range of coping behaviors,
including heterosexual activity, use of alcohol
and drugs, dating the opposite sex, fathering a
child or becoming pregnant, and immersing
themselves in sports or school activities.
Youth of color face additional stresses and
challenges in integrating their sexual, racial,
and ethnic identities (Hunter & Schaecher,
1995; Tremble, Schneider & Appathurai, 1989).
Racial and ethnic identities are established at
early ages, before a person becomes aware 
of same-sex feelings that may signal a 
nonheterosexual identity. Adolescents who may
be gay have little support for developing an
LGBT identity. At the same time, they interact
with three separate communitiesincluding
their ethnic or cultural community, LGBT 
communities, and mainstream culturenone of
which provide support for all aspects of their
multiple identities. Having to manage more
than one stigmatized identity increases the
adolescents level of vulnerability and stress
(Greene, 1994). Because ethnic minority 
communities are important providers of 
essential emotional and practical support, their
LGBT youth are particularly vulnerable to 
rejection. Openly identifying themselves as gay
may jeopardize acceptance by the family and
ethnic community of youth. Thus, many youth
of color hide their sexual orientation and, as a
result, are often less visible than their
Caucasian gay peers. Depression and risk for
suicide appear to be high for many of these
young people (Rotheram-Borus, Hunter &
Rosario, 1994). 

Most LGBT youth grow up to lead satisfying,
productive lives, but some young people are
more vulnerable and are at greater risk than
others. A past history of abuse and neglect,
severe stress, and underlying emotional 
disorders may influence a young persons 
ability to cope. Hetrick and Martin (1987) have
Clinical Issues With Youth

     Average Age (Years) Event Occurs 
Behavior/           Earlier Studies*        More Recent
Identity Studies**
            Males     Females   Males   Females 
First     13         1416         9           10
awareness 
of same-sex 
attraction   
First same- 15            20       1314     1415
sex 
experience

First self-             1921      2123    1416     1516
identified as 
lesbian or gay  

101

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suggested that adolescents with these histories
may account for the majority of gay youth who
attempt suicide or who develop serious 
substance abuse problems.

Abuse and Homelessness

In the National Lesbian Health Care Survey,
lesbians who had been sexually abused, 
sexually assaulted, or victimized reported 
significantly more depression and alcohol
abuse than lesbians who did not report these
experiences (Descamps et al., submitted for
publication). Other studies show victims of 
child sexual abuse are at increased risk for 
substance abuse (Dimock, 1988; Zierler et al.,
1991), suicide (Briere et al., 1988), running
away from home (Briere et al., 1988), and HIV
infection (Bartholow et al., 1994; Zierler et al.,
1991).
Homelessness is a particular concern for LGBT
youth, because many teens may run away as a
result of harassment and abuse from family
members or peers who disapprove of their 
sexual identity. Still others may be thrown out
of the home when their parents learn they are
gay. Statistics are not available on the actual
percentage of street youth who may be lesbian
or gay, but youth service providers agree the
percentage is very high, and reports from vari
ous studies show ranges from 20 percent to 40
percent (Kruks, 1991; Los Angeles County
Task Force, 1988; Seattle Commission on
Children and Youth, 1988; Stricof et al., 1991).
Homeless youth are at high risk for exploita
tion. Without an education or job skills, they
may become involved with survival sex
(exchanging sex for food, drugs, or shelter),
drug dealing, or other illicit activities (Clatts &
Davis, 1999).

Like their heterosexual peers, LGBT homeless
and runaway youth have many health and
social problems, often as a result of abuse and
neglect. These include serious substance
abuse and mental health problems, being at
high risk for suicide, sexually transmitted 
diseases (including being at high risk for
HIV/AIDS), pregnancy, and many chronic
health problems (Hoffman, Futterman &
Myerson, 1999).
LGBT youth are at high risk for antigay 
violence such as physical attacks, verbal and
physical abuse, and harassment (DAugelli &
Dark, 1995; Dean, Wu & Martin, 1992). Youth
of color and those who are openly or 
stereotypically gay are more likely to be 
victimized, and anecdotal reports suggest that
transgender youth may be at greatest risk.
Antigay attacks heighten an adolescents 
feelings of vulnerability, often intensify a young
persons own inner conflict with his or her 
sexual identity, and may cause the youth and
others to perceive the attacks as a punishment
for being gay. Lesbians who are victims of hate
crimes report significantly higher levels of
stress, depression, and alcohol and drug abuse
than those who were not victimized (Descamps
et al., submitted for publication).

Ironically, while coming out to peers and adults
may reinforce adolescents feelings of comfort
about their sexual identity, it greatly increases
their risk for violence and harassment, even by
their families (DAugelli, Hershberger &
Pilkington, 1998).

Assessment and Treatment

LGBT youth experience countless challenges 
in attempting to manage their stigmatized 
identity. Assessment and treatment should
address the adolescents social environment,
sexual identity development, stage of coming
out, gender identity, support network, impact of
multiple identities (such as gender, ethnic, and
cultural identities), level of disclosure about their
sexuality, and knowledge and use of safer sex
practices. Providing safety and giving support
are essential elements in prevention and 
treatment of substance abuse in LGBT youth.
Clinical Issues With Youth

102

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Case Study

David is a 16-year-old gay youth who identified himself as gay at age 12 but did not come out to others
until he met another gay youth on the Internet last year. His father was a heavy drinker and physically
abused David and his mother. His father left home when David was 11. Since then, David has been raised
by his mother, a restaurant manager, in a medium-sized city in the Midwest.

David began drinking beer with friends in seventh grade and smokes marijuana when he can get it. Alcohol
helps him relax in social situations and makes it easier to pretend that hes straight. It helps reduce feelings
of isolation and depression. David was afraid to come out to friends at school and had not told anyone he
was gay until he found a gay youth Web site last year. Through the Web site, he connected with other gay
teens who provide emotional support. This is Davids only source of support and has helped reduce his 
feelings of isolation, but none of these youth live nearby. His mother usually works on weekends, and David
has been able to drink without anyone finding out. His drinking has increased during the last 2 years, and
his grades have begun to drop. He has become increasingly irritable, and arguments with his mother are
escalating. David was dropped from the track team last year for failing to attend morning practice, but no
one at school or home noticed the early warning signs of substance abuse.

David began having sex with young men he met in a public park when he was 14. He did not know how 
to meet other gay people until he heard someone joking about a park across town. David feels more 
comfortable having a few drinks before he has sex and rarely uses condoms.

Davids experiences are common for gay youth who use alcohol and drugs to cope with loneliness and
social adjustment and to medicate themselves for depression and anxiety. Potentially, his substance abuse
problem could be identified by a perceptive teacher, school counselor, or pediatrician. In many cases, 
however, adolescent substance abuse is not identified until youth get into trouble or alcohol and drug use
escalates. In Davids case, early intervention could help prevent more severe dependency and could help
him develop social and interpersonal skills, including the capacity for chemical-free intimacy and for 
discussing risk reduction with his sexual partners.
Clinical Issues With Youth

Suggested Interventions

Finding drug treatment programs for teens like David is a challenge. Very few resources for drug treatment
and aftercare exist for LGBT youth. Hunter and Haymes (1997, p. 156) noted: With few exceptions, appro
priate models for this population have not been designed. And those that exist have not been evaluated.
Consequently, these youth are continually forced into straight, traditional drug treatment programs, which
almost always fail to meet their needs. Youth care providers and counselors caution that LGBT youth may
be harmed by programs that lack appropriate content or experience.

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Chapter 12
Related Health Issues

Dennis J. Ghindia, Ph.D., Rhode Island College School of Social Work, Providence, RI
Susan Hart, LICSW, C.A.C., AIDS Action Committee, Boston, MA
Harvey Gochros, University of Hawaii at Manoa School of Social Work, Honolulu, HI
William J. Pellicio, LICSW, LCDP, Addiction Technology Transfer Center of New England,   
Providence, RI
Introduction

Once a client begins to address his or her
substance abuse problem, he or she may
face a variety of additional health problems,
some of which may be due to poor self-care.
Lesbian, gay, bisexual, and transgender
(LGBT) people in recovery have similar
health concerns and face many of the same
physical and mental health crises as anyone
else in recovery. This chapter provides a
brief introduction to some of the health 
problems facing LGBT individuals as they
begin their recovery from substance abuse.
Health assessments and interventions for
substance-using LGBT clients should
include the same components as those for
other clients and some additional 
components that are unique to or more 
common among LGBT individuals.

Many people who abuse substances have
co-occurring mental health disorders, such
as affective disorders, eating disorders, or
other psychiatric illnesses. Substance abuse
clouds judgment and contributes to 
hazardous behaviors that can lead to illness,
such as HIV/AIDS, sexually transmitted 
diseases (STDs), hepatitis, and injuries.
People who abuse substances may have
neglected their health and nutrition and may
smoke cigarettes. Some may have been the
victims of domestic violence or hate crimes
resulting in posttraumatic stress disorder.
When considering these factors, providers of
substance abuse treatment for LGBT clients
should, as with any client, screen for other
What providers will learn
from this chapter:

  The health concerns of 
substance-abusing LGBT 
individuals

  Some of the mental health
issues that substance-
abusing LGBT individuals
face

  What is currently known
about interpersonal 
violence and substance
abuse in the LGBT 
community

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health problemsfor possible co-occurring
mental disorders, poor nutrition, poor dental
care, liver disease, STDs, HIV/AIDS, violence,
sexual abuse, and incest. In this way, 
substance abuse treatment providers can
assist their LGBT clients in accessing 
appropriate medical care and treatment for
their health and mental health concerns.

The abuse of alcohol and other mood-altering
substances can also affect the treatment of
HIV/AIDS. For example, substance abuse and
its associated mental impairments can interfere
with clients ability to comply with very 
complicated medicine regimens. Strict 
adherence is crucial to the effectiveness of the
powerful new medications used to combat HIV.
Substance abuse also affects clients ability to
take their medication properly. 

Gay and Bisexual Men

Gay and bisexual men who are sexually active
with multiple partners are more susceptible to
STDs and HIV/AIDS. Substance-abusing gay
and bisexual men may be at an even greater
risk for infection than non-substance-abusing
gay and bisexual men if their substance abuse 
disinhibits safe sex practices. Moreover, even
when men refrain from high-risk activities, such
as unprotected anal sex, they may engage in
other activities, such as unprotected oral sex,
that likewise increase their risk for STDs, such
as gonorrhea and chlamydia. Gay and bisexual
men may be exposed to STDs at multiple sites,
such as the pharynx and rectum, and may be at
risk for anal trauma or the human papilloma
virus. Thus, screening these men for all STDs
and HIV is recommended. Screening for syphilis
is recommended as well because it is often
asymptomatic and is increasing in incidence.

Gay men are at higher risk for hepatitis A and
hepatitis B through sexual contact. Hepatitis C
also may be spread by sexual contact,
although transmission via infected needles is
probably a far more significant route and is of
concern to all injection drug users. All clients
should be referred for vaccination for hepatitis
A and hepatitis B as a public health measure.
Because so much of the focus for gay and
bisexual men is on STDs and HIV, other 
significant health risks often are neglected.
However, as for all men, cancer and heart 
disease remain the most significant causes of
death and morbidity. High stress and smoking
may increase these risks. It is especially 
important to advise clients of these risks and
the importance of prevention and regular 
medical screening for these conditions.

Lesbian and Bisexual Women

Even though research about the health issues
of lesbian and bisexual women has increased
during the past decade, knowledge of many of
their health concerns, including substance
abuse, is still limited. It is known that 
substance-abusing lesbian and bisexual
women have many medical risks similar to
those of substance-abusing heterosexual
women. Alcoholic women tend to have higher
rates of fatty liver disease, alcoholic hepatitis,
and cirrhosis (Woolf, 1983), as well as a higher
risk of muscle weakness, muscular pain, and 
osteoporosis (Woolf, 1983). Because the
majority of lesbians have had heterosexual
intercourseoften without birth control or 
protection against STDsthey are at risk for
both pregnancy and STDs (OHanlan, 1995).
Research information is limited, but some
STDs, such as the human papilloma virus, 
bacterial vaginosis, and Trichomonas, can be 
transmitted among women, although female-
to-female transmission of HIV is extremely rare
(only two cases have been reported). Lesbian
and bisexual women who use injectable drugs
are at high risk for hepatitis B, hepatitis C, and
HIV/AIDS and should be screened for these
diseases. Some lesbian and bisexual women
may be sex workers and may have been
exposed to STDs, HIV, and trauma.
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For lesbians, negative experiences with health
care providers and the lack of providers who
are knowledgeable about lesbian issues may
have been a barrier to proper diagnosis and
treatment. In addition, some experts speculate
that lesbians may have an increased risk for
specific health problems, such as cancers of
the breast, colon, and ovaries; endometriosis;
and bacterial vaginitis. These higher risks are
based on factors such as a higher fat intake,
alcohol abuse, not bearing children, and 
inconsistent medical care (OHanlan, 1995).
Providers may not test for STDs and 
pregnancy, incorrectly assuming that lesbians
do not have sex with men. Moreover, lesbians
may be offered pap smears less often than 
heterosexual women, presumably because
doctors assume they do not need them as
often (Kerner, 1995).

Transgender Individuals

The health concerns of transgender individuals
are numerous. A study of 500 transgender 
individuals in San Francisco (Clements et al.,
1998) showed a 35-percent HIV prevalence
rate among male-to-female (MTF) transgender
individuals and a 65-percent HIV prevalence
rate among African-American MTF transgender
individuals. More than 15 additional studies
showed similar high rates of HIV infection in
transgender individuals who were primarily
MTFs in the sex industry and also at high risk
for substance use. These findings underscored
the great need for prevention and appropriate
care for this underserved population.

MTF and FTM (female-to-male) transgender
individuals also face the risks associated with
hormones, alcohol, and drugs. A particular 
concern is FTM hormonal use, because male
hormones are injected. The use of needles
raises the risk of hepatitis C and ovarian cystic
syndrome and may increase the risk of
injectable substance relapse. Hormones can
damage liver function and, with the added
effects of alcohol and drugs, the combinations
may be even more harmful. Indeed, increased
risks of liver cancer and cirrhosis have been
noted in the medical literature regarding 
hormones and alcohol and drugs. 
Common Barriers to LGBT Individuals
Receiving Adequate Health Care

LGBT individuals have been marginalized by
some segments of the health professions.
Historically, their sexual orientations and 
gender diversity were labeled deviant or 
pathological by many in the medical and
psychiatric community. As a result, many gays
and lesbians do not disclose their sexual 
orientation to their health care providers
(Cochran & Mays, 1988). Consequently, many
LGBT individuals, particularly transgender 
individuals, are reluctant to use mainstream
health care services and are medically 
underserved. However, LGBT health advocates
and professionals have lobbied for changes in
mainstream professional organizations that
have resulted in policy statements addressing
the needs of LGBT clients and the formation of
official LGBT affiliates, such as the American
Psychological Associations Task Force on the
Status of Lesbian and Gay Psychologists and
the American Psychiatric Associations
Committee on Gay, Lesbian, and Bisexual
Issues. Although these changes have been
important steps in establishing ethical guide
lines for appropriate care, many health and
mental health treatment providers remain
uncomfortable with sexual diversity and 
continue to discriminate against LGBT clients. 

A 1994 survey of the membership of the
American Association of Physicians for Human
Rights (now called the Gay and Lesbian
Medical Association) (1994) found that, of 711
members, 52 percent had observed the denial
of care or the provision of suboptimal care to
lesbian and gay clients. Eighty-eight percent
heard colleagues make disparaging remarks
about their lesbian and gay clients. However,
64 percent of the members stated that it is
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important for clients to reveal their sexual 
orientation but also noted they risk receiving
substandard care when doing so. Transgender
individuals are even more marginalized and are
often denied care, and LGBT individuals of
color may experience racial bias in addition to
homophobia. Thus, sensing these prejudices,
many LGBT persons have not used the health
care system adequately. 

Their hesitation to seek health care may result
in later diagnoses of illnesses, which results in
poorer treatment outcomes. Many physicians
are ignorant of the special health concerns of
LGBT individuals, such as the possibility of
anal warts in gay men or the surgical and 
hormonal treatment options for transgender
individuals. 

Common Mental Health Issues That LGBT
Individuals May Face

Substance-using LGBT clients struggle with
mental health concerns and illnesses similar to
those of their heterosexual counterparts. They
suffer from affective disorders, posttraumatic
stress disorder (PTSD), sexual trauma, suicidal
ideation and behaviors, eating disorders, and
the full range of mental disorders.

However, LGBT individuals have the added
stress of struggling to consolidate stigmatized
sexual or gender identities, making choices
about coming out to family and friends, fear of
prejudice, and being at increased risk of 
violence. In general, researchers suggest that
individuals who feel more comfortable about
their sexuality and gender identity are more
resilient, have better coping skills, and are better
able to articulate their mental health needs.
However, many clients in substance abuse 
treatment may not be out and may be very
uncomfortable with their identity. This presents
several stumbling blocks for the counselor and
the client, including the possibility of inappropri
ate counseling and an increased risk of relapse.
Research on the mental health needs of 
lesbians and gay men has increased 
substantially during the past two decades.
However, significant gaps still exist. The
process of coming out as a lesbian or gay man
can be extremely stressful, yet there is virtually
no research on effective ways of coping with
this process, and there has been even less
research on the mental health of lesbians and
gay men who are nonwhite, adolescent, 
elderly, or coping with disabilities (Rothblum,
1994). There is also very little research on
bisexual and transgender individuals. However,
some suggest that many transgender 
individuals struggle with low self-esteem,
depression, and fear about the reality of their
vulnerability to personal violence.

Past sexual abuse and trauma may well lead to
other mental illnesses, such as PTSD, and
complicate treatment for substance abuse. For
example, an outcome study of lesbians and
gay men who had completed inpatient sub
stance abuse treatment found that 44 percent
had been sexually abused (37 percent of
males and 67 percent of females) and 
abstinence was much more likely among those
who had not experienced abuse (Ratner,
Kosten & McLellan, 1991).

Interpersonal Violence in the LGBT
Community

Historically, differences in philosophy and 
terminology have blocked collaborative care for
clients involved in both interpersonal violence
and substance abuse (CSAT [Center for
Substance Abuse Treatment],1997c).
Interpersonal violence has been defined as the
use of intentional verbal, psychological, sexual,
or physical force by one intimate partner to
control another (CSAT, 1997c). Nonetheless, a
marked link between interpersonal violence
and substance abuse is well documented
(Pernanen, 1991; Windle et al., 1995; Bennett,
1995). Up to one-half of the men who commit
acts of interpersonal violence also have 
substance abuse problems (Gondolf, 1995;
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Leonard & Jacob, 1987; Faller, 1988), and
women who abuse alcohol and other sub
stances are more likely to be the victims of
interpersonal violence (Miller, Downs &
Gondolfi, 1989; Bureau of Justice Statistics,
1994; Stark & Filcraft, 1988; Gorman et al.,
1995).
Less is known about the relationship between
substance abuse and interpersonal violence in
the LGBT community. Perhaps the LGBT 
community has been reluctant to call attention
to the issue of interpersonal violence out of
concern for reinforcing the stereotype that
homosexuality is inherently dysfunctional.
Fortunately, the seriousness of interpersonal
violence has finally been acknowledged by the
LGBT community over the past decade (Elliot,
1996). The first account of lesbian battering
was published in 1986 (Lobel). Experts 
estimate that interpersonal violence occurs at
about the same rate in same-sex relationships
as in heterosexual relationships (Island &
Letellier, 1991; Lobel, 1986). Rates of partner
violence range from 8 to 46 percent (Elliot,
1996). The National Lesbian Health Care
Survey (Bradford, Ryan & Rothblum, 1994)
showed an 8-percent rate of partner violence in
a diverse, nonclinical sample of nearly 2,000
lesbians. In a study of 90 lesbian couples, 46
percent of the couples experienced repeated
acts of violence in their relationship (Coleman,
1990). And of 1,000 gay men surveyed in the
Northstar Project, 17 percent reported having
been in a physically violent relationship (Gay
and Lesbian Community Action Council, 1987).

In a study of 228 gay male perpetrators, Farley
(1996) found the following contributing to gay
interpersonal violence:

  40 percent abused drugs.

  87 percent had previous mental health 
treatment.
  93 percent reported physical abuse as a
child, and 67 percent reported sexual abuse
as a child.

  53 percent reported physical abuse as an
adult.

  40 percent reported alcohol abuse in their
family of origin.

  80 percent had a previous history of being
an abuser in an adult relationship.

Assessment 

Substance abuse in the LGBT community has
been exacerbated by internalized homophobia
(Ghindia & Kola, 1996) so that many LGBT
individuals feel isolated and victimized. The
isolation may be intensified further by mistrust
of treatment providers and a lack of civil rights
protection. Seeking professional or legal help
for interpersonal violence is equivalent to 
coming out (Elliot, 1996). These barriers may
make it more difficult to identify LGBT victims
or perpetrators of interpersonal violence.
Consequently, LGBT clients in substance
abuse treatment should be screened to identify
both batterers and survivors of interpersonal
violence (CSAT, 1997c). Indicators of 
interpersonal violence include the presence of
physical injuries, especially in visible areas,
inconsistent or evasive answers regarding
injuries when questioned, a history of relapse
or noncompliance with substance abuse 
treatment goals, and stress-related conditions
and illnesses (CSAT, 1997c).

As with all clients, practitioners should gather
information about the partners treatment of the
client. Interpersonal violence may be a factor if
the client states that the partner tries to isolate
him or her socially, tries to prevent him or her
from attending treatment or self-help programs,
threatens to abandon him or her, or damages
property. 
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The practitioner should ask questions in an
affirming and culturally sensitive manner.
Establishing rapport and trust is critical in 
accurately gathering sensitive information.
Care in selecting words and phrases that
reflect sensitivity to LGBT issues is imperative.
Potentially difficult questions should not be
raised too quickly or the client may feel 
overwhelmed or threatened and refuse to
cooperate.

Clients should always be interviewed about
interpersonal violence in private, even if the
client requests the presence of another 
individual who is not the batterer (CSAT,
1997c). Putting the client at risk by interviewing
him or her in the presence of others should be
avoided because batterers may manipulate
family members and others.

Practitioners should include questions about
sexual abuse that reflect their sensitivity to
LGBT concerns. Questions about the clients
family of origin should be posed in a way that
helps the client speak openly. When working
with LGBT individuals, the service provider
should help clients feel safe and assure them
that confidentiality is respected. These issues
frequently provoke great discomfort in all
clients, and LGBT clients may feel additional
discomfort because of some apprehension
about mental health practitioners in the LGBT
community.

Screening of possible batterers should be 
conducted with the same emphasis on 
confidentiality, safety, and cultural sensitivity.
The practitioner should ask clients about 
abusive behavior using the technique of 
circumstantial violence (Kantor & Strauss,
1987). Simply put, this involves using a third-
person example so as not to personalize the
question, thereby making the client defensive.
For example, Some people think that under
the right circumstances, its okay to hit your 
partner. Under what conditions do you think
violence might be justified? (CSAT,1997c).
Then the practitioner could begin personalizing
the questions assessing self-control. For 
example, If you were confronted with 
overwhelming stress, do you think you could
keep your cool? Faced with that, what do you
think you would do? (CSAT, 1997c).

Questions should be supportive and affirming,
thereby encouraging genuine responses.
Gradually, the practitioner should ask specific
questions about the relationship, e.g., Have
you ever hurt your partner? It is critical to 
recognize that denial, rationalization, and 
minimization are strong mechanisms used for
both interpersonal violence and substance
abuse. Thus, it is critical that the practitioner
guard against being manipulated or misled by
excuses and that batterers be held responsible
for their actions (CSAT, 1997c).

Finally, the treatment provider should avoid 
colluding with clients in denying the implication
that substance abuse causes interpersonal 
violence. Practitioners should watch for clients
who blame others for their battering or 
substance abuse. For successful treatment
outcomes, clients must take full responsibility
for their behavior.

Interventions 

If a client is identified as either a batterer or a
survivor of interpersonal violence, he or she
should be referred to a support group, to a 
batterers intervention program, and for 
ongoing consultation with an expert in the
treatment of domestic violence (CSAT, 1997c).
Exactly how to refer survivors depends on the
situation. If immediate danger is present, 
suspend the interview. The provider should be
familiar with deescalation methods and have
established links with other treatment providers
and police (CSAT, 1997c). The practitioner
should be aware of available resources with
expertise in interpersonal violence and LGBT
issues. 
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Past trauma has been associated with 
subsequent substance abuse. For many in the
LGBT community, trauma not only results from
childhood physical and sexual abuse but also
from internalized homophobia, cultural 
heterosexism, and gay bashing. It is important
for the practitioner to consider these issues as
LGBT clients move toward abstinence because
they can be powerful relapse triggers. 

Just as substance abuse does not cause or
excuse violent interpersonal behavior, HIV
infection does not cause battering.
Unfortunately, many in the LGBT community
who are assaulted by their HIV-infected 
partners blame the stress of HIV infection for
the violent behavior (Letellier, 1996). Treatment
providers should not collude in this denial of
responsibility and should consider the 
comorbidity of HIV infection, interpersonal 
violence, and substance abuse in planning
assessments and interventions. 

The treatment for both substance abuse and
interpersonal violence should be conducted
concurrently. The fundamental goal of 
treatment for both is to create, nurture, and
strengthen the individuals capacity to maintain
intimate relationships that are free of violence
(Byrne, 1996) and substance abuse.
The skills used in assessing substance abuse
are useful for assessing interpersonal violence,
regardless of the clients sexual orientation. A
practitioner is likely to encounter the same
defensive strategies (e.g., denial, defensive
ness, blame). Assessment and intervention
strategies do not require new theoretical
approaches or skills. However, the practitioner
must consider the safety of the victim and 
perhaps the practitioners own safety when
intervening. The same competencies and
approaches can be used with LGBT 
individuals. Successful treatment outcomes for
LGBT individuals depend on creating an open
and trusting atmosphere, taking care not to
make hetereosexist assumptions, and having
an understanding of the importance of 
confidentiality and disclosure issues. Working
with LGBT individuals requires a thorough 
knowledge of the effects of cultural 
heterosexism on the LGBT client and the use
of existing empirically derived practice skills.
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Related Health Issues
Case Example

Ron, a 34-year-old African-American male, presents to your substance abuse treatment agency at the 
insistence of his employer for alleged difficulties at work. Apparently, he has come to work late on numerous
occasions with alcohol on his breath. During his assessment, he informs you that he has been drinking
excessively over the past few months and, as a result, has been unable to get to work on time. He also
vaguely reports engaging in high-risk sexual behaviors. During the assessment, you notice black and blue
marks on Rons arms and neck. He tells you that for about 3 years he has been living with another man who
recently has been diagnosed with HIV and now has symptoms. 

How would you proceed with the assessment? What questions would you ask and how would you ask
them?

Suggested Interventions

  Conduct a standard substance abuse assessment.

  Attempt to connect interpersonal violence, the stress of being in a relationship with someone with HIV, and
substance abuse using LGBT-sensitive language. This may help the client gain insight and create an 
environment conducive to further discussion.

  Include questions about a history of family abuse or posttraumatic stress disorder and current relationship
issues such as ways of expressing anger and frustration, issues of power and control, and issues of 
gender roles.

  After establishing sufficient rapport, mention that interpersonal violence is not uncommon in relationships.
Do not assume because the client has a bruise that he or she is the victim.

  Take steps to ensure the safety of the client if he or she is in danger.

  Conduct interventions for substance abuse and interpersonal violence concurrently, if possible, within the
same organizational structure.

  Ensure that a female batterer of a lesbian in a womens shelter cannot gain access to the shelter.

  Refer clients promptly to a practitioner or an agency that has expertise in interpersonal violence and that
is sensitive and knowledgeable about LGBT issues.

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Case Example

Deedee, a 52-year-old African-American lesbian, reported to her substance abuse treatment counselor that
she found a painful lump in her breast. The counselor knew that Deedee had not seen a doctor in more than
5 years and that she was extremely tense around health care providers. Deedee has a history of childhood
sexual abuse and is not comfortable with anyone touching her. She has had bad experiences with health
care providers and has been treated disrespectfully because of her lesbian identity. Her counselor was quite
concerned about the pain Deedee was experiencing but unsure what to do.
Related Health Issues
Suggested Interventions

Health care workers and substance abuse counselors should recognize that some of the health care 
concerns of LGBT individuals are a product of past bad experiences with health care providers. There are 
a number of ways that helping professionals can address these problems with their clients. For example:

  The counselor should ensure that Deedee is aware of the importance of being evaluated and treated for
her potentially life-threatening condition. 

  Substance abuse treatment programs should develop partnerships with LGBT-sensitive primary care
physicians and clinicians, therapists, and psychiatrists for referring clients to other practitioners who 
provide sensitive care.

Other suggestions include:

  Help LGBT clients be more comfortable in disclosing their sexual identity.

  Integrate LGBT-inclusive language and lifestyles into curriculums. 

  Use gender-neutral questions, and communicate a nonjudgmental attitude.

  Make sure the health practitioner takes a sensitive but thorough sexual history to determine the 
appropriate STD screening and treatment if necessary. 

  Focus risk-reduction education not only on HIV and other STDs but hepatitis as well.

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Chapter 13
Counselor Competence in Treating 
LGBT Clients

Dana G. Finnegan, Ph.D., C.A.C., Naples, FL
Emily B. McNally, Ph.D., C.A.C., Naples, FL
E. Bernard Anderson, Jr., M.S., M.A., NCAC, ICADC, C.C.S., Florida Addictions and 
 Correctional Treatment Services (F.A.C.T.S.), Tallahassee, FL
Candace Shelton, M.S., CADAC, Consultant, Tucson, AZ
Introduction

Counselors will encounter and provide 
treatment to lesbian, gay, bisexual, and
transgender (LGBT) clients in all treatment
settings: residential, intensive outpatient,
outpatient, crisis intervention, and the 
criminal justice system. 

The Center for Substance Abuse Treatment
(CSAT) published a Technical Assistance
Publication (TAP) in 1998 titled Addiction
Counseling Competencies: The Knowledge,
Skills, and Attitudes of Professional Practice,
in which the professional addictions 
counseling field, represented by leaders of
national counseling organizations, identified
eight practice dimensions. The dimensions
are (1) clinical evaluation, (2) treatment
planning, (3) referral, (4) service 
coordination, (5) counseling, (6) client, 
family, and community education, (7) 
documentation, and (8) professional and
ethical responsibilities. Proficient knowledge
and skill in each of the dimensions is 
necessary for effective practice (CSAT,
1998b). The development of effective 
counseling practices in the field of addictions
depends on the presence of attitudes in
which openness to alternative approaches,
appreciation of diversity, and willingness to
change are present and consistently 
practiced (CSAT, 1998b).

In the counseling competencies model, a
counselor needs to respect the client and
his or her frame of reference; recognize the 
What providers will learn
from this chapter:

  How counselors can
become more aware of
their homophobia and 
heterosexism, how these
biases can lead to mis-
treatment, and how to
monitor and manage 
their own biases

  How to provide good 
quality, fair, ethical, and
competent treatment to
LGBT clients

  How to provide LGBT-
sensitive treatment

  What counselors should
consider in treating LGBT 
criminal justice clients

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Counselor Competence in Treating LGBT Clients
importance of cooperation and collaboration
with the client; maintain professional objectivity;
recognize the need for flexibility and be willing
to adjust strategies in accordance with client
characteristics; appreciate the role and power
of a counselor as a group facilitator; appreciate
the appropriate use of content and process
therapeutic interventions; and nonjudgmentally
and respectfully accept the clients cultural,
behavioral, and value differences. These best
practice methods are critical when working with
LGBT clients. 

The most important ethical issue in counseling
is the protection of clients well-being and 
safety, based on an ethos of care and a
covenant of trust between clients and 
counselors (Peterson, 1992). In this capacity,
counselors acknowledge and manage the
power accruing to them so that they can use
that power constructively and ethically (Gartrell,
1994). Thus, counselors need to be aware of
how clients who have been or are being 
discriminated against may respond to others
power. Clients who have been traumatized may
be overly passive and accepting or very 
oppositional. These behaviors are important
information for the counselor, and an aware
counselor will provide a safe environment for
the client in which to work through his or her
feelings. Counselors need to be aware of and
monitor their use of authority so that they do
not push or force clients to do something they
are not ready to do. In the case of LGBT
clients, counselors should not out or push a
client to share his or her sexual orientation or
gender status in the name of honesty and good
treatment. 

At the same time, the counselor should help 
create a safe environment for clients who are
ready to come out in treatment to do so.
Counselors need to use their authority to
ensure their LGBT clients safety when it is
necessary to protect LGBT clients from overt
expressions of homophobia (or biphobia or
transphobia) by other clients or staff. Most
clients who present for treatment have to deal
with the shame and guilt of their drug-using
behavior. It is important for counselors to
remember how their words can activate clients
shame; this is especially important when 
working with LGBT clients, who have been
traumatized by both their alcohol or drug abuse
and the heterosexist attitudes and behavior
they must deal with.
Counselors Professional Responsibility

In the counseling competencies model, a 
counselor is responsible for self-monitoring,
obtaining proper supervision, and adhering 
to professional and ethical standards.
Establishing the proper ethos of care for LGBT
clients requires that counselors be aware of
and work though their own feelings about these
clients. 

Self-monitoring is the means for 
accomplishing this task. Counselors should be
aware of countertransference. Counter-
transference is the process of counselors 
seeing themselves in their clients, 
overidentifying with their clients, meeting 
their personal needs through their clients, or 
reacting to a client because of unresolved 
personal conflicts (Corey, 1991). 

Recognizing the manifestations of 
countertransference reactions is one of the
most essential elements of effective counsel
ing. Unless counselors are aware of their own 
conflicts, needs, assets, liabilities, beliefs, and
values, they might use the counseling process
more for their own purposes than for their
clients. This self-monitoring is very important
when working with LGBT clients. Counselors
need to examine their beliefs about lesbians,
gay men, bisexuals, and transgender people
because their own beliefs underlie 
countertransference. 

Some important questions counselors need to
ask themselves are the following:

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  Are there myths and stereotypes about
LGBT people that I believe? Do I, for
instance, believe that gay men are child
molesters? That LGBT people try to recruit
others, especially children, to their orientation
and lifestyle? That lesbians, gay men, 
and bisexuals would all choose to be 
heterosexual if they could? That transgender
people want to change genders because
they are really homosexual?

  Do I believe that having sex with someone of
the same sex or having sexual feelings
toward someone of the same sex indicates
that the person is lesbian or gay? Do I
believe that the sexual act, by itself, 
constitutes sexual orientation or identity? Do
I believe that having a lesbian or gay or
bisexual or transgender orientation is 
unnatural, immoral, sick, or disgusting? 

If counselors agree with any of these 
questions, there is a real need for education,
training, supervision, and consultation before
they work with LGBT clients because their 
ability to fairly and competently treat LGBT
clients is questionable. Unless these coun
selors are actively seeking to change or alter
these beliefs, they should not treat LGBT
clients. 

A method of managing countertransference
issues, prejudices, and difficult clients is by
supervision. Supervision provides the 
counselor the opportunity for processing 
experiences with clients that may be 
problematic and may be creating anxiety that
can interfere with the counseling process. If a
counselor is aware of negative feelings about
LGBT clients, it is imperative that those issues
are taken to supervisors and worked through
immediately. If a counselor is aware of his or
her prejudicial behavior toward an LGBT client,
he or she should be willing to behave different
ly or transfer the client to someone who is 
comfortable working with that client.
Helping Clients Heal From the Negative
Effects of Homophobia and Heterosexism 

Neisen (1993) discusses the process of 
recovering from shame associated with 
heterosexism. Counselors who want to help
their clients heal from homophobia and hetero
sexism may find the following steps helpful.

Breaking the silence parallels the process of
coming out. It is important for LGBT individuals
to tell their stories and to address the pain of
being different in a heterosexist society. The
counselor can:

  Encourage a discussion of how the client hid
his or her LGBT feelings from others

  Explore the emotional costs of hiding and
denying ones sexuality

  Discuss attempts the client has made to
change in an effort to fit in

  Examine negative feelings of self-blame,
feeling bad or sick, and the impact of
shaming messages on the client

  Foster the clients courage to accept and
speak up about who he or she is.

Establishing perpetrator responsibility
allows clients to understand their struggle in
the context of discrimination and prejudice. The
counselor can:

  Help clients manage anger in a constructive
manner rather than direct it toward 
themselves 

  Help clients understand that anger and a
negative self-image are the result of cultural
victimization and not a personal defect

  Shift clients perspective by drawing parallels
to the process of recovery from physical or 
Counselor Competence in Treating LGBT Clients

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Counselor Competence in Treating LGBT Clients
sexual abuserecognizing that they have 
suffered a form of abuse

  Ensure that the treatment environment 
fosters behavior by staff and clients that is
not hostile to LGBT individualsa difficult
task in the case of subtle or covert 
behaviors.

Reclaiming personal power involves helping
clients:

  Improve their self-concept and 
self-confidence

  Identify internalized negative messages that
result from cultural victimization and 
heterosexism

  Change negative messages to positive,
affirming statements about themselves

  Find positive, affirming expressions for 
spirituality to combat any negative messages
about their own morality that clients may
have received

  Recognize residual shame and a victim 
mentality and begin to release it

  Integrate public and private identities

  Build a support network of individuals who
accept and value them for who they are.

Practical Suggestions for Providing
Competent Treatment

How can a counselor self-monitor when 
treating LGBT clients? The first issue is what
counselors and agencies, via construction of
psychosocial histories and intake forms, ask or
do not ask clients at intake. If clients are 
routinely asked about partners or significant
others, but this question is omitted with LGBT
clients, LGBT clients lose the opportunity to tell 
their counselor who they really are. Some
LGBT clients may not want to reveal their 
sexual or gender orientation, but if counselors
do not ask, they may treat the clients false
self (Winnicott, 1965), that is, the self that is
presented to the world to protect the identity
that is repressed and stigmatized. Treating 
the false self, by not asking about sexual 
orientation in an accepting and nonjudgmental
way, is acting unethically and does a 
disservice to the client.
Following are some guidelines, or dos and
donts, for counselors who are or who wish to
be sensitive to the needs and feelings of their
LGBT clients and improve their own treatment
and counseling skills.

Dos

  Do create safety for LGBT clients. This can
include clearly stating what you can and will
hold in confidence and what you will share
with your team or your supervisor; assuring
clients of your own supportive attitudes; and
protecting LGBT clients from others 
homophobia.

  Do know the population. Read about LGBT
people. Get to know LGBT people, especially
those in self-help groups and nonclients.
Know what LGBT resources are available for
clients and how to access them. Recognize
that it is easy to shame LGBT clients
because of their internalized homophobia
and their substance abuse.

  Do create an atmosphere that is supportive.
On forms and in all verbal interchanges, use
inclusive language. For example, instead of
asking about marital status, ask who the
partner or significant other is. Instead of 
asking for the names of next-of-kin in case 
of emergency, ask for the name of the 
responsible party and that persons 
relationship to the client.

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  Do acknowledge clients significant others
and encourage their participation in the 
treatment. Hang pictures and posters of
known LGBT people (e.g., athletes, historical
figures); have books about LGBT subjects on
tables and in waiting rooms; post lists of
LGBT-friendly Alcoholics Anonymous/
Narcotics Anonymous/Al-Anon/Adult Children
of Alcoholics meetings in visible places.

  Do be guided by your LGBT clients. Listen to
what they say is comfortable for them.
Support them in making decisions about
coming out, self-disclosing, or accepting their
identity. 

  Do get training to help you become less 
heterosexist and increase your knowledge
and understanding.

Donts

  Dont label your clients. For example, when a
client says he is in a long-term relationship
with another man, do not say, Oh, then you
must be gay. It is for the client to label 
himself or herself. 

  Dont pressure clients to come out. Respect
their sense of where they are in this process
and their need to feel safe.

  Dont ignore significant others and family
members. Dont assume because people are
not related by blood or marriage that they
are not extremely important to the client.

  Dont interpret on behalf of the client by 
saying It must be hard being a lesbian, or
You must be angry because your parents
dont accept your being a person of 
transgender experience. Follow the clients
lead. A comment that is empathetic in one
context may be invasive in another.
Treating LGBT Clients in the Criminal
Justice System

Treating LGBT clients in the criminal justice
system presents special challenges for the
counselor who has to balance security 
protocols with maintaining his or her 
professional and ethical responsibilities. It is 
especially important that counselors present
themselves in a manner that gains clients trust
so that the clients can process issues that may
involve their sexuality or gender identity. 

In the correctional institution setting 
homophobia, transphobia, and heterosexism
are even more prevalent than in society in 
general. Stigmatization is more intense, 
resulting in extreme closeting on the part of
many incarcerated LGBT offenders. The LGBT
offenders sexuality, if known, may be 
considered an attribute of his or her criminality.
This is an issue that should be processed 
appropriately in treatment.

Some incarcerated LGBT offenders express
themselves by clear and flagrant presentation
while others choose to hide their sexual 
orientation or gender identity to avoid punitive
consequences from other prisoners. LGBT
couples may state to their fellow inmates that
they are strongly committed to each other and
are monogamous. 

Treatment documentation and security of
records are important. Counselors may find it
helpful to inform their immediate clinical 
supervisor about LGBT cases and provide
progress reports and assistance in managing
issues such as clients who are used to being
out and open but are forced while incarcerated
to hide their identities.

A history of rape, family-of-origin issues, and
unresolved grief are prevalent in incarcerated
LGBT clients. Due to the homophobia/ 
transphobia/heterosexism of institutional staff
and the other offenders, incarcerated LGBT
Counselor Competence in Treating LGBT Clients

119

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clients may have trouble bonding with other
LGBT offenders. These clients usually present
with profound feelings of isolation, fear, depres
sion, and anxiety and have difficulty trusting
others.

Most correctional facilities endorse the 
traditional 12-step model of treatment in 
conjunction with therapeutic community 
treatment. In most of the settings, an LGBT-
specific 12-step support group will not be 
available for the LGBT client. Rational-emotive
therapy is also utilized in many correctional
settings, and counselors should not give the
impression that LGBT clients sexual 
orientation is a negative behavior that 
needs to be changed. 
Before an LGBT client is released, his or her
counselor may be the only professional who
can adequately provide the specific referrals
needed by the client for community reentry.
This is a case management function, and the
referrals and recommendations made by the
counselor are crucial to helping the LGBT
client reenter society and stay clean and sober.
Counselor Competence in Treating LGBT Clients
Case Example #1

Yoko was out as a lesbian while going through treatment in a 14-day inpatient facility. Because some of the
other clients were homophobic, she was subjected to ridicule, vicious insults, and some threats. Although
Yoko managed to stick it out and get some help with her addiction, she was clearly harmed by her experi
ence, both by the direct homophobia of her fellow clients and by the staffs homophobic attitudes and inability
to help and protect her. Not only did this experience harm Yoko, but it also affected Sally, a closeted lesbian.
Sally observed the abuse perpetrated on Yoko but was too terrified to help. She felt terrible about herself for
not speaking out, but she was confused by her anger at Yoko for making treatment more difficult.

Suggested Interventions

The counselors should have addressed the homophobia of the other clients and helped them look at it and
stop the antigay behavior. Such prejudice and bad feelings are harmful not only to the recipient and the
identifying bystander but also to those harboring and acting on such malicious feelings.

Case Example #2

John is a 43-year-old male who acknowledged his homosexuality several years ago after years of trying to
deny his sexual attractions to other men. When John was a child, his parents suspected he was gay
because he did not show much interest in male activities. When he was 15 years old, his parents sent him
to a prestigious hospital hoping that he would be cured of his homosexuality. John returned to school and
did what was expected of him: He played sports and dated. He thought that perhaps his psychiatrist was
right, that his homosexuality was just a phase. He was a good student and had a small group of friends.
He dated several girls, but he never felt romantically or sexually attracted to them. After graduation, he 
attended college and found his attraction to men was intensifying. John married in his senior year in college,
thinking that maybe if he met the right girl and settled down, these feelings would go away. Over the
years, he and his wife had two children. Nevertheless, Johns same-sex attractions increased. John began
to secretly frequent gay bars to meet gay men. On a number of occasions, he had sex with these men, but
only after first getting drunk. He dated one man for 6 months. However, this man left him because of Johns 
alcohol abuse and because he was still in the closet. Johns alcohol abuse and his shame about his 
homosexuality have deeply affected his emotional well-being and all aspects of his life. John recently 
separated from his wife. He arrived in treatment stating he knows he is gay, but because he still has 
difficulty accepting himself, he engages in substance abuse to hide his pain.

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Suggested Interventions

It is important for the counselor to assure John that he is safe to share his story and his pain. John 
needs validation that, in spite of his parents good intentions, it was inappropriate to cure him of his 
homosexuality. John is likely to be too vulnerable to share his pain in a group setting at this time. John
needs the opportunity to discuss, in individual counseling sessions, the prejudice and pain he has endured
and how it is related to his substance abuse. Although only the beginning of Johns healing, it should not be
ignored. It is a critical part of his therapy in early sobriety. Because John is at high risk for relapse while his
self-esteem and self-acceptance are low, the counselor can assist John when he senses the time is right by
identifying gay Alcoholics Anonymous meetings as one means to help John meet gay people who accept
themselves. The counselor can also help by referring John to a therapist after he finishes treatment so that
he can continue working on issues of self-acceptance.
Counselor Competence in Treating LGBT Clients

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    SECTION III: 
     PROGRAM 
ADMINISTRATORS GUIDE

-----------------------------------------------
Chapter 14
Policies and Procedures
Brenda L. Underhill, M.S., C.A.C., Underhill & Associates, Berkeley, CA
Edwin M. Craft, Dr.P.H., M.Ed., LCPC, Office of Evaluation, Scientific Analysis, and
Synthesis, Center for Substance Abuse Treatment, Substance Abuse and Mental Health 
Services Administration, Rockville, MD
Introduction

This chapter addresses the specific 
administrative policies and procedures that
need to be implemented to help ensure that
the infrastructure of the program is sensitive
to and culturally competent with lesbian,
gay, bisexual, and transgender (LGBT)
clients. Administrators should understand
that in order to provide effective recovery
services to LGBT individuals, all aspects of
a program should be examined for overt and
covert expressions and perceptions of
heterosexual biasfrom outreach (including
public relations) to aftercare services. A
commitment should be made at every level
of the program, from the board of directors
to the direct line staff, to design and deliver
services in a manner sensitive to the needs
of LGBT individuals.

A program committed to serving LGBT
clients should first demonstrate its 
commitment in written administrative policies
and procedures. When implemented, these
policies and procedures will help ensure that
the delivery of fair and equitable clinical
services is built into the fabric of the
organization and does not depend only on
personal commitment by staff members.
These policies and procedures need to be
comprehensive and permeate the entire
continuum of care and all agency activities.

Strategies and Recommendations

Suggested administrative policies are
described below for an agencys mission, 
treatment programming, promotional 
What providers will learn
from this chapter:

  Administrative policies and 
procedures for serving
LGBT clients in the 
following areas:

  Organizational mission

  Outreach and promo
tional materials

  Advertising and public 
relations

  Community relations

  Administrative

  Personnel

  Staff training

  Program design and 
implementation

  Aftercare

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material, advertising and public relations, 
personnel, training, and aftercare services.
These suggestions are not intended to be
definitive; they merely provide a foundation on
which organizations can base programs and
policy changes. Every policy and procedure
needs to be tailored to meet the specific needs
of the agency and to consider the type of
services (i.e., modality) being delivered and
geographic area (i.e., urban or rural).

Organizational Mission

Because LGBT communities are underserved
and often invisible, it is important that treatment
providers make a commitment to serving 
this population and incorporate it into the 
organizations mission statement, philosophy,
and service literature.

Administrators should check and edit the 
mission philosophy or service statement to
ensure it includes a commitment to serve
LGBT communities.

Policies and Procedures Regarding
Outreach and Promotional Materials

Consideration of the following points is critical
when preparing promotional materials to 
distribute to potential clients, the community at
large, and policymaking and funding sources.

  Ensure that promotional materials include
information about LGBT-specific services, if
appropriate.

  Use language that specifically identifies
LGBT individuals as people the program is
attempting to reach.

  Include images in promotional materials that
depict individuals identifiable as LGBT 
individuals.

  Enlist the assistance of focus groups 
composed of a culturally diverse selection 
of LGBT individuals in the development of
promotional materials for your agency.
Advertising and Public Relations Policies
and Procedures

The following points are often overlooked in the
promotional activities of mainstream substance
abuse treatment organizations. Note that 
messages that reach LGBT individuals through
mainstream media can be especially powerful.

  Advertise programs and events in LGBT
periodicals as well as in the mainstream
press and those publications that are geared
to particular cultural communities.

  Create LGBT-sensitive public service
announcements (PSAs) about your services
for radio and television. Lobby the stations to
carry the PSAs by personally meeting with
the public service director.

  When producing cable TV programs on drug
addiction and recovery for distribution to
local public access cable stations, include
LGBT clients and staff.

  Include articles by and about recovering
LGBT individuals in newsletters.

  Submit articles about substance abuse
issues in LGBT communities to LGBT 
periodicals as well as to the mainstream
press and those publications that are geared
to particular cultural communities.

Community Relations Policies and
Procedures

Following are some suggestions for developing
a seamless plan of communication and support
between mainstream substance abuse 
treatment centers and LGBT communities.

  Provide speakers on substance abuse issues
to LGBT organizations.
Policies and Procedures

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  Encourage staff to join boards, task forces,
and commissions that advocate for 
empowerment on behalf of LGBT clients.

  Support LGBT-specific events in the 
community (dances, readings by LGBT 
writers, theater and music performances, and
LGBT pride marches) through sponsorship,
staff support, advertising, and distribution of
announcements or by cosponsoring such
events with LGBT communities.

  Form relationships with local LGBT and
womens bookstores; provide space for them
to sell books at events held at your agency.

  Provide an information booth at LGBT street
fairs, as well as at events geared to specific
cultural communities.

  Sponsor drug- and alcohol-free social events
and sporting activities for LGBT individuals.

  Enlist the help of recovering LGBT 
substance abusers who might be willing to
serve as mentors or sponsors for LGBT
clients in your treatment facility.

  Help advocates for LGBT substance abuse
services be represented on local, State, and
Federal planning and policy boards.

Administrative Policies and Procedures

Instituting the following policies and procedures
helps create a climate that ensures LGBT
clients do not experience or perceive 
discriminatory practices or harassment.

  Create or confirm the existence of agency
policies regarding freedom from discrimina
tion and harassment based on sexual 
orientation, gender, and cultural background. 

  Create procedures for filing complaints and a
process for resolving reported violations of
these policies. 
  Ensure the enforcement of these policies at
every level of the program, from the board of
directors to the direct line staff, in such a way
that individuals filing reports are not 
traumatized further.

  Investigate every complaint of discriminatory
practices reported by LGBT clients and their
family members.

  Ensure that all personnel from the board of
directors to volunteers are trained, on a 
regular basis, on antidiscriminatory policies.
Training should be experiential as well as
didactic and include discussions of subtle
forms of discrimination and harassment as
well as blatant forms of this behavior. Ensure
that all personnel are familiar with the 
procedures for reporting violations.

  Review all operational procedures, from 
initial phone contact through the intake
process, to ensure that heterosexual bias
has been eradicated and inclusive terms are
available as options.

  Use the phrase clean and sober as
opposed to straight to refer to individuals
who are drug-free, since straight is often
used to refer to individuals who are hetero
sexual.

Personnel Policies and Procedures

Inclusion of the following policies and 
procedures in agency operations will help
ensure a nondiscriminatory environment for
both clients and staff as well as equal 
representation of LGBT viewpoints in 
program and policy development.

  Include sexual orientation and gender 
identity in your nondiscriminatory 
employment policy. 

  Develop and implement grievance 
procedures for employee reports or 
Policies and Procedures

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complaints of discrimination based 
on sexual orientation or gender identity. 

  Enlist openly LGBT members to serve on the
board of directors and in other leadership
positions. Ensure that LGBT individuals of
color are represented in proportions that
reflect the community demographics.

  Include partners in the definition of family
when writing bereavement policies or sick
leave policies on caring for family members.

  Ensure that the organization has a 
contagious-disease policy that includes
HIV/AIDS (as opposed to an AIDS policy).

  Employ openly LGBT individuals as staff 
and consultants.

  Advertise job openings in LGBT publications.

  Establish an LGBT advisory board to help
with program design, services, and commu
nity outreach to advise the board of directors,
administration, and staff. 

  Review the ability of staff to be inclusive and
supportive; directly confront overt 
discrimination. Hold staff and leaders
accountable for upholding the policies as set
forth. The degree to which this performance
goal is or is not met should be reflected in
promotions and merit salary increases.

Staff Training Policies and Procedures

Establishing the following policies and 
procedures will ensure that new and incumbent
staff are aware of the agencys LGBT-
supportive stance on an ongoing basis.

  Ensure that all new employees are familiar 
with agency policies regarding hiring of and
providing services to LGBT clients.
  As a part of regular staff training, include
such topics as LGBT cultures and 
communities.

  Ensure that staff members are allowed to
explore their fears and prejudices in a non-
threatening environment.

  Have up-to-date national and local listings 
of resources and services available within
LGBT communities and have them in offices
and waiting rooms for easy access by clients
and staff members.

  Organize cross-training between local LGBT
and community groups and your agency.
Exchange information about substance abuse
and recovery services for information about
the LGBT community and its resources.

Program Design and Implementation
Policies

Implementation of the following program design
and implementation policies will help ensure
that adequate resources are directed toward
meaningful activities for LGBT clients from
diverse backgrounds.

  Ensure that child care services are designed
to include LGBT parents. Design workshops
on parenting that are not biased toward 
heterosexuals.

  Utilize focus groups of recovering LGBT 
individuals in designing and expanding 
services to ensure the services meet the
specific needs of LGBT clients.

  Ensure that case conferencing and clinical
supervision address any issues raised in
treatment by LGBT clients.

  Provide education for heterosexual clients
about language and behaviors that show 
Policies and Procedures

126

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bias toward LGBT people. Establish firm
guidelines regarding client behavior, and 
consistently enforce these guidelines to
ensure a treatment atmosphere of safety 
for LGBT (and all) clients.

  Emphasize and enforce the confidentiality of
all treatment services and printed materials
at staff trainings and all client functions.

  Make all family services available for the
domestic partners and significant others of
LGBT clients in your program. These may
include conjoint therapy, family therapy, or
groups.

  Be sure there are social events and activities
appropriate and relevant to LGBT clients of
diverse cultural backgrounds.

  Create opportunities for LGBT clients to
attend workshops or meetings (including 
12-step meetings) that are culturally specific.
This can be done in conjunction with local
LGBT program resources. Provide transporta
tion for your LGBT clients to these events.

  Make sufficient financial commitment and
invest adequate resources to allow your 
program to fully implement these policies
and procedures.

Aftercare Policies and Procedures

Aftercare is critical for any client being dis
charged from a substance abuse treatment
program. Establishing the following policies
and procedures will help ensure adequate
postdischarge care for LGBT clients.
  Identify a contact person who is an openly
LGBT staff member and who will be 
available to LGBT graduates if they face 
any recovery crisis after discharge.

  Establish training procedures in which all
staff members are educated about issues
LGBT individuals face upon discharge.
Include workshops on relapse triggers 
specific to LGBT individuals in recovery.

  Ensure that discharge procedures help LGBT
clients develop relapse prevention strategies
for high-risk situations specific to them, such
as reentering bar-oriented LGBT communi
ties, coming out to their family of origin if
they decide to do so, and dealing with homo-
phobia, discrimination, and/or gay bashing. 

  Ensure that discharge procedures include
providing each LGBT client with a 
comprehensive list of LGBT-specific and/or
LGBT-sensitive community resources and
services, along with clear information about
how to access these services.

Following is a case example of a large,
California-based mainstream substance abuse
treatment program that has implemented spe
cific policies and procedures for serving LGBT
clients. The coauthors appreciate the efforts of
Dr. Brian Greenberg and Ms. Christine Lanieri
in providing this information. 
Policies and Procedures

127

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Case Example

Walden House, Inc., is a large, nonprofit organization providing substance abuse rehabilitation services in
San Francisco and the greater California community. Founded in 1969, Walden House has grown and
thrived within the culturally diverse San Francisco environment. The agency now provides services to more
than 3,500 individuals each year in its residential and outpatient programs. Approximately 20 percent of the
clients in Walden Houses main city-funded programs fall into the categories of lesbian, gay, bisexual, and
transgender (LGBT). In its Ryan White CARE Act programs serving individuals with HIV/AIDS as well as
substance abuse issues, more than half the clients are LGBT. 

San Francisco is a nationally recognized Mecca for members of LGBT communities. The citys cultural 
diversity and progressive politics provide opportunities for real advances in LGBT rights. Gay and lesbian
elected officials are a powerful force in local politics. LGBT people are actively involved in the local 
decisionmaking process regarding substance abuse, human services, and public health funding. The city
actively prosecutes hate crimes, and many local businesses recognize the LGBT community through
domestic partner initiatives, specific marketing campaigns, and sponsorship of events. 

Recognition of LGBT lifestyles, values, and families is part and parcel of the fabric of the Walden House
work and treatment community. The agencys commitment to cultural competency for LGBT clients is
demonstrated through a number of administrative, clinical, and business policies and practices. The Board
of Directors includes openly gay and lesbian members. Staff members who are LGBT are frequently open
about their sexual orientation, and the agency ratio of LGBT staff to LGBT clients is two to one. 

As a therapeutic community, Walden House promotes an atmosphere of acceptance and celebration of all
cultures represented in the treatment environment. There is no tolerance within the Walden House 
community for discrimination, including homophobia, transphobia, racism, sexism, or any other 
discriminatory practice. LGBT people are included in the agency nondiscrimination statement and mission
statement. Walden House offered domestic partnership benefits to staff even before the city of San
Francisco mandated it for county contractors. Agency outreach literature describes services offered to these
and other specific populations. Articles in the Walden House Journal have profiled out clients, staff, and
board members. Staff members on the Walden House Special Populations Task Force help ensure cultural
competency for LGBT clients. An agency representative serves on the San Francisco city and county LGBT
Task Force. Data are collected on the number of LGBT persons served, and evaluation of the efficacy of
treatment for LGBT populations is conducted on a regular basis.

In the treatment milieu, the special needs of LGBT clients are considered in the overall assessment 
process. LGBT clinical support groups are held bimonthly and are open to persons who are either LGBT or
questioning their sexual identity. Therapists, counselors, and managers who openly identify themselves as
LGBT are employed throughout the agency. LGBT clinical specialists are frequently included in the 
treatment planning team for LGBT clients. The client grievance procedure provides an avenue for 
addressing any perceived or actual wrong experienced by participants. Clients have the right to have 
representatives of their own choice at grievance hearings, and if LGBT issues are raised, an LGBT staff
member is often made available to hear the grievance with other appropriate staff.

An example of Walden Houses active involvement in the LGBT community is its participation in the Annual
San Francisco Gay, Lesbian, Bisexual and Transgender Pride Parade. Walden House clients volunteer to
collect donations, staff an information table, sell beverages, and have a float and large contingent in the
parade. The event caps Pride Month, during which clients participate in special educational and recreational
events. Heterosexual clients and staff participate in these activities as well. 
Policies and Procedures

128

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Dr. Brian Greenberg can be reached for further
information at 

Walden House
520 Townsend Street
San Francisco, California 94103
4155541480
E-mail: bgreenb488@aol.com

In developing this publication, several 
conversations were held with representatives
of Inter-Care, a New York City-based private
for-profit substance abuse treatment program.
Inter-Care has gained a reputation in the LGBT
community for safe and effective treatment by
implementing many of the policies and 
procedures recommended in this chapter. Its
steps included modifying history/intake/assess
ment forms to include LGBT-relevant issues,
displaying LGBT-positive posters and reading
materials at the clinic, providing staff training
on issues of importance to LGBT individuals,
and aggressive marketing of the program in the
community. Inter-Cares efforts resulted in a
fivefold increase in LGBT clients. Andrew
Cicchetti, the former director of the Inter-Care
LGBT program, is available as a resource and
can be reached at 
210 East 21st Street
New York, New York 10010
2125056212
E-mail: atcicchetti@worldnet.att.net
Policies and Procedures

129

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Chapter 15
Training and Education

Sheppard B. Kominars, Ph.D., Educational Management Consultant, San Francisco, CA
Roxanne Kibben, M.A., LADC, NCAC II, R. Kibben Company, Minneapolis, MN

Introduction

This chapter presents an introduction to
implementing the changes necessary 
to create an LGBT-sensitive substance
abuse treatment environment, while at the
same time improving the quality of training
and education programs for substance
abuse treatment practitioners and auxiliary
staff. Administrators have a responsibility to
ensure that all staff, not only clinicians,
receive training and education to improve
their sensitivity toward all individuals.
Working to eliminate discrimination, both
overt and covert, should be an ongoing
activity. 

As lesbian, gay, bisexual, and transgender
(LGBT) individuals become more accepted
and visible, they are seeking culturally 
sensitive, if not culturally specific, substance
abuse treatment services. To help develop
LGBT-sensitive care, providers can find
competent care standards in the Center for
Substance Abuse Treatment (CSAT)
Technical Assistance Publication #21,
Addiction Counseling Competencies: The
Knowledge, Skills, and Attitudes of
Professional Practice (1998b), and in the
1999 CSAT publication, Cultural Issues in
Substance Abuse Treatment (1999b). 

Training and education programs seek to
improve understanding of the complex
issues with which LGBT individuals struggle.
To support the diverse LGBT population, 
educators, administrators, substance abuse
treatment professionals, nurses, clinical
supervisors, students, other professionals,
What providers will learn
from this chapter:

  Training and educational
issues related to serving
LGBT clients

  Strategies and action steps
for implementing training

  Essential LGBT-specific 
educational experiences
for improving competen
cies of professionals and
support staff

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and local communities all should be considered
in the educational process.

A holistic approach to treatment is most likely
to enable LGBT individuals to effect real
change in their lives. Therefore, a multifaceted
approach is suggested to improve the present
situation, wherein treatment professionals and
society have incomplete and inadequate infor
mation that often leads to a misunderstanding
of LGBT issues and even a denial that LGBT
individuals have special needs.

Substance abuse treatment professional
training programs, faculties, institutions,
administrators, health care gatekeepers, 
and community settings all require education
and training. Targeting certain community
dimensions is crucial to the success of a
training or education program.

Issues To Consider

The following information could be included in
a training or educational program.

Barriers to Treatment Access

Barriers to adequate substance abuse 
treatment for the LGBT community have been
touched on in other chapters. In addition to the
reasons any prospective client might have, the
reasons LGBT individuals may avoid or delay
seeking professional care include fear of 
disclosing their sexual orientation or gender and
previous experiences with health care providers
who attempted to convert them to heterosexuali
ty, who attributed their substance abuse to their
sexual or gender orientation, or who were 
otherwise judgmental and unsupportive.

Engagement and Retention

LGBT individuals may leave treatment 
prematurely for the same reasons as 
non-LGBT clients. But LGBT clients may have
additional treatment difficulties if a facility lacks
culturally specific services, if it lacks self-
identified LGBT practitioners or sensitive 
counselors, if it has few contacts with the 
non-substance-abusing LGBT community, or if
it fails to engage non-LGBT clients in exploring
their prejudices or honoring diversity.
Relapse Prevention

While many programs address relapse 
prevention, LGBT clients may need additional
help to find LGBT-specific resources, which
may be scarce outside metropolitan areas.
LGBT clients may have difficulty addressing
problems with their sexual or gender orienta
tion and may have difficulty with their families
of origin, complications related to other addic
tive behaviors, and issues related to HIV/AIDS,
such as grief and loss or medication compli
ance. Additional counseling referrals for these
issues may be required.

Lacking specific and often essential information
about the special problems of LGBT clients,
professionals may attribute treatment failures
to the clientele rather than to the insufficient
training and education about LGBT issues that
resulted in inappropriate treatment by the
providers.

Strategies

An integrated training and education system
addresses both content and process and uses
experiential as well as didactic methods. It
addresses six components:

  Trainees
  Faculty or trainers
  Program 
  Institutional systems
  Professional peers
  Community.

Improving present treatment conditions for
LGBT clients requires a comprehensive 
training approach that includes the six 
Training and Education

132

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components. Long-term results are more likely
with an approach that addresses these 
components. The process of implementing
training and program change begins with a
commitment to action by decisionmakers.

The intention of training and continuing 
education is to increase the sensitivity and
competence of the staff and, ultimately, to
improve treatment outcomes. The learning
objectives are to:

  Raise awareness of culturally specific issues
and the sensitivity of all involved persons

  Identify and become fluent in LGBT- 
appropriate and sensitive language

  Implement explicit nondiscrimination policies
and procedures

  Develop skills to support LGBT individuals in
substance abuse treatment services

  Compile a resource list of local, regional, and
national support services.

Training should at least result in LGBT-tolerant 
treatment. Beyond that, however, training can
help practitioners help their clients be more
comfortable with themselves and their lives. In
gender-specific treatment, services should
include attention to LGBT issues. Assuming
that the separation of men and women will
enable practitioners to address LGBT needs is
false. Treatment that is LGBT antagonistic
should be changed but with the realization that
great effort and patience will be required.

Program content should be specifically shaped
by the target audiences understanding of
LGBT issues.
Addressing the Six Components Effectively

Component 1: Trainees

Trainees include behavioral health 
professionals; licensed and/or certified 
counselors; students enrolled in counseling
education programs; conference and seminar
attendees; staff at inservice training; primary,
secondary, and tertiary caregivers; staff of
health maintenance organizations (HMOs);
case managers; primary care physicians; 
probation officers; and so forth.

Action Steps

  Recruit and select LGBT individuals of
diverse ethnicity for counselor education 
programs and work settings.

  Develop students awareness of the need to
understand LGBT issues.

  Provide counseling and other appropriate
measures for students struggling with their
own homophobia or negative attitudes
toward LGBT persons.

Component 2: Faculty or Trainers

The faculty or trainers are members of 
counseling and social work departments
responsible for curriculum development, course
delivery, and practicum supervision. They 
prepare professionals and support staff for the
behavioral health professions and provide
training at seminars and workshops as well.

Action Steps

  Develop faculty and agency awareness of
the need for improved understanding of
LGBT issues.

  Attain and maintain a diverse faculty with
theoretical and practical expertise in LGBT
treatment and care. 
Training and Education

133

-----------------------------------------------
  Recruit LGBT faculty and staff who can 
provide instruction, supervision, and services.

  Encourage and support all faculty and staff
to continue their education in LGBT 
treatment areas.

  Support faculty and staff research in LGBT
treatment.

  Assign decisionmaking roles to faculty who
are knowledgeable about LGBT issues. 

Component 3: Program

Managed care organizations, consumers, and
quality improvement measures demand that
health care be evidence based. Therefore, any
training or educational program needs to be
based on current research findings. Training
elements should include assessment of need,
attitudinal behavior changes, skills training,
methods development, training and education
program evaluation, and actions to implement
change. 

Action Steps

  Conduct an assessment of the current level
of tolerance, sensitivity, and affirmation of the
treatment agency staff.

  Gather and review pertinent research and
theoretical material.

  Recruit skilled professionals as trainers and
educators, and/or develop an interagency
training alliance.

  Develop program materials and methods that
are site- or client-specific. 

  Determine methods for evaluating the 
effectiveness of the training or educational
program.
Attitudinal Behavior Changes and Skills Training

  Utilize experiential exercises that uncover
hidden biases in a safe manner (e.g., 
roleplay a 21-year-old coming out to his 
parent or ask participants to introduce 
themselves as lesbian, gay, bisexual, or
transgender individuals).

  Encourage exploration of stereotypes and
language, values, and behavior differences.

  Use various methods incorporating adult
learning styles to increase skill development. 

  Use additional resources available on videos
and films.

Methods Development

  Make LGBT sensitivity and competency
training a priority in the basic curriculum or in
the inservice training schedulean important
first step in implementing this type 
of program.

  Redesign existing programs to include
LGBT-related competencies. Use a team
approach involving academic and clinical
staff and, if possible, a team member from
the LGBT community at large.

  Develop courses awarding continuing 
education units (for academic and/or profes
sional credit) for professionals and support
staff.

Evaluation

  Give pretests and posttests to evaluate 
training.

  If possible, make videotapes or audiotapes
of clinical sessions before and after training
to ascertain whether there have been
changes in the ability to treat LGBT clients.
Training and Education

134

-----------------------------------------------
  Collect client satisfaction and followup data
from LGBT clients treated at the same site
over time. 

  Conduct quality improvement studies 
focusing on the effects of LGBT sensitivity
and competency training.

Component 4: Institutional Systems

For the purpose of this volume, the phrase
institutional or agency systems refers to the
individuals who serve as gatekeepers:
administrators of organizations, departments,
and schools who are responsible for the
delivery of programs and services; boards of
directors; and other staff.

Action Steps

  Gain administrative awareness of the need
for improved understanding of LGBT issues.

  Create an administrative environment 
supporting LGBT care, treatment, and 
confidentiality.

  Require LGBT competency and sensitivity at
all levels, including policy development.

  Institutionalize a policy for ongoing 
recruitment and selection of LGBT adminis
trative, professional, and support staff. 

  Encourage and support the use of LGBT
staff and faculty to provide instruction and
supervision.

  Institute administrative and clinical policies to
endorse LGBT sensitivity and competency
training, LGBT treatment, and unbiased care.

  Allocate curriculums, time, and resources for
training.
Component 5: Professional Peers

Effective techniques for training and skills
development and what works often are the
subject of consultations among professionals.
This important dimension of the training
process plays a significant role in introducing
important ideas to newcomers and improving
practice by long-term practitioners as well. 

Action Steps

  Increase professional peers awareness of
the need for improved understanding of
LGBT issues.

  Articulate the need for implementing 
programs at all levels of practice in 
professional associations.

  Convene conferences about LGBT 
treatment.

  Involve LGBT professionals in policymaking.

Component 6: Community

The family, neighborhood, town, city, State, and
region in which LGBT clients are treated is
their home. The response of the community
to LGBT clients is a crucial factor in their care
and treatment.

Action Steps

  Provide counseling services to the families of
LGBT clients at all socioeconomic levels.

  Provide information on treatment and the
special needs of LGBT clients to relevant
parties in the community: government 
officials, police, and all criminal justice 
professionals.

  Create task forces to work directly with LGBT
interest groups.
Training and Education

135

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Training and Education
A Training Model

The State of New York designed a model
curriculum program detailed in Working With
Lesbian, Gay, Bisexual and Transgender
Clients in Alcoholism and Substance Abuse
Services: Trainers Manual, (New York State
Office of Alcoholism and Substance Abuse
Services, Academy of Addiction Studies, 1996).
This manual presents a core curriculum and
specific modules for both theory and skill com
petency. The curriculum includes information
on the need to raise consciousness about
LGBT clients, stereotyping, myths, homopho
bia, and terminology. An example of the
resources included in it is shown in exhibit
151, the Cass Model of Lesbian and Gay
Identity Development. This model can be espe
cially helpful for substance abuse treatment
practitioners who are treating LGBT clients and
who want to understand the stages their clients
may be in or moving through. This kind of
understanding will help practitioners provide
more sensitive and effective treatment. Other
resources in the curriculum are the Kinsey
Scale, the Fifield study, the McKirnan and
Peterson study, and organizational develop
ment tools that address diversity in the 
workplace and homophobia/heterosexism
assessment surveys.
To receive this curriculum call or write to: 

Office of Gay and Lesbian Health Concerns
125 Worth Street, Suite 601

Box 67

New York, NY 10013
2127884310
or
Community Health Project
208 West 13th Street, Second Floor
New York, NY 10011
2126753559

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              Exhibit 151: 
Cass Model of Lesbian and Gay Identity Development
Training and Education
Stage I: Identity Confusion
Occurs when a person begins to realize that he or she may relate to and/or identify with being gay or 
lesbian; a process of personalizing the identity.
Tasks: Exploration and increasing awareness
Feelings: Anxiety, confusion
Defenses: Denial
Recovery: Having a confidential support person

Stage II: Identity Comparison
Occurs when a person accepts the possibility that he or she might be gay or lesbian.
Tasks: Exploration of implications, encountering others like oneself
Feelings: Anxiety, excitement
Defenses: Bargaining and rationalizing
Recovery: Meeting gays and lesbians in recovery

Stage III: Identity Tolerance
Occurs when a person comes to accept the probability that he or she is gay or lesbian.
Tasks: Recognizing ones social and emotional needs as a gay man or lesbian 
Feelings: Anger, excitement
Defenses: Reactivity
Recovery: How to be gay or lesbian and stay sober

Stage IV: Identity Acceptance
Occurs when a person fully accepts rather than tolerates being gay or lesbian.
Tasks: Development of community and acculturation
Feelings: Rage, sadness
Defenses: Hostility toward straight culture
Recovery: Lesbian and gay recovering community building

Stage V: Identity Pride
Occurs when a person immerses himself or herself in the lesbian and gay community and culture to live out
his or her identity.
Tasks: Fully experiencing being gay or lesbian, confronting internalized homophobia
Feelings: Excitement, focused anger
Defenses: Arrogant pride and rejection of straight culture as the norm
Recovery: Sexuality, identity, and recovery

Stage VI: Identity Synthesis
Occurs when a person develops a fully internalized and integrated lesbian or gay identity and experiences
himself or herself as whole when interacting with others in every environment.
Tasks: Coming out as fully as possible; having an intimate gay or lesbian relationship; self-
actualization as a gay man or lesbian

Feelings: Excitement, happiness
Defenses: Minimal
Recovery: Maintenance (end stage)

Adapted from Cass, 1979

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Chapter 16
Quality Improvement and LGBT Clients

Fred Rachman, M.D., Medical Director, Howard-Brown Health Center, Chicago, IL
Kevin McGirr, R.N., M.S., M.P.H., San Francisco Division of Community Mental Health
Services, San Francisco, CA
Introduction

This chapter offers suggestions on how to
incorporate an evaluation of substance
abuse treatment services for lesbian, gay,
bisexual, and transgender (LGBT) clients
into an agencys quality improvement pro
gram. It will help leaders create questions
and monitor responses about the issues 
and recommendations raised throughout 
this volume.

The conceptual framework common to all
quality improvement programs includes the
following steps:

  Define quality in terms of concrete 
functional processes and outcomes that
can be assessed

  Implement some means of measuring
such processes and outcomes

  Evaluate the data over time with respect
to goals and/or external benchmarks

  Analyze the factors and processes that
impact performance

  Identify priorities for improvement

  Make process and procedural changes as
appropriate

  Continuously monitor the effects of these
changes.
What providers will learn
from this chapter:

  How leaders determine
whether quality assurance
efforts are needed

  Specific questions that
help define quality in 
providing treatment to
LGBT clients

  How leaders monitor and
assess efforts to improve
quality

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A Framework for Functionally Defining
Quality

Because any discussion on the quality of care 
provided for LGBT communities is, by 
necessity, a discussion of cultural competence,
quality indicators should be functional 
measures of this competence.

The central mission of accrediting bodies such
as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), the
National Committee for Quality Assurance
(NCQA), and the Commission on the
Accreditation of Rehabilitation Facilities (CARF)
is to establish standards for what they consider
the key functions of substance abuse treatment
centers and indeed all health care organiza
tions. These standards provide frameworks for
quality improvement that can be adapted to the 
specific task of improving service to LGBT 
individuals. In addition to ensuring a 
comprehensive approach, the use of standards 
provides the added bonus of assisting the
organization during external surveys and
reviews.

The outline that follows shows how JCAHO
standards can be used to address quality
improvement with respect to service to LGBT
individuals. Standards developed by NCQA or
CARF could be used similarly. Adapting the
standards is fairly straightforward. For 
example, standards for leadership are directed
at how well an organization plans, structures,
and delivers its services to meet the needs of
its users, who are defined by the demographics
of people in the service area. This means that
the organization should both know about and
appropriately serve LGBT individuals within its
service area.

Leadership

  Do needs assessment and planning activities
include LGBT clients in the community? Is 
their inclusion proportional to the percentage
of the population they represent?
  How does the organization design services
to meet the needs of the LGBT community,
and how well are these services delivered?

  How effectively does leadership identify and
cultivate community resources for LGBT
clients?

Human Resources

  How does the organization measure and
improve the competency of its staff in serving
LGBT clients?

  What kinds of educational and training 
activities address these competencies?

Patient Rights and Organizational Ethics

  Are LGBT clients cultural, psychosocial, 
spiritual, and personal values respected? 

  Do LGBT clients significant others or sup
port people participate in care decisions? 

  Do LGBT clients receive information about
their condition that recognizes their special
circumstances and helps them make
informed decisions?

  Do policies and procedures for LGBT clients
address circumstances in which care will not
be given because their condition or lifestyle
conflicts with staff members values, ethics,
or religious beliefs?

  How are privacy rights of LGBT clients 
protected?

Education of Patients and Families

  Are educational materials appropriate and
relevant for LGBT clients? 
Quality Improvement and LGBT Clients

140

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  Are educational programs accessible to
LGBT clients significant others and support
people?

Assessment of Patients

  Are relevant medical issues and social
issues effectively and comfortably identified
for LGBT clients?

Care of Patients and Continuum of Care

  How do care plans demonstrate sensitivity to
the needs of LGBT individuals? 

  Do discharge plans take into account the
lifestyles and personal support systems of
LGBT clients?

Management of Information

  Is the information system set up to collect
data important to LGBT clients?

  Do assessments of information requirements
include the special needs of LGBT clients,
the providers serving them, and other service
agencies?

  Does the information system facilitate 
tracking performance and outcome data for
the LGBT client base?

Performance Improvement

  Do aspects of the performance improvement
plan include specific monitors of and quality
improvement activities aimed at services for
LGBT clients?

Collecting Baseline Data

Quality improvement programs measure 
performance against baseline data. This
means adding appropriate data fields for
recording ones transgender identity, sexual
behavior or identity, and information about
significant same-sex relationships to forms
used to collect client demographic data. Coding
this information will require programs to respect
consumers wishes about confidentiality but
also provide information on ones sexual
orientation and gender differences, issues, 
and concerns.
Many people feel that this is personal 
information, that asking about it is awkward
and inappropriate, and/or that peoples right to
privacy must be protected. Providers should be
mindful that the guiding rationale for collecting
sexual orientation and transgender identity
information is to determine whether these com
munities are being properly served and what
health problems they are experiencing. On this
last point, confidentiality should always be of
concern. Clients can never be forced to provide
any demographic information, but policies to
preserve privacy rights should not keep people
from communicating and recording their sexual
orientation or transgender identity if they
choose to do so. 

The ability to elicit baseline demographic data
about their LGBT client population is an 
important measure of competency for LGBT
care providers. Many, if not most, staff members
will need formal training on how to ask the 
necessary questions. Training relating to 
collecting this information will need to consider a
variety of factors (e.g., age, culture, ethnicity,
and individual consumer differences). Self-
administered questionnaires could be used. By
providing a blank space where they can identify
their gender if they choose, the items on such
questionnaires can be posed to clients so it is
not necessary for them to commit to being either
male or female. Eli Colemans assessment tool
(1987) shown in chapter 1 is an example of an
effective form. It will be important to explore how
to collect these data later in the treatment
episode if they are not volunteered at intake or
during assessment.
Quality Improvement and LGBT Clients

141

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The initial staff training on data collection will
provide agency leadership with an important
gauge of the attitudes and comfort level of staff
working with LGBT clients. The close attention
and expressed commitment of leadership is, 
therefore, of critical importance. Because staff
competency and comfort are important, 
baseline data on this issue should be collected
at the start of training and throughout
training/performance improvement efforts.

Once baseline information is gathered, the 
percentage of LGBT clients using the facility
should be compared to the best available 
estimates of the percentage of LGBT 
individuals in the community at large.
Comparing the two numbers will provide 
important information on how well the facility is
meeting LGBT clients needs. Even if the 
proportion of LGBT clients matches or exceeds
the proportion of LGBT individuals in the 
community at large, there may be considerable
room for improvement in working with LGBT
individuals considering that clients may hide
their identities because of lack of support or
fear of persecution, especially in areas where
there is no visible LGBT community. Ironically,
those who are uncertain about disclosures or
reluctant to disclose that they are (or might be)
LGBT individuals may likely require the most
support concerning these issues.

The key questions that every program should
address are:

  How well does the program or staff elicit
information regarding clients sexuality? Is
the atmosphere uncomfortable?
  Are LGBT outreach efforts effective?
  Are there actual disincentives for such clients
to seek care at the center?

Monitoring Progress

A variety of means can be used to monitor
progress with respect to quality improvement
goals.
Client feedback is a very valuable source of
information in the initial assessment phase of
the project, in monitoring progress, in identify
ing specific areas that need improvement, and
in soliciting suggestions on how improvements
could be made. Client satisfaction surveys
can include questions to assess the LGBT
friendliness and competence of the staff and
facility. Questions can be indirectly worded, as
seen in the sample survey form (exhibit 161). 

Another tool that might prove useful is the
guest clienta volunteer who visits the 
facility, uses some aspect of care, and then
reports his or her experiences. Guest client
activities can range from a simple phone call
for information to completing a formal intake.
Participation in group therapy is probably not
appropriate. It is important to inform staff that
such a program is being implemented and
present it as a way of gathering information
rather than as a way of checking up on people.
If the agency is unable to find appropriate 
volunteers, seek assistance from local LGBT
social service agencies or other organizations.

Exit interviews and patient satisfaction
interviews are also excellent ways to obtain
direct feedback and solicit suggestions. All
clients should be asked routinely to participate
in these interviews, not just openly gay, 
lesbian, transgender, or bisexual clients.
Questions on the staffs comfort with issues
pertinent to gender or sexual activity should be
posed to all clients and in such a way that the
sexual orientation of the client is not an issue.
The interviews should also include questions to
assess the staffs comfort with LGBT issues.
This can be their last opportunity to communi
cate acceptance and willingness to discuss
LGBT concerns. It should be made clear to
clients that refusal to participate will not affect
treatment in any way and that any comments
will be kept in the strictest confidence.
Quality Improvement and LGBT Clients

142

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    Exhibit 161: 
Client Satisfaction Survey
Quality Improvement and LGBT Clients
Todays Date:_________
Please do not identify yourself. This is an anonymous survey. No individual person or information regarding a specific
event will be identified. Declining to complete this survey in no way affects the services and care you receive. 
  Did you feel comfortable discussing sexuality issues with your therapist? 
Very comfortable

Somewhat comfortable

Somewhat uncomfortable

Very uncomfortable
  Did you feel comfortable discussing sexuality issues in therapy group?
Very comfortable

Somewhat comfortable

Somewhat uncomfortable

Very uncomfortable
  Did you feel that you could openly discuss your relationships and involve your significant other in 
treatment/discharge plans? 
Very comfortable
Somewhat comfortable
Somewhat uncomfortable
Very uncomfortable
  Do you consider yourself 
Heterosexual

Gay

Lesbian

Bisexual
Transgender
Unsure
Questioning?
  Did you discuss your sexuality at any time with any of the following? Check all that apply:
Therapist

Other clinical staff

Administrator

Other clients
  With which individuals do you feel comfortable discussing any aspects of your personal life or sexuality?
Therapist

Other clinical staff

Administrator 

Other clients
  Was your significant other acknowledged?
Consistently and directly
Occasionally or indirectly
Not at all  Continued

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         Exhibit 161:
Client Satisfaction Survey (continued)
Quality Improvement and LGBT Clients
  Was your significant other included in treatment plans?
Consistently and directly
Occasionally or indirectly

Not at all
  In general how comfortable are you in this facility with regard to your LGBT identity?
Very comfortable

Somewhat comfortable

Somewhat uncomfortable

Very uncomfortable
  How comfortable was your relationship with other clients with regard to your LGBT identity?
Very comfortable

Somewhat comfortable

Somewhat uncomfortable

Very uncomfortable
  If you are a transgender individual, did you feel your gender identity was acknowledged as you wished by
  Therapist yes no
  Other clinical staff yes no
  Administrator yes no
  Other clients yes no
  Did facilities such as inpatient rooms and bathrooms meet your needs? yes no
  How could we acknowledge your needs as an LGBT individual more effectively?
_________________________________________________________________________
_________________________________________________________________________
DEMOGRAPHICS:
Age Today: _____ Biological Sex:     M     F
Race/Ethnicity: White _____ African American _____
Asian _____ (Specify ethnicity)____________________________________
Pacific Islander ____ (Specify ethnicity)_____________________________
American Indian____ (Specify ethnicity)______________________________
Hispanic____
Primary language spoken at home:     English Spanish Other (Specify)____________________ 

Adapted from Coleman, 1987
144

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Additional strategies could include using focus
groups run by staff or local advocacy 
organizations and examination of service 
utilization patterns to determine whether LGBT
clients are missing appointments, dropping out
early, or showing a high incidence of 
complaints and grievances.

Information from all of these sources should go
regularly to the quality improvement committee
and clinical and administrative leadership. As
significant issues are identified, they should be
incorporated into the agencys quality improve
ment strategies. Again, assistance from LGBT
advocacy groups and other LGBT treatment
programs will be valuable in addressing specif
ic issues. As with any quality improvement
effort, continuous reassessment of the avail
able data or information is essential to main
taining positive ongoing results.

Evaluating Outcomes

Ultimately, the goal of quality improvement with
respect to service to LGBT clients is to achieve
better treatment outcomes. It is important to
look at measures of treatment efficacy in the
overall context of the number of LGBT clients
in treatment. At this point, specific outcome
measures can be evaluated. These include 
the following:
  Number of LGBT clients abstaining from 
substance use

  Number of LGBT clients relapsing

  Number of LGBT clients readmitted.

Outcomes for LGBT clients can be compared
with outcomes in the agencys general client 
population. Although it may not be possible to
do this in a statistically significant manner due
to the relatively low number of LGBT clients or
differences in case complexity, this comparison
is a functional measure of how effective the
agencys program is for LGBT clients and is
useful if interpreted appropriately. Outcome
data for LGBT clients can also be compared,
over time, to baseline LGBT client participation
rates to measure how quality improvement
activities have impacted care. Finally, the
agencys outcomes can be compared with
outcomes of organizations that have well-
established programs for LGBT clients. This
last comparison may be useful in establishing
realistic, yet appropriately ambitious, bench
marks and goals. Contact with other agencies
may also help identify technical assistance and
new practices and skills that might further
enhance treatment quality.
Quality Improvement and LGBT Clients

145

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Quality Improvement and LGBT Clients
Case Example

XYZ Hospital is a comprehensive substance abuse treatment program in a large metropolitan area. The 
program includes a 125-bed inpatient unit, an intensive outpatient program, and a day hospital program. 

The facility is located in one of the citys most densely populated gay and lesbian areas. Its leaders gained
awareness of the community by reading local area newspapers, noting gay-oriented businesses, and
through self-identified LGBT staff and clients. It was principally gathering information through exit interviews
with clients and regularly assessing the volume of LGBT clients served relative to the service area. Based
on these assessments, three goals were set: (1) improving the comfort level of clients in groups; (2) helping
clients feel more comfortable disclosing their identities; and (3) attracting more LGBT clients to the program.
At the time of the initial evaluation, there were two or three openly gay or lesbian clients in each of the 
program components.

Around this time, the hospital was approached by a national gay- and lesbian-targeted substance abuse
treatment program that wished to establish an LGBT-specific program at the hospital. Its leadership felt that
the program would assist it in achieving its goals and chose to go forward.

Since the program began, there have been significant increases in the number of LGBT clients served. In
the most recent survey, 10 of 90 inpatients, 6 of 20 intensive outpatients, and 10 of 60 day hospital patients
identified themselves as LGBT individuals. A market survey revealed that the visibility of the program in the
community has been greatly enhanced, and regular client satisfaction surveys reported that LGBT clients
feel much more comfortable in treatment, particularly in group settings, and are more satisfied with hospital
services overall. 

The program currently monitors outcomes in terms of the number of readmissions within a set number of
days, adherence to treatment plans, and the number of clients who drop out of treatment. Staff members
compare data on LGBT clients with data on clients in the general population cautiously, because LGBT
clients have been shown to be at much higher risk and have more complicating factors than clients from 
the population at large. Staff members are trying to find other ways to compare data and are using outside
resources to help them adjust risk factors for better data interpretation.

146

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Chapter 17
Using Alliances and Networks To  
Improve Treatment for Lesbian, Gay, 
Bisexual, and Transgender Clients

Renee Lohman, M.B.A., The Lambda Center/Lesbian Health and Wellness Center, Washington, DC
Nancy Kennedy, Dr.P.H., Center for Substance Abuse Prevention, Substance Abuse and Mental 
 Health Services Administration, Rockville, MD
Saul M. Levin, M.D., M.P.A., Access Consulting International, Washington, DC
Frank Y. Wong, Ph.D., Center for Health Services Research and Policy, George Washington 
 University School of Public Health and Health Services, Washington, DC
Chwee Lye Chng, Ph.D., University of North Texas, Denton, TX

What providers will learn
from this chapter:

  The rationale for alliance
building among LGBT 
communities

  The essential elements of
alliance building

  How managed care 
affects care for LGBT 
individuals

  How alliances and 
networks can be used to
help with the financing
and delivery of treatment
services for LGBT 
individuals
Introduction

This chapter provides information about the
rationale for alliance building between 
substance abuse treatment providers and
the lesbian, gay, bisexual, and transgender
(LGBT) community, the steps of alliance
building, the impact of managed behavioral
health care for LGBT individuals, com
ponents of effective alliances, and examples
of LGBT provider networks. 

Rationale for Alliance Building and 
First Steps

Providers who are moving into this service
area typically do not have strong ties to
LGBT communities or to service 
organizations that traditionally have provided
services to these individuals. It will be 
important to build alliances both with the
LGBT community and with organizations,
service providers, and agencies in the 
community at large. 

Once the decision has been made to 
introduce or strengthen treatment services
for LGBT individuals, a small contingent
should begin to enlist support among the
targeted organizationsthe public health
groups, local health advisory committees,
and other organizations that have a stake in
improving substance abuse treatment for
LGBT individuals. It is important that the

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Clients
s To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender 
treatment facility not promote itself as LGBT
sensitive or providing LGBT services until this
important groundwork has begun and 
adequately trained staff members are in place.

The LGBT community is well schooled in 
working together and forming alliances. These
alliances serve several important functions.
They bring people together socially, provide a
culture and ideology, accept same-gender 
orientations and behaviors, and validate
lifestyles. Many LGBT communities, when
addressing societal problems such as 
substance abuse or HIV/AIDS, recognize the
value of establishing alliances with other
groups. Alliance building has proved to be a
powerful tool for LGBT community develop
ment (see Guinier, 1994; Vaid, 1995).
Candidates for alliance building can be LGBT
focused (e.g., the Human Rights Campaign) or
non-LGBT focused (e.g., an HIV/AIDS 
organization, Alcoholics Anonymous, State and
regional health departments, corporations, 
volunteer-based organizations, and 
universities). Some additional candidates for
alliances are LGBT community centers 
(several hundred are located throughout the
United States), LGBT social organizations
(which frequently are important resources in
suburban and rural areas), AIDS service 
organizations, and the many LGBT Alcoholics
Anonymous chapters. Primary medical care
providers who provide LGBT-sensitive services
are also an important resource. 

Some LGBT community organizations 
emphasize independence and work on the
same issues in isolation, creating the potential
for duplicating services. In the wake of 
managed cares influence on behavioral health
care, better case management, networking of
services, and mergers, many alliances have
been formed in the past decade. Other 
organizations have gradually moved toward
cooperation and help one another to 
accomplish mutually beneficial goals.  
Alliances exist on a continuum of cooperation,
ranging from loose referral relationships to  
formal coalitions with set organizational 
structures. Alliance building starts with 
recruitment of members and development of a
mission and goals. A summary of the essen
tials of forming effective formal alliances and
making them work is presented in exhibit 171.

It is important to emphasize to staff members
and potential allies that creating a culturally 
responsive environment for LGBT clients is
integral to providing a safe setting for all clients
and to helping all people in recovery learn to
live in a diverse society.

To build support for the alliance, identify 
possible organizations and individuals in the
community who have a stake in reducing 
substance abuse in the LGBT communities.
Designate alliance members to visit these
potential participants. Some will need little 
persuasion, whereas others will require greater
efforts. Inform potential members of the 
advantages of minimizing LGBT substance
use. Solicit letters of support from a variety of
key people in the community (e.g., politicians,
religious and community leaders, health
providers, business persons, legal 
organizations) who may convince hesitant
members that broad-based support for
addressing LGBT substance abuse treatment
already exists.

The Impact of Managed Care on Behavioral
Health and LGBT Individuals

By the end of 1995, the behavioral health care
benefits of 142 million individuals were 
provided under managed care contracts (IOM
[Institute of Medicine], 1997), and the number
continues to grow. Both private and public
health care purchasers are largely contracting
with managed behavioral health care 
organizations (MBHCOs) (IOM, 1996, 1997) 
to organize specialized mental health and
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             Exhibit 171: 
Forming Effective Alliances and Making Them Work

Recruitment
Seek support from a broad cross-section of the community. Contact key community leaders early in the
process. The broader the coalition, the more effective it will be.

Encourage alliance members to view their decision to improve substance abuse treatment for LGBT people
as an act of compassion and as a way to help in the recovery of all substance-abusing persons.

Use duplicate representation strategically because peers are greatly influenced by peers. For example, hospital
administrators trust the opinions of other administrators, and counselors will sympathize with other counselors.

Persuade member organizations to designate a representative who has decisionmaking authority and
attends meetings consistently. Involve top management, but not at the expense of leaving out lay persons
and community workers in the LGBT communities. 

Dont let the presence of professionals, or any one group, dominate the vision, agenda, and outcome of the
alliance. 

Decisionmaking
Identify a coordinator for large and complex alliances to facilitate meetings and the workings of the group.
The coordinator should have expertise in interpersonal relations, negotiation, team-building, and group
dynamics as well as the support of all alliance members. 

Insist that there be no independent decisions without the endorsement of all alliance members. 

Define a common mission and set collective goals. Consensus building is vital to alliance effectiveness. 

Define consensus building as Can you live with this? and not as Do you agree with this?

Conflict Resolution
Be sure that each member appreciates the contributions of the others and acknowledges that each member
has its own history, structure, and agenda. An established agency with a large budget and many members
may contribute differently than does a young organization with a modest budget, few staff members, and
limited membership; both types of contributions should be valued by alliance members.

Remember there may be a need to agree to disagree on some issues while staying focused on the common
mission. 

Use subcommittees to provide a forum for discussion of conflicts. They can then formulate recommenda
tions for the alliance and present them at subsequent meetings (where emotions are kept at bay). 
Insist that disagreements remain within the group and not be discussed in the community at large.

Publicity and Communications
Disseminate decisions made at alliance meetings throughout the community as well as to the boards, staff,
and volunteers of the member organizations. 

Credit all members of the alliance on your letterhead and in any publicity materials. 
Continued
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Clients
                 Exhibit 17-1:
Forming Effective Alliances and Making Them Work (continued)

s To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender 
Use a catchy name and logo. Publicity material should include the names of all member organizations.

Use community newsletters and local media to inform the community about the goals and progress of the
alliance. 

Distribute background information to demonstrate the need for substance abuse treatment for LGBT people. 

Recognize potential opposition to the groups mission, and do not underestimate the impact of people with
different opinions. A common misperception is that substance abuse treatment for LGBT clients promotes
homosexuality or bisexuality. Respond by explaining that LGBT treatment is not about sex but about 
recovering from alcohol and drug abuse. 

Anticipate opposition, and develop an alternative strategy that explains clearly the goals and activities of the
alliance. 

Use a variety of channels to disseminate information, including news conferences, news releases, letters to
the editor, letters to legislators, and public endorsements from reputable community and professional
groups. 

Frame the discussion of LGBT substance abuse in easily understood terms and in a realistic cultural context.

Advocacy
Work both with and outside the government system in a coordinated fashion. Attend meetings with 
government officials, politicians, staff, and city councils in a small group while still maintaining broad 
representation. Interact with politicians on a nonpartisan basis, meet with all political parties, and utilize 
political affiliations of individual alliance members to gain access.

Remember that your goal in part is to educate others so they can advocate for your issues. 

Before meeting with officials or politicians, research their positions on substance abuse treatment in the
LGBT community. If they are opposed to improving treatment, try to gain their support. If they are sympa
thetic, enlist their support by asking for ways in which your alliance could help them accomplish the common
goal. Be flexible; however, discuss any shifts in position with the alliance to gain its approval. 

Always provide cogently written, brief, printed materials about the alliances goal. Do not provide inaccurate,
misleading, or self-serving information. Follow up with a letter of thanks and a summary of agreements or
positions as you understand them. 

Participation and Leadership 
Ensure effective leadership to inspire member participation. Involvement can be improved if people feel that
the alliance belongs to them and that their ideas and membership are valued.
Create a leadership development plan to increase the pool of experienced and skilled members who rotate
through leadership positions so that the alliance can be sustainable and effective.

Insist that the leader delegate tasks so that participants know what needs to be done.
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Case Example
Resource Center of Dallas: Alliance Building at Work

The Resource Center of Dallas (RCD), founded in 1983 in Dallas, Texas, is an excellent example of the
power of alliance building within the LGBT community. It is a nonprofit corporation established by the Dallas
Gay and Lesbian Alliance to promote understanding of sexual orientation and to study the effects of discrim
ination based on sexual orientation and their implications for public policy. As AIDS became an increasingly
critical area of concern for the gay and lesbian community, RCD expanded its mission to encompass HIV,
health, and substance use issues. To ensure communitywide support for its activities, it emphasized forging
alliances with non-LGBT communities and with community agencies. Its board, staff, and volunteers believe
in the importance of developing and maintaining alliances with those of other genders, sexual orientations,
and ethnicities. More than 50 percent of its volunteers and board members are self-identified heterosexuals.
There is a concerted effort to have gender and ethnic diversity at every level of the organization. 

According to Jamie Schield, Co-Executive Director of RCD, the center has a history of alliance building with
a wide array of organizations, ranging from those that are totally independent (resistant to alliance building),
to those opting for a less formal arrangement (e.g., monthly luncheon meetings of area HIV/drug educators),
to those favoring a formalized, structured alliance (e.g., the HIV Prevention Community Planning Coalition
for Region III, Texas). To effectively reduce substance abuse and to promote health and wellness in the
LGBT community, RCD is now creating alliances with others in the community. Schield emphasized that
although individuals or groups that are in alliance with RCD may not share similar values or perspectives,
for they live, dress, recreate, and often see things very differently from RCD, it is precisely this difference in
view that is most effective. The fact that RCD is working with others as a group to address the issue of 
substance abuse in the LGBT community, despite cultural and individual differences, resonates with the
community, adding credibility to RCDs message. The Alliances membership legitimizes the issue, and the
public now perceives broad-based community support, effectively weakening RCDs opponents ability to
label RCDs efforts as those of special interests.

RCDs alliance-building process involves both LGBT and non-LGBT community groups. They include 
representatives from the faith community (Cathedral of HopeMetropolitan Community Church; Potters
HouseTransformation Treatment Center), ethnic groups (African-American Health Coalition, Dallas
Intertribal Center, La Sima Foundation), volunteer-based recovery programs (Alcoholics Anonymous), 
substance abuse treatment councils (Greater Dallas Council on Alcohol and Drug Abuse), emergency 
temporary shelters (Austin Street Shelter, Welcome House, Inc., Johnnies Manor), drug intervention pro
grams (Ethel Daniels Foundation, Inc., Oak Lawn Counseling Services), aftercare programs (Community
Alcohol and Drug After Care Program, New Place, Inc.), public health programs (Dallas County Health and
Human Services, Parkland Health & Hospital System), veterans organizations (Veteran AffairsNorth
Texas Health Care System), and non-LGBT community groups (Parents, Families and Friends of Lesbians
and Gays, PFLAG Dallas).
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substance abuse treatment for enrollees
independently from overall health care.

Purchasers, either private or public, contract
with mental health and substance abuse 
treatment specialist organizations or preferred
provider networks to organize specialized men
tal health and substance abuse treatment for
enrollees independently from overall health
care. Typically, MBHCOs assign specialist 
gatekeepers to assess and monitor clients
need for access to and utilization of treatment
within the network (ASAM [American Society of
Addiction Medicine], 1999). Most individuals
with private insurance have their behavioral
health care needs met by some type of
MBHCO (Schoenbaum, Zhang & Sturm, 1998).
Managed care presents challenges for all
behavioral health care providers and particularly

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s To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender 
so for those targeting LGBT individuals,
because LGBT concerns are not well 
understood byor even visible tothe 
leadership of managed care organizations.

The specific needs of LGBT individuals are 
not well understood by managed care 
organizations (MCOs). Moreover, few LGBT
health care consumer organizations have
overtly voiced the specific needs and concerns
of this multicultural group. LGBT individuals,
especially LGBT persons of color, thus remain
hidden, neither accessing the health care sys
tem nor communicating honestly with health
care providersall of which has deleterious
consequences for LGBT individuals needing
treatment services. Clearly, providers of 
services to LGBT populations have much to
gain by working together to make the case for
improved services. Fortunately, there are many
groups attempting not only to make LGBT con
cerns visible to managed care administrators
but also to deliver improved services.

Designing and implementing successful 
treatment practices requires knowledge of the
target populations. Thus, the critical need for
administrators is to understand the existence of
these subpopulations and to invite different
LGBT populations to participate in the design
of services and polices. Acknowledging this
diversity and building appropriate mechanisms
for consumer input will enhance the probability
of successful treatment. 

Why should a managed care and a clinical 
program consider a partnership between an
LGBT program (LGBT-sensitive) and managed
care? Managed care has recharged 
consumerism and awakened the health care
delivery system to the requirement of providing
access and quality services to an enrolled 
population in a culturally and linguistically
appropriate manner (Kennedy, 1999). Some
LGBT consumers or clients or patients 
(whatever terminology individuals wish to use
in their self-identification) and LGBT health
care providers are highlighting the needs of
these constituencies to be taken care of in an 
appropriate and professional manner. However,
in so doing, consumers risk not only antigay
bias but also the stigma of identifying predis-
posing health conditions, such as HIV/AIDS,
addictive diseases, and mental disorders, that
may alter benefits packages dramatically.
Another difficulty is that LGBT-identified 
persons can be seen as high-cost-of-care
populations. Although data are not available to
support or refute this supposition, several 
reasons can be suggested for the possibility of
increased costs. First, managed care seeks to
limit the number of patient visits and shorten
the length of visits. As a result, a trustful
provider/patient relationship may not develop
and, therefore, disclosure of a persons sexual
orientation or sexual identity may not occur.
The lack of this vital information may reduce
the likelihood that appropriate care is provided
in a timely fashion, thereby potentially raising
its cost. Finally, some insurance companies
have taken steps to reduce the probability of
insuring an individual who may someday 
contract HIV (Li, 1996).

LGBT providers are also in a precarious 
positionself-disclosure may result in their
exclusion from provider networks. The
American Association of Physicians for Human
Rights (now Gay and Lesbian Medical
Association) (1994) found that 17 percent of
self-identified gay and lesbian physicians had
been fired, refused medical privileges, or 
denied employment because of their sexual 
orientation.

Despite the experiences of LGBT consumers
and providers, incentives exist for MCOs to
provide LGBT-sensitive services. It can be
advantageous to a managed care company to
attract business. Similarly, competent LGBT
providers enhance the managed care 
companys panel of providers and also satisfy
the cultural and ethnic competency standards
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articulated in some States Behavioral Health
Request for Proposal (RFP) (e.g., Iowa
Substance Abuse RFP, pp. 3017).

Concerns About Managed Care
Organizations

As managed care increasingly dominates both
private and public sector mental health and
substance abuse treatment services, serious
concerns have been expressed by key 
stakeholders about whether managed care
financing, if not properly administered, might in
fact cause greater disparities than the fee-for-
service system in meeting the critical needs of 
individuals with behavioral problems.

Their specific concerns include the following
(Surles & Fox, 1998):

  Cost-cutting, which potentially threatens the
quality of care

  Restructuring of services away from local,
community-based approaches

  Relocation of services, which threatens
accessibility

  Services provided to consumers by mental
health professionals not familiar with the 
language, cultural values, and multiple needs
of different groups

  Consumers lack of knowledge about how
the managed care system works

  Language differences that interfere with
communication and access to resources.

Professional guidelines, consumer report
cards, and accrediting organizations are 
mechanisms that ensure provision of culturally
competent health care services. Attention or
inattention to cultural issues impacts both 
service delivery and service utilization that, 
in turn, affect not just quality, access, and 
utilization, but also costs. There would likely be
an improvement in the utilization of services if
policies, procedures, and guidelines addressed
the unique cultural issues of consumers and
providers (Lu, 1996).
Within the Federal Government, the Health
Care Financing Administration is in the process
of developing standards (1998) within its
Quality Improvement System for Managed
Care to include a statement that speaks to
nondiscrimination for managed care enrollees
based on sexual orientation.

The two largest accreditation bodies for 
managed care organizations are the National
Committee for Quality Assurance and the Joint
Commission on Accreditation of Healthcare
Organizations. Neither organization has yet
issued professional standards of practice 
related to the treatment of LGBT individuals,
nor has either developed standards or quality
measures regarding treatment of LGBT 
individuals that managed care organizations
would be required to meet. Thus, for the 
consumer member of a managed care plan,
whether public or private, there is no single
requirement to ensure nondiscrimination based
on sexual orientation.

Beyond one very specific project in
Massachusetts (see the case example 
following), other position or issue 
statements can be found within several of the
national associations that represent mental
health practitioners. For example, the National
Association of Social Workers (NASW) has
developed a Policy Statement (1996) that 
articulates its position that a same-gender 
sexual orientation should be afforded the
respect and rights given an other-gender orien
tation. NASW also supports curriculum policies
in schools of social work that eliminate 
discrimination against lesbian, gay, and 
bisexual people and encourage the 
implementation of continuing education 
programs on practice and policy issues 
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s To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender 
relevant to lesbian, gay, and bisexual people
and cultures, as well as human sexuality.

The American Psychiatric Association (APA)
has, since 1974, affirmed that certain sexual
orientations are not a mental illnesses and has
removed this diagnosis from all subsequent
editions of the Diagnostic and Statistical
Manual of Mental Disorders (DSM). The prac
tice guidelines APA issued in 1995 prohibited 
specific discrimination against gay and lesbian
clients (1995). In 1997, the American
Psychological Association (in press) adopted 
a Resolution on Appropriate Therapeutic
Responses to Sexual Orientation. In affirming 
a set of 13 principles, the American
Psychological Association officially opposes
portrayals of LGBT persons as mentally ill
because of their sexual orientation and sup
ports the dissemination of accurate information
about sexual orientation and mental health and
appropriate interventions in order to counteract
bias that is based on ignorance or unfounded
beliefs about sexual orientation.

A cursory review of key managed care 
stakeholders identified a significant number of
professional associations, provider groups, 
private and public purchasers, accrediting
groups, and others in a position to affect or
advocate policy changes that specifically
include sexual orientation or sexual identity
as an important issue relative to clients and
providers, including the following: 

  Academy of Managed Care Pharmacy 

  Addiction Prevention and Recovery
Administration, Washington, DC 

  American Medical Association Council on
Scientific Affairs 

  American Medical Student Association 

  American Counseling Association 
  Cambridge Preferred Provider Network of
New York 

  Council for Accreditation of Counseling and
Related Educational Programs 

  Employee Assistance Professional
Association 

  National Association of Alcoholism and Drug
Abuse Counselors 

  Patients Bill of Rights 

  Pacificare of California

  Seattle-King County (WA) Department of
Public Health 

  Waukesha (WI) Memorial Hospital, Health
System and Health Care, Inc. 

In addition, the American Federation of State,
County and Municipal Employees (AFSCME)
continues to work to promote the rights of its
lesbian and gay union members via the 
promotion of legislation that affects domestic
partner benefits and to oppose discrimination
based on HIV status. AFSCME has also issued
a report (1994) resulting from its Presidential
Advisory Commission that clearly states con
sumer rights issues within managed care. 
The Gay and Lesbian Medical Associations
(GLMAs) recent policy (1998) strongly urges
HMOs [health maintenance organizations],
PPOs [preferred provider organizations], and
other managed care organizations to identify
and provide referrals to providers with compe
tence in LGBT health so that optimal patient
care can be rendered to LGBT people.
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Advocacy Efforts and Partnerships To
Improve LGBT Care

No study or organized body of literature exists
documenting the success or failure of managed
care relationships formed between LGBT-
focused programs and MCOs. What is known
is that some MCOs and many LGBT providers
are reaching out to one another to improve
care for LGBT individuals. Some examples are
listed below, and contact information is provid
ed in the box at the end of the chapter.  

  In researching written information from 
managed care organizations that indicated a
sensitivity to LGBT competency, some 
clearly stated language was found within the
body of a proposal of one managed care
organization stating that it will apply cultural
competency standards and be sensitive to
diversity brought about by a variety of factors
including ethnicity, language, lifestyle, age,
sexual preference and socioeconomic 
status. This proposal is to manage 
behavioral health care for a public sector
county-based contract.

  More than 14 MCOs have formed contractual
relationships for primary physical health care
services with the new Lambda Medical
Group in Los Angeles (Jean, 1998). The
major insurance plans accepted by it include
Blue Cross, CIGNA, Medi-Cal, and
MediCare. The Lambda Medical Group
expects to serve 4,400 patients per year.

  In Washington, D.C., The Lambda Center,
with its comprehensive continuum of 
inpatient, partial hospitalization, and 
outpatient services that have been made
available via a joint-venture partnership, has
been highly successful in attracting the 
attention of MBHCOs and other MCOs in the
Mid-Atlantic region. Contracted rates with
more than 10 MCOs have been established
for The Lambda Centers acute care services 
(inpatient hospitalization, detoxification,
ambulatory detoxification, partial 
hospitalization, and intensive outpatient 
programs), and future plans will include 
contractual arrangements with a therapist
network for the outpatient services 
component of the continuum. Part of the 
success is due to a full-scale LGBT-
sensitivity and -competency training and 
education campaign for MCO case 
managers and senior staff of the MCOs that
is being conducted by The Lambda Center in
collaboration with the Lesbian Health and
Wellness Network (LHWN). 

  LHWN, also based in Washington, D.C., is
working closely with District of Columbia
public sector programs through the Addiction
Prevention and Recovery Administration, the
D.C. Public Benefits Corporation, the
Womens Health Initiative, and the District of
Columbias Medicaid program to incorporate
training programs in the Districts managed
behavioral health care readiness program. In
addition, LHWN will be integrally involved in
further network expansion efforts, and the
LHWN network of providers will actually be
listed in the provider directories as a block of
lesbian-competent providers.

  The Pride Institute, founded in Minneapolis,
Minnesota, began as a residential treatment
facility for gay men and lesbians. Today, the
Pride Institute manages mental health and
addiction programs for LGBT individuals in
several cities, including Fort Lauderdale,
Chicago, Minneapolis, and New York, and in
the Dallas area. Admission to Pride Institute 
programs is offered through a nationally
advertised toll-free number. It is one of the
only programs for LGBT individuals with a
long-term residential treatment component;
these components are based in Minnesota
and Fort Lauderdale.

  ALTERNATIVES, founded in 1998, offers a
dual diagnosis program for LGBT 
communities in Los Angeles and, now, in the
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s To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender 
San Francisco Bay area. Similar to the Pride
Institute, ALTERNATIVES contracts with 
hospitals to manage and staff separate 
inpatient units for gay men and lesbians.

LGBT Provider Networks

With the advent of managed care panels, 
individual providers (e.g., physicians, nurse
assistants, social workers, and psychologists)
may join those panels to satisfy contractual
specifications negotiated with private or public
purchasers. In addition, many MCOs allow
practicing groups to join. Thus, different 
specialty networks have formed, which then
collectively apply to the different MCOs in the
area for enrollment in the MCO panels. Some
providers affiliated with LGBT clinics have cre
ated networks that provide either MCOs or
managed care panels with a cadre of providers
with expertise in the treatment needs of LGBT
individuals.

A variety of LGBT provider networks have
formed throughout the United States. The 
networks are at varying levels of sophistication
in developing relationships with MCOs.
Examples of these provider networks are noted
below.

  The Gay, Lesbian, Bisexual, Transgender
Psychotherapist Association of the Greater
San Francisco Bay Area is a nonprofit group
of more than 175 LGBT psychotherapists
covering the Bay area in California.
GAYLESTA, as it is called, has developed a
referral service, educational programs, peer
consultation groups, a speakers bureau, a
newsletter, and a prelicensed psychothera
pist committee. GAYLESTA has also 
prepared a referral directory that is available
to the public.
  The Lesbian Health and Wellness Network is
a 150-member provider network based in
Washington, D.C., but with members in some
States. In addition to the creation of a
provider manual and a referral system, this
network is actively involved in providing
LGBT-competency training for mainstream
providers.

  The Los Angeles Lambda Medical Group is a
medical center connected to the L.A. Gay &
Lesbian Community Center that provides 
primary and preventive health care by 
physicians who specialize in the health care
needs of lesbians and gay men.

  The Lambda Center and Therapist Network
is an LGBT-specific continuum of inpatient
and outpatient mental health and addictions
services in Washington, D.C., that was
begun by the Whitman-Walker Clinic and
The Psychiatric Institute of Washington (a
psychiatric hospital). The formation of a 
far-reaching provider network in the
Baltimore-Washington area has recently
been formalized.

 Fenway Behavioral Health Services in Boston
is a program for gay men diagnosed with
mental health and addiction problems, based
in the Fenway Gay/Lesbian Community
Center. Referrals are made to a network of
therapists.

Substance abuse treatment programs have
many potential allies. Identifying and working
with these allies is extremely important, 
particularly in building community support for
LGBT services and in successfully navigating
the managed care environment. 
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Case Example

The Lesbian, Gay, Bisexual, and Transgender Health Access Project, a collaborative community-based 
program funded by the Massachusetts Department of Public Health, Boston, Massachusetts, has developed
Community Standards of Practice for Provision of Quality Health Care Services for LGBT clients. The 
projects mission is to foster development and implementation of comprehensive, culturally appropriate, 
quality health promotion policies and health care services for lesbian, gay, bisexual, and transgender people
and their families.

Working closely with consumers and clinicians across Massachusetts, the LGBT Health Access Project
works to confront the insensitivity and ignorance that many LGBT individuals have experienced in accessing
health care and related services. Additionally, the project works to support LGBT individuals in 
understanding and acquiring the quality care they need. The Community Standards of Practice is the 
outcome of this work and was developed to provide a benchmark for both providers and consumers in the
development of and search for welcoming, culturally competent, and responsive care.

The Community Standards of Practice and quality indicators are meant to guide and assist providers in
achieving a set of goals that include:

  The elimination of discrimination on the basis of sexual orientation and gender identity

  The promotion and provision of full and equal access to services

  The elimination of stigmatization of LGBT people and their families

  The creation of health service environments where it is safe for people to be out to their providers.

The standards address both agency administrative practices and service delivery components, including the
following areas:

  Personnel
  Clients rights
  Intake and assessment
  Service planning and delivery
  Confidentiality
  Community outreach and health promotion.

There are 14 standards in all, accompanied by appropriate indicators for each standard. (The standards can
be accessed via the Internet at www.glbthealth.org.)
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s To Improve Treatment for Lesbian, Gay, Bisexual, and Transgender 
Advocates for LGBT-Specific Health Care Services

Gay and Lesbian Association of Retiring Persons, 3109661500
Gay & Lesbian Issues Committee/Employee Assistance Professionals Association, 7035226272
Gay and Lesbian Medical Association (GLMA), 4152554547
Gay, Lesbian, Bisexual Employees of the Federal Government, 2025439583
Human Rights Campaign, 2026384160
Kaiser Permanente Pride, 5109874148
National Association of Lesbian & Gay Addiction Professionals (NALGAP), 7034650539
National Latina/o Lesbian, Gay, Bisexual & Transgender Organization, 2024668240
National Lesbian & Gay Nurses Association, 7189331158
Parents, Families and Friends of Lesbians and Gays, 2026384200

LGBT Health Care Providers and Behavioral Health Care Programs Serving LGBT Clients

Alternatives  Los Angeles & San Francisco, CA, 8003425429
Callen-Lorde Community Health Center  New York, NY, 2122717200 
Chase Brexton Clinic  Baltimore, MD, 4108372050
Health Initiatives for Youth (HIFY)  San Francisco, CA, 4154875777
Fenway Community Center  Boston, MA, 6172670900
Hartford Gay & Lesbian Health Collective  Hartford, CT, 8602784163
L.A. Gay & Lesbian Center  Los Angeles, CA, 2139937400
New Leaf Services  San Francisco, CA, 4156267000
Pride Institute, Minneapolis, MN, 80054Pride
Project Connect  New York, NY, 2126207310
Stepping Stone  San Diego, CA, 6195431346
Stonewall Recovery Services  Seattle, WA, 2064614546
The Lambda Center  Washington, DC, 8772LAMBDA
Whitman-Walker Clinic  DC, MD, and VA, 2027973500
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Chapter 18
Recommendations

This chapter provides 
recommendations for:

  Additional research needs

  Clinicians on improving
treatment for LGBT clients

  Improving training about
LGBT issues

  Administrators on 
improving treatment for
the LGBT community

  Managed care, program
planning, and quality
assurance
Introduction

Lesbian, gay, bisexual, and transgender
(LGBT) individuals are entitled to services
provided in a safe and appropriate environ
ment and should not be denied services
based on their sexual orientation. The 
treatment provided should be sensitive to
and supportive of the unique needs of the
client. Therefore, substance abuse treatment
providers, counselors, therapists, adminis
trators, and facility directors need to become
aware of the issues facing LGBT clients.
With this knowledge, they can design 
quality treatment programs that provide
effective, ethical, and informed care for
LGBT clients. This improvement in care will
improve outcomes for LGBT clients, and
treatment providers will reach a previously
underserved population. 

Recommendations for Research

LGBT populations abuse substances at
rates that are the same as or higher than
the rates in the general population, but more
information is needed in this area. Future
studies should create a clearer distinction
between substance use and substance
abuse, employ more vigorous sampling
methodology, establish prevalence and 
incidence rates for the specific substances
of abuse, and identify the effects that age,
sexual identity, discrimination, and 
heterosexism have on substance use and
abuse among LGBT individuals. In addition,
substance abuse among lesbians, bisexual

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women, and transgender individuals should be
further studied and substance abuse among
them distinguished from substance abuse
among gay and bisexual men.

Innovative LGBT-specific intervention and
treatment approaches are needed and should
be researched and developed. Health care
providers and delivery systems should develop
new models of intervention and treatment 
targeted especially to LGBT individuals.
Researchers, government agencies, and 
community-based organizations should work
together to create innovative outreach efforts,
prevention campaigns, and standards of 
treatment for LGBT individuals.

LGBT-identified researchers, scientists, and
consumers should be included in public health
policy formulation and resource decision 
matters related to substance abuse prevention
and treatment.

Recommendations for Clinicians

To provide quality care for LGBT clients, 
treatment providers need to learn about sexual
orientation and gender identity and how these
are determined. Counselors need to know
more about how LGBT individuals learn to
acknowledge and accept their sexual orienta
tion, about the stages of coming out, and about
how to meet the needs of clients, regardless of
sexual orientation. Counselors can help LGBT
clients recover from substance abuse and
addiction by being empathic, supportive, and
nonjudgmental and assisting clients to:

  Integrate their sexual identity

  Become more self-accepting

  Heal from shame resulting from 
heterosexism, internalized homophobia, 
and substance abuse.

The counselor should help the recovering
LGBT individual connect with a community that
will help him or her heal, such as 12-step or
other self-help groups, other LGBT individuals
in recovery, and the clients own family of
choice. The counselors should learn to provide 
sensitive support for LGBT clients families 
and partners. 
Counselors should remember that LGBT
clients may have additional health concerns
such as co-occurring mental illnesses,
HIV/AIDS, STDs, liver disease, hormone-
related issues, and hepatitis B or C.
Counselors should screen for other health
problems and for domestic violence. Any
assessment should be framed with sensitivity. 

Counselors must confront their own negative or
ambivalent feelings about homosexuality and
learn to provide quality care that is sensitive,
supportive, and comprehensive.

It is a challenging task to provide services that
are appropriate, accessible, cost-effective, and
quality driven. The following section includes
selected recommendations for achieving this
goal. 

  Counselors and treatment providers need to
reexamine their treatment approaches and
take steps to move them to LGBT-sensitive
and supportive modalities.

  Internalized homophobia, anti-LGBT bias, 
and heterosexism may contribute to the use 
of alcohol and drugs by LGBT individuals.
Providers should learn the effects of these 
negative biases on the LGBT individual and
community and how to help LGBT clients
affirm themselves and address negative 
feelings. A better understanding is needed of
the interplay between sexual orientation and
the sociocultural context in relation to 
substance use, abuse, and treatment.

  Treatment providers should learn about 
substance abuse in the LGBT community.
Substance use, especially alcohol, is often
an integral part of the LGBT social life and 
Recommendations

160

-----------------------------------------------
is connected to sexual identity formation,
coming out, and self-acceptance processes
for many LGBT persons. 

  Treatment providers should work at the 
individual clients comfort level related to his
or her sexual orientation issues and consider
how the clients feelings about his or her sex
ual orientation affect the clients recovery.

  All staff and clients should not assume that
stereotypes and myths about LGBT individu
als are true. Each LGBT individual is unique.

Recommendations for Training

A limited number of facilities offer LGBT-
sensitive treatment. The training of professional
and support staff to serve LGBT individuals in
their own communities is critical for improving
treatment and treatment outcomes.
Considerations for improving training to enhance
treatment for the LGBT community follow.

  Provide training to staff members in cultural
diversity and sexual orientation sensitivity to
promote better understanding of LGBT popu
lations. Education topics should be diverse
and applicable to all LGBT populations and
include topics of sexual orientation, sexual
identity, gender, and sexual behaviors.

  Use LGBT-specific training and educational
programs to ensure that quality care is 
provided. Educators and trainers with 
expertise in LGBT issues should develop
training programs, manuals, books, videos,
films, CD-ROMS, and other interactive 
training technology focused on LGBT 
treatment that can be widely disseminated. 

  Provide sensitivity training when LGBT
clients and heterosexual clients attend the
same group therapy sessions. Counselors
should protect LGBT clients from homopho
bic behavior. LGBT clients should not be
forced to discuss sexual orientation or
behaviors if they are not comfortable doing
so. If the facility provides LGBT-only groups,
attendance should be voluntary and confi
dentiality should be respected. 
  Assess staff comfort, experience, and 
competence in serving LGBT individuals
before developing a training program, during
training, and after providing training.

Recommendations for Administrators 

Managed Care 

Managed care and other health care provider
networks should strive to improve their 
LGBT sensitivity. 

  Managed care organizations (MCOs) panels
of providers should include LGBT providers
and LGBT-sensitive providers. 

  LGBT medical and professional organiza
tions should request that MCOs include
LGBT providers and an LGBT category 
as a recognized subgroup of the health 
insurance plan. 

  Managed behavioral health care 
organizations should be able to inform case
workers of subcategories of providers; for
example, a caseworker should have enough
information to be able to refer a client to 
substance abuse treatment services that are
identified as LGBT sensitive.

  LGBT programs should join other networks
to ensure culturally competent services.

  Service purchasers such as MCOs, health
maintenance organizations, and employee
assistance programs should identify and use
resources for providing culturally competent
substance abuse treatment services to LGBT
clients.
Recommendations

161

-----------------------------------------------
Program Planning

  Program administrators, counselor training
program directors, and substance abuse
treatment educators should encourage 
planning for and implementation of training
programs to serve substance-abusing LGBT
clients. 

  Once an LGBT-sensitive program is 
established, providers should develop 
programs for drugs such as cocaine, crack,
methamphetamine, and other addictive drugs
that are challenging to treat.

Quality Assurance

To ensure high-quality treatment:

  Providers should evaluate their programs.
They should collect appropriate demographic
data to establish baseline information about
LGBT clients. They should design and 
implement appropriate client satisfaction
measures that provide specific feedback
about how well the organization is serving
LGBT clients.

  Community services personnel, professional
associations, and others engaged in training
mental health and social work professionals
and support staff should review and revise
their existing policies to reflect LGBT needs.

  Service providers should review policies and
procedures to improve sensitivity toward and
effectiveness in serving LGBT clients. 
  Providers should develop better LGBT- 
specific outcome data. They should compare
the numbers of clients served, overall 
satisfaction results, and treatment outcomes
among identified LGBT clients with data 
pertaining to the general treatment population.

  Providers should consult with persons with
expertise in LGBT issues, such as clients,
staff, advocacy groups, or organizations, to
provide assistance in developing an LGBT
program that is sensitive, supportive, and
effective. 

  Providers should promote application of 
standards by accrediting bodies such as 
the Joint Commission on Accreditation of
Healthcare Organizations, the National
Committee for Quality Assurance, and the
Commission for the Accreditation of
Rehabilitation Facilities to specifically
acknowledge and address the needs of
LGBT individuals and provide appropriate
education for surveyors from these bodies.
Treatment accreditation bodies should 
mandate demonstrated proficiency in LGBT
health and safety issues.

It is hoped that this volume will assist 
administrators and clinicians in forming a better
understanding of LGBT people, their problems
with substance abuse, and the unique 
challenges they face and that the knowledge
gained about designing programs for LGBT
clients will be used to create a more 
comfortable environment for LGBT clients. 
Recommendations

162

-----------------------------------------------
SECTION IV: 
APPENDIXES

-----------------------------------------------
Appendix A
Glossary of Terms

The following terms are meant to guide the reader by providing clarity. However, it should be noted
that some of the definitions continue to evolve over time as language changes from generation to
generation.

AcculturationAccommodation to the rules
and expectations of the majority culture without
giving up cultural identity entirely. 

AgeismDiscriminatory behavior relating to
age.

AssimilationAdaptation to a new culture by
taking on a new identity and abandoning the
old cultural identity.

BiphobiaIrrational fear and dislike of bisexuals.

BisexualMan and woman with a sexual and
affectional orientation toward people of both
genders.

Circuit PartyWeekend dance party usually
attended by urban gay males. These parties
typically occur on a holiday weekend, and just
as with many dance clubs and bars, many of
their patrons are involved in substance use 
and abuse.

Coming OutIndividual and personal process
by which a person accepts his or her homosex
ual or bisexual orientation and transforms it
from a negative to a positive thing in a culture
that is homophobic and does not validate and
affirm diversity and difference. It is a process of
healing from homophobia and heterosexism
and taking on a positive identity. It may include
sharing this process and its outcome with 
others or it may be private.  

ConfidentialityRestriction against disclosure
to certain persons or institutions of medical or
personal information about a client without his
or her consent.
Co-occurring DisordersCondition in which 
a person has more than one disorder or 
disease.

CountertransferenceProcess of counselors
seeing themselves in their clients, overidentify
ing with their clients, meeting their own 
personal needs through clients, or reacting to a
client because of unresolved personal conflicts.

Cultural CompetenceBroad-based and
diverse understanding of, and ability to respond
and relate to, culturally specific nuances, 
communication styles, traditions, icons, 
experiences, and spiritual traditions of a given
culture or cultures.

DenigrateTo cast aspersions on, to defame,
or to deny the importance or validity of 
something or someone.

DysphoriaState of feeling unwell or unhappy.

EpidemiologyIncidence, distribution, and 
control of disease in a population.

Family of ChoicePersons an individual sees
as significant in his or her life. It may include
none, all, or some members of his or her family
of origin. In addition, it may include individuals
such as significant others or partners, friends,
coworkers, etc.

163

-----------------------------------------------
Family of OriginBirth or biological family or
any family system instrumental or significant in
an individuals early development.

Gender IdentitySense of oneself as male or
female. As a comparison, a person may be
born biologically male yet have a female 
gender identity.

HermaphroditeA person born with both
male and female reproductive organs. 

HeterosexismValue and belief that 
heterosexuality is the only natural sexuality
and that it is inherently healthier than or 
superior to other types of sexuality.
Heterosexism is the ideological system that
denies, denigrates, and stigmatizes any 
nonheterosexual form of behavior, identity,
relationship, or community.

HeterosexualsTerm used to describe those
individuals with a primary sexual and 
affectional orientation toward persons of the
opposite gender. Heterosexuals are often
referred to as straight.

HolisticConsideration of the entire individual
(physical, intellectual, emotional, spiritual, and
environmental).

HomophobiaIrrational fear or dislike of
homosexuals. This includes the discomfort and
dislike that some heterosexuals have toward
lesbian, gay, bisexual, and transgender 
individuals.

HomosexualTerm used to describe an 
individual with a primary sexual and affectional
orientation toward persons of the same 
gender. Male homosexuals are often referred
to as gay, whereas female homosexuals are
referred to as lesbians.

Internalized HomophobiaAccepting and
believing the negative messages of the 
dominant group as they relate to gay men and
lesbians; the internalized self-hatred that gays 
and lesbians struggle with as a result of 
heterosexual prejudice.
Life CycleStages of development (infancy,
childhood, adolescence, young adult, adult,
elder).

LookismPrejudice that some people harbor
based on a limited and narrow definition of
what physical traits are desirable.

MethamphetaminePowerful central nervous
system stimulant. A synthetic drug that has a
high potential for abuse and dependence. It is
illegally produced and sold in pill form, 
capsules, powder, and chunks. Methamphet
amine was developed early in this century from
its parent drug amphetamine and was originally
used in nasal decongestants, bronchial
inhalers, and the treatment of narcolepsy and
obesity. In the 1970s, methamphetamine was
classified a Schedule II druga drug with little
medical use and a high potential for abuse.

Next of KinPerson or persons designated in
case of emergency. Traditionally this 
designation has been used only for immediate
family of origin or married partners.

NonoperativeThe status of a transsexual
individual who will not undergo sex 
reassignment surgery. Also called non-op. 

Out or Out of the ClosetRefers to varying
degrees of being open about ones 
homosexual or bisexual orientation.

Passive PartnerTerm frequently used in 
reference to male-to-male sexual behavior,
specifically the receptive partner during sexual
intercourse.

Postoperative PersonTranssexual who has
completed gender reassignment surgery.

Power of AttorneyLegal document in which
one person authorizes another person to act
on the formers behalf.
y of Terms
Appendix AGlossar

164

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Preoperative PersonTranssexual who is
contemplating gender reassignment surgery.

Quality Improvement ProgramA systematic
effort undertaken by an organization to analyze
processes and procedures and identify and
implement changes in order to achieve more
desirable outcomes.

RaveType of dance party at which many of
the patrons are involved in substance use and
abuse.

Ryan White Care ActFederal legislation that
authorizes funding for the support of people
with HIV/AIDS.

SeropositiveSerotype that suggests 
someone has experienced infection in the past.

Sex Industry WorkersIndividuals (either
male or female) who work as prostitutes, 
hustlers, or escorts and are in the business of
providing sex for money, drugs, or housing.

Sexual HarassmentAn illegal act that
occurs in a place of employment when one
person inflicts on another conversations or
actions of a sexual nature. This behavior can
either involve the condition of concrete 
employment benefits for sexual favors or 
create a hostile or offensive working 
environment for those involved and can be
grounds for legal recourse.

Sexual Identity or OrientationThe erotic,
physical, and emotional attraction to members
of ones own gender, the opposite gender, or
both genders and ones conscious or subcon
scious decision to define and label this affinity
and attraction.

Significant OtherA life partner, domestic
partner, lover, boyfriend, or girlfriend. Because
gays and lesbians still are not allowed to be
legally married in the United States (although
they are allowed to in some European 
countries), significant other is equivalent to the
term spouse.
Sodomy LawsState statutes (which vary by
State) that prohibit contact between the mouth
or anus of one person and the sexual organs
of another person (consensually or otherwise).

SynthesisCombining of often diverse 
conceptions into a coherent whole.

TransferenceRedirection of feelings and
desires.

Transgender PersonOne whose gender
identity is not congruent with his or her 
biological gender, regardless of the status of
surgical and hormonal gender reassignment
processes. Sometimes used as an umbrella
term encompassing transsexuals, transvestites,
cross dressers, and others. The term 
transgender refers to a continuum of gender
expressions, identities, and roles, which
expand the current dominant cultural values of
what it means to be female or male.

TransphobiaIrrational fear or dislike of 
transgender individuals.

TranssexualIndividual with biological 
characteristics of one sex who identifies 
himself or herself as the opposite gender.
There are female-to-male and male-to-female
transsexuals: Transsexuals usually desire to
change their bodies to fit their gender identities
and do this through hormone treatment and
gender reassignment surgery.

Treatment ReadinessStage or phase that
an individual may be in related to changing
alcohol and drug use activities (i.e., decrease
harmful alcohol- and drug-related behaviors).
Appendix AGlossar
y of Terms

165

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Appendix C
Acronyms

AA Alcoholics Anonymous
ACLU American Civil Liberties Union
ACOA Adult Children of Alcoholics
ADA Americans with Disabilities Act
ADM alcohol, drug abuse, and mental health
AFSCME American Federation of State, County, and Municipal Employees
AIDS acquired immunodeficiency syndrome
AMBHA American Managed Behavioral Healthcare Association
APA American Psychiatric Association
API Asian/Pacific Islanders
ASI Addiction Severity Index
CARF The Rehabilitation Accreditation Commission
CDC Centers for Disease Control and Prevention
CEU continuing education unit
CMA crystal methamphetamine
CSAP Center for Substance Abuse Prevention
CSAT Center for Substance Abuse Treatment
DSM Diagnostic and Statistical Manual of Mental Disorders
EAP employee assistance program
ERISA Employment Retirement Income Security Act
FFS fee-for-service
FTM female-to-male
GHB gamma hydroxybuturate
GID gender identity disorder
GLMA Gay and Lesbian Medical Association
HEDIS Health Plan Employer Data and Information Set
HIV human immunodeficiency virus
HMO health maintenance organization
IDU injection drug user/intravenous drug user
IOM Institute of Medicine
IPA Individual Practice Association
ITA Its Time America!
IV intravenous
JAMA Journal of the American Medical Association
JCAHO Joint Commission on Accreditation of Healthcare Organizations
LGBT lesbian, gay, bisexual, and transgender
LHWN Lesbian Health and Wellness Network
MAP member assistance program
MAST Michigan Alcohol Screening Test
MBHC managed behavioral health care
MBHCO managed behavioral health care organization

187

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MCO managed care organization
MSM men who have sex with men
MTF male-to-female
NA Narcotics Anonymous
NAADAC National Association of Alcohol and Drug Abuse Counselors
NALGAP National Association of Lesbian and Gay Addiction 
                         Professionals
NASW National Association of Social Workers
NCQA National Committee for Quality Assurance
NGLTF National Gay and Lesbian Task Force
NHSDA National Household Survey on Drug Abuse
NIDA National Institute on Drug Abuse
OAS Office of Applied Studies
ONDCP Office of National Drug Control Policy
PAWS postacute withdrawal syndrome
PCCM primary care case management
PFLAG Parents, Families and Friends of Lesbians and Gays
PHO physician hospital organization
PMS premenstrual syndrome
POS point of service
PPO preferred provider organization
PSA public service announcement
PSN provider-sponsored network
PSO provider-sponsored organization
QISMC quality improvement system for managed care
RCD Resource Center of Dallas
RET rational-emotive therapy
ROTC Reserve Officers Training Corps
RWJF Robert Wood Johnson Foundation
SAMHSA Substance Abuse and Mental Health Services Administration
SASSI Substance Abuse Subtle Screening Inventory
STD sexually transmitted disease
TAP Technical Assistance Publication
TIP Treatment Improvement Protocol
WWATS Whitman-Walker Clinic, Inc., Addiction Treatment Services
Appendix CAcronyms

188

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Appendix D
Studies on LGBT Substance Abuse

Study  Study Population             Substance              Methodology           Comparison Group                  Outcome  Comments on
Use/Abuse    Outcome
Saghir et Lesbians                      Alcohol Convenience None 33% reported having a No comparisons can
al., 19701 N=200 sample problem with alcohol be made at this time
Fifield et Lesbians                      Alcohol Convenience None 35% reported having a  No comparisons can
al., 19771 N=57 sample problem with alcohol  be made at this time
Lewis et  Lesbians                      Alcohol Convenience None 28% reported having a No comparisons can
al., 19821 N=57 sample problem with alcohol be made at this time
Morales & Lesbians                      Alcohol Convenience None 27% reported having a No comparisons can
Graves,  N=129 sample problem with alcohol be made at this time
19831
Bradford & Lesbians                      Alcohol Population-based None 6%daily drinkers No comparisons can
Ryan,  N=1,917 (National Lesbian  25%drink 1+/wk be made at this time
19871 Health Care Survey) 30%drink 1+/mo
17%abstainers
Stall & Gay men                      Alcohol & Population-based Heterosexual men Gay men had greater
Wiley,  drugs (San Francisco Mens in San Francisco substance use
1988 Health Study) (excluding alcohol) than
heterosexual men 
McKirnan & Lesbians                      Alcohol Convenience General population 76% vs. 59%Moderate Lesbians had greater
Peterson,  N=748 sample women (Clark &  9% vs. 7%Heavy alcohol use than general
19891 Midinak, 19921 23% vs. 8%Problems population women
Bloomfield,  Lesbians                      Alcohol Convenience Heterosexual women 69% vs. 74%Moderate Lesbians had greater
19931 N=58 sample (N=397) 11% vs. 10%Heavy alcohol use than
13% vs. 3%In recovery  heterosexual women
20% vs. 16%Abstainers

189

-----------------------------------------------
190 Appendix DStudies on LGBT Substance Abuse

Study Study Population           Substance Methodology          Comparison Group Outcome Comments on 
Use/Abuse  Outcome
Skinner, Lesbians & gay         Alcohol, cigarettes,       Convenience Heterosexuals Lesbians & gay men had
1994 men marijuana & other        sample greater substance use
illegal drugs than heterosexuals
Skinner &  Lesbians  Alcohol Convenience General population       32% vs. 28%1-4 drinks/mo Lesbians used more
Otis, 19961 N=500 sample women 26% vs. 11%5-19 drinks/mo alcohol than general
N=725 12% vs. 2%20-30 drinks/mo population women
28% vs. 9%5+ drinks/occasion
Hughes et     Lesbians Alcohol or drug Convenience Heterosexual women   10% vs. 2% Lesbians used more
al., 1997 N=284 problems sample N=134 77% vs. 85%Light/moderate substances than
2% vs. 2%Heavy heterosexual women        
19% vs. 13%Alcohol problems
Clements et  Transgender  Intravenous drug Convenience None 34% MTF w/lifetime IV drug use    No comparisons can be
al., 1998 persons use sample 18% FTM w/lifetime IV drug use    made at this time
(N=515)
Woody et Men who have sex    Alcohol, nitrite Convenience General population      This nongeneral sample of MSM    MSM used more
al., 1999 with men (MSM)       inhalants,                     sample men                            who were specifically at risk         substances than general
and are at specific    hallucinogens, for contracting HIV disease was    population men
risk for HIV/AIDS      stimulants, sedatives, 21 times more likely to use 

(N=3,212) tranquilizers,  nitrite inhalants, 6 times more
marijuana, cocaine likely to use hallucinogens, 4 
times more likely to use 
stimulants, 7 times more likely 
to use sedatives, and 5 times 
more likely to use tranquilizers
Cochran &    Same gender (male) Alcohol Population- Opposite-gender          10% of males with partners of       Same-sex partners used
Mays, 2000   partners (N=98)     dependence (DSMIV)  based (1996 National   (female) partner(s)       the same gender vs. 7.6% of        more substances than
Same gender Drug dependence Household Survey of    only (N=3,922)            males with partners of the op-       opposite-sex partners
(female) partners      (DSMIV)         Drug Abuse) Opposite-gender          posite gender exhibited symp-          
(N=96)                     (male) partner(s)         toms of alcohol dependence.
only (N=5,792)            7% of females with partners of    
the same gender vs. 2% of fe
males with partners of the oppo
site gender exhibited symptoms
of alcohol dependence.
5.7% of males with partners of 
the same gender vs. 2.8% of 
males with partners of the oppo
site gender exhibited symptoms
of drug dependence.
5% of females with partners of
the same gender vs. 1.3% of
females with partners of the op
posite gender exhibited symp
toms of drug dependence.

-----------------------------------------------
Study Study Population            Substance Methodology Comparison Group Outcome Comments on
Use/Abuse Outcome

Cochran        Same gender Alcohol                         Population-based      Same gender partner    Lesbians were 2 times more         Lesbians were at higher
et al.,  partners (gay and     dependence (DSM-IV)    (1996 National           (male) vs. opposite        likely to use alcohol in the past      risk for alcohol use than
in press     lesbian) (N=194) Household                gender partners (male)  month, 3.5 time more likely in       heterosexual women
Opposite gender Survey of Drug         Same gender partner     the past year, 5 times more
partners (N=9,714) Abuse) (female) vs. opposite     likely to use alcohol every day,
gender partners            2.25 times more likely to get
(female)                       intoxicated, and 4 times more
likely than heterosexual women 
to get intoxicated weekly. There 
were no differences between 
gay and straight men.
Welch,  New Zealand  Drugs Survey None 76% reported using cannabis No comparisons can
Howden- lesbians once (lifetime) and 33% reported be made at this time
Chapman &    N=200 use in the last year
Collings, 31% used recreational drugs
1998  other than alcohol and cannabis 
at some time, and 4.5% 
reported past year use

1As cited in Hughes, T. (November 1999). Sexual Identity and Alcohol Use: A Comparison of Lesbians and Heterosexual Womens Patterns of Drinking. 
Presentation conducted at the National Institute of Mental Health.

191 Appendix DStudies on LGBT Substance Abuse